Author Archives: Abebayehu Yilma

In-door Air Pollution Impacting the Health of Women & Children in Developing Countries: Priority for Health Policymakers

In-door air pollution (IAP) caused by unprocessed wood fuels is impacting the health of the poor, where disproportionate numbers are residing in developing countries.[1] Approximately 90% of rural households in developing countries are relying on wood, dung and crop residues as their main energy source and the numbers are expected to increase.[2] Such energy sources are cheap and easily available locally. However, there are not very clean nor efficient. Besides the fuels, poor functioning stoves and housing conditions make them highly vulnerable. Although a massive shift to kerosene is expensive, promoting the use of charcoal with enhanced stove system will reduce the health impact.

IAP caused by unprocessed wood fuels is threatening the health of the poor in many ways. When they are burned, they leave behind high concentrations of invisible breathable particles of a variety of gases and chemical products. For example, study in rural part of Nigeria shows that the mean concentration of nitrogen dioxide, sulphur dioxide, carbon monoxide, and hydrogen sulphide always stay higher than the permissible limit.[3] The amount of these substances in a poorly ventilated home can exceed WHO’s standard of particle size by more than 20 times.[4]  Particles less than 2.5 micro can penetrate deeply into the lungs and cause multiple health issues.[5] In fact, there are substantial literatures indicating positive correlations between higher concentrations of total suspended particulates and higher rates of mortality.4,5,[6]

As a result, nearly 2 million deaths from various illnesses were reported and among these deaths, 44% were due to pneumonia, 54% from chronic obstructive pulmonary disease, and 2% from lung cancer, where women and children accounted the highest.[7] In rural part of many developing countries, women do most of the cooking, thus they are subjected to continued exposure. It is estimated that 59% of all the deaths attributed to IAP are among female.[8] Children are also considered the second victims. While cooking mothers often carry young children, thus children are exposed to those breathable particles for prolonged period. As a result, 56 % of all the deaths attributed to IAP are among children younger than 5 years old.7 Indeed, the health impact of women and children creates huge economic burdens to the community and in general to country.

To avert the deaths we need to promote alternative energy sources. Although a massive shift to kerosene is preferred, in rural setting it is a very expensive investment, thus is not a cost-effective strategy. However, many alternative mitigation strategies can be promoted to save lives.  The use of charcoal in the few pockets where unprocessed wood fuels are being used widely would be more affordable. Such a measure would have immediate health benefits and lower the mortality. Charcoal, when burned, releases reduced concentrations of harmful particles and more useful energy than unprocessed wood fuel.9 By supplementing with behavioral changes such as keeping children away from stoves and cooking areas, it is possible to achieve significant reduction in mortality. To compensate the wood harvested, the promotion of charcoal use should always be introduced with strong forest policies such as tree replanting to encourage sustainable forest and woodland. Furthermore, to offset part of the emissions due to carbon combustion, it is critical to adapt low-carbon and more productive charcoal production techniques. Sugar charcoal is considered to contain pure carbon than wood charcoal, for instance.[9]

Along with the promotion of charcoal, major changes in housing designs is also crucial to allow adequate ventilation. For example, allowing cooking areas to remove excess hot air and introduce clean air. Replacing the traditional cooking stoves with technologically enhanced stoves will also help to minimize the emission of pollutants. Over the years various types of technologically improved stoves have been tested in many parts of developing countries. The Clean Cook stove, which is tested in Ethiopia, showed reduction in the average particles concentration by half, for example.[10] Similarly cleaner cooking technologies are testing various improved stoves for their efficiency in villages in India, Bangladesh, and Haiti.[11],[12]

The health impact of IAP from unprocessed wood fuel is very huge and should be a priority for policymakers in developing countries. Recognizing this, in 2010, the formal U.S. Secretary State, Hillary Clinton, made a speech in which she underscored the huge impact of IAP in many developing world. There is no doubt that the above mitigation strategies will help reduce some of the health impacts.

[1] Duflo E, Greenstone M, Hanna R “Indoor air pollution, health and economic well-being” Published by Copernicus Publications on behalf of the Institute Veolia Environment.

[2] Bruce N, Perez-Padilla, and Albalak R (2000) “Indoor air pollution in developing countries: a major environmental and public health challenge” World Health Organization

[3] Oguntoke O, Opeolu BO, Babatunde N (2010) “ Indoor air population and health among rural dwellers in Odeda area South-Western Nigeria” Ethiopian Journal of Environmental studies and management. 3(2): 1-8.

[4] Yassi A, Kjellstrom T, de Kok T, Guidotti TL. Health and energy use. Basic Environmental Health. New York: Oxford University Press; 2001:315.

[5] United States Environmental Protection Agency. Revisions to the National Ambient Air Quality Standards for Particles Matter. Federal Register, July 18 1997, 62: 38651–38701.

[6] World Health Organization. Indoor Air pollution and Health: Fact sheet. No 29

[7] World Health Organization. Indoor air Pollution and health: Fact sheet accessed on 2/26/2014.

[8] Skolnik R (2012) “Global health 101” 2nd Edition: American Public Health Association Press. Page 146-147.

[9] FAO Corporate Document Repository “Chapter 10-using charcoal efficiency retrieved on 3/2/2014.

[10] CEIHD/Gaia Association (2007) “ Indoor air pollution monitoring Summary report” Center for Entrepreneurship in international health and development, School of public health, University of California, Berkeley California.

[11] Abhishek Kar, Ibrahim H. Rehman, Jennifer Burney, S. Praveen Puppala, Ramasubramanyaiyer Suresh, Lokendra Singh, Vivek K. Singh, Tanveer Ahmed, Nithya Ramanathan, Veerabhadran Ramanathan. Real-Time Assessment of Black Carbon Pollution in Indian Households Due to Traditional and Improved Biomass Cookstoves. Environmental Science & Technology, 2012;

[12] A. M. Mobarak, P. Dwivedi, R. Bailis, L. Hildemann, G. Miller. Low demand for nontraditional cookstove technologies. Proceedings of the National Academy of Sciences, 2012; DOI: 10.1073/pnas.1115571109


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Decentralization to improve health delivery not merely a byproduct of political changes

Decentralizing the health service delivery provides a unique opportunity to improve health performance at the district level. Decentralization approach includes transferring financial, administrative, ownership, and political authorities for alternate institutions in the peripheral. The rationale for transferring such power is; local decision makers have access to better information on local circumstances than central authorities, thus they have all the legitimacy to modify services, operation, spending pattern as it suits to the local needs and preferences.

In the past, various forms of decentralization have been instituted in many developing nations and the results have not always resulted in an improvement of the health of the national population for many reasons. For instant, in Chile and Mexico, when decentralization of the health sector was implemented, municipal authorities were given decision making power with respect to health including employing health professionals. However, the central government retained economic power over the national health budget, thus the local authorities were unable to address health needs of the their people because they were not able to pay salaries of their workers.[1] On the other hand, when China implemented decentralization in the 1980s, the local public health authorities
 were given full control of health services delivery, however the central government decreased the national provided health budget and imposed user fees and taxes on families for health services.[2] In contrast to the above examples, Cameroon and Brazil’s implementation of decentralization proved to be the best models not only in controlling specific disease, but also in improving health services delivery nationally.[3] One of the noticeable benefits of the decentralization approach was enabling of efficient distribution of antiretroviral treatments to control HIV/AIDS. For example, Cameroon provided medical access to 58% of all eligible HIV/AIDS patients; this is one of the highest treatment rates in Africa.[4]  Brazil once had very high prevalence of HIV/ADIS similar to South Africa, however through the decentralization approach, it was able to stabilize the HIV epidemic to levels resembling those of the United States and Western Europe[5]. The secret to their successful implementation of decentralization was attributed the central government that fully decentralized its national health planning, health financing and community participation programs.

The above examples demonstrate how difficult the implementation of decentralization can get and how easily the system can be manipulated to pursue other political aims. When implementing decentralization, additional reforms such as allocation of financial and qualified personnel must be followed. The focus for decentralization is to make the operation of health facilities efficient, thus routine regional supervision of the health facilities and standardization of drugs and treatment plans should continue until the peripheral administrative are fully capable of handling all the tasks. The national government should continue investing on peripheral health systems and not to pursue other political aims with name of decentralization. If decentralization is implemented correctly, the positive outcomes will include equitable resource allocation between urban and rural areas, improved health service delivery in rural areas, and increase in access to essential medicines.

[1] Khan, S.& Willis, K. (2009) Health Reform in Latin America and Africa: decentralization, participation and inequalities. Third World Quarterly, 30 (5), 991-1005.

[2] Blumenthal, D. & Hsiao, W. (2005). Privatization and its Discontents – The Evolving Chinese Health Care system. New England Journal of Medicine, 353(11), 1165- 1170.

[3] Berman, P.A. & Bossert, T.J. (2000). A Decade of Health Sector Reform in Developing Countries: What Have We Learned? DDM Symposium. DPE-5991-1-A-00-1052-00

[4] Loubiere, S., Boyer, S., Protopopescua, C., Bononod, C.R., Abegad, S., Spirea, B. & Moattia, J.(2009). Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers. Health Policy, 92(2/3), 165-173.

[5]  Case in global health delivery (2011) “HIV/AIDS in Brazil delivering Prevention in Decentralization Health System” Harvard Medical School.

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Golden opportunity for countries in Sub Saharan Africa to scale up health finances

While the big news at 2013 United Nation General Assembly was, diplomatic breakthroughs on Iran and Syria, post-2015 got a pretty good airing as well.  At the Millennium Development Goals (MDGs) special event on September 25th the leaders discussed the substantial advancement that has been made in meeting several of the MDG targets. However, the key question for countries in Sub Saharan Africa is how to sustain the successes. Maximizing their capacity in health service delivery is vital and allocating more finances and combating corruption in health sector can do this.

The region is known for its weak health service delivery and as a result it became the experimental center for most of the MDG targets. According to the WHO ranking, countries in sub Saharan Africa perform the lowest in terms of health service delivery indicating that countries do not efficiently spend the financial resources that they do have for health services. For example, in 2009 countries in sub-Saharan Africa spent less than 9.5% of GDP that the middle and high-income countries spend on health[1]. Most MDGs goals can be addressed when health service delivery is effective for intervention to the problems. As populations rises, and chronic diseases burden increases the right number of trained health workers and well-equipped health facilities appear to be essential in delivery of adequate responses to any potential catastrophic health challenges ahead. Therefore, it is time for countries in this region to find alternative mechanisms to raise more finances to strengthen their health sector.

After decades of economic stagnation, economic growth across Sub-Saharan Africa is increasing by more than 5% per year and it is expected to accelerate moderately every year[2]. Such economic growth suggests potential additional funds for the health sector. Foreign and domestic private and public investments are the main attributers for the economic growth[3], thus introducing temporary additional taxes on most profitable sectors will generate additional funding for the government. Furthermore, the current economic growth will be expected to increase the household income, thus there is an opportunity for the government to introduce tax on purchase price. All the generated revenues can go directly into national health system to scale up the health finances. The additional finances will help to build more clinics and hospitals especially in rural areas, help to train more health workers, strengthening the health facilities, provide needed ambulance and emergency cares. Furthermore, as brain drain is a serious problem in the region, the introduction of additional funds will help to raise the salaries of health professionals to a competitive level, thus retain the manpower.

The governments need to take necessary measures to ensure that sufficient anti-corruption and good governance processes are in place prior to starting to reimburse own and donor funds. Many countries in this region are recipients of a large number of donor funds for health[4]. Since funding from donors may sometimes be higher than a national health budget, it is; therefore, highly vulnerable to corruption. As a result in the past there were many incidents of corruptions by officials at various levels. For instant, in 2009, Zambia’s high-level officials in the Ministry of Health and Social Welfare paid $1.4 million for consultants for workshops that did not take place [4]. In this regards the government and donors should introduce various mechanisms to control the health finances. In low resource setting, involving citizens in monitoring major funding will be a cost effective approach. For example, in Colombia the government and donors have set up a social control fund and because of this, the country was able to save as much as US$5.4 million from corruption [4]. Without a proper health finance control mechanisms and a surge of additional funds to the health sector, the quality of the health services will remain weak and as a result it will complicate the roads to achieve the MDGs and countries will be unable to cope with the challenges imposed by chronic disease and population rises. Therefore, now is the time for countries in Sub Saharan Africa to reform their health finance approaches.

[1] World Health Organization (2010) “Responding to the challenges of resources mobilization: Mechanisms of raising additional domestic resource for health”

[2] International Monitory Fund (2013) “World economic and financial surveys, regional economic outlook: Sub Saharan Africa”

[3] World Bank (2013) “An analysis shaping African’s economic future”

[4] United Nation Development Programme (2011) “Fighting corruption in the health sector, methods, tools, and good practices”

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