The health benefits of interventions to reduce indoor air pollution from solid fuel use: a cost-effectiveness analysis Sumi Mehta and Cyrus Shahpar [1] WHO-CHOICE, Evidence and Information for Policy, World Health Organization, 20, Avenue Appia CH-1211 Geneva 27, Switzerland E-mail (Mehta): smehta@healtheffects.org The air pollution-related health benefits of interventions to reduce indoor air pollution from cooking and heating with solid fuels are evaluated in South and South-east Asia, Africa, and the Americas using generalized cost-effectiveness methodology. Three scenarios are assessed: 1) providing access to cleaner fuels, (2) providing access to improved stoves, and (3) providing part of the population with access to cleaner fuels and part of the population with improved stoves. All intervention sce- narios are compared with the current situation, i.e., the ‘‘business as usual’’ scenario where current exposures to indoor air pollution from solid fuel use would be sustained. Two major health outcomes associated with indoor air pollution are addressed, namely acute lower respiratory infections (ALRI) in young children under five years of age and chronic obstructive pulmonary disease in adults over twenty. While providing access to cleaner fuels has a larger health impact on the population than improved stoves, there are considerable health benefits associated with improved stove use. Improved stoves are also much more cost-effective than cleaner fuels. Of the cleaner fuels, kerosene, or paraffin, is more cost-effective than liquified petroleum gas (LPG), since kerosene is cheaper than LPG. Concerns about kerosene use, including poisoning, explosions, and possible carcinogenic effects, should be carefully considered before recommending its widespread use over LPG, however. This analysis offers further support for the argument that, from a public health point of view, there should be a continued emphasis on the promotion of improved stoves, as well as other locally appropriate means to reduce exposures within solid fuel-using households, until everyone can be given access to cleaner fuels. 1. Background Cooking and heating with solid fuels, such as dung, wood, agricultural residues, charcoal, and coal, remains the most widespread traditional source of indoor air pollution (IAP) exposure on a global scale. People cook with solid fuels at least once a day in around half of the world’s house- holds [Smith et al., 2004]. In rural areas of developing countries, the prevalence of solid fuel use is even higher. For example, around 80 % of Indian households use solid fuels as their primary household cooking fuel [GoI, 1991; IIPS, 2002]. Combustion of solid fuels in inefficient stoves under poor ventilation conditions results in large exposure burdens, particularly for women and young chil- dren, who spend the greater part of their time at home. At the intersection of household energy and public health, the reduction of exposures to indoor air pollution is a major concern. Practically speaking, before choosing an ‘‘ideal’’ intervention, efficacy, cost, and time taken to attain adequate intervention coverage need to be consid- ered. Providing access to cleaner fuels certainly has a larger health impact on the population than improved stoves. As dramatic increases in access to cleaner fuels at the household level are unlikely to occur in large popu- lations in the short term, however, the viability of venti- lation options as interventions should also be addressed. It may be more practical in the short run to encourage people to improve ventilation until they have access to cleaner fuels. Moreover, if reduced exposures via im- proved ventilation significantly decrease morbidity and mortality, resulting in increased productivity, people may be able to shift up the energy ladder towards cleaner fuels sooner. The impact of interventions on the reduction of two major health outcomes associated with indoor air pollu- tion, namely lower respiratory infections (LRI) in young children under five years of age and chronic obstructive pulmonary disease (COPD) in adults over twenty, is evaluated here. These two health outcomes are responsible for nearly all of the 1.6 million deaths attributable to in- door air pollution each year [Smith et al., 2004] 2. Methods Methods for conducting generalized cost-effectiveness analysis (CEA) have been developed by the World Health Organization to evaluate the efficiency of different inter- ventions and/or intervention scenarios [WHOCC, 2003]. Energy for Sustainable Development l Volume VIII No. 3 l September 2004 Articles 53