Evaluating the effectiveness of policy interventions to reduce indoor air pollution in rural PRC

Fei Yu
Joint Environment and Health CoP Seminar 7 September 2012
Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

2 Million Deaths a Year
Cookstove smoke kills 1 person every 16 seconds - almost half the world's population still cooks food, boils water, and warms their homes by burning wood, animal and agricultural waste, and coal in open fires or rudimentary cookstoves

Rudimentary State of Heating, Cooking Stoves in Rural China
Solid fuel: biomass and coal. In rural China, reliance on solid fuel is virtually 100%.

Solid Fuel Use, IAP and Health

Probable role of biomass smoke pollution in risk of ARI, especially child pneumonia and related ailments Women and children are most affected

Leading Risk Factors for Disease Burden in Western Pacific (China) Developing Countries
Attributable disease burden (total 240 million DALYs) 0%
Alcohol use High blood pressure Smoking Underweight Indoor smoke from solid fuels Overweight and obesity Low fruit and vegetable intake High cholesterol Iron deficiency Unsafe water, sanitation, and hygiene Occupational risk factors for injury Unsafe health care injections




Male Female

Ezzati et al. 2002, 2004; WHO 2002

2010: U.S. Secretary of State Hillary Clinton announced the formation of the Global Alliance for Clean Cookstoves

Goal of developing better cookstove technology and installing 100 million cleanerburning stoves in developing countries a partnership led by the UN Foundation $250 million over the next 10 years

Are Clean Stoves Effective?

Project Sites: Poor Rural Areas in Four Chinese Provinces

Low income level and high illiteracy rates (especially for females)


Inner Mongolia Shaanxi

Winter conditions in at least two of the test areas are harsh
Severe levels of IAP

All use solid fuels as the main source of energy

Intervention Groups

In each province  1 township receive stove plus behavioral intervention  1 township receive only health education  1 township receive no intervention  One exception Each township select 7-8 villages about 500 households Total 5,500 households

Project Interventions
Two forms of interventions: a) Full : improved stove + Health education/behavioral activities b) Health education and behavioral activities only

Project Interventions (Continued)

Health education and behavioral activities in schools, villages and demonstration sites:  Sources of IAP were explained  Benefits of stove/ventilation improvements were illustrated  Alternatives for stove use behavior were demonstrated  Health hazards of IAP exposure were explained

Project Activities
Mar – Apr 2003 Apr - Oct 2004 Mar - May 2005

Health evaluation, household survey and health survey Intervention

Main Hypotheses
Improved stoves and behavioral interventions reduce levels of indoor air pollution Childhood respiratory diseases will be less in the households that received interventions to reduce IAP

Example of Pollution Data in Gansu
Average PM Concentration of Three Groups
0.3 0.25

0.2 0.15 0.1 0.05 0 Control B Groups S+B
EPA guideline

Before After

IAP Concentrations

Differences in PM, CO and SO2 average concentrations not significant possibly due to small sample sizes 80 households in each province. Effects vary by province and by location in the house – need for regulating the stoves
Cook rooms typically not significant  Bedrooms some significant

Definition of ARI

AURI -- coughing and some difficulty in breathing, accompanied by some combination of a sore throat, ear discharge and runny nose
ALRI -- severe coughing with fast breathing and/or chest in-drawing

ALRI is the leading cause of mortality among children under 5 in developing countries.

Source: WHO

Summary ARI Statistics Sample

ALRI data




Objective: whether interventions (treatment) reduce in ARI incidence levels. One way to get around the problem of possible non-random assignment of treatment is to do a Difference-in-Difference analysis. DID compares the before and after changes in ARI incidence between the treatment groups and the control groups. Matching is an alternative: find similar pairs and compare differences in outcome.

DID works when there is no difference in time trends between the groups.
Outcome variable Y

Treatment Effect

Control Group

Treatment Group t1 Intervention t2 t

Summary Results of ARI Outcomes

Stove and behavioral interventions resulted in statistically significant reductions in ALRI and AURI incidence with few exceptions;

There is no evidence that stove plus behavioral interventions results in additional marginal benefits compared to behavioral interventions alone.

Valuation of Annual Health Benefit from Stove and Behavioral Interventions

Benefit Analysis for ALRI Percentage Reduction from Baseline Rate Benefit Analysis for AURI 25% 40%

Percentage reduction from baseline rate
Total Benefit per Household (USD) Low High



201 382

300 567

Annualized Cost of Interventions

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Stove plus behavioral interventions Cost per household: 55-68 USD Behavioral interventions Cost per household: 10-12 USD Marginal cost of stove intervention Cost per household 45-57 USD

Cost-Benefit Analysis

Cost is well below the range of estimated benefits in all provinces;

Behavioral interventions appear to be more cost-effective than stove combined with behavioral interventions.

Are Clean Stoves Effective?

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Esther Duflo, Michael Greenstone and Rema Hanna Location: Rural Orissa, India Local NGO and inexpensive stoves $12 Sample: 2,600 households Micro medical CO monitor for exposure Lung functions Timeline: 2006 - 2010


Take-up and usage of new stoves low and decline over time 7.5% decrease in CO of exhaled breath in first year, but effect declines to zero in subsequent years No effect on lung functioning, infant mortality, cough, etc.

Random Exposure Study of Pollution Indoors and Respiratory Effects
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Smith, McCracken, et al. 2002-2004 in highland Guatemala Stoves $100 and $150 combined with weekly inspection for proper use Passive CO diffusion tubes for exposure 515 children under 18 months and 532 mothers 52%-61% reduction in PM and CO levels No significant reduction in ALRI among children No significant effect on lung functions among women


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Improper stove and fuel use Non-linear dose response functions Ambient air quality in the local vicinity may not have been improved. Behavioral intervention alone could result in significant health benefits among children under five. It also appears to be more cost-effective than stove and behavioral interventions combined.

Applications of Impact Analysis

Providing Health Insurance through Microfinance Networks in India

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Banerjee , Duflo and Hornbeck Partners: Swayam Krishi Sangam (SKS) Fieldwork implemented by: Centre for Micro Finance (CMF) Sample: 201 villages in Bidar and Gulbarga districts Timeline: 2007

The Impact of the Alatona Irrigation Project in Mali