Air pollution kills more Indians than any other risk factor with estimates ranging from 15 to 20 lakh premature deaths annually. Although outdoor air pollution garners most public attention, it is well-known in health circles that pollution from chulhas is about half of the problem because people in households are directly exposed to such pollution. It is less well-understood, however, that the two are linked: One of the reasons India has such bad outdoor air pollution is that nearly 200 million households are still burning biomass every day for cooking. Solving the household dirty fuel problem will also help reduce the outdoor air problem, although not solve it on its own.
Although reducing outdoor air pollution remains difficult for Indian policymakers given the multiplicity of sources involved, the country is making major strides in addressing household air pollution. First with the Give it Up scheme and now with the Pradhan Mantri Ujjwala Yojana (PMUY) programme, the Ministry of Petroleum and Natural Gas (MoPNG) has targeted 5 crore BPL households to be connected to LPG by 2019, a massive increase in the rate of uptake by historical and global standards. Discussions are on to double the target for early next decade. This would mean a remarkable enhancement of clean kitchens for hundreds of millions of people. But accomplishing the project will involve major challenges.
An LPG connection is a necessary first step, but there is need to ensure usage as well. An LPG connection alone does not help health much if the cylinder and stove sit unused in a corner, and are used occasionally for making tea. A near-full transition to LPG as the main cookfuel is needed to stop the household and ambient pollution from traditional biomass use. Although experience from all over the world shows that gas is a superior and aspirational fuel and that households can reasonably be expected to eventually shift to using it, there has not been much experience in creating the incentives for poor households to move quickly through the transition. Cost is certainly an issue, but for hundreds of millions in India, other issues are also important, such as reliable and rapid access to refills, clear messaging around health, and changes in community expectations.
The health sector has long dealt with these issues. It does no good just to give people access to latrines, condoms, birth facilities, and vaccines, if no one uses them. As with LPG, access is essential, but that is just the beginning to secure health benefits. Thus, in the next stages of the LPG programme there would be real advantage if the two sectors, petroleum and health, were to work together to make sure LPG makes its full contribution of health — the former to provide access and the latter to help ensure usage.
One arena with which India’s health sector has good experience is conditional cash transfer (CCT) or the provision of cash incentives for specific behaviours that promote health in vulnerable groups — one such project is the Shishu Suraksha Karyakram (JSSK) programme among poor pregnant women. It has recently been expanded under the Pregnancy Aid Yojana scheme to provide a minimum of Rs 6,000 in incentives for healthy practices during pregnancy in poor households. There are risks with this approach, of course, but it works well if the funds are reserved for producing highly-effective behavioural changes that do not result in long-term financial commitments and, importantly, are transferred directly to the women’s bank accounts where they are most likely to be used for the benefit of the household.
There is a parallel opportunity for LPG use — to initiate a sub-programme of the PMUY that focuses on providing not only LPG connections but refills during pregnancy to all biomass-using households. The impact on birth weight and other adverse birth outcomes for a pregnant woman using biomass has been established in several studies in India; a recent study in Africa shows reduction in hypertension in pregnancy with clean fuel use. Thus the Rs 1,800 or so that the LPG would cost during a pregnancy to maximise the reduction in biomass smoke looks to be well worth the cost for the country. The project could be supported by the ugraded JSSK programme.
Such a joint effort between MoPNG and the Ministry of Health and Family Welfare (MoHFW) to promote the health and well-being of poor pregnant women — and by extension, their newborn children — could serve as a model for future collaborative efforts that might be undertaken by the MoHFW to address other pressing sources of air pollution. Such innovative partnerships are required to address India’s complex development challenges.