The Research and Development Agenda
WHO has, through a process involving multistakeholder meetings and reviews, developed some consensus on research and development priorities for household energy, IAP, and health (see for example WHO 2002a). Effective coordination is a prerequisite because of the need for input from, and collaboration between, many different organizations and "actors" that have generally not previously worked in partnership on this issue. One recent response to this need has been the establishment of the Partnership for Clean Indoor Air, following the Johannesburg World Summit on Sustainable Development in 2002 (EPA 2004; http://www.pciaonline.org/).
The evidence base on health effects requires further strengthening, particularly to quantify the effect of a measured reduction in IAP exposure on the risk of key outcomes (for example, ALRI). A randomized controlled trial is currently under way in Guatemala, focusing primarily on ALRI in children up to 18 months of age (Dooley 2003); however, at least one other such trial on another continent would be desirable. Also required are observational studies for outcomes for which few studies currently exist, including tuberculosis, low birthweight and perinatal mortality, cataracts, asthma, and cardiovascular disease. A small number of such studies are in progress, but further effort is required, with perinatal outcomes being a particular priority.
Despite limitations in the evidence on health effects, what is known about the health, social, and economic consequences of current patterns of household energy use in poor countries is of sufficient concern to press ahead with an active program of research and development regarding interventions. This activity should address both the technology (and associated knowledge and behavior) and the approaches taken for implementation. Although some development and innovation in technology and fuels (for example, clean fuels derived from biomass) are likely to be valuable, the single greatest challenge is to promote wider access to—and adoption of—existing knowledge and interventions. Projects and programs currently in progress or being developed should be carefully evaluated using quantitative and qualitative methods to assess a range of effects. Work is currently under way to develop suitable methods and tools for this purpose (WHO 2005). Experience and lessons learned need to be disseminated widely to ensure that they reach governments, donors, researchers, NGOs, and communities. As part of this effort, WHO is developing a resource for countries that offers information on the effectiveness of interventions as well as the enabling factors that facilitate long-term, sustained adoption and use of suitable improved technologies in different settings (WHO 2004c).
Economic assessment, including cost-effectiveness analysis, has a valuable part to play. Critical issues resulting from limited evidence have been identified about estimations and assumptions for costs, exposure reductions, health effects, and averted treatment costs, as well as the current inability to assess national and subnational cost-effectiveness. CBA may be more suitable for interventions in this and similar areas but will require better description of environmental, social, and economic effects and further development of valuation methods. New health studies and broadly based evaluations of interventions should help fill some of these gaps.
Determination of the macroeconomic costs to countries of current household energy use and the potential gains resulting from change to more efficient and cleaner options could substantially add to the case for action.
Monitoring progress requires the development and testing of standard indicators for use in such policy documents as the World Development Report and for routine application at national and subnational levels. The Millennium Development Goal Indicator on the proportion of the population using solid fuels is a key starting point, and WHO, the reporting agency, is working to broaden the monitoring of this indicator through international surveys, such as demographic and health surveys (ORC Macro 2004), the Multiple Indicator Cluster Survey (UNICEF 2004), and the World Health Survey (WHO 2004d), as well as through work on regional and national indicators conducted under the Global Initiative on Children's Environmental Health Indicators (WHO 2004e). Future reporting will need to be further refined by taking into account differences in cooking practices (for example, type of stove and cooking location), as well as in fuel use for lighting and heating.
Advocacy for stronger action, internationally and in countries, is required. Products and guidance for a range of audiences should be prepared, with clear messages on the extent of the problem, the population groups most affected, what works, and what should be avoided. Tools such as the recently published guidelines on estimating the national burden of disease from solid fuels will help provide local evidence to argue for greater attention and action (Desai, Mehta, and Smith 2004).
