The 400-KW solar plant of the Bamyan Provincial Hospital in Afghanistan provides for the majority of the electricity supply for the Hospital.
AKDN / Sameer Dossa
The 400-KW solar plant of the Bamyan Provincial Hospital in Afghanistan provides for the majority of the …
AKDN / Sameer Dossa
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As healthcare providers, AKHS has a particular responsibility to invest in health care approaches that take care of current patients’ needs while safeguarding the wellbeing of future generations. The hospitals and health centres of AKHS therefore promote actions that continue to deliver quality care but that are simultaneously good for the environment. Good stewardship of the environment is one of the cornerstones of AKDN’s (and AKHS’s) ethical framework.
Children receive immunisations in northern Pakistan under the Hayat project which uses a mobile application that helps track health services delivered by field workers. Hayat is a mobile health application and web portal developed by Aga Khan University.
AKU
Health Service Delivery
AKHS's overall approach to climate-smart and environmentally-friendly health care is based on:
- Emphasising health promotion, disease prevention and primary health care. The aim is to avoid people getting sick in the first place, which in turn, prevents the need for travel, diagnostic and medical interventions – all of which have high costs to patients as well as the environment.
- Using technology to help patients receive information and care close to home. AKHS uses and plans to invest further in digital health solutions, telephone consultations and telemedicine to support remote diagnosis and consultations. This, in turn, limits travel needs but also allows for quicker detection and resolution of health problems – all of which are also good for the environment as well as patients. Find out about the AKDN Digital Health Resource Centre.
- Using evidence-based approaches driven by population health needs. The philosophy of this approach is to minimise unnecessary consultations, interventions and treatment.
The hospital in Bamyan’s special low-impact, rammed earth architecture is designed to be not only culturally sensitive to the surrounding area, but also climate-friendly, durable and seismic-resistant.
AKHS
Greening Facilities
Eco Design
All new facilities are designed to meet the best of possible environmental standards. AKHS is also actively retrofitting older facilities, with an emphasis on reducing carbon emissions, air pollution, energy and water consumption. AKHS is also considering preparation and adaptation for more severe weather extremes as a result of changes in climate.
Our architects and engineers have a longstanding tradition of working together to build facilities that both fend off the worst of the weather and make full use of natural light and ventilation. In turn, all such features reduce energy needs for heating, cooling and lighting. New facilities aim to satisfy the requirements for Excellence in Design for Greater Efficiencies or “EDGE” certification.
Energy efficiency is a criterion for all major equipment. Better energy solutions for fixtures and fittings, and energy and water consumption are also continually being sought. Typically, AKHS hospitals use LED and sensor-responsive lighting, water efficient taps, toilets and Energy Star-rated equipment and appliances.
For newer projects, wherever space permits, engineers install rainwater harvesting mechanisms to make the most of rainfall. Treated water is also routinely used for flushing toilets and irrigating grounds. Some facilities have reverse osmosis plants to produce the highest quality drinking water on site – preventing the need to transport potable water, which comes at a high cost to the environment. Plans are in place to install these features at all locations gradually. Wherever possible, and generally for larger projects, heat from generators and other equipment is being considered for heating water and supplementing heating, too.
Renewable Energy
In terms of solar power, our investment in this area really took off in 2016, when AKHS in Afghanistan with partners were constructing a new hospital in Bamyan. The site for this hospital was off the electric grid, requiring creative energy solutions. While solar looked promising in the long-term, the estimated costs for installation were very high. However, the projections seemed worth pursuing. Once funding was secured, a 400 KW solar energy system was installed, which at the time was the largest within AKDN. Fortunately, the experiment worked out far better than expected. In this region, summers provide up to 14 hours of sunlight a day. Through this experience, AKHS learned what is now obvious: hospitals consume most energy during the day (night use is restricted to lighting and emergency procedures); and as such, solar is a particularly good solution for health operations. From a financial perspective, it will take about six years to recoup the costs of the Bamyan investment, where solar currently provides 50-60 percent of all energy needs. As this installation generates more energy than can be saved, plans are underway to add more and better batteries which will reduce fossil fuel use even further.
The Aga Khan Medical Centre Gilgit, Pakistan.
AKDN / Christopher Wilton-Steer
Since the Bamyan experience at Bamyan Provincial Hospital, every AKHS installation has aimed to explore and maximise the use of solar energy. Recent projects include retrofitting an old facility at the Aga Khan Comprehensive Health Centre in Singal, Northern Pakistan; five additional Basic Health Centres in Gilgit-Baltistan, Pakistan; the Aga Khan Outreach Health Centre in Kuze, Mombasa; Aga Khan Medical Centres in Kisii, Kimilili and Bungoma in Kenya; the expanded Aga Khan Hospital Kisumu; the Aga Khan Medical Centre Mwanza in Tanzania; and the Aga Khan Medical Centre Salamieh in Syria. Aga Khan Health Services, Afghanistan, has solarised 123 out of its 235 facilities. Current plans also include installing a 1200 kWh solar system at Aga Khan Hospital Dar es Salaam, Tanzania, a 440-kWh solar power system at Aga Khan Hospital Mombasa, and 13 more Basic Health Centres in Pakistan. The solarisation project is ongoing, with many more facilities across AKHS planned for inclusion.
For these projects, estimates for solar covering energy needs range from 40 to 90 percent, with cost recovery projections between five to eight years. In the future, AKHS expects even better results as prices of solar installations continue to reduce and technology improves. In areas with less sunlight, such as Northern Pakistan, AKHS is exploring geothermal energy prototypes as well.
AKHS has won two awards for our solar projects, including from the Prince Sadruddin Aga Khan Fund for the Environment and the Access 2 Energy (A2E) award for the Health Centre in Singal in Northern Pakistan and the Medical Centre in Mwanza in Tanzania, respectively.
Read more (PDF):
- Afghanistan – Solar power
- Afghanistan – Transition from generators to hydropower
- Syria – Solar power
Environmentally-friendly operations
AKHS has an ongoing work agenda to increase the use of renewable energy and gain energy efficiencies both within its larger hospitals and its field operations. We are also actively pursuing ways to minimise waste through more prudent use of items and better waste management.
A large part of the agenda focuses on reducing greenhouse gas emissions through innovations in transport, water consumption (recycling and conservative use) and air-pollution; as well as using a carbon lens to guide purchasing decisions for pharmaceuticals, medical devices, food and other products. Efforts are underway to work with suppliers to identify and address hotspots.
Read more (PDF):
Waste Management
Waste management begins with being conservative with what one uses in the first place, but also segregating waste. Where possible, we use options such as sterilisation / chemically treating or burying waste in preference to incineration. Additionally, kitchen waste is either used for animal feed or composting, while paper, metallic material, used cooking oil and e-wastes are recycled with certified companies.
Incineration
Hospitals and health facilities use incinerators to burn hazardous waste. AKHS takes special care to ensure that we conduct incineration in the most energy-efficient and environmentally friendly way. This starts with training. Without training and support, operators tend to burn more waste than they should.
For waste that has to be burned, AKHS ensures that each incineration cycle uses the full capacity of the incinerator, limiting wasted space. This practice maximises the use of energy and greatly reduces the amount that is burnt.
Given the generally poor practices in this field, AKHS has started offering freed-up space in its incinerators to other health facilities. In the instance of Gilgit Medical Centre in Northern Pakistan, this facility offers incineration services to private health operations as well as the regional government hospital. In the process of these collaborations, better waste management by all partners has been the result. A further incinerator is being installed to expand the offer of these services to facilities in three districts within a hundred miles and to widen better practices in the process. We have calculated that the environmental benefits far outweigh the cost of transporting waste to this central facility. We hope to continue to expand best practices in waste management and incineration within our countries of operation.
As technology improves, AKHS replaces older units with those that are better designed in terms of energy use and air pollution. Our latest installation at Dar es Salaam is one of the very highest of fuel-efficient designs rated for medical, municipal and animal waste incineration. It is expected to result in next to no direct pollution. For example, at a burn rate of 200kg/hr, the following emissions are expected: CO₂ 5 percent, O₂ 6 percent, SO₂ 6 percent, H₂O 29 percent, N₂ 54 percent, smoke 0 percent and odour 0 percent.
Waste minimisation
When AKHS embarked on the journey to reduce its negative impact on the environment, proper waste management was one of the low-hanging fruits. Many facilities adopted tactics to reduce the waste burden on landfills or incineration by optimising minimisation at the source, composting, reusing, and partnering with recyclers.
Read more (PDF):
In 2019, AKHS started identifying the types and volumes of anaesthetic gases it was using during surgeries. It stopped using the most potent greenhouse gas, Desflurane, and made better substitutions wherever it was possible.
AKDN / Kamran Beyg
Anaesthetics
Many anaesthetics are known to contribute significantly to health care’s carbon footprint. As well as being powerful greenhouse gases, some anaesthetic gases are also ozone-depleting substances and as such, also have consequences for skin cancer. Consequently, we are looking at ways to reduce emissions from these products.
In 2019, we started identifying the types and volumes of gases we were using and making better substitutions wherever possible. As a result, AKHS health facilities have stopped using the most potent greenhouse gas, desflurane. However, isoflurane, halothane, sevoflurane, and nitrous oxide which are also problematic from the perspective of global warming, and in some cases ozone depletion, are still being used.
AKHS staff are actively working on reducing the impacts of these gases by:
- wherever possible, changing from high-carbon or ozone-depleting gases to lower carbon and more ozone friendly alternatives;
- exploring the reduction of nitrous oxide and replacement in surgery with oxygen or medical air;
- increasing the use of low-flow anaesthesia to reduce the volumes used of all gases;
- using alternatives to fluorinated gases, such as intravenous anaesthesia; and
- wherever possible, capturing and reusing anaesthetic gases.
In all instances, AKHS is examining ways to use these gases prudently and experimenting with novel techniques which reduce consumption – but without compromising safety. In many cases (but not all), making such changes also reduces costs.
A group of AKHS anaesthetists are working on implementing changes and sharing lessons learnt across the network. AKHS is also seeking opportunities to share information on the carbon footprint and ozone depletion qualities of anaesthetic gases with anaesthetists in private and public sectors to influence best practice more broadly.
The relative impacts of anaesthetic gases are shown in the table below. The Ozone Depleting Potential (ODP) of each gas is compared with the most common ozone depleting substance, CFC-11; whereas the Global Warming Potential (GWP) is shown relative to the most common greenhouse gas, carbon dioxide.
|
|
Ozone Depleting Potential |
Global Warming Potential, |
|
CFC-11 |
1 |
|
|
CO2 |
|
1 |
|
Halothane |
1.56 |
50 |
|
Enflurane |
0.04 |
816 |
|
Isoflurane |
0.03 |
510 |
|
Desflurane |
0 |
2540 |
|
Sevoflurane |
0 |
130 |
|
Nitrous oxide |
0.017 |
265 |
While halothane is not a very potent greenhouse gas, it is nevertheless, a potent ozone-depleting substance. Ways to limit its use are being explored. Nitrous oxide is a fairly potent greenhouse gas and has some impact as an ozone depleting substance, too. Given the large amounts of nitrous oxide used, this is a significant contributor to both ozone depletion and climate change and therefore also a concern.
Inhalers
It is well known that air pollution is a problem in many low and middle-income countries where AKHS works, but what is not known is the fact that some treatments for respiratory illness can contribute to climate change.
In particular, pressurised Metered Dose Inhalers (pMDI) use gases to deliver medications which are potent greenhouse gases. The propellant gases used in pMDI are up to 3,350 times more potent than carbon dioxide as greenhouse gases. A single pMDI, if fully used, can release as much greenhouse gas emissions as a small car driven for 180 miles; a single patient may use more than 12 inhalers a year.
Fortunately, there are alternatives. Some propellant inhalers are better than others for delivering the same type of drug; either they use less propellant or a less damaging propellant. In most cases, dry powder-based inhalers can be just as clinically effective and have a small fraction of the environmental impact. For these reasons, dry powder inhalers are predominantly (90 percent) prescribed in Sweden.
We are committed to reducing our own contributions to air pollution and the carbon impacts of respiratory care including:
- reducing the contribution of all our operations to air pollution (e.g. through smart choices of fuels used and incineration practices in health facilities);
- reviewing how inhalers are prescribed, dispensed, and used (often inhalers are not fully or properly used, reducing their health benefits and creating unnecessary waste);
- favouring lower-carbon or propellant-free inhaler alternatives where clinically appropriate; and
- disposing of inhalers in an environmentally safe way.
We started examining the inhalers we were purchasing in 2019, and began an education programme to alert physicians and pharmacists to the relative impacts of different inhalers. In 2020, a system was established to track procurement and prescription practices with the aim to make changes and reductions wherever possible. We intend to share information on the carbon footprint of pMDI and alternatives with health professionals in private and public sectors in the countries within which we work.
A range of estimated carbon impacts of several common inhalers can be seen below:
|
Inhaler |
Drug |
Propellant |
Global warming potential of propellant relative to CO2 |
Est. carbon footprint of propellant per device |
|
Ventolin Evohaler |
Salbutamol |
HFA134a |
1300 |
24kg (estimated @ 18.5g propellant) |
|
Salamol E-Breathe |
Salbutamol |
HFA134a |
1300 |
10kg (estimated at 7.5g of propellant) |
|
Flutiform |
Fluticasone Propionate/ Formoterol Fumarate |
HFA227ea |
3350 |
37kg (estimated @ 11g of propellant) |
|
Symbicort Turbohaler |
Budesonide/Formoterol Fumarate |
None-Powder |
0 |
0kg |
AKDN’s Carbon Management Tool
To reduce our carbon footprint, we must first measure it. But in 2019, existing tools, such as those available for calculating the carbon emissions from electricity and transport, were far from intuitive. Many used out-of-date carbon conversion factors or lacked data for countries where AKHS works. We therefore collaborated with the Aga Khan University to develop a tool that would work in low- and middle-income countries.
The tool can be used by other stakeholders within and beyond the health sector. It is an all-in-one tool to capture all data sets and work with readily available data. It is simple to use without any prior knowledge in the field. It functions in a way that educates users, generating costing information and diagnostic dashboards to help identify hotspots and inform users about corrective actions. Since mid-2020, all AKHS facilities have been using this tool to report quarterly data.
Using AKDN’s Carbon Management Tool to Evaluate AKHS’s Carbon Footprint
All operations have annual action plans to reduce their carbon footprint based on improving energy and water efficiency, reducing consumption and waste, greening the supply chain, shifting to environmentally friendly inhalers and anaesthetic gases, and instilling behaviour change. We monitor our carbon footprint through quarterly calculations of emissions related to standard factors such as energy consumption and transport, as well as health-specific items such as anaesthetic gas and inhaler use. Importantly, AKHS also calculates the impact of procurement, which accounts for between 70 and 90 percent of our total footprint.
- Read a brief description of the tool.
- See how to use the tool: English written instructions / French written instructions.
- Download the tool in English or French, along with a manual.
- Access the training videos from the AKF Learning Hub. These are open to anyone after establishing a (free) account.
- For further information or support, write to healthcarbonfootprint@akdn.org.
Advocacy and Influence
As AKHS progresses, we learn from others and share our experience with others within and beyond the health sector. With this in view, we strategically collaborate to disseminate our expertise and tools, including to local governments, academia, partners, and the World Health Organization (WHO). This collaboration involves conducting online sessions and actively participating in various fora, such as the UNFCCC Conference of the Parties (COP) and the Alliance for Action on Climate Change and Health (ATACH). Through direct engagements and in partnership with WHO, representatives from Ministries of Health and Environment from various countries worldwide have received orientation training on using AKDN’s carbon management tool and on how to plan actions to align with the UNFCCC COP26 Health Programme commitments.
We engage with communities and health systems to support adaptations to and withstand the consequences of extreme weather events. As we implement actions, we will continue to use our voice as health advocates to increase attention to the climate agenda and influence policies and practice at local and global levels.
Read more (PDF):
Country case studies (PDF)
- Afghanistan – Solar power
- Afghanistan – Solar refrigerators
- Afghanistan – Transition from generators to hydropower
- Kenya/Kisumu – Composting kitchen waste
- Kenya/Mombasa – Restoration of mangrove forests
- Pakistan – Environmentally friendly air conditioners (AC)
- Syria – Solar power
- Syria – Greening the transport fleet
- Tanzania – Minimising kitchen waste