The Aga Khan Health Services (AKHS) manages health operations in eight low- and middle-income countries (LMICs), encompassing around 500 health facilities and hospitals. Its operations span all levels of the health system and emphasise comprehensive primary health care.

In late 2019, AKHS was tasked to aim for net zero operations, by, if not before, 2030. In response, it defined a strategy which started with benchmarking its carbon footprint, developing and implementing plans to reduce emissions and sharing lessons learnt with other local stakeholders – particularly government – for wider impact. The team has developed an innovative carbon emissions benchmarking tool that is now attracting organisations across the world.

“One of AKDN’s ethical principles is good stewardship. At AKHS, we take that principle seriously, and we try to reduce our carbon footprint where we can.” Dr Gijs Walraven, AKDN Director for Health

Dr Fawzia Rasheed is Senior Advisor to the AKDN Director of Health. She has a PhD from the London School of Hygiene and Tropical Medicine and has extensive experience in working with ministries of health and UN agencies to create new initiatives. Her role in catalysing AKHS’s environmental engagement brings together her interests in nature, medical research and problem solving. Here, Fawzia tells us about how the emissions tool came about and how it demonstrates a clear business case for organisations to reduce their carbon footprint.

When we were given the aim of becoming carbon neutral by 2030 we didn’t know if it was realistic – the Chinas and Americas of this world are aiming for 2050. And we, at AKDN, do all kinds of things from industry to health care, areas that are particularly polluting relative to other sectors. When we started, the prevailing view was that decarbonising efforts should not be the concern of LMICs given that most carbon emissions arise from wealthier countries. Funding opportunities for poorer countries was and remains adapting to climate change – preparing for more malaria and so on. The impression around becoming carbon neutral was that it would be expensive.

But AKDN is an exceptional organisation, there are such talented people and the dimensions of our work are incredibly broad, which makes the possibilities to do new things and realise big ideas unique. I think that we are going to be trailblazers in this field, we will show others the way to go faster and we will make it very difficult for people to justify going slower.

How did the emissions tool come about?

AKHS was already working in climate-friendly ways in that we emphasise keeping people healthy, and to avoid unnecessary health care, we practise evidence-based medicine which limits unnecessary consultations and interventions. We also use technology to offer health care as close to patients as possible.

We were doing a variety of things that made good management and finance sense, which also happened to be greener, from reducing plastic use to using solar power and carpooling. As I was tasked with being responsible for green practices, I researched and wrote up briefs around specific and obvious things like choosing less carbon-intensive products, moving away from meat, sugar and processed food in canteens, examining what is bought and the associated packaging, waste disposal, transport use and so on, and then had conversations with the relevant staff. There was cross-country enthusiasm – and I connected those working on similar themes to jump-start learning across operations. Staff were quick to identify solutions and progress made was shared to inspire others to similarly engage. Staff were also engaged in some community projects such as planting mangrove forests and they continued to seek out new opportunities.

We needed some hard data to identify where we could make the most difference and to track progress made through our interventions. We started by using the commonly available measurement tools, but they were klutzy and difficult to use and each required orientation. A lot of benchmarking tools required consultants or were behind paywalls. We needed a user-friendly tool that would cover the basics but also calculate health-specific items, including the products we buy, as these form a large part of our carbon footprint. With technical support, and in collaboration with the Aga Khan University, we designed a tool that would use the latest data, be comprehensive, simple to use and light enough to share on email and use offline. We incorporated feedback from staff and shared the features with an expert panel hosted by the World Health Organization (WHO) who endorsed our approach.

What insights did the tool offer AKHS?

The tool showed us that items for which AKHS is not directly responsible – including procured products and services – represented roughly 80 percent of our carbon footprint. Of the areas where we have direct control, grid electricity generated 47 percent of our emissions, followed by generators at 26 percent, anaesthetic gases at nine percent, refrigerants and travel at eight percent each and waste at two percent.

As might be expected, outreach and primary care had a much lower footprint than hospital-based operations. Transport represented the largest source of direct carbon emissions for outreach work; while for facilities, running equipment and heating and cooling buildings were mostly responsible. The tool also offered unexpected insights: one facility had a leak in anaesthetic gases, while another could save money and emissions by changing its AC system.

How does carbon reduction result in financial savings and improved services?

We started working with the countries that together represent 55 percent of our footprint, Tanzania, Pakistan and Kenya, to make the greatest carbon dent there first. While collecting data over 2021, staff initiated some low- and no-cost measures to reduce emissions. High-end incinerators have been installed in Tanzania and Pakistan which will reduce air pollutants. New solar photovoltaic installations were introduced in Kenya (Mombasa), Pakistan (Singhal) and Tanzania (Mwanza), reducing the carbon impact of electricity use by six percent. In Tanzania, solar heating was installed in place of diesel, saving US$ 61,299 per year, and films for X-rays and ultrasound were replaced with digital reports. The use of virtual meetings, teleconsultations and e-learning, accelerated by COVID-19 restrictions, are similarly reducing both emissions and expenditure.

The tool was showing a clear business case for the measures necessary for reducing our carbon footprint, particularly in the face of rising oil prices. With countries like Afghanistan and Syria experiencing extensive power outages, it was also apparent that without having our own renewable energy supplies in place, health service delivery was at risk. With solar and batteries, we could reduce our dependence on expensive diesel imports and we could keep services going. So next, we systematically assessed the impact and costs of energy-saving measures and investments in renewable energy and energy-efficient equipment.

The cost to make improvements across areas including lighting, cooling, pumps, fridges, insulation, electric vehicles and solar panels was US$ 11.7 million. These sums (along with no-cost changes to the uses of anaesthetic gases) were projected to reduce AKHS’s carbon emissions from 12,385 to 5,311 tonnes or by 57 percent overall. With current energy and fuel costs, this would translate to a little over a five-year payback – a 20 percent annual return on investment.

At a time when the health sector was preoccupied with the pandemic, were colleagues able to engage with the climate initiative?

It's remarkable that staff have done what they've done in the face of COVID-19. They've had calamity after calamity to surmount. Staff were working flat out, with safety concerns for themselves, their patients and their families. But people have understood that the story of COVID-19 is directly related to the problems of our planet and that health workers will continue to face problems if we don't get our act together.

I'm a believer in working with people to identify solutions that are based on capacities and realities. There wasn't a single person I spoke to that didn’t share concerns. As well as establishing systems for collecting data and identifying what needed to be done, we jointly identified pet projects around staff interests and capacities that they could take forward, turning concerns into something positive. We set up WhatsApp groups and I’d write up what they were doing and share it with focal points, which helped with establishing a dynamic community. Keeping up the dialogue and interpersonal exchanges was also important for all of us to stay buoyant in the face of frequently depressing items in the news.

To go from measuring to strategic implementation depends on raising awareness and creating a staff movement. Changing behaviours needs broad understanding and buy-in, it’s a buzz that everyone has to be part of. We have a core list of about 150 people directly responsible for various aspects of this work across AKHS, and there are many others engaged too.

We went through a blue skies exercise with the teams asking: “If money were no object, what could we do to reduce our footprint?” The measures they came up with amounted to reducing our footprint by 60 percent. We haven’t completed the exercise – there is much more we can do before we will likely need to consider insets or offsets to get all the way to net zero.

Not all ideas could be automatically translated into action at the beginning as finances were needed in many cases. As such, while we made progress with no- or low-cost interventions, things didn’t move quickly. But now we've turned a corner through presenting the best of business case investments and received funding to get moving. We’re also progressing with training others to use our methods and have developed stand-alone training materials for this to facilitate wider impact. For our own staff, we’re building systematic training, as part of career development, and experimenting with how best to formalise what people do on this agenda as a formal part of their job descriptions and performance evaluations so that there’s full recognition for what has so far been volunteer work.

Staff have been writing abstracts for conferences and applying for prizes for their work. I've had the British Medical Journal and The Lancet ask me on behalf of AKHS to write pieces for them. I know where our results show promise and are good to profile and share with others. With support, our staff have drafted such publications and we’ve just learnt that two additional papers have been accepted, which is great.

Our staff on the ground are also making presentations to governments, and are rehearsing to do orientations in their own countries and languages. We're building a formidable number of champions within the network. All of this has been made possible through the active support of leadership, particularly Gijs and our regional and country CEOs – there has been a lot of staff time invested in this work.

How are you using the tool to take action?

We expect to make dramatic carbon reductions ourselves, particularly in primary healthcare settings. We’re in a good position to persuade policy makers and investors to adopt similar approaches and to take them to scale. We've got high visibility and are participating in influential discussions and fora – our long-built positions of trust of our host governments and the public will help. We also have, through AKDN’s network, many opportunities for innovation and creative thinking.

We have just started opening our doors to the public, and we are prepared to handle high interest. We have a step-by-step manual and we’re working on a series of videos to go with it. We’ve had about four orientation sessions and hope to keep these going on a regular basis. So far, people who’ve attended and asked for the tool include universities such as Yale and the London School of Hygiene and Tropical Medicine, consultancy groups, C40, a network of cities that now has 96 members, Standard Chartered Bank, the Clinton Health Access Initiative and the Global Fund. I’m on the governance committee for climate action of the International Hospitals Federation, which works in 92 countries. They’ve developed an initiative to examine how they can get all their members to be involved in “greening up” health care. I’m hoping to interest them in using the tool – benchmarking is something that increasingly all health operations will be asked to do. And in a couple of weeks, the WHO is hosting a meeting with more than 25 countries represented (ministries of health and the environment) and we're providing a training of trainers workshop for all of them.

The emissions tool is free to use and open to all. Learn more with our guide, or to access the tool, write to [email protected]