Energy poverty ⁽²⁾ is a prominent socio-economic concern in Nigeria and has been described by Horton as “a hugely neglected determinant of human health.”⁽³⁾ He further suggests that international organisations like the World Health Organisation (WHO) and World Bank have continuously failed to connect energy and health in their country work.

One in eight Nigerian children will die before their fifth birthday,⁽⁴⁾ over 17 times the average for children in developed countries (1 in 143).⁽⁵⁾ So far, most interventions targeting the major immediate drivers of under-five mortality in Nigeria have had limited success. Hence, there is a dire need to identify the underlying determinants of under-five mortality in order to improve the current situation. This paper examines the link between energy poverty and the under-five mortality rate (U5MR)⁽⁶⁾ in Nigeria by examining it in relation to the primary drivers of under-five mortality.

Energy poverty and under-five mortality in Nigeria

The “proximate determinants” of childhood mortality in developing countries include environmental contaminants, maternal factors, personal illness, injury and nutrient deficiencies, all of which are influenced by socio-economic factors.⁽⁷⁾ These socio-economic variables are key to understanding the Nigerian context and may explain the greater mortality risk under-five Nigerian children face compared to their counterparts in the developed world. One such socio-economic factor is access to electricity.

Nigeria is endowed with abundant natural energy resources, such as crude oil, natural gas, coal, lignite and hydropower, among others. However, in 2013, 44% of Nigerian households were without electricity.⁽⁸⁾ This is only a small improvement from 2008, when 50% of households had no access to electricity. There is also a wide disparity in lack of access to electricity between rural and urban areas (66% versus 16% respectively) which has lingered since 2008.⁽⁹⁾ There are several direct mechanisms through which this energy poverty contributes to under-five mortality in Nigeria.

Infants and young children are traditionally carried on their mothers’ backs while cooking in Nigeria. With about 70% of households relying on solid fuels for cooking,⁽¹⁰⁾ the majority of these susceptible children are regularly exposed to harmful emissions of biomass smoke, which significantly increases risk for acute lower respiratory tract infections,⁽¹¹⁾ upper respiratory tract infections and asthma,⁽¹²⁾ and pneumonia.⁽¹³⁾ The predominant use of firewood for cooking and the fact that pneumonia is the single most important cause of under-five mortality in Nigeria implicates energy poverty as a significant determinant of under-five mortality.

Neonatal deaths also account for about one third of all under-five deaths in Nigeria. Epidemiological evidence has demonstrated a link between exposure to smoke from firewood and adverse birth outcomes, such as intra-uterine growth restriction, low birth weight ⁽¹⁴⁾ and still birth.⁽¹⁵⁾ Although further research is needed in this area, evidence from studies regarding the harmful effects of environmental tobacco smoke, as well as exposure to carbon monoxide (a major by-product of traditional fuels), provides strong support for the potential negative outcomes of smoke exposure.⁽¹⁶⁾ Open and uncontrolled flames generated by cooking with traditional fuels are also hazardous in more immediate ways, specifically to children in such households. These children are also prone to accidental kerosene poisoning. A South African study showed that by substituting electricity for other non-modern energy sources, approximately 35,000 burn incidents per year and a total of 4,899 poisoning deaths due to accidental kerosene intake a year could be averted.⁽¹⁷⁾

Furthermore, due to the considerable amount of time it takes to gather firewood, many households tend to conserve this inefficient biomass fuel by boiling less water, cooking less healthy food, as well as reducing re-warming of food.⁽¹⁸⁾ Consequently, this increases the risk of developing diarrhoea and malnutrition,⁽¹⁹⁾ which are major causes of under-five mortality (11% and 55% respectively).⁽²⁰⁾ In addition, a Nigerian study showed that household use of a refrigerator independently reduced child mortality rate considerably.⁽²¹⁾

Constant power supply provides energy not only for cooking and refrigeration but also for pumping water and sterilization, thereby supporting consistently safer water supply. Sixty-six million Nigerians do not have access to piped water in their homes and therefore rely on unsafe sources for drinking water.⁽²²⁾ Unsafe drinking water accounts for approximately 88% of diarrhoeal-related deaths worldwide, with under-five children most affected.⁽²³⁾ Furthermore, even with access to pipe-borne water, when power supply is frequently interrupted, it can result in negative pressure which can draw external contaminants into the water system.⁽²⁴⁾

Energy poverty not only compromises health but it also impacts healthcare delivery: Erratic or protracted lack of access to electricity prevents refrigeration of vaccines and medicines; compromises equipment sterilization and prevents the use of life-saving devices such as oxygen concentrators and nebulizers. After sunset, poor lighting - augmented with use of candles or kerosene lamps - adversely affects patient examination, laboratory and radiological evaluation and surgeries, thereby delaying prompt diagnosis and treatment. It can further isolate health services in that a lack of connectivity prevents access to new knowledge / medicines available online or through energy-based telemedicine systems. ⁽²⁵⁾ Doctors and nurses are often discouraged from working in such health facilities - usually located in rural areas where they are most needed - by the inadequate or absent power supply.

Limitations of access to modern energy on improving child health outcomes in Nigeria

By improving access to regular supply of modern energy, the potential for improved child survival rates in Nigeria is thus enhanced. However, this intervention alone may not successfully reverse U5MR due to marked shortfalls in other socio-economic determinants needed to improve child health, such as female illiteracy. Cultural factors also have extensive negative impacts on the absorption of modern energy services in developing countries, particularly in rural areas.⁽²⁶⁾ Above all, healthcare system factors, such as high out-of-pocket payment systems and the grossly understaffed health workforce in Nigeria, cannot be overlooked.⁽²⁷⁾ However, despite the current multi-dimensional limitations, it is possible to significantly reduce U5MR via a multi-faceted approach by prioritising access to modern energy and integrating schemes within the context of local needs so that they are absorbed and sustainable.

Since provision and absorption of modern energy services will not be immediate or automatic, individual level changes should be prioritised and encouraged, such as safe home practices, like keeping children away from smoke, ensuring cross ventilation and using solar water heating to reduce need for fire.⁽²⁸⁾ Increased awareness of the harmful effects of firewood smoke is fundamental,⁽²⁹⁾ particularly in rural areas. These messages may be shared through existing available media, for example town criers and via influential organisations like women’s groups, age-grade associations and religious institutions. However, in Nigeria, kinship and community ties are widespread and community-level interventions are thus also important.⁽³⁰⁾ To guarantee local participation and sustainability, it is necessary to increase community awareness and to ensure that feasible projects based on local needs are implemented.⁽³¹⁾ Success will be enhanced when relevant stakeholders in the communities are involved, and pilot studies are carried out to assess the people’s knowledge and perception of both traditional and modern energy as well as possible forms of energy that they will accept.

Ultimately, the government should act as the unifying body and create a supporting platform for organisations to partner with and assist in providing modern energy services to all, while it focuses on improving other socio-economic determinants, exploring cleaner energy options, expanding the national grid and implementing more efficient strategies for improving power supply.⁽³²⁾

Conclusion

Given the high U5MR, it is unlikely that Nigeria will meet its fourth Millennium Goal target of about 71 per 1,000 population by 2015. Thus far, efforts have been directed at improving direct causes of under-five mortality, and while significant progress has been made, more is needed. In order to reduce the U5MR, evaluation of the underlying socio-economic determinants of child health, particularly energy poverty, is therefore crucial, mainly because of its devastating impact on child health. The fact that Nigeria has abundant natural energy resources that can be successfully harnessed implies a need for action in this space. A strong political commitment and diversification both in modern energy sources and supplies is strategic and necessary if Nigeria is to enjoy the health benefits of access to modern energy.

Written by Gladys Onyinye Olisaekee ⁽¹⁾

NOTES:

(1) Dr Gladys Onyinye Olisaekee is a Research Associate with Consultancy Africa intelligence (CAI), and is a medical doctor and public health specialist. Contact Gladys through CAI’s Public Health Unit ( public.health@consultancyafrica.com). Edited by Claire Furphy. Research Manager: Deanne Goldberg.
(2) Defined by the International Energy Agency as lack of access to modern energy services, including household access to electricity and clean cooking facilities.
(3) Horton, R., 2007. Righting the balance: Energy for health. The Lancet, 370(9591), pp. 921.
(4) ‘Nigeria demographic and health survey 2013: Key Findings’, National Population Commission [Nigeria] and ICF International, 2014, http://www.population.gov.ng; ‘U5MR in Nigeria is 124 per 1,000 live births, compared to 5 per 1,000 live births in United Kingdom. The state of the world’s children 2014 in numbers: Every child counts’, UNICEF, January 2014, http://www.unicef.org.
(5) Nte, A., ‘Child survival in resource-limited settings: The issues, challenges and way forward, an inaugural lecture (No. 91)’, 9 August 2012, http://www.uniport.edu.ng.
(6) Under-five mortality rate (U5MR), simply known as child mortality rate, is the probability of a child dying between birth and five years of age, expressed per 1,000 live births, if subject to current age-specific mortality rates. World Health Organization website, http://www.who.int.
(7) Mosley, W.H. and Chen L.C., 1984. An analytical framework for the study of child survival in developing countries. Population and Development Review, 10, pp. 25-45.
(8) ‘Nigeria demographic and health survey 2013: Final report’, National Population Commission [Nigeria] and ICF International, June 2014, http://www.population.gov.ng.
(9) Ibid.
(10) For more detail on domestic energy consumption in Nigeria, see Oseni, M.O., 2012. Households’ access to electricity and energy consumption pattern in Nigeria. Renewable and Sustainable Energy Reviews, 16(1), pp. 990-995; ‘Nigeria demographic and health survey 2013: Final report’, National Population Commission [Nigeria] and ICF International, June 2014, http://www.population.gov.ng.
(11) Perera, F.P., 2008. Children are likely to suffer most from our fossil fuel addiction. Environmental Health Perspectives, 116(8), pp. 987-990; ‘Addressing the impact of household energy and indoor air pollution on the health of the poor: implications for policy action and intervention measures’, World Health Organization, 2002, http://www.who.int.
(12) Bruce, N., Perez-Padilla R., and Albalak R., 2000. Indoor air pollution in developing countries: A major environmental and public health challenge, Bulletin of the World Health Organization, 78, pp. 1078-1092.
(13) Smith, K.R., Mehta S., and Maeusezahl-Feuz M. (eds), 2004. “Indoor air pollution from household use of solid fuels” in Comparative quantification of health risks: Global and regional burden of disease due to selected major risk factors (Vol. 2). World Health Organization: Geneva.
(14) Mishra, V. et al., 2004, Maternal exposure to biomass smoke and reduced birth weight in Zimbabwe. Annals of Epidemiology,. 14(10): pp. 740-747; Boy, E., Bruce N., and Delgado H., 2002. Birth weight and exposure to kitchen wood smoke during pregnancy in rural Guatemala. Environmental Health Perspectives, 110(1), pp. 109-114.
(15) Pope, D.P. et al., 2010. Risk of low birth weight and stillbirth associated with indoor air pollution from solid fuel use in developing countries. Epidemiologic Reviews, 32, pp. 70-81.
(16) Ward, C., S. Lewis, and Coleman, T., 2007. Prevalence of maternal smoking and environmental tobacco smoke exposure during pregnancy and impact on birth weight: Retrospective study using Millennium Cohort. BMC Public Health, 7(1), http://www.biomedcentral.com.
(17) Electrification and health: The interface between energy, development and public health: Technical report, 1995. Research Council, Community Health Research Group: Tygerberg, South Africa.
(18) Brenneman, A. and Kerf M., ‘infrastructure & poverty linkages: A literature review’, The World Bank, 18 December 2002, http://www.ilo.org.
(19) Ibid.
(20) Nte,A., ‘Child survival in resource-limited settings: The issues, challenges and way forward, an inaugural lecture (No. 91)’, 9 August 2012, http://www.uniport.edu.ng.
(21) Oni, G.A., 1988. Child mortality in a Nigerian City: Its levels and socioeconomic differentials. Social Science & Medicine, 27(6), pp. 607-614.
(22) ‘Progress on drinking water and sanitation: 2012 update’, UNICEF ad Wirkd ealth Organization, 2012, http://www.unicef.org.
(23) ‘Guidelines for assessing the risk to groundwater from on-site sanitation’, ARGOSS, 2001; UNICEF handbook on water quality, 2008. UNICEF: New York, http://www.unicef.org.
(24) Macy, J.T. and Quick R.E., Transmission and prevention of water-related diseases. Water And Health, 1, pp. 1-6.
(25) Flavin, C. and Aeck M.H. ‘The potential role of renewable energy in meeting the Millennium Development Goals’, Energy for Development. 2005, http://www.worldwatch.org.
(26) For more details, see Murphy, J.T., 2001. Making the energy transition in rural east Africa: Is leapfrogging an alternative?, Technological Forecasting and Social Change, 68(2): pp. 173-193; Osei, W.Y., 1996. Rural energy technology: Issues and options for sustainable development in Ghana. Geoforum, 27(1), pp. 63-74; Matinga, M.N. and Annegarn, H.J., 2013. Paradoxical impacts of electricity on life in a rural South African village. Energy Policy, 58(0), pp. 295-302.
(27) See ‘World health statistics 2012’, WHO, 2012, http://apps.who.int; ‘Human resources for health country profile – Nigeria’, Africa Health Workforce Observatory, October 2008, http://www.unfpa.org.
(28) ‘Addressing the impact of household energy and indoor air pollution on the health of the poor: implications for policy action and intervention measures’, World Health Organization, 2002, http://www.who.int.
(29) Interventions such as provision of brief advice to increase people’s awareness have been shown to be an effective health improvement strategy, and individual behaviour change is generally easier to achieve than changes in the social or environmental circumstances contributing to health outcomes. See Harris, J, et al., ‘A review of the cost-effectiveness of individual level behaviour change interventions’, North West Public Health Observatory, February 2011, http://www.nwph.net.
(30) Recent studies have shown how kinship and community ties were successfully used to implement several developmental projects in Nigeria. Victor, O.U. and Hope E.N., 2011. Rural–urban ‘symbiosis’, community self-help, and the new planning mandate: Evidence from southeast Nigeria. Habitat International, 35(2), pp. 350-360; Ibem, E.O., 2009. Community-led infrastructure provision in low-income urban communities in developing countries: A study on Ohafia, Nigeria. Cities, 26(3), pp. 125-132.
(31) Flavin, C. and Aeck M.H. ‘The potential role of renewable energy in meeting the Millennium Development Goals’, Energy for Development, 2005, http://www.worldwatch.org.
(32) For more on the Nigerian government’s efforts at improving power supply see the Nigeria Electricity Privatisation (PHCN) website, http://www.nigeriaelectricityprivatisation.com and the Federal Ministry of Power website, http://www.power.gov.ng.