Calculating the carbon footprint of AKHS operations
In order to reduce the carbon footprint of Aga Khan Health Services (AKHS) facilities, it had to first be measured. But at the beginning of AKHS’ efforts in 2019, existing tools, such as those available for calculating the carbon emissions from electricity and transport, were found to be far from intuitive.
Additionally, many used out-of-date carbon conversion factors or lacked data for countries where AKHS works. A decision was therefore taken that AKHS would develop a tool that would work in LMICs.
The tool would be transferable to other stakeholders within health as well as sectors other than health. The design specifications for the tool included: an all-in-one tool for all data sets that uses readily available data, is simple to use without any prior knowledge in the field, and functions in a way that educates users, including the provision of costing information and diagnostic dashboards to help identify hotspots and inform users about corrective actions.
The Aga Khan Health Services (AKHS)'s 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.
In terms of solar power, AKHS’s investment in this area really took off in 2016, when the Aga Khan Health Services in Afghanistan with partners were constructing the then 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 provided up to 14 hours 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 6 years to recoup the costs of the Bamyan investment where solar currently provides 50-60% 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.
Since the Bamyan experience, every AKHS installation has explored and aimed for the maximum possible use of solar energy.
More recent projects include retrofitting an old facility at the Aga Khan Comprehensive Health Centre in Singal, Northern Pakistan and at the Aga Khan Outreach Health Centre in Kuze, Mombasa. The design of the proposed expansion at the Aga Khan Medical Centre Gilgit, Pakistan and the Aga Khan Hospital Kisumu, Kenya also include solar energy. Current plans also include a 40KW solar system for the Aga Khan Medical Centre, Mwanza, Tanzania and a similar system for the Aga Khan Medical Centre Salamieh, Syria. For these projects, estimates for solar covering energy needs range from 40% to 90%, 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 its 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.
In Dar es Salaam, Tanzania, the Aga Khan Health Services not only burns its own waste, but offers to safely dispose of the medical waste of other health facilities using the latest incineration technologies.
AKDN / Amie Konteh
Hospitals and health facilities use incinerators to burn hazardous waste. AKHS takes special care to ensure that it conducts incineration in the most energy-efficient and environmentally friendly way, which starts with training. Without training and support, there is a tendency of operators to burn more waste than they should.
Waste management begins with being conservative with what one uses in the first place, but then also segregating waste. Where possible, AKHS uses options such as sterilisation/chemically treating or burying waste in preference to incineration. 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 100 miles and to widen better practices in the process. AKHS has calculated that the environmental benefits far outweigh the cost of transporting waste to this central facility. AKHS hopes to continue to expand best practices in waste management and incineration within the countries it works in.
As technology improves, AKHS replaces older units with those that are better designed in terms of energy use and air pollution. AKHS’ latest installation at Dar es Salaam is one of the very highest of fuel-efficient designs rated for medical, municipal and animal waste incineration and 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%, O₂ 6%, SO₂ 6%, H₂O 29%, N₂ 54%, smoke 0% and odour 0%.
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
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, staff at the Aga Khan Health Services (AKHS) are looking at ways to reduce emissions from these products.
In 2019, AKHS started identifying the types and volumes of gases it was 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;
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 relative to CFC-11
Global Warming Potential, relative to carbon dioxide
While halothane is not a very potent greenhouse gas, it is nevertheless, a potent ozone depleting substance and as such, 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.
AKHS staff are looking for ways to reduce the ecological footprint of hospitals and medical centres like this one in Kisii, Kenya.
AKDN / Lucas Cuervo Moura
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%) prescribed in Sweden.
AKHS is committed to reducing its own contributions to air pollution and the carbon impacts of respiratory care including:
Reducing the contribution of all its 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 (oftentimes 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;
Disposing of inhalers in environmentally safe way.
AKHS started examining the inhalers it was purchasing in 2019 along with 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. AKHS intends to share information on the carbon footprint of pMDI and alternatives with health professionals in private and public sectors in the countries within which it works.
A range of estimated carbon impacts of several common inhalers can be seen below:
Global warming potential of propellant relative to CO2
Est. carbon footprint of propellant per device
24kg (estimated @ 18.5g propellant
10kg (estimated at 7.5g of propellant)
Fluticasone Propionate/ Formoterol Fumarate
37kg (estimated @ 11g of propellant)
As part of a pilot, kitchen staff at the Aga Khan Hospital in Dar es Salaam, Tanzania, reviewed menus to track food waste (while calculating their carbon equivalencies).
AKDN / E-Motion
While it is well known that nutrition has an important role in optimising health, there is less awareness of the considerable impact of food on environmental sustainability.
Currently, global food systems contribute to an estimated 26 percent of human activity-linked global emissions. Unless dietary patterns change, global food systems alone are expected to exceed the Paris climate agreement limit of 1.5℃ by 2050.
The world also faces an immense challenge of feeding growing populations, and in many of the countries in which the Aga Khan Health Services (AKHS) works, there are already land and water shortages. Adding global warming to these existing pressures suggests that food insecurity is going to be an increasing problem. Against this backdrop there is ample evidence of nutrition problems with wide-spread stunting, as well as rising obesity, cardiac disease and diabetes. Current thinking indicates that the scale of changes required for reasons of health and sustainability is best achieved through consumers and demand creation rather than suppliers.
AKHS was guided in its study of food offerings at its hospitals by the findings of the EAT-Lancet Commission (https://eatforum.org/eat-lancet-commission/) on Food, Planet, Health, which promotes a “flexitarian” diet. The term “flexitarian” represents a combination of the words “flexible” and “vegetarian”. The diet entails: no processed meat, small amounts of red meat (one serving per week), moderate amounts of other animal-source foods (poultry, fish, and dairy), and generous amounts of plant-based foods (fruits, vegetables, legumes, and nuts).
AKHS began investigating ways to promote wholesome food choices that are sustainable, have co-benefits for health, the environment, and are generally more affordable, which is especially important for the communities we serve.
AKHS has already started reforms in a number of its health facilities. In 2020, and as part of a pilot, kitchen staff in AKHS hospitals in Kenya, Tanzania and Tajikistan reviewed their menus with the support of dieticians and used a food calculator (developed in house) to indicate the carbon equivalents of food items and to track food waste. It was clear that healthy alternatives were possible that also substantially reduced dependence on carbon-intensive products, specifically meat, dairy, fish and oil, as well as processed and frozen foods. Equipped with this data and additional supportive information, the following changes were made:
Food waste has almost entirely been eliminated through a combination of more prudent purchasing, better synchronisation of meals in response to demand and recycling food waste for compost and animal feed – much of which is taken home by staff as well as farmers.
Meat and dairy products have been substantially reduced.
Soft drinks have largely been phased out in favour of fruit juices, and deep-fried sugary snacks are no longer served. There is also a larger emphasis on baked and steamed products.
Fresh food has almost completely replaced frozen and tinned products which, apart from the health benefits, has also reduced energy needs for refrigeration and freezing.
Food is increasingly being sourced locally and through locally vetted producers with greater attention to seasonal items.
Materials are being shared to educate patients and staff on diets that are beneficial for health and the planet.
All plastic and single use cutlery and crockery have been phased out.
Changes in food have raised awareness among staff and patients.
Going forward, AKHS hopes to implement these changes in all its health units. It would like to enter into dialogue with local municipalities to pursue means to work with stakeholders to increase food recycling and reduce landfill. For example, in one district in Kenya in which AKHS operates, food waste currently constitutes around 20 percent of landfill.
AKHS also plans to discuss the benefits of flexitarian diets with local communities and to encourage changes in animal husbandry and agricultural practices. It also plans to increase sourcing from local producers in order to help generate employment. Chefs are inviting their counterparts from government facilities and hotels to share what they are learning.