PROTOCOL: Access to Electricity for Improving Health,Education and Welfare in Low- and Middle-Income Countries: A Systematic Review

The Problem, Condition or Issue

The International Energy Agency (IEA) estimates that more than 1.3 billion people (or about one-sixth of the world's population) are still without access to electricity, while another 1 billion have unreliable access (International Energy Agency [IEA], 2013). The global population without access to electricity is concentrated in Sub-Saharan Africa, South Asia, and to a lesser extent in East Asia and the Pacific (IEA, 2013). Combined, the Sub-Saharan Africa and South Asia regions account for more than 80 per cent of all people worldwide lacking electricity access (IEA, 2013). Electrification rates vary widely between rural and urban areas. The massive gains in global access to electricity over the last two decades have primarily been in urban areas. Over 80 per cent of the global population without access to electricity are concentrated in rural areas; for example, in Sub-Saharan Africa the rural electrification rate is just 14 per cent, compared with 60 per cent in urban areas (IEA, 2013). Expansion of coverage through grid extension in rural areas is challenging. Large numbers of people remain unconnected because of the high costs of grid extension. Grid expansion costs are generally high in rural areas because rural areas are characterised by low population density. This implies that electricity distribution costs must be spread over fewer numbers of households, thus resulting in high unit costs per household. Off-grid options are now available in many countries as transitional alternatives to grid-based electricity -- often at a lower cost than conventional technologies. For low-demand users in geographically remote areas, these options could potentially serve as long-term solutions as well. Costs for off-grid technologies have come down significantly over recent years, stimulating a growing market for small rural energy service companies. Hundreds of companies and other organisations now produce and distribute these systems, which have been introduced in practically all countries of the world.

Even where electricity is within reach, inability to pay is a significant barrier for many households. High grid-connection costs (which can be as much as $250 even when subsidised) and electricity prices (for on-going consumption) constrain energy use among households that cannot afford them. Bernard (2012) reviewed a number of studies and found that within grid-electrified villages, connection rates were 12 per cent in Botswana, 39 per cent in Ethiopia, and 30 per cent in Senegal. Low connection rates are particularly prevalent among poorer households. Heltberg (2003) found that less than five per cent of the households in the lowest income quintile in Ghana and South Africa have access to electricity, while it is 50 per cent for the highest quintile. The high initial investment cost of technologies such as solar systems is also a major barrier for rapid deployment of off-grid solutions in rural electrification. A recent study of off-grid technologies in Kenya found that only five per cent of households with access to solar kits purchased one (Jacobson, 2007).

In addition to the population that does not have access to electricity, up to a billion people, especially in developing countries, are subject to unreliable and low quality grid supplies, resulting in short- or long-term power outages in an area. In many developing countries, grid-connected electricity provided by utility companies suffers from frequent breakdowns (resulting in irregular power supply), and problems of quality (resulting in low or fluctuating voltage; that is, brownout). An irregular power supply may mean momentary loss of power or blackouts (that is, total loss of power) that may last from a few minutes to several weeks. Both interruptions in service and irregular voltage in an electrical power supply can cause poor performance of equipment or even incorrect operation. In addition, power is often supplied only at odd hours (such as midnight or midday), when the need for electricity is minimal.

Problems with the reliability of decentralised systems also threatens the viability of many off-grid projects to provide electricity. A literature review by Nieuwenhout et al. (2001) showed how inadequate service infrastructure and organisational and technical problems raised doubts about the effectiveness and suitability of off-grid solutions for rural development. It highlighted the problem of poorly designed systems and insufficient after-sales support and technical assistance, suggesting that neglect of maintenance and service requirements (for example, only low quality replacement components that are often not fully compatible with the system) may lead to frequent failures and user dissatisfaction that, in turn reduce motivation to continue repayment of fees to comply with rental or purchase agreements.

Electrification provides power for domestic uses (lighting, cooking, TV, radio, communication) productive uses (for example, water pumping, fencing, cooling, mills, sewing machines, and so forth) and public uses (for example, schools, health facilities, police stations). Those who lack access to electricity rely on traditional biomass sources, such as firewood, charcoal, manure and crop residues. The largest populations that rely on traditional biomass for energy are in the developing regions of Asia, with 836 million in India alone (IEA, 2013). Such sources of energy are often time-consuming to collect and, as they emit harmful indoor air pollutants when burned, can be detrimental to health. Other sources of energy used in the absence of electrification, such as candles, kerosene and batteries, are often expensive to purchase. Studies have shown that poor households end up paying a higher share of their income for energy consumption. For example, the Energy Sector Management Assistance Program [ESMAP] (2003) study in the Philippines reported that poor households appear willing to pay large amounts for the energy sources they use in the absence of electrification. Bernard (2012) reports that energy expenditure is about four per cent of total expenditure of the poorest rural households in Ghana, seven per cent in South Africa, 10 per cent in Ethiopia and 15 per cent in Uganda. Illegal and secondary connections, which serve a significant proportion of the population in many countries, also pose a major safety hazard, as well as lost revenues to utility companies.

The Intervention

The focus of this review is the expansion of access to electricity in developing countries. As there is no universally accepted definition of “access”, developing an appropriate definition was a challenge. Doing so is important, however, as the definition will influence the types of interventions that we are interested in.

The aim in this review is to capture the multi-faceted, multi-tier nature of “electricity access”. Therefore our definition:

Goes beyond a household focus (that equates access to electricity with the availability of an electricity connection at home or the use of electricity for lighting) to include productive and community access to electricity.

This definition of “access to electricity” will be reflected in the types of interventions that meet the criteria for the review. We envisage three broad types of interventions: ○

Interventions which increase electricity coverage through provision of the physical means of accessing electricity

The main categories of intervention are detailed in Table 1 (see methods section for further information on eligible interventions).

How the Intervention Might Work

A review seeking studies investigating relationships between energy, welfare and gender captured predominantly observational studies with population samples sufficiently large to support multivariate regression for controlling potential confounders (Kohlin, Sills, Pattanayak, & Wilfong, 2011). The authors summarised desired outcomes from electrification as longer working days, better access to information, better and safer lighting, greater efficiency in domestic and caring responsibilities and expanded opportunities for income generation. Their putative pathway between household electrification were drawn from the literature but supported by few robust studies of impact:

In general, light and TV are the first common uses of electricity, accounting for at least 80% of rural electricity consumption… Electricity displaces more expensive candles and kerosene lamps, thereby reducing indoor air pollution and fire and burn risk, and providing higher quality light. Lighting and television help improve access to information, the ability to study, and extend the effective working day. Lightly also improves the productivity of many household activities.

Kohlin et al. (2011) also found observational studies addressing electrification of communities. These indicated potential positive effects through better schools (where teachers are less absent and spend more time planning lesson), better health care (through refrigerated storage), better security (for example, with street lighting), greater social capital (through lighting for evening gatherings), employment opportunities associated with the generation and transmission of electricity and other economic opportunities (for example through improved communication with the market and processing or storage facilities). Lastly, wider environmental impacts may result from reduced deforestation and more or less pollution, depending on how the electricity is generated.

This literature also suggested differential gender impact:

Providing electricity to communities and homes and motor power for tasks that are typically considered women's work can promote gender equality, women's empowerment, and women's and girl's access to education, health care and employment, although sustainability and scaling up face additional difficulties. Kohlin et al. (2011) identified household studies that associated electrification with: reduced time spent by women collecting firewood and water; disproportionate increases in female employment, possibly by freeing women from time consuming domestic tasks such as cooking; and even greater impacts when accompanied by social marketing, finance schemes for appliances, or enterprise schemes for women to access electricity services. The review authors were convinced by studies of rural electrification demonstrating increased women's work outside the home, especially for younger women. Evidence of education and health benefits from electrification appear less differentiated by gender, although fertility rates are lower in rural areas with consequent benefits for women. Studies also implicate television as a route to women's empowerment possibly through exposure to role models of emancipated women in fictional TV dramas.

This gendered analysis Kohlin et al. (2011) and an earlier investigation of the welfare gains associated with electricity access (Independent Evaluation Group [IEG], 2008) informed an initial logic model. Figure 1 illustrates the final model employed to frame the current review.

OPEN IN VIEWER

1

Causal Chain for Access to Electricity and Potential Outcomes

In this model (read from left to right in figure 1), increased coverage of electricity generation and transmission provides opportunities for communities to access electricity. Community access to electricity improves temperature control (ambient temperature and refrigeration for safer food), water supplies and lighting in public spaces and the use of mechanical and information/communication technology (ICT). Within these communities, household access to electricity depends on affordability, which is determined by pricing, grants and subsidies. Household access allows similar opportunities for temperature control, clean water, lighting, labour saving devises and ICT. Electricity for cooking reduces the need for collecting fuel, simultaneously saving time and human energy and reducing indoor air pollution. Better lighting within communities and households reduces accidents and (fear of) crime. More time, energy, lighting and ICT leads to better information access and education, public services, employment opportunities and productivity. Taken together these improve human rights. The overall result is better health and welfare. On a scale larger than households and communities, increasing electrification has broader environmental impacts, changing forestation, atmospheric carbon and climate change.

Why it is Important to do the Review

It is generally recognised that energy issues must be dealt with in order to alleviate poverty in the developing world (Department for International Development [DFID], 2002; Sachs, 2005). Although energy is not one of the Millennium Development Goals (MDGs), the MDG Summit considers it essential for achieving most of the goals. A growing number of governments, Non-governmental Organisations (NGOs), international agencies, and businesses are working to overcome energy poverty. Since 2002, the International Energy Agency (IEA) has been focusing on the topic through the improvement of energy demand and supply situations in developing countries, devoting a chapter to explain the roles of energy for the development in its World Energy Outlook 2002 (IEA, 2002). In 2012, the Sustainable Energy for All (SE4ALL) global initiative was launched by the Secretary-General of the United Nations in partnership with the World Bank and the IEA to reach universal energy access, improve energy efficiency, and increase the use of renewable energy by 2030. The initiative was launched to coincide with the designation of 2012 as the International Year of Sustainable Energy for All by the UN General Assembly. In the 1990s the World Bank Group expanded the scope of its projects and adopted a new wave of rural electrification projects that were carried through the following decade, with renewable energy as the choice among off-grid options. This evolution was supported by a greater involvement of the private sector, and the advent of the low carbon agenda at the global level. Moreover, power sector privatisation and energy sector reform more broadly became the main focus of World Bank Group projects, which then shifted from supporting state owned enterprises to unbundling and power market development. The policy paper on power sector (World Bank, 1993) governed the World Bank Group's support during the 1990s. More recently, in 2012, the World Bank Group became partner of the Sustainable Energy for All (SE4ALL) global initiative launched with the Secretary-General of the United Nations and the IEA to reach universal energy access, improve energy efficiency, and increase the use of renewable energy by 2030. In July 2013, the World Bank Group outlined its future sector directions in the document “Toward a Sustainable Energy Future for All”, containing a number of actions and initiatives to improve electricity access (World Bank, 2013). To date, 68 developing country governments have adopted formal targets for improving access to electricity. According to the IEA, between 2010 and 2030 an average of $14 billion will be spent annually in extending access to modern energy services (IEA, 2013).

The case for electricity as a promising way of improving socio-economic outcomes for people in low- and middle-income countries (LMICs) is well documented in the available literature (Khandker, Barnes, & Samad, 2012). Having access to electricity for domestic, productive and public uses is considered important for a range of social development impacts, including productivity, income, health, education, potable water and communication services (Barnes, 1988; Bose, 1993; Domdom, Abiad, & Pasimio, 2000; Fitzgerald, Barnes, & McGranaan, 1990; United Nations Development Programme [UNDP], 2005; World Bank, 2002). Whilst there have been efforts to draw together this literature, there are no existing systematic reviews which aim to systematically collect and statistically synthesise students on effects of electrification in LMICs on health, education and welfare outcomes. Existing reviews are more limited in scope, and/or methodological rigour. In recent years, the World Bank has initiated both impact studies and monitoring and evaluation of its own projects in this area. A mid-1990s review of Bank experiences of rural electrification in Asia provided ‘generally pessimistic’ findings (IEG, 1994). A more recent review sets out to examine whether progress has been made since then (IEG, 2008). This study used some components of systematic review in its portfolio assessment: it aimed to include all World Bank project documents, and extracted data and reported results systematically. Moving beyond studies of electrification projects funded by the World Bank, several traditional literature reviews based on non-systematic searches exist (Bernard, 2012; Kohlin et al., 2011; Nieuwenhout et al., 2001). In addition, several systematic reviews in this area have been conducted. A recent review conducted for the Collaboration for Environmental Evidence (CEE) examined the impact of investments in electricity on agricultural productivity; narrative synthesis was used to combine studies (Knox, Daccache, & Hess, 2013). Although statistical meta-analysis was used in the systematic review by Thillairajan, Mahalingam, & Deep (2013), the outcome of interest was limited to ‘access to electricity’. Finally, a further study conducted for CEE which systematically reviewed the literature on major barriers to increased use of modern energy services and interventions to overcome these also used a narrative approach to synthesis (Watson et al., 2012). These are problems that this systematic review aims to remedy, thereby adding value to the existing body of research on this topic.

A related systematic review is also currently underway (Bensch, Munyehirwe, Peters, & Sievert, 2014). This review is interested in the most effective mechanisms for achieving universal access to electricity, with the primary outcome being increased access to electricity measured by regional or national electrification rates. Ultimate welfare outcomes (poverty reduction, economic growth, and so forth) are not the subject of this review.

None of these systematic reviews aim to systematically collect and statistically synthesise studies on effects of electrification in LMICs on health, education and welfare outcomes. Taking into account both these specific gaps in the evidence base and policymaker priorities this review will build on the World Bank Group's main energy evaluation study (IEG, 2008) which focused on the fifteen year period spanning FY1999-2013, by updating and enhancing the knowledge on the topic through a systematic review of relevant studies.

Criteria for including studies in the review

Search strategy

A comprehensive search strategy will be used to search the international research literature for qualifying studies. To reduce the omission of relevant studies and ensure our search is as unbiased as possible, a wide range of sources will be used to capture both academic and ‘grey’ literature. Manual searching techniques will be used to supplement the electronic searching of bibliographic databases and library catalogues. The search strategy includes many sources with a specific focus on low- and middle-income countries.

Selection of studies

Review management software, EPPI-Reviewer 4, will be used to manage the entire review process (Thomas, Brunton, & Graziosi, 2010). Potentially relevant items identified through the electronic search of bibliographic databases will be imported into EPPI-Reviewer (and will later be screened against the eligibility criteria). Details of eligible studies identified through the non-electronic searches will be entered into the reviewing software manually.

Selection of primary studies will be based on the pre-developed selection criteria described above. The criteria will be piloted by two researchers who will screen (on titles and abstracts) a 10 per cent sample of reports independently and compare their results. Discrepancies will be resolved by further review of the respective titles and abstracts and agreement reached by discussion. This process will be repeated until consistency in application of the selection criteria is achieved. Screeners will be required to err on the side of caution; in case of any uncertainty full text copies will be ascertained.

Full texts will be retrieved for all studies that appear to meet the inclusion criteria on the basis of the information in their titles and abstracts, and each of these papers will be closely examined by a minimum of two reviewers to determine eligibility.

All study selection and information retrieval activities in the review will be documented and described in sufficient detail in the final report so that the processes can be replicated by other researchers. Summary flowcharts will be used to convey relevant information.

Description of methods used in primary research

The following four studies exemplify the methods likely to meet the eligibility criteria for the proposed review.

Khandker, S. R., Barnes, D. F., Samad, H. A., & Minh, N. H. (2009). Welfare impacts of rural electrification: Evidence from Vietnam. (Policy Research Working Paper 5057). Washington, DC: World Bank.

This paper investigates impacts of the World Bank financed Rural Electrification project (REI) in Vietnam on households' cash income, expenditure, and educational outcomes. Panel surveys fielded in 2002 and 2005 were used. The survey data covered communes already having electricity, those that would receive electricity under the project, and areas which were not scheduled to receive electricity within a five-year time frame (the control group). In a few survey areas electricity has been provided by non-World Bank entities; therefore, besides estimating the impacts of rural electrification, this study also investigates if impacts are different for project (World Bank-implemented) and non-project electrification. Rigorous estimation techniques are used to estimates the benefits of both commune and household electrification. For example, the authors implement a household-level fixed effects (FE) regression technique that controls for both the observed and unobserved characteristics that possibly influence the outcomes.

Asaduzzaman, M., Yunus, M., Haque, A., Azad, A., Neelormi, S., & Hossain, A. (2013). Power from the Sun: An Evaluation of Institutional Effectiveness and Impact of Solar Home Systems in Bangladesh. Bangladesh Institute of Development Studies.

This study investigated solar home systems (SHS) installed by the Infrastructure Development Company Limited (IDCOL) in Bangladesh. The World Bank were among the partners supporting the programme. The study used several sources of data including a large household survey among SHS adopters and non-adopters. A total of 4000 households were surveyed in 128 villages (64 ‘treatment’ or supplied with SHS, 64 ‘control’ without such supply). The population for the sample of households was the records of IDCOL. The villages and households were chosen at random, and propensity score matching techniques were used to create a match between the treatment and control groups. The study assessed various socio-economic impacts, direct and indirect, on households and its members, including those on women.

Peters, J. (2013). Impacts of pico-photovoltaic systems usage on the energy poor - A randomized controlled trial in rural Rwanda. RWI.

This study evaluates take-up behaviour and impacts of a Lighting Africa-certificated Pico-PV kit marketed by the British company ToughStuff International. ToughStuff received a start-up support from the Dutch Daey Ouwens fund to launch its activities in Rwanda. The Pico-PV kits comprise a small 1W panel, a 40 lumen lamp, a mobile phone charger and a radio charger. A randomised controlled trial (RCT) was conducted in 15 remote communities in which households do not have access to electricity and rely on candles and kerosene for lighting and dry-cell batteries for radio usage. Pico-PV kits were randomly distributed among 300 households in 15 villages after a baseline survey in late 2011. These 300 households were revisited in June 2012 for a follow-up survey. Indicators examined are energy expenditures, lighting usage, mobile phone usage, and radio usage as well as knowledge about contraceptive usage, family planning, and malaria prevention.

Dinkelman T (2011). The effects of rural electrification on employment: New evidence from South Africa. American Economic Review. 101(7): 3078-3108.

This study estimates the impact of South Africa's mass roll-out of electricity to rural households. It uses several data sources and two different identification strategies (an instrumental variables strategy and a fixed effects approach). The author's main approach is to estimate community-level employment growth rates in communities that do and do not receive an electricity project between 1996 and 2001, instrumenting for project placement. This involves collecting and matching administrative data on roll-out in rural KwaZulu-Natal with geographical data and two census surveys. As a complement to the main analysis, a fixed effects strategy is used to estimate the impact of electrification on a richer set of labour market outcomes: employment, hours of work, wages and earnings. For this analysis, the author constructs a four-period panel of magisterial districts (agglomerations of communities) from cross-sectional household survey data in 1995, 1997, 1999, and 2001 and addresses non-random project placement and confounding economic trends by directly controlling for magisterial district fixed effects and trends.

Data extraction and critical appraisal

Two reviewers will independently evaluate each study using a tool developed specifically for this review (see Appendix 4 for a draft version). A coding manual will also be available to reviewers to guide the process.

Eligible studies will be coded to capture both substantive and methodological characteristics. The coding will focus on the following features of the studies: general study characteristics, such as source of study funding; variables related to the characteristics of the study samples, the nature of the intervention and its implementation; study methods; and outcome measurements. The study results and conclusions will also be extracted, and effect sizes calculated where the data allows. The reviewers will attempt to contact the authors of studies that are missing data that are essential for the review.

Information about the quality of the reporting will be extracted and a risk of bias assessment undertaken. We intend to use a previously used tool appropriate for experimental and quasi-experimental studies using complex statistical procedures (Waddington et al., 2012). Studies will be critically appraised according to the likely risk of bias based on the quality of methods used for addressing confounding and sample selection bias; the extent of contamination (spillovers and crossovers to comparison groups); outcome and analysis reporting bias; and other sources of bias. Examples of additional sources of bias include: concerns about blinding of beneficiaries, personnel delivering the intervention, outcome assessors and/or data analysts (detection bias or placebo effects); courtesy bias from outcomes collected through self-reporting; attrition or other forms of missing data; whether data on the baseline was not collected, or collected retrospectively; reliability of outcome measures; whether groups were treated equally (in all respects other than receipts of the intervention); and whether any ancillary/subsidiary/adjusted analyses that were presented were pre-specified or exploratory.

Again drawing on Waddington et al. (2012) and Baird et al. (2013) the summary assessment of risk of bias will proceed as follows: Low risk of bias: studies in which clear measurement of and control for confounding was made, including selection bias, where intervention and comparison groups were described adequately (in respect of the nature of the interventions being received) and risks of spillovers or contamination were small, and where reporting biases and other sources of bias were unlikely. Medium risk of bias: studies where there were threats to validity of the attribution methodology, or there were likely risks of spillovers or contamination, arising from inadequate description of intervention or comparison groups or possibilities for interaction between groups such as when they are from the same community, or reporting biases suspected. High risk of bias: all other studies. The detailed description of the risk of bias tool is included in Appendix 5.

Piloting of the coding tool will be undertaken by members of the review team who will work independently on a purposive sample of eligible studies (selected to test the tool on the full range of included study designs) before meeting to compare their decisions. Reviewers will be retrained on any coding items that show discrepancies during this process and the coding manual will be adapted accordingly. This process will be repeated until a very high level of consistency in reviewers' application of the codes is achieved (at which point the tool will be finalised). The remaining studies will be coded by different combinations of two reviewers who will independently extract information from each study report and then come together to compare their decisions. Any uncertainties and discrepancies will be resolved by discussion, further review of the respective study reports and, where necessary, consultations with a third reviewer.

Data analysis