Factors Related to Health Service Utilization among Adolescent Girls in Urban Slums of Jaipur, India

### **Impacts of Air Pollution on Health and Cost of Illness in Jakarta, Indonesia**

**Vivian Pun1, Ginanjar Syuhada2, Adiatma Yudistira Manogar Siregar3, Adhadian Akbar3 , Donny Hardiawan3, Adi Darmawan4, Sri Hayyu Alynda Heryati4, Raden Driejana5, Sumi Mehta2, Daniel Kass2 , and Ririn Radiawati Kusuma2**

<sup>1</sup> Formerly Vital Strategies

2Vital Strategies

3Faculty of Economics and Business, Padjadjaran University

4Environmental Agency of DKI Jakarta

5Faculty of Civil and Environmental Engineering, Bandung Institute of Technology

Air pollution is a major threat to the 10 million people living in greater Jakarta, where annual ambient PM2.5 concentrations are the highest among Indonesia's urban centers and several times higher than WHO healthbased guideline levels. Conservative modeled estimates from the Global Burden of Disease (GBD) study suggest that air pollution caused over 5000 deaths in Jakarta in 2019. This study uses local air quality and health data from the Environmental Agency of DKI Jakarta and the Jakarta Health Agency to quantify the health and economic impacts of air pollution in DKI Jakarta Province, including 1) health impacts due to air pollution, focusing on adverse health outcomes in children, premature mortality, and daily hospitalizations, and 2) economic impact associated with air pollution-related health impacts. The health burdens attributable to air pollution were estimated using the latest GBD 2019 methodology and the best available concentrationresponse functions. The economic burden associated with the health impacts of air pollution was calculated using cost-of-illness and the value of statistical life year approaches. Over 7,000 adverse health outcomes in children, over 10,000 deaths, and over 5,000 hospitalizations can be attributed to air pollution each year. The total cost per year of these health impacts reached approximately IDR 41.2 trillion, or around 2.2% of Jakarta's gross domestic, regional product, with almost all costs due to premature deaths. Results will inform the design of solutions to address priority sources of pollution with a public health lens. The approach is also replicable to other geographies concerned about the impact of air quality and is already being adapted for use in Sao Paolo, Brazil.

Vivian Pun1, Ginanjar Syuhada2, Adiatma Yudistira Manogar Siregar3, Adhadian Akbar3, Donny Hardiawan3, Adi Darmawan4, Sri Hayyu Alynda Heryati4, Raden Driejana5, Sumi Mehta2, Daniel Kass2, and Ririn Radiawati Kusuma2

1 Formerly Vital Strategies

<sup>2</sup> Vital Strategies

3 Faculty of Economics and Business, Padjadjaran University

4 Environmental Agency of DKI Jakarta

<sup>5</sup> Faculty of Civil and Environmental Engineering, Bandung Institute of Technology

#### Results

*Figure 1. Air quality levels in Jakarta, 2019.*

Abstract: Poor air quality has been strongly linked to non-communicable diseases, including chronic heart and lung disease, and adversely affects children and the elderly, our most vulnerable members of society. This study quantifies the health and economic impacts of air pollution in Jakarta Province, the capital of Indonesia, including 1) adverse health outcomes in children, premature mortality, and daily hospitalizations, and 2) the cost of air-pollutionrelated health impacts. Methods: We evaluated the health and economic impacts of PM2.5 and ozone, both of which exist at levels exceeding the Indonesian National Ambient Air Quality Standard and the World Health Organization's health-based guidelines. We selected the following health outcomes: adverse health outcomes in children, adverse birth outcomes, mortality, and hospitalizations. We calculated the annual average concentration of PM2.5 and O3 to estimate mortality and adverse health outcomes in children attributable to air pollution. Meanwhile, the 24- hour average (for PM2.5) and the 8-hour average (for O3) were calculated to estimate hospitalizations attributable to air pollution. The health burdens attributable to air pollution were estimated using the latest Global Burden of Disease Study 2019 study methodology and the best available concentration-response functions. The economic burdens were calculated using cost-of-illness and the value of statistical life-year approaches. In Jakarta, over 7,000 adverse health outcomes in children, over 10,000 deaths, and over 5,000 hospitalizations can be attributed to air pollution each year. The total cost per year of the health impact of air pollution has reached approximately IDR 41.2 trillion, around 2.2% of Jakarta Province's GDRP. The current study fills important knowledge gaps about the health impacts of air pollution in children. The study findings also provide timely and valuable inputs for the Environmental Agency's Grand Design to identify and understand the full magnitude of the air pollution burden in Jakarta, and to formulate clean air solutions.

#### Introduction

Air pollution is a major threat to the 10 million people living in the Jakarta area. Based on the data from the Environmental Agecy of DKI Jakarta, the annual ambient PM2.5 conce ntrations in Jakarta are the highest among all of Indonesia's urban centers. Conservative estimates from the Global Burden of Disease study suggest that air pollution caused 5,054 deaths and 168,000 years were lost to ill-health, disability, or premature death in DKI Jakarta Province in 2019.

Global evidence on the adverse health impacts of air pollution is consistent and clear. Air pollution has detrimental effects for all age groups in our society. Poor air quality has been strongly linked to non-communicable diseases (NCDs), such as cardiovascular and chronic respiratory diseases and lung cancers, and it adversely affects children, our most vulnerable members of society. Being exposed to polluted air may have prolonged impacts on children's health (e.g., impaired cognitive and socioemotional development), and can lead to an increased risk of chronic respiratory illness, cardiovascular disease, and diabetes throughout life.

This study quantifies the health and economic impacts of air pollution in DKI Jakarta Province, the capital of Indonesia. First, this study calculates the health impacts due to air pollution, focusing on adverse health outcomes in children, premature mortality, and daily hospitalizations. Second, the study estimates the economic impact associated with air-pollution-related health impacts. The results of this study will deliver valuable inputs for the Grand Design conducted by the Environmental Agency to identify and understand the full magnitude of the air pollution burden in Jakarta, and for the formulation of solutions to address priority sources of pollution.

*Table 2. Impacts of daily exposure to PM2.5 and ground-level ozone on hospitalizations, 2019.*


*Table 3. Annual economic cost of health impact attributable to air pollution in DKI Jakarta (in billion IDR), 2019.*


#### Conclusions

We estimated that, each year, air pollution causes more than 10,000 deaths, more than 5,000 hospitalizations for cardio-respiratory diseases, and more than 7,000 adverse health outcomes inchildren. The total economic burden attributable to air pollution was estimated to be IDR 52.1 trillion (2.2% of GRDP). The study findings provide valuable inputs for the Environmental Agency's Grand Design to identify and understand the full magnitude of air pollution burden in Jakarta, and to formulate clean air solutions.

#### Acknowledgments

This project was funded with support from Bloomberg Philanthropies. We thank the Environmental Agency of DKI Jakarta for providing us with the air quality data and the Health Agency of DKI Jakarta and the Indonesia Healthcare and Social Security Agency (BPJS) for providing us with the health data.

#### Methods

We evaluated the health and economic impacts of PM2.5 and ground-level ozone, both of which exist at levels exceeding the Indonesian National Ambient Air Quality Standard (NAAQS) and the World Health Organization's health-based guidelines. We calculated the annual average concentration of PM2.5 and O3 to estimate mortality and adverse health outcomes in children attributable to air pollution. Meanwhile, the 24-hour average (for PM2.5) and the 8-hour average (for O3) were calculated to estimate hospitalizations attributable to air pollution. Daily air pollution data for 2019 were provided by the Environmental Agency of DKI Jakarta. Daily average concentration levels for PM2.5, O3, NO2, and SO2 were collected from the air quality monitoring stations located in five districts: Central Jakarta, North Jakarta, South Jakarta, East Jakarta, and West Jakarta.

According to the available risk estimates from the Global Burden of Disease (GBD) Study 2019 and the epidemiologic literature, we selected the following health outcomes:


• Hospitalizations: two hospital admissions from cardiovascular diseases and respiratory illnesses.

The health burdens attributable to air pollution were estimated using the latest GBD Study 2019 study methodology and the best available concentrationresponse functions. The economic burdens associated with the health impacts of air pollution were calculated using cost-of-illness and the value of statistical life-year approaches.

*Table 1. Impacts of annual exposure to PM2.5 and ground-level ozone on mortality and adverse outcomes in children, 2019.*

