A Healthcare Facility With Unreliable Electricity Access Is As Good As One With No Electricity Access At All
The COVID-19 pandemic has proven that investing in public health infrastructure is a necessity to the health of our global society. In an interconnected world, having reliable healthcare services in every regional neighborhood translates to better health and safety outcomes in the global community at large. We wanted to explore the energy infrastructure available to the healthcare community in Uganda, so at the start of the pandemic in March 2020, we surveyed nearly 60 Ugandan healthcare facilities, many located within refugee camps, to evaluate their energy infrastructure capacities. What we found was that many of these healthcare facilities lacked even the most basic equipment needed to respond to health crises such as the COVID-19-pandemic. Specifically, almost two-thirds of the clinics - 35 out of 57 - did not have reliable electricity access.
Unfortunately, this is the reality of most healthcare facilities in low resource settings. Results of a survey in 2017 from healthcare facilities in 78 low- and middle-income countries showed only 41% of these facilities had reliable electricity access (Cronk & Bartram 2018 - Link). To address that gap, a study by the UN Foundation and SEforALL in 2019 (Link) proposed a holistic framework for national policy makers and multilateral organizations based on three criteria:
organizational sustainability
economic sustainability
and technical sustainability.
Each of these criteria is divided into four phases that start from inception of core ideas and objectives, evolves to design, then to implementation and completes with Operation and Maintenance (O&M). Following figure illustrates this framework:
The framework developed by UN Foundation and SE4ALL to address sustainability concerns in healthcare facilities and school electrification plans.
[Adopted from Lasting Impact: Sustainable Off-grid Solar Delivery Models to Power Health and Education (2019)]
While this framework provides a model for adopting sustainability in large-scale electricity access plans, in this article I use the data from our case study to provide actionable recommendations for the local implementers and grassroots organizations that promote healthcare facility electrification on a smaller scale. In my opinion, a successful adaptation of sustainable development happens at the nexus of nation-wide policy reform that facilitate a top-down support for sustainability practices along with grassroots and local practitioners that materialize such policies in a bottom-up response. Therefore, this article takes the evidence collected in our case study into account to provide a roadmap for local practitioners, iNGOs and grassroot operations to align with the larger dialogue around sustainability as it appears on a national and international scale.
I argue that providing unreliable electricity to healthcare facilities is as detrimental as providing them with no electricity at all. Without reliable electricity access, there is no dependable infrastructure or planning capacity to organize implementation and delivery of vaccination campaigns, effective distribution of medicine, or to perform surgeries, along with other essential healthcare services. The benefits of establishing a healthcare facility in an underserved region are undermined by unreliable access to electricity. By outlining the detrimental impact of providing unreliable electricity access to healthcare facilities, I present a practical approach to addressing the energy needs of healthcare facilities in low-resource settings.
Electricity access for health clinics should be evaluated differently from electricity access to households, businesses or in general communities. When technicians design electricity generation solutions such as distributed renewable energy (DRE) systems for communities, especially in low-resource communities, sometimes budgetary or logistical challenges may justify an undersized system. Undersized electric systems may fail to supply ample electricity for every hour of the day and every customer, leading to unreliable neighborhood electricity access. but overall the increased access to electricity contributes to improved regional livelihood. Unfortunately, adopting the same design strategy for healthcare facilities is unethical and catastrophic. Unreliable electricity access for health clinics is likely to worsen the public health situation, as explained below.
First, increasing electricity reliability will increase the emergency preparedness of the health system. A healthcare clinic needs to be consistently prepared for emergencies to happen at any time. If we can’t predict when a road accident occurs, we can’t predict when an injured person will need to check in for outpatient care. If the exact time of a natural birth is unknown, the clinic needs to be equipped to deliver babies around the clock. Unreliable electricity access routinely halts emergency preparedness, leading to weaker services provided to patients, and disturbing the trust of the target population in the healthcare system as a whole. .A loss of trust diminishes the reputation and trust for standard medical practices and services, leading to an increased reliance on witch doctors, to suffering chronic and aggravated pain, and to more severe implications of medical conditions. These outcomes create extra hurdles to a community’s chance at upward mobility, while also increasing dependency on urban health centers that are more likely to be overwhelmed with need, too far for patients to travel to, and too expensive for many patients to afford.
Second, healthcare services have only become more electricity dependent, meaning that disruption in electricity supply will only increasingly disrupt vital healthcare services. When technicians design electricity access systems for neighborhood communities, they plan for a worst case scenario of a brown out in the evening with flickering lights or a temporary blackout due to mini grid overloads. Interruptions to the electricity supply of a healthcare clinic has more serious consequences, such as disrupting ventilators enabling patients suffering respiratory distress to breathe. . In the case of health clinics, the risks associated with electrical unreliability could be life-threatening.
Third, because the electricity demand portfolio for clinics is significantly different from a community’s electricity needs, system design should reflect this.. While communities tend to have a peak in energy consumption needs in the afternoon/evening hours due to activities that require lighting and to family gathering activities such as cooking, a clinic could have a considerably different peak demand, based on its irregular need for heavy electric loads specific to patient needs. For example, an X-Ray machine would require higher electrical input, and would need to be available immediately for injured patients.The differences in demand portfolio should be reflected in energy system design through better sizing and portfolio of generation units, personalized storage unit sizing, and better load management strategies.
Due to the aforementioned need for emergency preparedness, the electricity reliance of healthcare equipment, and differing electrical demand portfolios, reliable electricity access is fundamental to clinic operations. Below, I describe a combination of policy and technical design approaches that may systematically address the challenge of cohesive electrical infrastructure implementation for health clinics. While the approach presented here is a practical plan for healthcare providers in low-resource settings, planning such projects on a national and international scale demands a slightly different approach. The framework developed by the UN Foundation and SE4All presents a holistic approach enabling a large group of healthcare operations such as national healthcare system to adopt a sustainable approach from establishing the goals for electrification and establishing standards through sustainability incorporated in project design and implementation, as well as sustainability in allocating financial resources for longevity of electricity access. Such processes tend to progress and materialize slower than readily available small scale grants and local level decision making for providing electricity access through operators, iNGOs, and actors such as faith-based organizations. Therefore, the discussion presented here intends to further shed light to such practices for electrification of healthcare facilities rather than national scale strategies and policy developments.
Evaluate electricity demand. During our data collection process, we came across multiple clinics with installed off-grid solar PV systems that are only sufficient for minimal lighting during the night. Some of these clinics have equipment such as electric autoclaves or baby warmers that require considerably more electricity than they have available to operate. There should be a holistic analysis of the energy demands of equipment allocated to each clinic to ensure that all equipment can operate. CLASP, an iNGO has developed a database of equipment that works reliably with solar off-grid systems, while acknowledging that there is a prevalent bias in healthcare equipment design that is reflective of electricity abundance context in the high-income countries (Link). An effective and systematic resource allocation avoids offering care equipment to a facility without any substantial electricity supply capacity. Therefore, governments and active organizations should adopt a holistic strategy that evaluates whether the electricity demand of allocated equipment is matched with the generation capacity designated to each clinic or not. It's important to allocate resources so that at least some equipment can operate reliably, rather than distributing equipment en masse that is nonfunctional without dependable electricity supply.
A clinic with a DRE (Solar PV) project under construction. The size of this system is likely to be able to provide reliable electricity to the clinic based on our baseline analysis.
A clinic with about an un-proportionally small solar PV generation capacity. Without significant diesel generation or reliable grid access, this clinic has an unreliable electricity access leading to significant public health and upward mobility challenges.
Distribute healthcare services on the basis of electrical capability. In many low-income regions, such as the refugee settlements we studied in this project, multiple clinics are dispersed throughout the region to provide health services to the population. Distribution of health equipment among these facilities based on electrical capacities of each facility improves the overall services offered to the public in the region. For example, facilities stationed alongside a main road can utilize grid electricity with a reliable backup source. Such facilities could better accommodate equipment that requires significant power to operate in a short timeframe, such as X-Ray machines. From an electricity distribution and resource allocation perspective, it is more efficient to connect high-powered equipment to grid and diesel generators, rather than developing an off-grid solar PV system to match the short term power draw of electricity intensive equipment. To make health services in the region more cost-effective, policy makers could also distribute health services among the facilities so that each facility offers a set of general services as well as an especially designated service. For instance, one clinic offers reliable service in the maternity ward along with outpatient care, while another may have comprehensive lab testing equipment along with outpatient care, and a third will have a dedicated surgery unit along with inpatient care. A distribution of services like this would create a comprehensive and reliable health system within the region, with minimal capital investment required for full-service electricity supply systems to every clinic. In this project, we used the data we accumulated to provide a policy support tool to prioritize clinics for energy retrofit projects so that the public health outcome of such investments are maximized for the target population.
Train healthcare practitioners for effective load management. This is an important issue especially for the clinics with distributed renewable energy (DRE) resources such as off-grid solar PV systems. Some healthcare equipment, such as baby warmers, incubators or electric autoclaves, use electricity to generate heat. These equipment often require some of the highest electrical inputs in order to function. There are two ways that DRE technologies could supply electricity for such equipment: when allocating electrical infrastructure, engineers may assume a worst case electricity demand scenario in which all or most of the heavy load equipment is plugged in and consuming electricity, or the design may rely on clinic staff to self-regulate electrical loads and avoid overexerting the clinic’s electrical capacity. To return to the example involving maternity equipment like incubators, baby warmers, and autoclaves, nurses may be able to productively manage their electric equipment needs by parsing tasks out throughout the day. For example, they may turn on the autoclaves to sterilize equipment during warmer hours of the day during which baby warmers are off. This could lower electricity demand in a given moment, allowing for smaller generation capacity to be sufficient for health services.
Design DRE equipment with reliable technologies. Reliable technologies may be viewed as a luxury in a health clinic with unreliable electricity access. We argue that so-called luxuries that lead to reliability of electricity are in fact necessities for health clinics. It is important that energy providers prioritize reliability and longevity of electrical services for health clinics. For example, using lead acid-based batteries could reduce the overall cost of developing an off-grid solar PV system, but studies suggest that durability of these batteries and the hazards associated with the chemicals used in them are among the serious concerns that should be thought through prior to utilizing them for DRE systems of health care facilities. Instead, Lithium-Ion based batteries despite higher capital costs, are likely to outperform lead acid batteries in terms of storage capacity, lifetime, and monitoring capabilities that justify the higher capital investment required.
Monitor DRE systems and effective operation and maintenance. Regardless of whether top quality components are used or the DRE system has a flawless design and implementation, without a systematic O&M (Operation and Maintenance) plan, the system will inevitably dysfunction. Thanks to technological advancements, it is becoming more convenient to integrate sensors and develop maintenance strategies to effectively service energy systems and manage their maintenance in a way that avoids significant operational and health-related costs for the clinics. An effective O&M strategy has two sides. First, it trains the local technicians and practitioners to perform regular inspections and fix the issues before small failures can create a domino effect and cause major service disruptions. Second, through effective monitoring, O&M should be organized to be able to effectively minimize the system down time, and ensure the long term reliability and longevity of services.
In conclusion, the pandemic exposed the vulnerability of our global society to the mass spread of viruses and diseases. One of the main lessons we should take away from this crisis is that investment in robust healthcare anywhere is a contribution to improved healthcare everywhere. Our studies of the energy capacities of various Ugandan health clinics revealed that unreliable electricity access in almost two-thirds of these facilities poses not only a great challenge for public health in the respective Ugandan communities, but also a threat to the stability of the global health community as large.