Energy for Rural Health Centers

Introduction

Health professionals in rural clinics face many challenges on a daily basis. Not only a lack of qualified medical staff, equipment and medicine can become a major obstacle in providing crucial basic health services for the rural population, also lacking or unreliable energy supply can be a severe problem.

If the cold chain is inoperable when supplies arrive, vaccines, blood, and other medicines may go to waste. Without proper electric lighting, most medical treatments can only be conducted at daytime, while emergency surgeries at night may only be illuminated by dim kerosene lamps or torches. Also for the provision of water, energy is frequently required for pumping and heating.

Despite its high relevance for the provision of health services, there is little reliable data on energy access in health facilities in developing countries.

In India, Rural Health Statistics 2018 data showed nearly 22% or 40,000 primary health centers in rural India are still operating without electricity supply.

A review led by the World Health Organization (WHO) in 2013 found nationally representative data for only 14 developing countries globally, 11 of them in sub-Saharan Africa. According to this review, one in four health facilities in Sub-Saharan Africa had no access to electricity, while only 28% of health facilities and 34% of hospitals had reliable access to electricity.

A recent survey of 78 countries found that only 41% of low- and middle-income country health care facilities have reliable electricity.

This is not only hampering proper medical services, electricity outages also can damage medical and diagnostic devices.

In addition to electricity, health facilities need thermal energy for cooking, heating, and sterilization. This demand is mostly met by direct combustion of fuels like kerosene, diesel, biomass or gas.

The widespread use of fossil fuels like kerosene for lighting or diesel for power generation, as well as biomass in inefficient cookstoves cause additional risks to staff, patients and the environment due to emission of particulate matter, black carbon and CO2, and fire hazards.

Selecting appropriate sources of reliable and sustainable energy as well as introducing measures for efficient energy consumption can help mitigate some of the challenges inherent in operating a health facility in the developing world.

This article will provide an overview on options for the improvement of the energy situation in rural health facilities.

Energy Needs in Healthcare Facilities

Health facilities have different energy needs according to their services provided and on consequently required loads. Some of the basic services include vaccine refrigeration, light, medical equipment, and surgical treatment. Further services include e.g. communication, water pumping and heating, space heating or cooling.

Successful development of reliable energy systems requires careful assessment of all aspects of health facility energy needs, including both electric and thermal energy needs.

Growing energy needs and foreseeable load increases in the near future also need to be considered when analyzing and determining a facility’s load profile. Procurement of more or  less energy-efficient medical equipment will influence the future load profile, as will energy-saving retrofits to the building itself. For more information about building efficiency, see WHO/World Bank 2015.

Classification of Health Facilities

Healthcare posts and clinics can be distinguished into three categories, namely low, medium, and large health facilities with different energy requirements accordingly.

Health posts are the smallest, most basic facilities. These locations typically will not have a permanent doctor or nurse on staff. They provide basic treatment for emergency cases, first aid, and where possible, basic immunization services. Due to the limited medical equipment used, the overall energy demand of health posts is relatively low. The energy demands of a health post is similar or less than that of a small health clinic.

Health clinics are generally larger than health posts and employ one or more full-time nurses. A health clinic offers a wider array of services than a health post and will possess equipment allowing for more sophisticated diagnoses. Rural health clinics generally fall into one of three categories (Categories I, II and III - see table below) based on the type and number of medical devices used in the facility and the frequency with which they are used on a daily basis. Local resources may make specific energy options more or less advantageous in each location.

The IEA describes the example of a ‘typical’ electrical load distribution of a small health facility in Cambodia (based on PV provision) as 35% lights, 14% fans, 34% lab equipment and 17% other, with the load curve increasing gradually to a midday peak and then decreasing gradually. 

Another example load profile of a medium size health facility shows that the highest energy consumption within day time is by laboratory equipment, while lighting systems and fans consume more during the night. The overall electricity distribution, however, shows that the main consumers are lighting systems and fans (57%), followed by lab equipment (29%) and other equipment (14%).

Other types of health facilities that require reliable and sustainable electrification include blood banks, stand-alone laboratories and pharmacies, and anti-retroviral treatment (ARV) clinics. Blood banks, stand-alone labs, and pharmacies will, depending on their size, utilize equipment similar to that found in small or medium sized health clinics and will have similar energy needs. ARV clinics will have significant energy demands similar to those found large-sized health facilities.

Health Facility Categories:

Category	Description
Category I Small / Health clinics or posts low energy requirements, 5 - 10 kWh/day	Typically located in a remote setting with limited services and a small staff They mainly cater to primary health, with treatments provided for most common diseases such as malaria and TB, in addition to maternal and child health services and first response to emergencies. Approximately 0 - 60 beds Electric power is required for: Lighting the facility during evening hours and to support limited surgical procedures (e.g. suturing) Maintain the cold chain for vaccines, blood, and other medical supplies - one or two refrigerators may be used Utilizing basic lab equipment - a centrifuge, hematology mixer, microscope, incubator, and hand-powered aspirator
Category II Medium-sized / District health centers moderate energy requirements, 10 - 20 kWh/day	They cater to larger populations than small rural health posts Approximately 60 - 120 beds Electric power is required for: Medical equipment similar to Category I Health Clinic; but frequency of use and number of devices are higher than those of Category I Separate refrigerators may be used for food storage and cold chain Communication device, such as a radio More sophisticated diagnostic medical equipment Advanced equipment, such as small size X-ray machine. Complex surgical procedures, such as dental health surgeries
Category III Large-sized health facility/ District or Regional hospitals high energy requirements, 20 - 30 kWh/day	Located in urban off-grid areas or cities Approximately 120 beds or more Large size facilities function as central hospitals which serve thousands of people. Therefore, their energy consumption is high They have several wards and include nursing school, staff house etc. May serve as a regional referral center and coordinate communication between several smaller facilities and hospitals in large cities Electric power is required for: Lighting the facility during evening hours Staff houses Medical equipment  and sophisticated diagnostic devices (x-ray machine, CD4 counters, blood typing equipment, etc.) requiring additional power Complex surgical procedures May need to communicate with remote health centers and hospitals by way of telephone, fax, computer, and Internet

Electricity needs

Some very common and basic devices or services that need electricity are the following:

Vaccine refrigeration

While refrigerators work 24h/day, they actually do not continuously consume power. To keep the internal temperature constant, the compressor or heater runs in a controlled duty cycle mode. Therefore, in order to obtain information about the daily energy demand of a refrigerator, the device's duty cycle must be determined (e.g. by listening), or by measuring the energy consumption for a period of time.

Lighting

This is a very essential service in rural health facilities, mainly at night. Quality and availability of light significantly improves medical emergency interventions, including first aid, birthing and surgery.

Medical equipment

A microscopes is an essential equipment in rural health facilities. In developing countries, common diseases which include HIV, syphilis, malaria, and anemia are diagnosed using a microscope.

Sterilization

Medical tools, including surgical equipment need to be sterilized. Often, sterilization of equipment by air requires a high temperature up to 160◦C for around two hours, while steam autoclaves, where a temperature of 120◦C is sufficient, are even more effective. Because of the required high temperature, sterilization equipment consumes a considerable amount of energy.

Basic needs assessment

When considering the type of electrification needed to sustain daily operations, a facility must first understand its basic needs. The needs assessment will include an inventory of the types of equipment used in the facility and the power required to operate each device. Understanding the average “daily load”, or the amount of power required to operate equipment under normal working conditions, will influence the choice of power supply. Once the daily energy demand is established, a range of electrification options can be considered. Understanding the need will also provide managers with a realistic budget for procuring, installing, and maintaining the new system.

Additionally, when determining how to electrify a healthcare facility, it can also be important to prioritize the electrification of equipment based on its criticality to patients’ survival and the facility’s operation. Franco et al. (2017) propose three categories: non-critical, non-secured and secured. Non-critical refers to equipment that is not critical to patient survival, such as air ventilation in the ward. Non-secured refers to equipment that is critical but can handle moderate voltage fluctuations of the network and short outages, often thanks to an integrated battery. Finally, secured refers to equipment that is critical and needs to be protected against voltage fluctuations. During a power shortage, this prioritization can help in effectively managing electricity production and consumption.

The table below shows a list of common health facility equipment and their respective power needs.

For further information about power requirements of electrical devices for health services see also tables 3 and 4 in the publication “Access to Modern Energy Services for Health Facilities in Resource-Constrained Settings” from WHO / World Bank 2015.

Electricity Supply

Stepwise Approach to Electrifying a Health Center

1. Identify the Health Center's Current Energy Demands
   Identify current energy needs and applications, e.g. for lighting, refrigeration, communication, etc.
2. Account for Near-Term Change
   Determine whether energy demands will change in the near-term.
3. Establish Target Energy Consumption in kWh/day
   Use tools such as the USAID Health Clinic Power System Design Tool (4 - Electric Load Inputs) or the Energy Audit Spreadsheet (Worksheet 7 - Future Electric Applications) to calculate the future electric energy consumption in kWh/day.
4. Determine Technologies Needed to Meet Target
   Evaluate energy technologies.
5. Procure, Design System, and Install Technology
   Select the most appropriate energy technology.
6. Maintain and Financing Your Energy Technology
   Institute financing mechanism(s) accounting for operation and maintenance needs and costs.

Remember to contact an expert for assessment, system design, procurement, installation, and maintenance of energy technologies!

Power Generation Options

After determining the facility’s typical daily energy usage, it is time to evaluate the energy technologies available to electrify your facility. Rural health clinics have a number of options available to supply reliable electricity. The best option for a given application depends on a number of factors, and in some cases a combination of measures may be the best solution.

Some factors to consider include:

• Reliability of local grid
• Local renewable energy resources (wind, solar, biomass)
• Local cost and availability of conventional energy sources (diesel, propane, gasoline)
• Local availability of systems, parts, service companies, and technicians
• Governmental policies and incentives
• System reliability requirements
• Technical capacity and funds for system maintenance and replacement
• Special considerations or desired operational characteristics - i.e. noise, emissions, etc.

Technological options to consider:

• Photovoltaic (PV)
• Wind
• Reciprocating Engines (generators)
• Hybrid Systems
• Grid Extension

The table below illustrates the key characteristics of energy generation technologies. Capital cost, operating cost, reliability, emissions, resource availability, and other factors should be considered when selecting an energy technology.

Energy Technology Characteristics:

Energy Technologies	Capital Cost	O&M Cost	Reliability	Durability	Special Considerations	Emissions	Optimal Use
Solar PV System with Batteries	Very high	Low	High (if maintained properly) or low (if not)	20-30 years (PV), 5 years (batteries)	Theft (batteries or panels); Vandalism (panels); Availability of trained technicians	None	Small Loads; Areas where fuel is costly or difficult to obtain
Wind Turbine with Batteries	High	Low-moderate	High (if maintained properly) or low (if not)	20 years (turbine), 10 years (blades), 5 years (batteries)	Theft (batteries); Lack of data on wind resources	None	Many moderate loads where resource is sufficient
Diesel Generator	Moderate-high	High	High	25,000 operating hours	Fuel spills; emissions	Very High	Larger loads
Gasoline Generator	Low	Very High	Moderate	1,000 - 2,000 operating hours	Fuel spills; emissions; flammability	High	Emergency Generator
Gas Generator	Moderate	High	Moderate	3,000 operating hours	Propane is of limited availability, but can use biogas	Low	Component in hybrid system or stand-alone
Hybrid System	Very high	Low-moderate	Very High	Varies; optimization greatly extends generator and battery life	Complexity for servicing	Low	Medium and large loads
Grid extension	Varies	None	Varies	High	Theft; extending grid allows connection of nearby homes to grid	Not local	Where grid is reliable and not too distant

The table Costs of Power Sources for different Health Clinic Categories below illustrates the estimated cost of various energy technologies for a range of clinic sizes. In general, renewable energy options (e.g., photovoltaic (PV) system) will have higher capital costs than diesel or other fuel-based electricity generating options. However, over the long-term, renewable systems will have lower operating costs and produce fewer or no emissions. In renewable energy systems, battery maintenance, occasional cleaning, and theft-prevention will be the major recurring costs. A hybrid system using an alternative energy source (e.g., PV system) and a traditional generator (e.g., diesel) will have a higher up-front capital cost than a renewable-only system; however, hybrid systems provide greater flexibility, including the ability for one system to support the other. For illustrative purposes, a PV/diesel hybrid is represented in the table Costs of Power Sources for different Health Clinic Categories. Actual prices in a given location may vary considerably from those used in the table.

Costs of Power Sources for Different Health Clinic Categories:

Technology	System Size	Capital ($)	Operating ($/year)	O&M Assumptions
Category I - 5 kWh/day
PV System with Batteries	1,200 W panels 20 kWh batteries	$12,000 system $2,000 batteries	$500	1% of system cost per year (includes maintenance and component replacement, does not include security); Amortized cost of replacing the batteries every five years (20% of battery cost).
Wind Turbines with Batteries	1,750 W turbine 20 kWh batteries	$10,000 system $2,000 batteries	$600	2% of system cost per year; Amortized cost of replacing the batteries every five years.
Diesel Engine Generator	2.5 kW	$2,000	$1,400	$0.0075/kWh maintenance, $0.67/kWh fuel ($1/liter for fuel is used), operating at 4kWh per day at 50% capacity, and replacement of engine every 10 years.
Hybrid Systems	1,200 W panels 10 kWh batteries 500 W engine	$12,000 PV system $1,000 batteries $500 generator	$450	1% of PV system cost per year; battery replacement every five years; 200 hours of engine operation per year; replacement of engine every ten years.
Grid Extension	n/a	$10,000+ per mile	$200	$0.10/kWh power
Category II - 15 kWh/day
PV System with Batteries	3,600 W panels 60 kWh batteries	$36,000 system $6,000 batteries	$1,150	Same as above.
Wind Turbines with Batteries	5,250 W turbine 60 kWh batteries	$28,000 system $6,000 batteries	$1,750	Same as above.
Diesel Engine Generator	2.5 kW	$2,000	$3,900	Same as above, operating at 15 kWh at 50% capacity.
Hybrid Systems	3,500 W panels 30 kWh batteries 1.5 kW engine	$35,000 PV system $3,000 batteries $1,000 generator	$1,350	Same as above, with 200 hours of engine operation per year.
Grid Extension	n/a	$10,000+ per mile	$550	Same as above.
Category III - 25 kWh/day
PV System with Batteries	6,000 W panels 100 kWh batteries	$55,000 system $10,000 batteries	$2,550	Same as above.
Wind Turbines with Batteries	8,750 W turbine 100 kWh batteries	$44,000 system $10,000 batteries	$2,900	Same as above.
Diesel Engine Generator	2.5 kW	$2,000	$6,400	Same as above, operating at 25 kWh per day at 67% capacity.
Hybrid Systems	6,000 W panels 50 kWh batteries 2.5 kW engine	$55,000 PV system $5,000 batteries $2,000 generator	$2,200	Same as above, with 200 hours of engine operation per year.
Grid Extension	n/a	$10,000+ per mile	$900	Same as above.

System Sustainability

In December 2010, ESMAP published the very resourceful handbook "Photovoltaics for Community Service Facilities" . It covers the most relevant issues regarding sustainability and long-term operation of community PV systems.

Importance of Maintenance

Regular and timely maintenance of all electrification equipment is essential to proper functioning of the equipment.

• Routine maintenance, as well as major overhauls and capital replacement, need to be planned and budgeted for in advance.
• Lack of maintenance ultimately will have a negative impact on reliability of power supply.
• Maintenance problems often are easily preventable, yet frequently overlooked.
• Emergency back-up generators should be checked periodically even if rarely used.
• Improper or insufficient maintenance can lead to substantial costs in the future.

Regular maintenance is well worth the cost, and programs installing energy systems at health clinics or other facilities should ensure there will be a commitment to servicing the system. Experts recommend training local personnel in the servicing of these systems or obtaining a long-term maintenance contract.

Financing of Operation and Maintenance

Clinic managers must develop a sustainable way to pay for the maintenance and operation of the system to ensure continuity of facility operations. Facilities should consider incorporating aspects of the innovative finance structures described below into their financial and operating practices.

User Fees

A “user fee” system involves building the cost of energy into the overall cost of medical services – passing the cost to the patient. Most rural medical clinics struggle to secure sufficient operating funds due to the inability to pass along true costs of medical service to users who lack the resources to pay actual costs. The inability of patients to pay, coupled with the challenge of managing the collection and disbursement of funds, makes this approach difficult to implement.

Sale of Excess Electricity

The sale of excess electricity offers a promising approach to finance operations. By installing a system with excess capacity, income from the sale of additional power can offset a portion, if not all, of the system’s operating costs.

• Bulk (Wholesale): By operating the power system as a small enterprise, excess electricity can be sold to nearby villages, factories, schools or facilities. The system must be sized to accommodate both the clinic and the potential customer base. Customers must be in close proximity to the system or transmission costs quickly make this approach prohibitively expensive. Maintenance requirements are also more complex.

• Point of Use Sale (Retail): When potential purchasers of power are too remote to obtain the electricity over transmission lines, the clinic can sell it at or near their facility. A small powering station can be established with fees charged based on the amount of power used, if metering is available, or according to time. For customers with transportable devices such as power tools, a small work area with outlets can be set aside adjacent to the power station where users can plug in equipment. Villagers can use these areas for income-generating activities. It may be feasible to establish a “mini industrial zone” near the clinic’s power system, providing an area with permanent workshops (sewing, weaving or repair services) or stores. The clinic could realize income from rent on the workshop/store space, the sale of electricity, and the pumping of water.

Institutional Management
Establishing an entity that has a stake in the continued successful operation of the system is crucial to cultivating a sense of ownership for on-going system operation. Innovative financing systems must be properly managed by organizations and individuals who use and pay for the power. Management structures include existing clinic management, nearby villages or facilities, or a new organization dedicated to providing oversight of the energy system such as a cooperative between villages. The cooperative can include an agreement with the clinic to manage any of the financing arrangements previously described. The level of responsibility of the cooperative can range from total operation and management of the system to simply keeping track of usage and payments.

Thermal Energy

Food Preparation

Cooking needs in rural health centers can be divided into two categories, depending on the target group, for whom the food is prepared:

• Food for staff: It depends mainly on the number of staff, the health center management and/or the degree of self-organization of the staff if the meals for staff members are prepared communally. In this case an institutional size stoves might make sense Examples: Both Mission and the Government hospitals in Mulanje District (Southern Malawi) have institutional size wood-fired rocket stoves to cater for the staff and the students of the nursing college. Cooking is done by a paid cook, who got trained on the proper use of the stoves. The firewood is provided by the hospital. Savings as compared to the open fire are between 70-80 percent.

• Food for patients: Most rural health centers do not provide meals for the patients, even if they have in-patient facilities. The meals for patients are prepared individually by the guardians who accompany the patient often with the main purpose to cater or prepare warm bath water for the patient. Thus individual cooking facilities are needed for the guardians. Usually food ingredients, fuel and cooking utensils have to be organised by the guardians and are not provided by the health center. Thus the most prevalent cooking facility is the makeshift 3-stone fire fuelled with firewood or any other biomass that the guardians are able to organise in the immediate surroundings of the health center. A good practice is when health centers provide a sheltered cooking place and define the area where cooking is allowed. To minimise the adverse effects of air pollution and prevent that smoke is adding to the ailments of the patients, this location should preferably be at a distance from the wards and care units. Mulanje Mission Hospital in Southern Malawi went even further: they had already a roofed kitchen for the guardians with 20 simple fireplaces. As hospital facilities were expanding and the number of in-patients increasing, the kitchen became small. With advice from GTZ-project staff on stove technology and kitchen design, they added another roofed kitchen with improved fixed ‘Epseranza’ -type stoves and good ventilation. In the first weeks the kitchen was not yet well accepted and rather empty, because people were not familiar with the stoves and were unsure how to use them. Upon realizing this, a permanent security staff of the hospital got trained on the correct stove use and was able to show the ever-changing users, who normally don’t use the kitchen longer than a few days. From then onward the kitchen became more and more popular as people became aware of he advantages: the new stoves were more economic, cooked faster, created less smoke, and the building had a better ventilation. Young mothers felt more comfortable bringing their babies in the new kitchen. The challenge is to organise the maintenance of the stoves, as some of the ceramic pot-supports of the ‘Esperanza stoves’ had gone missing and the stoves performed poorly without them.

Sterilization / Pasteurization

For the sterilization of instruments or the pasteurization of drinking water thermo-solar energy might be an option, if used with a (reusable) temperature indicator to ensure that the water has at some stage reached the required temperature. Solar energy is also a good option to heat bath water for the patients, if storage of hot water is provided. Solar energy is less suitable for guardian’s kitchens, as the requirement for food is often during hours, when sunshine is not available.

Project Experience

Experience and lessons learned, including project approaches, technical details and evidence for impacts of projects in Uganda and Ethiopia are discussed in the article "Photovoltaic (PV) for Health Centers - Project Experience". It aims at compiling experience from past and ongoing PV programmes for rural health centers.

For each project the following issues are covered:

1. Project Approach,
2. Project Outputs & Technical System Details,
3. Evidence for Impacts, and
4. Lessons Learned.

Further Information

• Access to modern energy and the impact on health
• Project Experience with PV for Health Centers
  
• Powering Health, USAID website covering all major issues on electricity supply for rural health centers. Several country case studies available. Offers tools for energy audits and load calculation. Highly recommandable!
• USAID: Powering Health: Electrification Options for Rural Health Centers - Step-by-step guide on energy needs, power generation options, and sustainability issues for rural health centers. Case studies from Botswana and Uganda.
• ESMAP: Toolkit for Community Facilities_IFC Training Module.pdf Photovoltaics for Community Service Facilities - Guidance for Sustainability. - Covers the most crucial issues regarding sustainability of community-based PV systems.
• National Renewable Energy Laboratory (USA) (1998): Renewable Energy for Rural Health Clinics - Publication on energy issues of rural health clinics: energy applications, electrical system components, system selection and economics, institutional considerations. Also provides case studies and lessons learned.
• Practical Action: Solar PV Refrigeration of Vaccines - Technical Background of solar refrigeration
• IEA: PV Systems for Rural Health Facilities in Developing Areas.pdf