Sandbox

Electrification of Six Health Centres in Rhino Camp and Imvepi Refugee Settlements in Uganda – Baseline Assessment Results

BACKGROUND

Uganda is among twenty countries with the largest population lack­ing access to electricity where only 43% of the total population have access to electricity. The importance of reliable, sustainable and accessible energy for health centers in undebatable. Electricity is required for lighting to visualize patients for examination, procedures, and monitoring; to operate life-saving electric medical devices and diagnostic equipment as well as sterilize equipment; refrigerate medicines and biologic samples for diagnostic testing; and facilitate communication between healthcare providers for emergency medical transport, consultations, coordination and more. Based on the results from the 2007 Uganda Service Provision, 58% of health facilities did not have access to electricity and only 15% had “reliable” electricity. When further disaggregated on the basis of health facility type, 60% of lower level health facilities do not have access to electricity.

Against this background, the GIZ programmes Energy Solutions for Displacement Settings (ESDS) and Energising Development (EnDev) intended to provide and install off-grid photovoltaic system (OGS PVS) for six health centres located within Rhino Camp and Imvepi Refugee Settlements in Terego and Madi Okollo districts, Uganda in 2021. This article provides a summary of the baseline assessment results that was conducted in 2021 prior to the electrification of these six health centers.

Methodology

The relationship between energy access and health is assessed using proxy indicators on facility performance (operating hours – night-time, total hours per day; clinic visits), availability of electricity and/or electrical equipment for health service delivery (specific to health facility (WHO/SARA and USAID/Measure Health surveys), and healthcare worker attitudes and motivation.

There are three main study limitations:

1.      Lack of facility disaggregated Health Information System

2.      Unequal sex ratio among community representatives

3.     Unable to access some solar components for observation and documentation 

Baseline Assessment Results

Selection of health centres

The six health centres were selected using 10 criteria: location, accessibility, current operation status and ability to offer primary health services, preparedness for COvid-19, existing/planned medical equipment that utilize energy, functioning health unit management committee, at least 1-2 permanent buildings for installation, security around the healthcare premise, energy gaps already identified as well as existing electrification or preliminary solarisation plans.  

Five health facilities fall under the direct managing authority of the Ministry of Health (MOH) (three in Terego and two in Madi Okollo in service 25 to 29 years) and one health facility is under the direct managing authority of International Rescue Committee (IRC) (in service for 5 years). Regardless of managing authority, all health facilities receive support – technical, infrastructural, staffing, and other – from the Ministry of Health, a multitude of implementing partners, and UNHCR. The managing authority of health facilities have important implications on the engagement of stakeholders for ownership, maintenance, and sustainability of the OGS PVS assets.

Across all health facilities, the largest number of nationals within catchment population are from South Sudan, followed by Uganda, and then the Democratic of Congo. Refugees from Burundi, Kenya, and the Central Africa Republic are also represented in Ocea HC II in Madi Okollo, Rhino Camp.

Overview of the selected health centers

Health Center	Refugee Settlement	District	Health Facility Level	Managing Authority	Years of Service	Catchment Population
						Refugee	Host	Total
Imvepi HC II	Imvepi	Terego	HC II	MOH	26	19,668	3,224	22,892
Yinga HC III	Imvepi	Terego	HC III	MOH	25	10,813	7.351	18,164
Siripi HC III	Rhino Camp	Terego	HC III	MOH	27	13,090	5,500	18,590
Ofua HC III	Rhino Camp	Terego	HC III	IRC	5	26,952	Unknown	Unknown
Ocea HC II	Rhino Camp	Madi Okollo	HC II	MOH	26	18,428	3,729	22,157
Odoubu HC II	Rhino Camp	Madi Okollo	HC II	MOH	29	12,461	4,500	16,961

Baseline: Electrification Status

None of the six health centres were connected to the national or community grid. However, all six health centres had at least one partially function OGS PVS and 3 health facilities had at least one diesel generator. Five had standalone EPI solar refrigerators to store and ensure cold chain of vaccines and oxytocin. Four had a We Care Solar installed to charge small devices, such as the HemoCue, Foetal Doppler, and mobile phone, and only 3 of the We Care Solar are functional as the battery of the We Care Solar was stolen at one facility. Finally, Two health facilities had Mobile Power (MoPo) power banks to provide additional power

Reliability of Electricity from the solar system

The table below shows the reliability of the solar electricity.

Reliability of Solar Electricity Measure 1: During the last 7 days, was electricity at all times from the main or any back up sources when the facility was open for services? 1=Always available (no interruptions) – green 2=Often available (interruptions of less than 2 hours per day) – yellow 3=Sometimes available (frequent or prolonged interruptions of more than 2 hours per day) – red Measure 2: How many days during the past week was electricity not available for at least 2 hours during a time the facility was open for services? This includes emergency services. 0-7
Reliability of Electricity	Imvepi HC II (Imvepi)	Ocea HC II (Rhino Camp)	Odoubu HC II (Rhino Camp)	Yinga HC III (Imvepi)	Siripi HC III (Rhino Camp)	Ofua HC III (Rhino Camp)
Outpatient	7	7	3	6	7	7
Pharmacy	7	7	3	6	7	7
Laboratory	7	7	3	6	7	7
Inpatient ward	0	Not wired	0	7	0	7
Maternity	0	7	0	7	0	7
HIV/TB Clinic	7	7	3	7	7	7
Nutrition Ward	N/A	N/A	N/A	7	N/A	7
SGBV Protection House	Not wired	N/A	3	0	N/A	N/A
Security Guard House	Not wired	Not wired	Not wired	7	Not wired	Not wired
Staff Quarters	7	7	3	7	7	7
		7
		7
		7
		7
		7
Isolation Ward	Not wired	Not wired	Not wired	Not wired	Not wired	COVID19 – 0
						TB ward not wired
Latrines + Bathing Shelters	Not wired	Not wired	Not wired	Not wired	Not wired	Not wired
Security lights	Gate - 7	IPD - 7	N/A	Gate – 0	0	0
				IPD – 0
				Isolation – 0
	Staff quarters - 0	Latrine - 7		Maternity - 7
Medicine Stores	7	7	0	6	7	7

Availability of solar lighting on a typical night in the maternity ward during dry and rainy seasons (data from 2021 Baseline Qualitative Interviews)

Health Center	Availability of Lighting on a Typical Night in Maternity Ward During Dry Season (January 2021)	Availability of Lighting on a Typical Night in Maternity Ward During Rainy Season (September 2020)	Difference in Hours of Availability of Lighting Between Dry and Rainy Seasons
Imvepi HC II	No data	No data	No data
Yinga HC III	7pm to 2am (7 hours)	7pm to 11pm (4 hours)	-3 hours
Siripi HC III	7pm to 5am (10 hours)	7pm to 2am (7 hours)	-3 hours
Ofua HC III	8pm to 6am (10 hours)	8pm to 2am (6 hours)	-4 hours
Ocea HC II	7pm to 2.30am (7.5 hours)	7pm to 10pm (3 hours)	-4.5 hours
Odoubu HC II	7pm to 6am (11 hours)	7pm to 2am (7 hours)	-4 hours

Maintenance of the energy systems

For diesel systems, all 3 health facilities reported having a routine preventive maintenance program. However, they do no have their own strategies for repair and replacement but rather report to donor in such cases. Only one facility had trained staff on maintenance and one reported on having an O&M manual.

For solar systems, 3/6 reported having a routine preventive maintenance programme for their solar systems. 1/6 reported receiving maintenance support from an external technician 2/6 reported performing on-site cleaning of the solar arrays, but without a specialized technician. If there were problems with the solar systems at the health facility, 2/6 facilities said they would call the donor for replacement and 4/6 facilities said they did not have a formalized system in place. None of the facilities reported having staff trained on how to maintain a solar system and one health facility (1/6) reported having an O&M manual for the solar system.

Electricity and Health Service Delivery

According to the five facility in-charges under the managing authority of the Ministry of Health, the first solar panels were installed when the health facilities were established for the arrival of the first wave of refugees from South Sudan over 20 years ago. Multiple partners, including Care International, Danish Refugee Council, and UNICEF, have since donated and installed different OGS PVS in select wards/ departments/ units and staff quarters.

While each health facility appears to have many OGS PVS, few of them are fully functional. Healthcare workers report frequent interruptions of electricity at the health facility, negatively affecting health service delivery and additionally making routine living within premises a challenge, exemplified by the need to trade-off between lighting or charging mobile phone - solar batteries in the staff quarters are not able to hold charge so they are unable to charge devices at night.

Healthcare workers have developed multiple strategies to mitigate the impact of energy deficit on health service delivery. These mitigation strategies are categorized into four main categories:

-       conserving energy for emergency use,

-       finding alternative systems for energy (e.g., dry cell batteries, diesel generator, Mobile Power battery banks, personal solar panels and battery banks)

-       use of manual, non-electric methods in consultation, diagnostic, sterilization of equipment, and reporting, improvising locale of service delivery to access energy (e.g., moving patient to another ward to access lighting or electricity)

-       patient referral to another health facility or sending out patient samples for analysis at another laboratory.

Ownership of Solar Systems

-       limited sense of ownership or personal responsibility for the existing OGS PVS with the exception of the Mobile Power charging stations

-       In general, healthcare workers and community representatives recognize that the OGS PVS belong to the health facility, but there is no designated person to look after these assets

-       If an OGS PVS stops working fully, then the health facility’s strategy is to call the district or the partner for help and replacement. According to several healthcare workers, capacitating the staff to look after the solar systems can help them feel ownership and responsibility towards these assets

à Enhancing ownership may strengthen healthcare worker’s accountability to using the OGS PVS appropriately. One healthcare worker suggested the formation of an accountability group within the staff to ensure careful and appropriate use of the solar systems

Capacity building for maintenance

-       0/6 have been capacitated to provide routine maintenance of the solar systems, not even non-technical aspects such as routine cleaning of the solar panels, dusting of the indoor components, and basic visual inspection of the arrays and wires

-       (0/6) are able to name a designated staff member who has received training or support to learn how to maintain the solar system, and 0/6 can produce an O&M manual on any of the existing OGS PVS

-       Interviewed healthcare workers and HUMC members were receptive and willing to learn how to monitor and provide basic maintenance for the OGS PV, recommending careful selection and training of more than one person so the facility does not lose capacity when a staff is rotated to another health facility, and that training and responsibility of maintenance should be given to staff who mainly reside within the catchment area, others recommended the security guard or general maintenance repair person (especially the government funded one) or  staff who hold responsibilities, such as the facility in-charge, store keeper, and laboratory technician be trained.

-       A District Health Officer said the district has four engineers – a district engineer, an electrical engineer, a mechanical engineer, and a road inspector with the electrical engineer expected to maintain electricity-related equipment in health facilities within the district. In reality, the district-level electrical engineer does not do so. The problem could be related to both lack of fuel for transport and management

-       The District Health Officer noted that Arua Regional Referral Hospital’s equipment maintenance unit has existing capacity and expertise on maintaining, repairing, and replacing solar components. It may be possible to leverage existing capacity within the region to support maintenance without having to transport someone from Kampala to Terego or Madi Okollo

Funding for maintenance, repair, and replacement of solar systems

-       primary source of funding from the donor that installed the OGS PVS

-       Two sources of internal funding are available to health facilities under the managing authority of the MOH: the Primary Health Care (PHC) Fund and Results-Based Financing and some of those funds could potentially be used for minor maintenance, repair, and replacement of OGS PVS equipment are. The PHC fund would not be a realistic source of funding to ensure routine maintenance of the solar systems by a trained technician.

-       A District Health Officer identified two potential sources of funding electrification of health centres from the district health system: the Capital Development Fund and the District Development Equalization Grant.

-       A District Health Officer raised the idea of asking healthcare workers to pay for electricity at the staff quarters as a strategy to ensure sustainable financing of OGS PVS services. However, an implementing partner disagreed with this idea and felt it would disincentivize staff from working in these remote, hard-to-reach settings.

-       As a result of limited funding opportunities and the recognition that repairs and replacements of solar components, such as batteries will exceed what is available from the PHC funds, HUMC, health facility staff, and district health officers feel that GIZ should budget funds to support the maintenance of OGS PVS.

-       HUMC and healthcare workers are eager for support to initiate income-generating activities in order to generate funds to support the minor maintenance and repair of the solar systems. Each site had its own ideas of what would work in its setting (see below table). Notably, these income-generating activities would need an injection of start-up capital in order to be functionalized.

Ideas of income generating activities to sustain OGS PVS

Health facility	Proposed Income Generating Activities to sustain OGS PVS	Proposed Management of Income-Generating Activities
Yinga HC III	Canteen with excess energy to charge phones and power a refrigerator to sell cold drinks, also offer mobile money services HUMC can also sell some trees they own	HUMC
Imvepi HC II	Canteen with excess energy to charge phones, sell cold drinks, and power a photocopier so they can offer photocopying services	HUMC
Ocea HC II	Kiosk with excess energy to charge phones at a fee of 300 shs. Power a refrigerator to sell cold drinks, sell home-made bread in canteen, offer printing and photocopying services, start a saloon for shaving hair for men and women, put up a place to repair phones and computers, sell airtime,	No data
Siripi HC III	Charge phones at 300 shs, call upon RWC and community members to make contribution to solar systems, sell cold drinks in fridge, offer photocopying services, sell dry ratios, start mobile money services, ask GIZ to bring power banks for rental (similar to MoPo) so they can hire out the power banks for money	LCs and healthcare workers
Ofua HC II	Collect contributions from community members of about 100-500 per individual, work through “block leaders”, borrow money from the saving group, use excess energy to charge phones of 500 UGX, sell cold drinks, sell mixed goods – soap, biscuits, books, pens, cosmetics, torches, and batteries	HUMC
Odoubu HC II	Use excess energy to buy a photocopier and printer, offer phone charging at 500 UGX, start a photo studio, put a pool table at the youth friendly services and charge people to play it, laundry services to wash and iron people’s clothes, start a saloon for men and women, sell drinks and put a TV to entice people to come	HUMC and community leaders
DHO Terego	Charge healthcare workers residing in staff quarters with OGS PVS for the electricity	District level – DHO, CAO, and LCV Catchment area - Facility in-charges and sub-county chiefs as direct overseers of these health facilities Within health facility activity - HUMC chairperson

RECOMMENDATIONS

Figure Model Sustainability Framework (United Nations Foundation and Sustainable Energy for All, 2019)

1.      Ensure adequate sizing of solar systems to fully functionalize health service delivery

a.      Consider energy needs specific to the ward/department/unit

b.      Take into account user behaviour’s impact on energy demands

c.      Take into account varying functionality of solar batteries between dry and rainy seasons

2.      Develop and implement an O&M plan for each health facility

a.      Develop a capacity building strategy that enables health facilities and regional district health teams and energy partners to achieve knowledge and skills on how to operate and maintain the OGS PVS

b.      Identify and engage relevant stakeholders to be responsible for O&M of the OGS PVS

c.      Select staff from within the health facility, HUMC, district health team, implementing partner, and donor to undergo training on how to operate and maintain solar systems

d.      Train local and regional staff on operations and basic maintenance of OGS PVS

e.      Prepare a step-by-step O&M manual with clear, easy to understand instructions and pictographs to facilitate comprehension

f.       Prepare a routine maintenance checklist for facility staff ensuring routine cleaning and basic maintenance and for the solar energy company technician to provide more in-depth assessments on functionality and maintenance

g.      Prepare a contact information sheet with relevant names, phone numbers, and WhatsApp contacts so health facilities can reach out to the correct individual for support, questions, and repair. Similarly, ensure GIZ and energy company have the relevant health facility staff’s contact information.

h.      Ensure health facilities have the protective and maintenance equipment needed to perform routine, preventive maintenance

i.       Provide routine supportive supervision (e.g., monthly or quarterly) to the designated individuals within the health facility and district health teams on how to operate and maintain the solar systems

                                        i.     and adjust level of support accordingly

j.       Prepare a laminated simple, visual aide for each location (e.g., wall socket, lighting per ward/unit/department) to remind users on what devices can be powered, what devices cannot be powered, times of days when socket can be used (or no restrictions) to ensure the solar batteries are not over-used

k.      Work with HUMC to form an accountability group with designated individuals responsible for checking appropriateness of electrical usage

                                        i.     Check in and provide relevant feedback to the accountability group/ individuals on appropriate use of solar energy

3.      Develop and implement a sustainability plan for each health facility

a.      Identify and engage relevant stakeholders

b.      Clarify roles and responsibilities for operations, maintenance, repair, and replacement of OGS PVS

c.      Work with relevant stakeholders to develop a context-specific sustainability plan

d.      Ensure communication and coordination between personnel responsible for the maintenance of OGS PVS with personnel responsible for managing and implementing the income-generating activity

4.      Leverage health system strengthening opportunities with the anticipated improvement in availability and reliability of electricity

a.      Electricity is a necessary precondition to effective health service delivery. However, electricity alone cannot improve health services or health outcomes.

b.      Improved health outcomes can be achieved with preconditions are met with targeted health system strengthening (technical, equipment, supply chain, and human resource).

c.      Energy and health sector partners should work together to leverage expected adequate and reliable electricity for select health system strengthening interventions

5.      Measuring impact

Document indicators and impacts using the domains identified in the theory of change; consider adapting Energy for All (SEforALL) Monitoring, Evaluation, and Learning Framework’s standardized indicators for inputs and outputs.