Energy Access and Health Outcomes

Covid-19 has highlighted many of the world’s inequities, including uneven access to vaccines and treatment. The pandemic has also illuminated the energy poverty in various countries that creates logistical challenges in distributing vaccines. Several weeks ago, CSIS convened a workshop of energy and public health experts to examine the links between energy access and health outcomes, as well as the role of energy in healthcare infrastructure related to Covid-19.

The lack of clean cooking fuels creates a pernicious public health challenge. The World Health Organization estimates that 91 percent of the global population breathes polluted air, which causes about 7 million premature deaths annually. Ambient air pollution is a significant risk factor, but household air pollution alone leads to 3.8 million deaths annually. More than 2.6 billion people around the world rely on polluting sources for cooking fuels, including solid fuels such as wood and coal. Workshop speakers noted that the lack of clean cooking fuels contributes to premature deaths from heart disease, strokes, and lung cancer—caused by direct exposure in the home as well as the presence of black carbon in ambient air. For these reasons, Sustainable Development Goal (SDG) 7.1 (part of SDG 7) sets a target of universal access to affordable, reliable, and modern energy sources by 2030.

Poor access to electricity is also a significant barrier to quality health care. One study of eight countries in sub-Saharan Africa found that only 28 percent of healthcare facilities had reliable access to electricity, while 26 percent of facilities in the surveyed countries had no access to electricity at all. The lack of consistent, reliable electricity inhibits the use of heart rate monitors and dialysis equipment, constrains laboratory testing, and makes it difficult to properly sanitize medical equipment.

Participants in the workshop noted other benefits to consistent access to electricity, including better staff morale and increased visibility and use of healthcare facilities. Reliable electricity supplies can help reduce infant mortality rates by providing better lighting for births at night. One workshop participant noted that in clinics without electricity, medical staff must rely on flashlights or mobile phones for night births.

One challenge is that electricity access for health facilities is a cross-cutting issue. Health ministries are not always cognizant of the energy requirements of health facilities and may be more focused on other aspects of access and quality of care. Energy officials, meanwhile, are less familiar with the needs of healthcare facilities. Well-meaning government officials and donors who want to provide new medical equipment, for example, may find that it is not fit for purpose. Several workshop participants gave the proverbial example of refrigerators and medical equipment gathering dust in clinics due to lack of electricity.  

Electricity Access for Healthcare Facilities

Much of the discussion focused on ways to improve electricity access for healthcare facilities, including the benefits and drawbacks of various approaches. Many organizations are working to enhance electricity access in sub-Saharan Africa by connecting hospitals and clinics to solar-powered mini grids. Distributed generation can reduce reliance on grids with inconsistent supplies, as well as exposure to high electricity tariffs. Several workshop participants shared lessons learned from these efforts.   

In Sierra Leone, the United Nations Office for Project Services (UNOPS) has an initiative to connect healthcare facilities in rural areas to renewable energy mini grids. The venture, funded by the former UK Department for International Development and implemented by UNOPS, has created nearly 100 mini grids to electrify rural communities, with an agreement that healthcare facilities would receive free electricity up to a maximum allocation. After the first 54 mini grids were built, private companies were invited to bid on public-private partnership agreements to operate the grids over a 20-year concession period. Three private companies are now running those grids and charge customers on a metered grid system. In a subsequent phase of the rural electrification project, private companies were invited to bid on contracts to build, operate, and maintain more than 40 proposed mini grids and were required to raise private capital to fund generation equipment. The mini grid systems were enabled by a cost-reflective tariff system intended to be affordable to people in rural areas.

The Power Africa initiative recently awarded a number of grants for healthcare electrification efforts to small solar companies in sub-Saharan Africa. The program prioritizes work with private sector companies to support local businesses and reduce the reliance on donors that can result from the “asset transfer model.” Electricity supply for healthcare facilities is an important part of broader efforts to finance and scale up off-grid electricity access.

Participants discussed the challenges inherent in rural electrification projects, including issues specific to healthcare facilities. One way to overcome resistance on this front is to ensure from the outset that both government ministries and private sector players are involved, and to ensure that such systems are “owned” and fully supported by the government. It can also be helpful to hire independent contractors or implementers to manage and oversee such initiatives.

Electricity tariffs are inevitably a source of controversy, with political sensitivities over complaints that prices are too high. By contrast, tariffs that are too low will be unsustainable and ultimately will threaten reliable supplies. In terms of tariff design, it is important to avoid tendering processes that center on prices or tariffs alone. A more sensible approach is to require that companies present a sound financial model and compete on their technical capacity.

Government officials often suspect that private companies will not be committed for the duration of a project, so one solution is to sign long-term contracts that bind the companies to provide continued service. Because solar systems require maintenance, especially as they age, it is important to set aside sufficient funds for operations and maintenance. Realistic tariffs can also ensure sufficient funds for operators to support expected operations and maintenance costs and hire qualified service companies. Energy experts in the workshop cited a need for better financing and risk education for health and energy officials on operations and maintenance needs. 

Energy Access and Covid-19 Logistics

Workshop participants also discussed the role of energy access in Covid-19 responses, including the need for energy to support vaccine distribution and storage. A number of organizations have launched Covid-19 vaccine initiatives that involve support for logistics and cold chain storage. These ventures often entail both direct financing to procure vaccine doses, as well as a project investment component to support cold chain refrigeration and other equipment. It is early days for most of these financing initiatives and money committed has not yet been spent.  

The pandemic presents an opportunity to respond to acute short-term needs while addressing underlying issues. New investments should help to improve long-term reliability and sustainability rather than entrench energy-inefficient systems. Workshop participants noted that healthcare facilities can provide an anchor load for electricity systems, helping to overcome the “valley of death” in which there is a recognized need for investment in electricity systems but a lack of confidence in future demand and ability to pay. There is potential for investment in electricity for healthcare facilities to touch off a virtuous cycle, delivering better energy services, positive health outcomes and usage of facilities, and therefore more revenue generation.

It is also important to make the right type of investments in cold chains. The World Bank and partner organizations such as the vaccine alliance Gavi and the World Health Organization are working on investing in equipment with less ozone-depleting substances, as well as retrofitting healthcare facilities and storage facilities to enhance energy efficiency. Workshop participants cited an interest in investing in cold chain technology that could eventually be used to support food storage and distribution. They also noted the lack of medical devices and equipment suitable for fragile operating environments that experience large swings in voltage and periods of power availability.

Finally, public health and energy experts noted a common problem in Covid-19 recovery spending: there is an urgent need to respond to this public health crisis, but we lack the data to craft the optimal response. Multilateral donor institutions do not always have a good sense of the overlap between health infrastructure and vaccination distribution strategies, hindering their ability to spend money effectively. And investment that could improve electricity supplies for communities that use a healthcare facility as an enabling hub or anchor point is often resisted by local communities that are wary of high electricity tariffs. More information on all levels would help to inform better consumer decisions and wiser infrastructure investments.

The fight against Covid-19 provides an opportunity to make investments that can alleviate longstanding, interrelated challenges of substandard energy services and poor health outcomes. With proper planning and strategies based on past success stories, this is an opportunity worth taking.  

Ben Cahill is a senior fellow in the Energy Security and Climate Change Program at the Center for Strategic and International Studies in Washington, D.C.  

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).  

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Ben Cahill
Senior Fellow, Energy Security and Climate Change Program