Initial technical assistance by U4E and BASE entails integrated design and implementation with local partners from the public and private sector so that a smooth handover of responsibilities is orchestrated as early as practicable for a pathway toward self-sufficiency. The emphasis is on models that are replicable in Africa and beyond where rising incomes and electricity access are driving ever greater adoption of mechanical cooling. The initiative operates within the context of the challenges of local finance, including consumer loan interest rates that are often above 20 percent.  

The technical team worked with the Government of Rwanda to negotiate discounts on the manufacturer’s suggested retail price (MRSP) of participating products to cover the cost of financing and offset the incentive for recycling old products. Such financial mechanisms can achieve a triple win: improve consumer access to high-quality equipment; safeguard the climate; and develop local financial intermediation services.  

A robust set of well-enforced criteria, with ongoing monitoring and oversight, and compelling marketing are key to keeping all parties aligned toward the success of the programme while maintaining healthy competition among participants. These criteria should: 

• Enable grid-connected households and small enterprises (on-bill) and salaried employees (on-wage) to finance efficient refrigerators and air-conditioning systems that are otherwise likely more expensive to purchase than inefficient competing products. 

• For officials, link with relevant development policy targets and agreements, MEPS and labels, and opportunities to address energy security and economic competitiveness considerations. 

• Provide a common set of terms and conditions that are agreed upon by all participating parties, and monitor compliance to ensure a level playing field. 

• Offer capacity building for participating vendors, banks, utilities, government agencies and waste management companies to ensure they understand their roles and responsibilities – start with a pilot phase to test readiness. 

• Raise customer awareness through a dedicated marketing campaign. 

• Allow time for importation of products that meet the eligibility criteria, making the case through the anticipated market demand potential. 

• Ensure relationship building among participating actors to ensure smooth functioning, and exchanges of information (e.g., for applications). 

• Include a mix of competing vendors and banks to allow for diversity of options but with a suitable pipeline of opportunity where all can benefit.
   

  

According to Chilling Prospects: Tracking Sustainable Cooling for All 2022 over 750 million Africans face cooling access challenges, and around half are on the brink of purchasing their first air conditioner or refrigerator. Even though a high-efficiency appliance typically costs consumers much less over its lifetime (due to reduced energy consumption), than an inefficient one, the higher upfront cost is a significant barrier for them. Moreover, they have no incentive to consider which refrigerant is utilized, so inefficient products utilizing high-GWP refrigerants remain predominant.

The R-COOL GO finance mechanism fixed a set of objectives and goals for newly certified sold appliances, unlocked finance, saved greenhouse gas (GHG) emissions and saved energy.

R-COOL GO from 2022 to 2025 (cumulative)

Measuring the impact of health facility electrification

Electricity is generally understood as a prerequisite to almost all aspects of a well-functioning health facility, but it is often difficult to measure or quantify the direct impact of electricity on health outcomes due to its many determinants and contextual factors. Therefore, impact is often measured indirectly through the lens of a specific aspect of health services, which can include service delivery, preventative care, vaccine storage and delivery, maternal health, and health-seeking behaviour. These pathways are examined in SEforALL’s recently launched Powering Healthcare Impact Factsheet, which compiles existing, published studies on the linkages between reliable power at health facilities and improved health outcomes.

While there are still several gaps in better understanding and specifically in quantifying the impact of reliable energy on health outcomes, the available research supports the importance of reliable power in the health sector. For example, a study in India found that primary healthcare centres without access to electricity had 64 percent less deliveries, 39 percent less in-patients, and 38 percent less out-patients. [1] Another study in Zambia found the acquisition of solar-powered microscopes led to a 25–30 percent increase in the number of people tested for tuberculosis (TB), contributing towards the increase in the TB cure rate from 62 percent  to 72 percent  in the area. [2]

Women are also disproportionately affected by low levels of electricity access, with a study in Uganda revealing that electricity had the second highest protective effect on maternity health after availability of midwives, reducing the case fatality rate by 61 percent. [3] While these data points provide a general understanding of the importance of reliable energy in a health facility setting, additional investment in impact data can allow the sector to better understand and quantify the impact that reliable power can have on health service delivery and health outcomes. 

Taking stock of global efforts

To gain a better understanding of global progress and identify potential opportunities for coordination, SEforALL circulated a sector-wide survey to document past (2015-2020), ongoing, and future health facility electrification interventions. Analysis of the resulting dataset, which includes more than 270 interventions by 81 organizations across 56 countries, showed an increase in the number of interventions, from 118 completed to 152 in the pipeline. Furthermore, the scale of interventions was larger, from 5,590 facilities targeted in completed interventions to 15,868 facilities targeted in ongoing/planned interventions. [4]

The survey also found that ongoing and planned interventions significantly favour the deployment of larger systems (above 1kWp), showing that increasingly organizations are including facility-wide energy needs in their project design. This trend could also be attributed to the significant decline in solar PV system costs in the past decade (by 82 percent between 2010 and 2019), [5] allowing implementation agencies to deploy larger solutions that can power more loads. 

Figure 1: Heatmap of completed and ongoing health facility electrification interventions

Country-level market assessments

To complement efforts to measure global progress of health facility electrification, country-level assessments present a key opportunity to analyze the energy access gap in the health sector in a more granular way, as well as identify the most appropriate technological and financial solutions to electrify health facilities at a national level. SEforALL and several other organizations are currently developing these types of country-level assessments, which can provide an important stepping stone towards project development. For example, SEforALL recently published the Powering Healthcare Market Assessment and Roadmap for Nigeria, which it developed with support from Power Africa and in close coordination with the Rural Electrification Agency and the National Primary Health Care Development Agency. This country-level assessment aims to provide the Government of Nigeria and its development partners with a data-driven overview and practical recommendations for planning and coordination of electrifying the country’s underserved health facilities. The analysis estimates that there remains an energy access gap in the public health sector of approximately 30 to 40 percent, primarily in primary health care facilities. The document also highlights a USD 525 million investment need to equip 10,000 primary healthcare centres with reliable and renewable power and keep them operational for 15 years.  

Building a global, multilateral, intersectoral platform

To overcome implementation barriers and achieve the goal of universal electrification of health facilities, stronger global ambition and increased coordination is needed. To address this, SEforALL and Power Africa led a coalition of organizations from both the energy and health sectors around a Multilateral Energy Compact for Health Facility Electrification, which was launched during the High-level Dialogue on Energy in September 2021. To raise global ambition, the Energy Compact has set a global, sectoral target of electrifying 25,000 health facilities with clean and reliable power solutions by 2025. The compact also targets challenges in data, coordination, and implementation models by setting ambitions to invest in better data. The Energy Compact also complements the Strategic Roadmap on Health and Energy under the Health and Energy Platform for Action (HEPA), a platform hosted by the World Health Organization (WHO) for energy and health stakeholders to coordinate their efforts to achieve Sustainable Development Goal 3 (SDG3) and SDG7 in parallel.

As the data and interventions referenced above show, the energy access gap is still significant, and progress is slow. Significant barriers remain, most notably on data availability, long-term sustainable delivery models, and innovative financing. However, the last few years have seen a significant upshift in both momentum and interest to address the issue of energy poverty in the health sector. To achieve the goal of universal electrification of health facilities by 2030, maintaining this momentum and strengthening intersectoral coordination will be crucial.

Notes and references

[1] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252705 
[2] https://www.tandfonline.com/doi/abs/10.1080/09709274.2008.11906112 
[3] https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2007.05.019 
[4] As of 20 April  2022. For updated numbers, please visit the Powering Healthcare Intervention Heatmap
[5] https://www.irena.org/publications/2020/Jun/Renewable-Power-Costs-in-2019

Gathering real-time and continuous temperature data

What we have learned in recent years is that when countries can see into their cold chain, decision-makers at all levels of the health system have a shared, objective understanding of cold chain performance. They can make informed decisions around planning, procurement and maintenance, and most importantly, they are better equipped to keep vaccines safe and potent. RTM devices automatically gather real-time, objective and continuous temperature data from vaccine storage and transport equipment, share those data with multiple stakeholders, and automate alerts and dashboard analytics that synthesize and contextualize the data.

The system saves health workers time by automatically and remotely collecting data, and it eliminates opportunities for human-prone errors from paper-based systems. It also provides a cost-effective and customizable way for countries to own their data, identify problems, procure and maintain equipment, and maximize their capacity for safely refrigerating their vaccine supplies. 

ColdTrace currently protects vaccines for one in ten babies born around the world every year. The system has been shown to reduce damage to vaccines by heat and cold by 68 percent and 67 percent, respectively. Helping countries avoid vaccine degradation due to temperature exposure — high or low — reduces waste and ensures effective immunization, ultimately reducing outbreaks of disease. 

Kenya and Tanzania are currently partnering with Nexleaf to get the right data to the right people at the right time, providing Ministry of Health personnel with the information they need to keep their fleet of vaccine fridges and transport carriers up and running. In December 2021, staff at a district vaccine store (DVS) in Tanzania received SMS alerts concerning a couple of faulty fridges and after looking at the data analytics, it was clear there had been a power outage. These data prompted a fast response from the DVS staff and power company who were able to resolve the issue within a few days, restoring reliable cooling to a store that plays a critical role in assuring the safety of thousands of vaccines distributed to local facilities. 

Tracking COVID-19 vaccines in Kenya

This real-time visibility into cold chain performance took on an even greater significance in early 2021 when countries started receiving thousands of doses of COVID-19 vaccines; Nexleaf’s work in remote temperature monitoring during transportation was well underway when the Kenya Ministry of Health requested sensor devices to monitor its valuable Pfizer and Moderna COVID-19 vaccines to ensure they stayed safe. So far, Nexleaf’s battery-powered and Bluetooth-enabled Trek device has been used to monitor all the transport routes of Pfizer (795,600 doses) and Moderna (880,000+ doses) vaccines that have been transported from the central vaccine store to the nine regional vaccine stores throughout Kenya.

The data collected via Trek are shared with health workers to show how the vaccines fared throughout the journey, providing evidence that vaccines are still potent and will protect the population effectively. The data are also organized into various visualizations that Ministry personnel can use to evaluate which vaccine distribution events maintained safe temperatures most effectively. These analytics have allowed for evidence-based discussions around the vaccine cold chain, not only for COVID-19 vaccines, but all childhood vaccines. With very clear protocols around vaccine temperature requirements and vaccine viability, health workers can use Trek data to make informed decisions rather than relying on guesswork, dispose of spoiled vaccines, and take steps to protect vaccines before they lose potency. 

Key to the value of remote temperature monitoring is the remote and automated nature of the data the system gathers. Using sensors to log and upload temperature and power availability data, the system eliminates error-prone manual data entry and enables push-button time-series data visualization. It can also provide insight into health facility power capacity, revealing how many hours of grid power flow to the facility, or whether a solar-battery system is functioning properly. Trek provides GPS route data that can give planners visibility into the locations and timing of problems that hinder efficient vaccine delivery.

As we look to the future, we believe the key to total system improvement lies in full end-to-end RTM at every storage point and transport leg of the vaccine cold chain. By 2025, we hope to see end-to-end RTM implemented in three low- and middle-income countries (LMICs), generating critical data to safeguard vaccines.

Our most crucial measure of success, however, is seeing evidence that the central Ministry of Health, health workers and personnel at every level are using data gathered by the system to guide their actions in their day-to-day work as well as in their country-wide cold chain planning, procurement and management. We also believe that the system will achieve its maximum utility when power availability and Trek route data can be leveraged effectively to provide benefits to planners beyond vaccine management, as more lifesaving equipment (such as oxygen concentrators) and critical medicines (such as insulin) are deployed to more and more remote clinics.

Meet our Global Panel on Access to Cooling member from Nexleaf Analytics