In this episode of the Power for All podcast, William Brent speaks with Jeff Stottlemyer of CLASP’s Clean Energy Access program. COVID-19 has highlighted a silent humanitarian crisis that has persisted for far too long -- the fact that hundreds of millions of people in Africa and Asia are still served by rural health clinics that have no electricity. While efforts to change that are gaining momentum, what’s come to light in the process is that this is much more than just about deploying solar panels and some batteries and ensuring that these systems are operated and maintained in the long term. As important, if not more, is the need for medical devices that are able to work in these clinics once they’re electrified. CLASP’s new report published through the Efficiency for Access Coalition talks about this critical, yet underappreciated challenge. Here’s a summary of the conversation:
Medical equipment should be built to succeed in weak-grid conditions
There is a lack of appropriately designed medical equipment and medical devices that can function with a small renewable energy system in a remote off-grid clinic, or a clinic in a peri-urban area that has a grid connection but the quality of supply is poor. Medical devices and appliances have to be designed differently than they are in the global north in order to function effectively for a long period of time. Currently, there are no supply chains and very limited availability of these kinds of medical equipment and devices, which impacts the lives of hundreds of millions of people. There is a disconnect between the global supply chain of medical devices and medical equipment and the needs of primary health clinics in remote villages. They need energy efficient, durable appliances that can operate in harsh environments, and in terms of most types of medical equipment, those products just don’t exist because most medical devices in the global market are manufactured for consistent grid connected facilities.
Mainstream medical equipment and medical device supply chains, and the manufacturers of those devices are optimizing their products to ensure that they deliver services consistently and safely. In clinical settings in the global north,the amount of energy access is effectively infinite so energy consumption and energy efficiency are not even in the conversation when these products are being designed. The primary concern has been around the device itself, whether it can do what it is meant to do, and safely. Some of the larger global medical equipment manufacturers interviewed spoke very frankly about never having even considered efficiency as a product design principle. So that really is the starting point for our work now.
A 2010 WHO statistic estimated that up to 70 percent of medical devices in the global south don’t function. This has to do with the nature and quality of energy supply that is often found in these types of areas. If a clinic has no electricity access at all, obviously, that’s a non-starter. You’re unable to power any medical devices. But many clinics have weak-grid or bad-grid connections, where there are frequent brownouts and blackouts. When there is energy supply, it fluctuates substantially. What this means is the voltage can swing much higher and much lower than it does on grids in the global north. And the amount of available power can vary greatly. These medical devices have not been built to handle this kind of fluctuation, and so they break. The number one cause of equipment failure in these clinical settings is the inconsistency and quality of energy supply.
One of the underlying reasons why it’s so challenging to think about developing a commercial market for these types of appliances is that in the global north there’s sometimes a glut of medical equipment. Maybe regulations change and a type of device is no longer allowed to be sold in a given market. And so we see a lot of these products are donated -- or dumped -- into markets where these regulations don’t exist. And where there is, of course, a need for equipment. Not all of this happens for bad reasons. Large global companies think they’re helping by donating massive amounts of equipment for free. But the reality is that this equipment is not designed to succeed for a long time in these conditions, but these are the only appliances that are available for the clinic to be able to provide that service. The lack of availability of options traps a lot of clinics and service providers into this vicious cycle of having to use equipment that isn’t appropriately designed, and then it breaks, and then it’s laying around, and so you’ve got to get more of it. And it’s the sort of thing that happens all over again.
Beyond lighting: Using renewable energy to provide holistic health care solutions
Another dynamic that the report goes into in great detail is the significant number of clinics in the global south that have bad grid connections. There’s also a shockingly large number of clinics that are operating with no electricity. Since the onset of the COVID pandemic, we have rightly seen increased recognition of this as a challenge in both the energy world and the public health world. There are a number of major new initiatives and investments that are focused explicitly on providing renewable energy systems to these clinics that have no access to electricity. But these initiatives are very complicated and resource intensive in and of themselves. And what we see typically, because of resource constraints, is the need to prioritize and make trade offs in terms of what a program can actually do. We tend to see this type of effort focus primarily on the provision of an energy system by itself. So if the clinic doesn’t have any energy, you drop in a solar panel, battery, maybe put a few lights on it, maybe include one of these vaccine refrigerators, and that’s it. That seems to be the limit of what happens in a lot of places. We know that lighting is an absolutely essential energy service in clinical settings, but once you have that as a starting point, you really need basic diagnostic tools, you need to be able to provide various types of primary health care services that require appliances and devices that use energy. So what we’re trying to do is to advocate for more holistic thinking when it comes to these kinds of interventions. In other words, let’s not just put a bunch of solar panels on the roof and call it good. But let’s actually bundle with those solar panels devices that are appropriate for those settings that can provide real healthcare solutions.
Lack of guidance on equipment and standards
There is no more or less uniformly accepted guidance on what types of appliances should be in various types of clinical settings, with the explicit purpose of designing an energy system for those clinics. There are many different lists of recommended equipment for health facilities. But we found that the contents of those lists often include everything. They include bandages, benches, tables, chemical agents for lab tests, as well as electrical appliances. And the information about the appliances is sometimes just the name of the appliance. And if you took one of those lists and wanted to design an energy system, you might find that there’s actually 15 different designs for one kind of appliance, and some of them may use completely different physical or chemical processes to deliver that service and have a range of energy requirements. These lists have not been created from a clinical electrification perspective.
Another challenge is that at the country level, ministries of health everywhere provide guidance on allowable equipment, whether it’s in terms of regulating imports, or whether it’s in terms of helping healthcare providers understand what should be in these clinical settings. But those lists are different everywhere. And the differences can be extreme. One country may have just one list of appliances which could be 1000 items long; another may have very detailed guidance on what appliances should be in what type of health facility; and still another country might have a combination of the two but still be very different. And so, if you’re an energy company that’s trying to meet this need of providing energy systems for clinical settings, it’s hard to even know where to start in terms of designing systems and solutions because it’s challenging to identify the appropriate appliances and devices that should be included in an energy system, let alone understanding what the potential energy requirements are and where to start looking for suppliers. It’s a very complicated network and the lack of clear and consistent guidance is a major inhibitor of making progress there.
Learning from vaccine cold chain success
There has been immense progress made in the vaccine cold chain sector, where health systems in many countries in the global south are supported by large scale, donor funded initiatives, which frequently include procurement of equipment. There’s also now increasingly large scale clinical electrification initiatives that include various types of energy system infrastructure as well. And so, if we wanted to incorporate a more holistic approach to appliances, these big procurement documents would need to include the right language that specified that an energy system needs to be equipped with an appropriate suite of appliances that have been designed to function with limited and inconsistent energy supply and in harsh operating environments. That would send a critical signal to the existing mainstream global medical equipment supply chains and provide a healthful opening for startups that may be interested in focusing explicitly on this need and would give them a much clearer path to growth and path to market and help create a more sustainable supply chain.
Breaking sector silos
One of the challenges about the health energy nexus is that the health world and the energy world, more specifically the energy access world, have not historically moved in the same orbits. So some of the most important work that’s getting done, and has been done by organizations like Power for All, SE4All and other such global initiatives have just been focused on creating space for the energy sector players and the health sector players to talk about the challenges and those efforts are all to some degree still nascent. They have been, rightly, focused on the highest level of strategic challenges around making a case for such a nexus, which is sometimes surprising that a case has to be made that energy is important for health service delivery. But it’s not intuitive, or certainly wasn’t intuitive for quite a while. So a lot of these initiatives are focused on unlocking the highest level of commitments to invest, they’ve been focused on policy issues. And they haven’t had the resources or the mandate to focus what is a technical, complex and very challenging set of issues related to medical equipment. So we see a real need for creating forums for even industry players for these medical equipment designers and suppliers to talk with the companies that are designing renewable energy powered solutions for primary health care centres in rural areas just to understand what the operating environments are like and what the nature of these energy systems are. Fostering this kind of dialogue can then translate into the design of the equipment in a transparent, open and ongoing way, which is critical to making progress in this area and can also help in breaking down the energy and health silos more generally.
The way forward
The report lays out a specific set of recommendations on the way forward that can be started on right away. The first thing is leveraging CLASP’s expertise and understanding around appliance performance, appliance testing, and appliance standards to work in collaboration with some of the leading public health organizations who have been doing the most important, most sophisticated thinking around this challenge and help address the fundamental barrier of understanding what the most broadly applicable suite of devices should be included in truly off-grid clinical settings. And then formatting and structuring that guidance with the explicit purpose of aiding energy system design.
Secondly, there’s the technical development that has to be with testing products, trying to understand what the energy requirements are of some of those products that are already in these places, and putting together some sort of data sets that allow us to understand the nature of the challenge right now from that technical point of view.
Thirdly, starting that dialogue, creating that convening space with interested partners is also a critical first step because this is where we’re going to be able to bring in all the perspectives that are needed to make progress on things like procurement and policy development.