The African villages where they’re located might be considered ‘the last mile.’ But the primary public health clinics in those villages are better called “front line.”
Frontline health clinics are first responders in the COVID-19 pandemic of 2020 as they were in the 2014 Ebola epidemic in Liberia and Sierra Leone and as they are every year in fighting malaria, HIV, cholera and so much more. Even without an immediate emergency, frontline clinics play a vital role in screening patients, administering vaccines and helping women deliver babies.
So it’s unacceptable verging on unfathomable that the vast majority of frontline clinics in sub-Saharan Africa don’t have electricity to power medical devices, charge phones and laptops or even provide lighting so doctors, midwives and other health workers can see at night.
Electricity was already essential for the world to have a shot at meeting Sustainable Development Goal No. 3, including the reduction, by 2030, of global maternal mortality rates to less than 70 per 100,000 live births (from 211 in 2017, and still much higher in low-income countries).
But it is the COVID crisis that has spurred the scramble to find sustainable financing solutions to bring reliable, renewable power to health facilities.
To help sustain the momentum, this week’s Agents of Impact Call No. 24 is bringing together health practitioners, solar developers, ministry officials, international donors and development bankers. Their innovative finance design challenge: Light every clinic (RSVP now).
“When COVID-19 disappears, we are at risk of finding ourselves back in the same position we were in,” says Sustainable Energy for All’s Jem Porcaro. “We know this is a risk, because we didn’t solve the problem during and post-Ebola. So there is a real urgency around leveraging the awareness that COVID has raised around the importance of power to the provision of health care.”
The overwhelming darkness of a health clinic without electricity became clear to me several years ago in a nighttime visit to a village in Uganda. I was accompanying a team from the nonprofit We Care Solar, which the next day was to install its modular “Solar Suitcase” to provide lighting and basic electricity, especially to promote healthy childbirth and reduce maternal mortality.
Without electricity, midwives sometimes must hold their cellphones in their teeth. Women bleed to death because they can’t be adequately monitored in the dark. There is almost nothing to compare with the direct impact of enabling midwives to do what they have been trained for: save the lives of mothers and babies.
I’ve been on We Care Solar’s board for the past decade and am proud that the organization has demonstrated solar solutions that have lit more than 5,000 frontline public health clinics. Co-founder Dr. Laura Stachel, an OB-GYN, has helped put lighting and electricity on the global health agenda. Other NGOs and development agencies have lit hundreds more.
That still leaves hundreds of thousands of frontline clinics in the dark in Africa, as well as in south Asia, Latin America and other regions.
Philanthropic donations or foreign aid has covered the cost of nearly all of the installations to date. Venture capitalists and other investors who have flocked to the growing off-grid solar markets for homes and businesses in Africa and elsewhere have not found their way to the inarguably messier challenges of financing improvements for remote, rural, underfunded public health clinics. Go figure.
From my perch at ImpactAlpha, I was convinced financing solutions must exist. The falling cost curves of renewable energy, coupled with the inarguable health impact of reliable electricity made for a compelling challenge for the purveyors of blended finance or catalytic capital. Surely, innovative financing could unlock the relatively modest capital required to light every clinic.
Such models were hard to find – until now. As part of We Care Solar’s 10th anniversary activities, ImpactAlpha is co-hosting an Agents of Impact Call to bring health, energy and financial practitioners together around a compelling design challenge. It’s a chance to show your stuff: Make the numbers work for the toughest case and conquering the rest of the market should be easy.
The obstacles to such solutions are old news in global health. What’s new this year are initiatives that borrow elements already working in adjacent sectors to craft a range of solutions for frontline clinics. Among the developments:
Service model. As in other parts of the solar markets, financing can turn high initial capital costs into longer-term operating costs, not unlike the way electric utilities already bill their customers. Among the nine solar ventures recently awarded grants from Power Africa through the U.S. Agency for International Development is Havenhill Synergy, which is using such an energy-as-a-service business model to electrify 21 rural healthcare facilities in Oyo State, Nigeria. In Ghana, PEG Solar will provide electricity access to 91 rural community healthcare facilities in Ghana with a similar service approach. SolarWorks! Plans to electrify 92 rural healthcare facilities in Mozambique’s Sofala province and cover operational and maintenance costs for five years.
Portfolio approach. GreenStreet Africa, led by New York-based GreenMax Capital Advisors, has developed a model that aggregates multiple smaller health care solar projects into portfolios large enough to attract local investors in commercial bonds. GreenStreet is working on a pilot with Nigeria’s Rural Electrification Fund and InfraCredit, a local bond underwriter and guarantor to supply reliable solar energy for a half-dozen healthcare facilities that rely on diesel generators and unreliable grid connections. The project is being incubated by the Global Innovation Lab for Climate Finance (see, “Eight climate finance innovations that can help accelerate a green recovery”).
Lease to own. Broken down solar systems litter health clinics across Africa. Solar technology can be fairly rugged, but has some known vulnerabilities, particularly battery life.
“There is no money to maintain and there is no clarity on who is responsible for what,” said Kjetil Røine of Norway-based Differ Group.
One solution to this misalignment is to create long-term service contracts that provide steady revenues over a period of time in return for service-level agreements that ensure that the systems continue to operate and generate electricity. Differ Group adds to the portfolio approach provisions for operations and maintenance to ensure that systems continue to generate power for the life of the financing. Røine says Differ ‘take responsibility for the entire value-chain,’ including not only hardware and installation but also five-year service contracts, subcontracted to local providers.
Donor collaborative. Under most of the models, the ultimate customers are country-level ministries of health. The U.N. Development Programme, through its Solar for Health initiative has install solar systems in more than 650 health facilities, including 405 in Zimbabwe and 145 in Nepal. Last year, UNDP enlisted KOIS and Differ to research innovative finance solutions to scale its activities in Malawi, Zimbabwe, Liberia, Namibia and Zambia. Among the findings: ministries of health have limited ability to pay for electricity and require coordinated donor support. Working with donor countries, the UNDP is seeking funding from the Green Climate Fund to leverage donor funding to provide guarantees and other mechanisms to backstop the health ministries.
“The business case for health clinic electrification is tough,” says USAID’s David Stonehill. “But with blended capital structures, new technology (PAYGO, remote monitoring), and an emphasis on “energy as a service” as opposed to the old procurement model, we can start to move the needle and make a difference.”