How Affordable and High-Performing Medical Technologies Can Enhance Off-Grid Health Services During COVID-19

By Jeff Stottlemyer and Hannah Blair of CLASP, Co-Secretariat of the Efficiency for Access Coalition.

While disrupting the daily lives of billions, the impacts of COVID-19 are felt the hardest by the world’s most vulnerable people. This series originally posted by GOGLA, developed by the Efficiency for Access Coalition, explores the implications of the pandemic on off-grid communities in sub-Saharan Africa and South Asia, and how solar technologies can support emergency response and bolster resiliency to a global shock like the coronavirus spread.

COVID-19 exposes long-standing gaps in clinic electrification

“Urgent intervention is needed to shore up the healthcare infrastructure in low-resourced countries, where most facilities lack basic electricity access and quality medical equipment. The off-grid solar industry can bridge this gap by rapidly mobilizing sustainable solutions to ensure reliable medical care is available to all, especially the two billion people at the base of the pyramid who are most vulnerable to the pandemic.” — Anshul Gaur, Director of Grants & Marketing at d.light

An estimated 33% of health facilities across sub-Saharan Africa have unreliable access to electricity, while up to 25% have no access at all. In rural India, more than 39,000 village-level health centers, currently serving 230 million people, lack electricity. Without modern energy services, healthcare professionals cannot utilize basic diagnostic tools, maintain adequate inventories of critical medicines and vaccines, or readily access information relevant to patient care.

The COVID-19 pandemic has further exacerbated this inequity in access to modern health services, with hundreds of millions of people unable to get tested for the virus or receive treatment if infected. As the pandemic has crippled some of the best-resourced health systems in the world, how can health systems with limited to no electricity or medical equipment respond to the global threat?

Medical cold chain is necessary for an equitable COVID-19 vaccine rollout

As the world turns its attention to the COVID-19 vaccine and a potential cure, the vast inequities in the health cold chain will present tremendous challenges for rollout. Prior to the pandemic, millions of children went unvaccinated against preventable diseases largely due to a lack of access to cooling infrastructure. In health facilities, refrigeration is required to extend and maintain stockpiles of medication and life-saving immunizations.

According to Efficiency for Access’ Off-Grid Market Survey, vaccine and blood bank refrigerators were ranked as the most important devices for health care delivery. In order to deliver the COVID-19 vaccine to 60–70% of the world’s population, representing 4.7–5.5 billion people, massive amounts of new cold chain equipment will be necessary. Vaccine refrigeration is perhaps the most developed off-grid medical service delivery appliance category, yet cost and technical capacity remain a barrier for mass rollout.

Gavi, the Vaccine Alliance, is working with governments to procure bulk high-performing vaccine refrigerators — they are investing $250 million to procure close to 65,000 units, including solar direct drive fridges, for nearly 50 countries. Yet, without adequate funding and equipment supplies, Gavi will still have to make difficult decisions about the trade-offs between the delivery of the COVID-19 vaccine/cure and other temperature-sensitive vaccines and medical products.

Existing medical equipment doesn’t fit the requirements of off-grid clinics

From our perspective, with the COVID-19 crisis — the focus is still more on energy supply systems, however developing and scaling appropriately and efficiently designed medical appliances is equally critical and needs much more attention from energy and health stakeholders. – Huda Jaffer, Director of SELCO Foundation

The lack of appropriately designed medical equipment is a less obvious, but significant challenge for successful health facility electrification. Current electrification initiatives often focus solely on the energy system, without adequate consideration for the sizing or sourcing of the medical equipment required to deliver health services. But what use is an urgent care facility without a vital sign monitor, steriliser, or x-ray machine?

Unfortunately, very few commercially available medical devices are designed to perform in resource-constrained settings and with a limited energy supply. In addition, solution providers — organisations that sell and/or deploy healthcare solutions, including solar energy companies — struggle to understand which types of medical devices they should include in their healthcare offerings.

In the pandemic context, they are often unable to find suppliers of appropriate and compatible versions of essential products like oxygen concentrators, ventilators, or sterilisers. This can lead to the deployment of solutions that lack the most essential medical equipment, or unnecessarily large and expensive energy systems that power inefficient equipment.

In some ways, it makes sense that clinic electrification efforts have largely ignored the specialised equipment required in clinical settings. Sourcing medical equipment presents a unique set of technical and commercial challenges that are particularly daunting for stakeholders whose primary focus is energy products intended for residential or commercial use. For their part, medical equipment providers are rarely asked to focus on energy efficiency or specialised product designs, as governments and donors often make procurement decisions based solely on cost.

Technical complexity poses a challenge to deployment of medical equipment

According to the World Health Organisation, there are over 2 million different kinds of medical devices on the market, across more than 22,000 categories of devices. Faced with this level of complexity, solutions providers must often make arbitrary choices or, at best, explore a limited set of options regarding which type of device to procure and who to procure it from.

For example, the Off-Grid Market Survey ranked sterilisers as one of the highest priority medical appliances during COVID-19. However, the Government of Ethiopia’s list of approved medical devices describes 12 different types of steam sterilisers, each with different designs and performance profiles, making it difficult to determine which, if any, would be suitable for a given health facility.

Thomas Rieger, CEO of Solarkiosk, experienced this challenge when designing a solar-powered COVID-19 test lab: “We decided to focus on a single manufacturer for key pieces of equipment, because otherwise we would have spent way too much time comparing products that we barely understand made by manufacturers we had never heard of, and with no way to compare quality.”

Even when solutions providers identify a specific type of medical device as indicated, commercially available versions of the same device are often highly energy intensive and incompatible with solar-powered systems.

Aside from some incubators and start-ups, very few companies make products that consider efficiency benchmarks and that work with solar. Almost all the products require an inverter, explains SELCO’s Jaffer. Inverters allow grid-compatible (AC) appliances to run on solar (DC) energy supply, but add an additional cost to running the system and are potentially less reliable than a system designed for DC appliances. Low quality inverters may also result in unexpected appliance performance issues, reduced lifetime of components and increased power use.

Health and energy sectors operate in silos

Silos between health and energy sector stakeholders — and government departments — remain a significant challenge for clinic electrification efforts generally, and the challenge is even greater when it comes to medical equipment. This is due in part to technological complexity, but also reflects the reality that existing efforts to convene the health and energy access communities, such as SEforALL’s Powering Healthcare initiative, are nascent and therefore must focus on a wide array of issues without the mandate or capacity to engage deeply with medical equipment.

Distributed energy companies attempting the enter the healthcare space struggle to navigate medical equipment supply chains made up of large multinationals as well as small, highly specialized medical technology companies and start-ups. Rieger describes it as “the most difficult sector we have ever encountered, where the suppliers often don’t perceive any incentive in engaging with a solar company like ours.”

Medical equipment suppliers, in turn, are largely unaware of the need for medical devices that are compatible with solar-powered energy systems and designed to function in harsh environments. “We were constantly searching for additional suppliers of advanced medical devices, but it’s challenging, as the majority of the suppliers don’t even have the sub-Saharan Africa market on their radar, and some even turned down our request because they did not have the capacity to start working in the region,” explained Gil Karie from Ignite Power.

Call to Action: Break down silos & catalyze innovation

The COVID-19 pandemic has shown that now, more than ever, the clean energy access and health sectors need to be working together. Partnerships would accelerate both of our efforts to increase global clean electrification and ensure communities have access to health services and life-saving vaccines, articulated Dr. Karan Sagar, Head of Health Systems and Immunisations Strengthening at Gavi Health.

There is an urgent need for a cross-sectoral convening — and commitment — focused explicitly on low resource settings. Such a convening space will build upon the existing efforts of early leaders on the health/energy nexus, while allowing the appropriate stakeholders to engage more deeply with technical, regulatory, and market challenges specific to medical equipment.

And as international actors like the WHO and Gavi — as well as local governments — direct resources to off-grid medical cold chain infrastructure for the eventual roll-out of the COVID-19 vaccine, such a convening space can help support the technical elements of these efforts.

Donors and investors should also make available funding dedicated to supporting innovations in high-priority medical equipment categories. Such funding can help break down the silos described above by raising awareness about the importance of off/weak-grid medical equipment, accelerate existing research and development (R&D) efforts, and encourage new players to engage with the medical equipment space.

This support should include direct R&D funding as well as competitions and innovation prizes that identify early-stage market leaders and innovators as well as provide signals to the broader market regarding product quality.