Powering Health

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Ethiopia

Map of Ethiopia and its neighbors.

The USG PEPFAR program is a multi-country, multi-billion dollar initiative to prevent and treat HIV AIDS in developing countries (www.pepfar.gov). The PEPFAR program in Ethiopia has found the effectiveness, sustainability, and reach of prevention, care and treatment programs are directly compromised by the lack of reliable power at health facilities.

The Challenge in Ethiopia

Ethiopia has one of the lowest per capita electricity consumption rates in the world. Availability of electricity is almost entirely concentrated in urban areas, even though 80-85 percent of the population is rural. The Government of Ethiopia has embraced an electrification strategy to increase electricity access from the national grid from 13 percent in 2002 to about 20 percent by 2012. The Government is also striving to provide universal access to primary health care by 2010. In order to meet its universal access goal, Ethiopia will need to construct a huge number of health facilities throughout the country in a very short period of time (around 2,500 health centers alone by 2010). Since the idea is to expand access to health care in areas currently unserved, it is likely that at least 50 percent of the new facilities will be in areas with no access to electricity (or water service).

The energy situation has a great impact on Ethiopia’s health care system, which essentially consists of a referral-based, three-tier system:

The outside of a small health clinic in Ethiopia. (Photo: Walt Ratterman)

• Health Posts: provide grass-roots outreach and counseling, preventive services and some maternity care.
• Health Centers: provide preventive, curative and rehabilitative services to the surrounding communities. Health centers currently have catchment areas of up to 100,000 people.
• Hospitals: provide comprehensive health services to patients referred by the health centers.

In addition, each region maintains at least one reference laboratory. The PEPFAR program works primarily with hospitals and health centers, as well as the reference laboratories. Virtually all of the PEPFAR-partner sites are connected to the grid. At the request of PEPFAR/Ethiopia, the USAID Office of Infrastructure and Engineering’s Energy Team conducted a two-week assessment of Ethiopian health facilities in April 2008.

Key Findings

The assessment team discovered that a) problems with electricity supply and quality significantly limit the ability of Ethiopian health centers and hospitals to deliver health services, and b) the implications of additional electrical system needs imposed by PEPFAR-related programs need to be recognized and dealt with by the program. Otherwise, many PEPFAR investments (particularly expensive, sensitive medical equipment) will be at risk, and the ability of Ethiopia’s health system to develop reliable networks to diagnose and treat HIV/AIDS will be compromised.

In Ethiopia, the following problems characterize health facilities connected to the grid:

Intermittent power supply

Brownouts are common (especially during the dry season), as the national utility is not able to meet demand throughout the system. However, electrical loads are not shed on a predictable basis, posing a serious challenge for facilities possessing expensive electrical equipment and running sensitive medical tests. The intermittent power supply necessitates the use of a back-up power source or special equipment (i.e., UPS systems) designed to safely power down equipment when the main power supply cuts off. Few facilities had this equipment reliably in place.

A closet full of non-functioning equipment at a health clinic in Ethiopia. (Photo: Walt Ratterman)

Poor quality power

The national utility has problems delivering electricity at the expected voltage, especially during times of drought. Voltage that is too low may prevent equipment from functioning; voltage spikes can damage equipment and make it unusable.

Inadequate wiring/electrical configuration

The internal wiring in most of the health facilities visited was substandard, causing a number of problems, including decrease in voltage and overheating (and in one regional lab, visible signs of an electrical fire). In addition, as health facilities expand, wire (often incorrectly sized) is simply strung from one building to the next rather than connected to a main service panel, further reducing voltage and available electricity supply.

Electricity needs not integrated into planning

At all levels, from PEPFAR partners to health facility managers to government planners, electricity needs have not been integrated into health program planning. As a result, resources are not being maximized and malfunctioning equipment is negatively impacting health delivery. The impact could be particularly strong in new facilities being planned for construction outside the grid. Options for providing electricity to these facilities should be assessed before they are built so construction designs can accommodate the selected electrical system and bulk procurements of energy generating equipment can be conducted. However, interviews indicate that few of the regional planners have the ability to conduct this kind of analysis.

Response

Based on the evaluation team's findings, PEPFAR/Ethiopia is striving to incorporate electricity needs into its planning processes. Engineers from USAID’s Office of Infrastructure and Engineering have conducted follow-up visits to design holistic infrastructure assistance to the Ministry of Health, to ensure that future health facility renovations and construction are built to modern standards. In addition, new PEPFAR contracts and existing budgets are being designed to incorporate the following measures:

• Install voltage regulators and UPS systems on key pieces of electrical/medical equipment.
• Upgrade internal health facility wiring, at least to PEPFAR-critical sites (i.e., laboratories, data analysis/info systems, blood banks, etc.).
• Ensure that PEPFAR-provided equipment is appropriate for the electrical configuration and staff capacity of the facility.
• Provide training to health facility staff how to use key pieces of electrical equipment.