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INTRODUCTION
National health facility mapping is not a requirement of the MEC 4722 Renewable Energy Capstone Project. Nonetheless, Capstone Project students need a basic understanding of both existing and emerging health facility mapping standards, as these standards inform electric power applications (and other energy intervention strategies) based upon energy needs for healthcare facilities by categorization or classification at required levels of care and service availability.   
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This lesson plan provides Capstone students with an overview of the "State-of-Play" in national health facility mapping, including existing and emerging donor requirements, and current health facility mapping reform efforts of the Republic of Uganda and the World Health Organization (WHO).

In the resources section, there is a brief presentation of the emerging integrated planning approach utilizing geographic information systems (GIS) and artificial intelligence (AI) for micro-grid development for healthcare facility electrification. The resources section also contains an informative webinar on Integrated Energy Planning (IEP) hosted by Sustainability for All (SEforALL).     
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Orientation: For an orientation on this topic, it will be useful to review emerging national health facility mapping standards emerging from the Sustainable Energy for All (SEforALL) Initiative publication, Powering Health Facilities - Approach, (2020) [1], before proceeding to the lesson plan, below. The emerging SEforALL standards are reviewed in the STANDARDS section of this lesson plan: 
LESSON PLAN
National Inventory of Health Facilities: Ministries of health are generally responsible for maintaining an inventory of healthcare facilities by categorization or classification of health facilities at required levels of care or service availability. The Ministry of Health (MoH) of the Republic of Uganda completed the National Survey of Health Facilities in 2018 [2] with support from the Monitoring and Evaluation Technical Support (METS) Programme at the Makerere University (MU) School of Public Health.

Table 1, Quantity of Health Facilities in Uganda by National Health Availability Standards Framework, below, summarizes the national inventory of health facilities in Uganda classified by designated levels of care, Table 2 provides the classification code (Level), catchment area (Population), and level of service (Services Provided).
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Table 1. Quantity of Health Facilities in Uganda by National Health Availability Standards Framework*
Source: Ministry of Health, National Health Facility Master List (2018), page 9. (See 2.0. Bibliography)
*The term "Clinic" represents a team of health personnel in the field and may or may not include a physical facility. 
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Table 2. Health Facility Availability Standards Framework
Source: Ministry of Health, National Health Facility Master List (2018), page 7. (See 2.0. Bibliography)

​The National Survey of Health Facilities in 2018 purports to provide the following information:
     (a)  a complete list of health facilities by location, level, ownership and status of functionality;
     (b)  unique codes for identification of health facilities and administrative units, which serves a single reference              point by all stakeholders; and
     (c)  a guide to effective planning for equitable distribution of resources, services, staffing, rational distribution of             medicines and supplies, and health care access. 
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Upon review of the report, item (a) lacks an indication of functionality; item (b) provides classification code by level of care (but not service availability); and item (c) lacks sufficient information to serve as a "guide" for effective planning for the equitable distribution of resources, services, staffing, rational distribution of medicines and supplies, and access to health care.

The National Survey of Health Facilities in 2018, furthermore, does not provide the following requirements for health facility mapping under the emerging SEforALL standards:
[2]   Current power status of each facility (access to electricity; power reliability), including type of             electric power resources (if any) and other existing energy resources and end-use application               (generator, fuel supplies, etc.);
[3]   Proximity to the national electric power grid, including overlay with current and near-term grid         extension plans;
[4]   Physical lay-out of the healthcare facility, including site map, facility floor plans;
[5]   GIS (geographic information systems) location; GIS location of nearest nation electric power grid           connection)
[6]   Medical equipment requiring electric power or other energy services, including specific                         requirements for current or planned level of care by existing or proposed categorization or                   classification of health facility;
[7]   Cold chain power status;
[8]   Description of catchment area, including geographic characteristics and demographic data;
[9]   Staffing requirements, including current or planned staffing;
[10]  Staff housing requirements (on-site vs. off-site); and
[11]   Planned facility improvements, including specific level of care requirements.​

​The National Survey of Health Facilities in 2018 may, if fact, have captured all or portions of items [8] through [10], above, including: a description of catchment area, staffing requirements (current and/or planned); staff housing requirements (on-site vs. off-site); and planned facility improvements to meet level of care requirements.

The published report, however, lacks data by facility and lacks utility to assess healthcare facility electrification requirements; and no access to survey data is currently available at the facility level. See Table 3, Sample Survey Data, Kyegegwa District, below, for published site-specific data: 
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Table 3, Sample Survey Data, Kyegegwa District
Source: National Health Facility Master List (November 2018); Ministry of Health (See 2.0. Bibliography) pg. 141.
 
Survey protocol is not disclosed in the National Survey of Health Facilities in 2018, but the survey data for the National Survey of Health Facilities in 2018 was likely collected ​utilizing the Service Availability and Readiness Assessment (SARA) protocol, described below:   

Service Availability and Readiness Assessment (SARA): The Service Availability and Readiness Assessment (SARA) [3], a joint effort of World Health Organization (WHO) and United States Agency for International Development (USAID), is a methodology designed to assess service delivery. The SARA methodology was built upon two research assessment tools:
  1. the service availability mapping (SAM) tool developed by the WHO, and
  2. the service provision assessment (SPA) tool developed by ICF International under the USAID-funded MEASURE DHS (monitoring and evaluation to assess and use results, demographic and health surveys) project, among others. 

​The SARA is currently a survey methodology combined with remote field data collection devices to collect and present basic information on health services: e.g., health infrastructure, human resources and services offered. Its main application is at the sub-national or district level, where health management teams can use the results to monitor health services. SARA data is complied at the national level and reported to the WHO utilizing a standard reporting framework.

Uganda has conducted three national Service Availability and Readiness Assessments (SARAs) to assess service delivery in health facilities. In 2012, a sample of 5 districts and 95 health facilities were surveyed. In 2013, 209 facilities in 10 districts were surveyed [4]. (The 2014 SARA Report is not available electronically.)

The SARA reports identify the percentage of facilities that offer a particular health intervention (service availability) as well as whether facilities offering the service have the minimum set of items (equipment, trained staff and guidelines, diagnostic capacity, and medicines) in order to provide an adequate level of service (service readiness). Table 3, Percentage of facilities with basic amenities items available (N=209), below: 

Table 3, Percentage of Facilities with Basic Amenities Items Available (N=209)
Source: Uganda Services Availability and Readiness Assessment 2013, Summary Report, pg. 3 (See 2.0. Bibliography) 

Note the 2013 SARA report (based on a sample of 209 facilities) indicates that 64% of health facilities have access to a power source. The breakdown of urban versus rural indicates that rural facilities have only 54% of the mean availability of basic amenities. The percentage to mean availability of access to power for rural communities is absent in the report. Also absent in the SARA report is an indication of the mean availability of adequate access by categorization or classification of healthcare facility at level of service availability. 

Note the SARA survey form in Table 4, 5.0 Medicines, Supplies and Equipment: Heath Infrastructure, Power Supply), below, is a dated form which contains the survey questionnaire concerning power infrastructure utilized in the Ministry of Health (MoH) National Support Supervision Guidelines for Health Services (3 September 2020) [5]. See Table 5, Proposed Structure for a SARA Energy Module based on SARA Core Infrastructure Survey (highlighted in yellow background) for current SARA energy module. 

Table 4. 5.0 Medicines, Supplies and Equipment: Heath Infrastructure, Power Supply
Source: Ministry of Health: National Support Supervision Guidelines for Health Services (2020), pgs. 33-34 (See 2.0. Bibliography) 

It is now universally understood that the SARA questionnaire is insufficient to address national planning for healthcare facility electrification. The SARA questionnaire fails to address standards for the mean availability of "adequate access" to power infrastructure by categorization or classification of healthcare facility at level of service availability. ​

Currently, there are two initiatives to address this shortfall in national health facility mapping:
  1. the WHO has made recommendations to expand a SARA questionnaire on electric power resources by categorization or classification of healthcare facility at level of service availability; and
  2. the Ministry of Energy Mines and Mineral Development has developed a Terms of Reference (TOR) for the World Bank funded Uganda Energy Access Scale-Up Project (EASP) aimed at establishing an Indicative Rural Electrification metric, or "standard" for electric power infrastructure in healthcare facilities to meet MoH designated levels of service availability by categorization or classification of healthcare facility.    

The WHO recommendations for an upgraded SARA energy module contains survey questions for multi-tiered measurement of electric power infrastructure. The full text of the proposed SARA energy module from Modern Energy Services for Health Facilities in Resource-Constrained Settings: A Review of Status, Significance, Challenges and Measurement (2015) [6], published by the World Health Organization (WHO), is posted in Table 5, below: 
Table 5. Proposed Structure for a SARA Energy Module based on SARA Core Infrastructure Survey
Note: Existing SARA energy questions are highlighted in yellow. Numbering of existing questions has been preserved, but order of some questions has been changed so as to accommodate an expanded survey format. New questions are generally proposed as additions but some are refinements of existing questions. 
Source: World Health Organization (2015); Modern Energy Services for Health Facilities in Resource-Constrained Settings: A Review of Status, Significance, Challenges and Measurement, Annex 1, pgs. 68-71 (See 2.0. Bibliography) 

The Ministry of Energy Mines and Mineral Development has developed a Terms of Reference [7] for the World Bank funded Uganda Energy Access Scale-Up Project (EASP). The TOR is aimed at establishing an Indicative Rural Electrification Metric (IREM), as the "standard" for electric power infrastructure in healthcare facilities to meet MoH designated levels of service availability by categorization or classification of healthcare facility.
 ​
The TOR provides the most current IREM for HC II and HC III facilities is as follows: 

     - HC II Electrification Status: 38% of 4,456 facilities are electrified; 2,776 facilities are not electrified;
     - HC III Electrification Status: 55% of 2,600 facilities are electrified; 1,162 facilities are not electrified.    

Based upon these most recent facility counts, it can be estimated that 73% of Uganda's rural populating of 33.5 million are served by a combined total of 3,938 HC II and HC III facilities that lack access to electricity.

The TOR defines EASP approach as a means to mitigate the shortfalls in maintenance and operational (O&M) practices, and to improve reliability of electricity supply. To achieve this goal, the EASP strategy will be to shift from procuring and maintaining the solar systems by the public institutions, to outsourcing the full-service to amortized-rent-to-own arrangements using private sector, energy service providers, under performance-based contracts. Additionally, the private sector must be encouraged to invest in the ownership of such installations since financing from governments and donors will be increasingly insufficient to serve all public institutions in Uganda. This approach will reduce the burden on the GoU to invest all capital cost upfront and will instead require it to arrange for regular payments to the private sector that include both capital cost (amortized) and operations and maintenance cost. 

This approach is premised upon previous World Bank experience in Sub-Saharan Africa which shows that despite availability of sizable capital investment to install solar systems at health centers, actual delivery is sometimes non-existent or substandard either due to non-functioning equipment (inverters, panels, batteries) that has not received adequate O&M or no systematic plan for regular O&M.

Under the ERT-2 project in Uganda, approximately 13 percent and 30 percent of solar energy packages installed in health centers and schools, respectively, are not functional. Under ERT-1, the degree of non-functionality is even more significant, reaching approximately 50 percent of solar energy packages installed in health centers and schools. Failure are attributed primarily to issues with batteries (85 percent) and other factors (15 percent) due to a combination of issues – inadequate funds for routine maintenance and component replacement, late release of funds for maintenance contractors and for purchase of defective components with solar panels, fuses, inverters, etc. 

The scope-of-work of the TOR advances the national health facility mapping in six subcategories of tasks with deliverables, as follows:

Task 1, Situational Assessment:
  •   Verify the existence of the facility at the specified location (district, community etc.) and assess the suitability of the structures to be equipped with an off-grid power supply
  •   Record by GPS the coordinates of the facility and map it on Google My Maps platform
  •   Record the names and contact details of key facility personnel and local government 
  • officials responsible for the operations of the facility;
  •   Determine level of mobile phone service (voice/text only, GPRS, EDGE, 3G, H/H+, 4G, 
  • none) at each facility to determine if remote monitoring technology can be deployed
  •   Describe the operation activity of the facility, including the operating hours, and expected 
  • daily electricity consumption (demand) patterns
  •   Record the number of rooms and list the potential / earmarked electrical equipment per 
  • room and the expected daily usage pattern of electricity
  •   Record existing/potential electrical equipment/appliances on site (e.g., refrigeration, 
  • sterilization, etc.), including their current physical state and utilization
  •   Describe the current level of functionality of the facility (fully functional, partially functional, etc.) and highlight key constraints to functionality (medicine, vaccinations, 
  • water supply, electricity supply, etc.);
  •   List all lighting and other equipment destined to be replaced by electrical equipment and 
  • describe how it is perceived in terms of efficiency, reliability, service quality and provide photographical evidence. (e.g., candle, kerosene lamp, battery-powered torch, cooking utensils, heaters etc.)
  •   Record the condition of the existing diesel / solar /other generator (if any), the average amounts of money spent monthly on fuel/wood/charcoal, initial costs (if relevant) including photos of the equipment, capacity and brand specifications of the equipment and nameplates where available
  •   Record the terms and conditions of and existing O&M contracts that apply to the above power supply system(s) and equipment.
  •   Assess potential space (in m2) that could be made available for a solar system (rooftop, land adjacent), the existence of shading impediments, roof facing directions with photographic records and explanations
  •   Determine the approximate downtime of all equipment per day/per month, due to lack of budget or technical reasons.
  •   Complete the site-specific Environmental and Social safeguards checklist as per World Bank Performance Standards.
  •   Develop and populate a survey questionnaire for interviewing key beneficiaries (relevant government officials, administrative staff, medical staff, and patients) on:
o The current and potential future electricity needs of the facility, including lighting and specialized
appliances; 
o The perceived (potential) benefits of solar power solutions;
o Concerns about the potential negative impact of solar systems; 
o Physical or other hazards that the solar installations might potentially be exposed to; 
o Perceived risk of theft or vandalism and potential mitigation measures;
o The perceived progress of electrification state of all nearby villages within 5 km of the site;
o Assess the facility’s existing monthly, quarterly and annual expenditures on energy services;
o Review the approved budget and actual release of funds historically;
o Assess their ability to pay for operation and maintenance costs of existing or new solar power systems;
o Assess their ability to pay for the capital costs existing or new solar power systems;
o Assess the potential of additional revenue streams if the facility is to be electrified. ​
  •  The survey questionnaire should be used to interview at least the following:
​               o Members of the Management team
               o Staff responsible for operations and maintenance
               o Local Government staff 
  •  Analyze and consolidate the findings into a written report, which shall be the basis of the planning and design phases to follow. ​
  •  Proposals for potential revenue streams should be tested with local governments as they will require authorization under the Local Government’s Act and, with Central Government as facilities would require authorization to collect non-tax revenue. ​

Task 2, Planning / Needs Assessment of required off-grid solar installations: 
  •   Scrapping inadequate power supplies,
  •   Upgrading existing functional units or ​providing new power supplies;
  •   Forecast the load pattern at each institution and categorize them into various groupings depending on the present and future energy loads;
  •   Listing electrical fittings and appliances required at each site with their electrical demand characteristics and usage patterns.
  •   Simulating the load curve of the facility allowing for at least 20% unforeseen load.
  •   Assessing the adequacy of existing solar systems installed on site to serve the perceived load.
  •   Assessing the viability to continue with existing systems in considering reliability, serviceability, technology, residual lifespan and contractual arrangements.
  •   Selecting standard design package to serve the perceived load.
  •   Determine the following cost aspects as inputs to the Financial and Economic analyses
    below: ​​​
o ​Capital costs for upgrading the existing supply systems;
o Capital costs for installing the new supply systems;
o Maintenance costs for upgraded existing supply systems;
o Maintenance costs for new supply systems;
o Capital costs savings realized by upgrading the existing supply systems; and
o Operating and maintenance costs savings by upgrading the existing supply systems. 

Task 3, Standard Designs of Installations by Type: 
  •   ​Based on Tasks 1 & 2, design standardized solar-powered service packages appropriate for the facilities with different ranges (4-6) of capacities. The designs should utilize the latest technologies that enable long-term system sustainability, particularly focusing on optimizing storage through high-cycle, deep-discharge batteries.
  •   For each design, estimate the CAPEX and annual O&M costs (including refurbishment) over the recommended usage period. This should include costs of replacing expensive items such as batteries after 5-7 years.
  •   The standardized designs should address all facility needs and allow for future electricity demand growth, including a 20% kWh and kW reserve margin
  •   The designs should allow for remote monitoring by GSM mobile network or alternative modalities where GSM coverage is poor;
  •   The design shall specify resilience to theft and physical or other hazards.
  •   These designs then need to be confirmed and approved by the various user Ministries,
    UNBS (the standards bureau) and ERA (the regulator)
  •   Compile CAPEX and OPEX programs (un-prioritized) of the above, assuming a certain
    rate of implementation, based on realistic budgets and technical assumptions. These will
    serve as inputs to, and be iteratively adjusted after, the financial analyses below.
  •   The public institutions should be availed the opportunity to review and approve the designs including approval of the minimum serviceable condition at handover when it
    occurs after the contract has expired. 

Task 4, Financial and Economic Feasibility Analyses: 
  • Financial analyses from the Service Providers position to determine the expected amortized cost to the beneficiaries, as follows: 
o The financial analyses shall be conducted per the agreed categories and be aggregated to reflect the      complete program per sector for each Ministry of the GoU benefitting from the program;
o The analyses shall ultimately produce the expected monthly lease cost per category allowing for cost of capital, finance cost, O&M costs, equipment (such as batteries) replacement costs, independent technical and residual value audits, equipment disposal costs, taxes, depreciation and propose an agreeable and justifiable internal rate of return (IRR) and profits margins; and
o The analyses shall assume that the ownership be transferred to the user Ministry at the end of the recommended lease period and reflect the estimated residual value at the end of the lease period, to be confirmed by an independent valuation in practice.
  • Economical analyses from the beneficiary Ministries position to determine the expected sustainability of implementing the proposed concept:
o The economic analyses shall be conducted per the agreed categories and be aggregated to reflect the complete program per sector for each Ministry of the GoU benefitting from the program;
o The economic analyses shall ultimately produce the expected cost and benefits per category considering current direct and indirect cost savings and the benefits derived from the implementation of the proposed concepts as compared to traditional procurement and maintenance of systems; and 
o The analyses shall assume that the ownership be transferred to the user Ministry at the end of the recommended lease period and reflect the estimated residual value at the end of the lease period, to be confirmed by an independent valuation in practice. 
  • Review of Government of Uganda constraints on payment for electricity service:
o Interview Personnel at MoH, MoES, MoWE, MEMD, and MoLG on challenges regarding payment to private sector, if any;
o Explore avenues for government ministries to pay for both capital cost and O&M component of electricity service; and
o Draft recommendations for adequate and regular release of funds to the private sector, for example: which government budgets or programs can be tapped into. 

​Task 5, Roll-out Program / Prioritization:
  •   Adjust the sequence and timing of the roll-out program, as may be required; 
  •   Establish a suitable scoring system for assigning electrification priority to the earmarked sites; and
  •   Coordinate with the MoH, MoES, MoWE, MEMD, MoLG, and the World Bank, to recommend the facilities to be electrified in a roll-out program.

Task 6, Development of an Implementation Strategy:
  •   Develop a detailed implementation strategy for the electrification of the facilities that are deemed feasible to benefit from the envisaged program considering the following strategies: ​​
o The earmarked facilities shall be grouped into geographical lots, include optimum number of sites to allow economies of scale for the private sector to invest in electrification of facilities and adopt long-term service contracts;
o The Service Providers shall provide technologies meeting technical and quality standards like IEC standards and approved by the national institutions; 
o The Service Providers shall be responsible for the detailed designs and have the flexibility to make reasonable adjustments to the described designs to improve efficiency and adapt to conditions dictated by the selected equipment and site conditions.
o Recommend key performance indicators (KPIs) to be adhered to by the service providers such as system reliability and availability, ensuring sustainability related to system design, O&M services;
o Suggest a third-party verification mechanism in case of disputes between Service Provider and Client on attainment of KPIs;
o Conduct a market sounding exercise to validate the approach and ensure there is adequate interest from potential Service Providers to ensure successful implementation and conclusion of contracts as earmarked in the concept; and 
o Revise the implementation strategy and develop appropriate tender documents. 
Source: Ministry of Energy and Mineral Development; Uganda Energy Access Scale-Up Project, Terms of Reference (2020); pgs. 5-13. (See 2.0. Bibliography) 

Conclusion: 

These two initiatives---the WHO recommendations to expand a SARA questionnaire on electric power resources by categorization or classification of healthcare facility at level of service availability, and the​ Ministry of Energy Mines and Mineral Development Terms of Reference (TOR) for the World Bank funded Uganda Energy Access Scale-Up Project (EASP)---are advancing an Indicative Rural Electrification metric, or "standard," for electric power infrastructure in healthcare facilities. The recommended and required protocols established under these initiatives, when combined with recent advances in GIS capacity and AI application, will advance the "State-of-Play" for national health facility mapping. However, the Renewable Nations Institute recognizes that the scope and scale of technical assistance, capacity building and decision support required for the development and implementation of standards at this level of detail and complexity (either in the Republic of Uganda across the more than 100 countries identified by the WHO as lacking in modern energy services in their national health systems) will require reimagining the delivery of support services.   
WEBINAR SLIDES - 11 MAY 2021
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