Out of the 538 health centres, about 97 health facilities do not have access to electricity while 221 health facilities do not have a reliable power supply. Since 83% of Rwanda’s population lives in the rural area, implies that only 12% of the population have access to electricity. From Table 1, a high mortality rate is observed among. While so many reasons may contribute to these high mortality rates, it can be inferred that some of these - deaths are accounted for by pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related deaths [22], [24], [25], [26].

With 83% of Rwanda’s population living in rural areas and hardly having access to the national grid, Rwanda has focused on providing electricity to the rural communities so that they may benefit from several micro-hydropower projects being rolled out. For example, more than 200 kW is expected from the 22 micro-hydropower plant projects, was commissioned by the Ministry of Infrastructure government to provide electricity in Western and Northern provinces of Rwanda, to over 800 households, health centres, schools, and small businesses [27], [28].

Although most rural communities in Rwanda are far from the national grid, Rwanda’s Global horizontal irradiance (GHI) shows enormous potential to provide power to the rural health centres as a backup power supply. The studies by the GeoSUN Africa solar map further shows that the average GHI in Rwanda ranges between 4.5-5.4 kWh/m²/day. In other efforts to improve health facility power deficit by the Solar Electric Light Fund (SELF) and the Partners in Health (PIH) organizations, five health clinics have been equipped with 3.4-4.3 kW solar photovoltaic (PV) systems to provide healthcare services for almost 400,000 Rwandans through powering laboratory equipment like blood analysis machines, microscopes, portable X-ray machine, sterilization devices, and centrifuges; provide refrigeration, telecommunications, and computers, etc In summary, poor of household electricity supply can contribute to non-neonatal deaths, because of indoor air pollution from kerosene fuel, candle, etc. and or even accidents from these poor lighting ways. Further, more indirect causes of both neonatal and non-neonatal deaths alongside the high turnover rate of health workers in rural health centres can also be attributed to poor electricity supply [29], [30].

To date, access to financial capital is a critical barrier to scaling up off-grid solar energy in Rwanda for basic lighting purposes and for powering basic mini-grid appliances like radios and televisions. Some Solar Light firms in Rwanda are attracting foreign and local debt and this has led to the establishment of the Scaling-Up Renewable Energy Program in Low Income Countries (SREP) - funded renewable energy fund. This promotes private sector investment in off-grid power solutions, especially in innovative financial schemes like Pay-as-you-go (PAYG) and debt-equity, Energising Development Rwanda (EnDev), and the SIDA-funded Scaling-up Off-Grid Energy (SOGER) programs. Further, the SREP-funded Renewable Energy Fund (REF) enhances mini-grid financing for health centers through its direct lending window approach. By December 2017, USD 34 million was invested in Solar Home Systems (SHS), while larger companies like Mobisol managed to secure debt-equity financing mechanisms amounting to USD 35 million in 2017. With these great financing mechanisms in place, Rwanda managed to attract USD 55 million in capital investment in 2019. Table 3 shows the current off-grid electrification status in Rwanda [31], [32]. Table 3 gives the current renewable energy power supply status of off-grid systems in Rwanda.

Table 3 shows the current renewable energy power supply in terms of SHSs and MGs, with targets for the year 2024. Although Rwanda has attracted substantial financial investment, a large gap as high as 50% still needs to be closed [32].

To further enhance financing mechanisms in Rwanda, the government has established the renewable energy investing model - the SREP-funded Renewable Energy Fund (REF) that is implemented in collaboration with the Rwanda Development Bank (RDB). The objective of Rwanda’s SREP Investment plan is to accelerate off-grid electricity access through stand-alone solar systems and renewable energy-based mini-grids through its Four-window Initiative that is implemented through the Rwanda Development Bank (RDB). Figure 2 shows the schematic window framework for the Rwanda REF Financing Program.

Figure 2.

SREP Funds - REF renewable energy financing framework in Rwanda

Figure 2 shows the four renewable energy financing mechanisms by RDB to a corporative initiative called Umurenge SACCO – Window 1, commercial, microfinance – Window 2, mini-grid developer – Window 3, and to local off-grid firms in Window 4 [31].

Due to poor public-private partnership relationships alongside pockets of bureaucratic issues to access the funds, small local firms are disadvantaged in accessing these funds while the large multinational companies easily meet the strict financing criteria put in place (Window 4). This implies that the impact of these funds requires capacity building within BRD to ably handle these financing programs and this will also extend the duration for the expected program outcomes. So far, the REF and RDB programs have demonstrated the ability to fulfill the International Monetary Fund’s SDG financing framework (Billions to Trillions) which is implemented through the Official Development Assistance (ODA) to invest billions in aid or grants in developing nations to catalyse and harvest trillions out of the public and private sector [33].

In Kenya, the ongoing pursuit to extend country the electrical network has brought about an increase in power access, especially in the Western part of Kenya. Although 73% of Kenya’s population lives in rural areas, the electrification rates in rural households remain extremely low, averaging 5% and 22% for rural businesses. Out of the 695 health centres, about 181 health facilities do not have access to electricity while 104 health facilities do not have reliable power supply sources [22], [34], [35].

In Kenya, about 56% of all the health facilities have a continuous water supply annually but 25% of these health facilities have an uninterrupted power supply. This is worsened by the fact that only 42.8 % of women in these hospitals have access. In addition to inadequate water supply, rural health care faces challenges such as a shortage of skilled midwives during childbirth, high employee turnover rates, and long distances to health centers [35], [36]. The Centre for Disease Control and Prevention (CDC) – Kenya cites the top 6 killer diseases in Kenya that contribute to poor health services as evidenced by the high mortality rates in Kenya to vulnerability to deaths from diarrheal diseases, HIV/AIDS, and TB, neonatal diseases, other non-communicable diseases, mental and substance abuse, and cardiovascular diseases. The diagnostic tools for these diseases heavily depend on having reliable electricity [37].

The absence of adequate and reliable power puts at risk the social well-being of millions of people, particularly women, and children, who frequently endure adverse effects of not having adequate healthcare services. In rural communities in Kenya, access to maternal and infant care administrations is still restricted because of the poor existence of maternal and infant care infrastructure [35].

Specifically, pneumonia, malaria, and cancer lead Kenya’s causes of death with 21,584 people dying from pneumonia in 2017, 17,553 deaths from malaria and 16,953 deaths from cancer, and HIV/AIDS being fourth with 8,758 deaths [38]. Out of all pneumonia deaths experienced in Kenya (21,584 deaths), child and maternal deaths take the largest share of almost 13,000 deaths which accounts for almost 60% of the highest killer disease [39].

The need for more resources to power the health sector was initiated by the Cleaner Energy for Health Care Conference (CEHCC) in Nairobi, Kenya because delegates realized that Kenya was highly resource-constrained concerning delivery of power to health facilities. Further, the CEHCC also concluded that solar photovoltaics and energy-efficient medical equipment have the potential to provide more resilient health systems in Kenya and sub-Saharan Africa [40].

One notable innovative project out of the CEHCC is Kenya’s Off-Grid Solar Access Project (KOSAP) which focuses on providing power to as many health facilities as possible with solar PV systems. The KASAP program is dedicated to delivering clean energy systems to the vulnerable in rural Kenya while boosting Kenya’s rural electrification rate.  It capitalizes on the strengths of institutional frameworks to drive country and community-led projects, significantly advancing progress towards the United Nations Sustainable Development Goals, specifically SDG 3 (Good Health and Well-being) and SDG 7 (Affordable and Clean Energy). The conceptual framework that guides the off-grid health system scale-up projects in Kenya through the CEHCC, is given in Figure 3 [41].

Figure 3.

Kenya's off-grid renewable energy financing model

Figure 3 shows a financing model for off-grid renewable energy model and synergies between renewable energy and health services. Although these thematic sectors hardly work hand in hand in the real world, the business world, the public sector, universities, private firms, and health practitioners need to start collaborating to improve energy access and efficiency.

Figure 4 shows the three pillars (planning and technical, institutional, and financial) which presents the synergies between the six thematic areas that form the Kenya National Electrification Strategy (KNES).

Figure 4.

National electrification investment model for Kenya [42]

The Kenya National Electrification Strategy (KNES) comprises the following six themes:

To achieve universal access to electricity for all Kenyans, a 5-year investment plan that was based on 2009 demographics was done in 2017 to provide electricity supply to 5.1 million customers at a connection rate of 100,000 new connections per month. The average household size in Kenya is 3.9 and this translates to 13.77 million households in Kenya with 10.1 million households living in the rural areas and only 1.414 million households electrified (14% electrification). This projection demographically still falls short of the required electrification connections, especially in rural areas. Table 4 KNES’ 5-year electrification investment budget plan and its target connections [43], [44].

Table 4 shows a 5-year breakdown of Kenya’s national electrification investment plan from 2017 to 2022 with a total investment of USD 2,748.9 million to carter for only 5,651,300 connections or households. With a rural population of 39.2 million, a mare connection target of 5.7 million people still leaves a large gap. Further, Kenya’s additional 5-year investment plan from 2023 to 2027 only adds USD 292.2 million to carter for an additional 767,510 connections giving a total of 6,418,810 total connections in 10 years. This investment plan is far from achieving the UN SDG 7 target concerning providing clean and affordable energy to all Kenyans by 2030. A gap of 69.6% unconnected households excluding the 14% electrification in rural areas.

Out of the 428 health centres, about 133 health facilities do not have access to electricity. This implies that the remaining 295 health facilities do not have a power supply. Since 47% of Ghana’s population lives in the rural area with an average 52% of its population having access to electricity points to the fact that almost 48% of Ghanaians are faced with compromised health delivery. Six of the top killer diseases in Ghana include malaria, lower respiratory infections, neonatal disorders, ischemic heart disease, stroke, and HIV/AIDS [45], [46].

In Ghana out of 428 health facilities, about 133 health have no access to power while 120 health facilities have no reliable electricity. This also compromises health care delivery. This contributes to deaths from pneumonia, birth asphyxia, meningitis among neonates, malaria, acute respiratory infections, etc. [22], [47].

Previous studies by Opoku et al. [48] in community-based health planning and services (CHPS) centers with 145 patients in Mamprugu Moagduri district in the northern region of Ghana, evaluated the potential impact of solar photovoltaic systems on the healthcare system service delivery and the socio-wellbeing of community for long-term sustainability. It was found that the CHPS centers were solar PVs that improved the healthcare service delivery because a 30% drop in prevalent diseases in the Mamprugu Moagduri district was recorded. The major interventions of installing solar PVs assisted in (i) storing medicines at temperatures below 30 °C, (ii) keeping vaccines at 3-7 °C (like snake bite vaccines), and (iii) retention of health workers like nurses who had to walk for about 18 km to purchase ice blocks to keep the vaccines as refrigerator supplement.

In Ghana’s health facilities, which offer child vaccination on a routine basis, 16% are restricted in this undertaking by the absence of power or fuel to keep up the prescribed temperatures for storing medicines [49]. The unreliable power supply can cause damage to both medical equipment and any other equipment. Previous studies by Opoku et al.[48], found that access to power in the health centers has more effect on females and children than men because they spend more time engaging in agricultural activities and fetching firewood for cooking, which could have been used for more productive economic activities.

Ghana is a hydro-dependent nation, accounting for about 60% of the total generated energy. Out of the 30.4 million people living in Ghana, 70% of them have access to power, making Ghana one of the nations with very high connection rates in sub-Saharan Africa with only 5 million people (30%) not having electricity. However, the remaining 30% is exceedingly troublesome and expensive to electrify using the Ghanaian electrical national grid because these places are remote, difficult-to-reach regions, including islands and lakeside regions. To address this deficit, a generation-mix strategy deploying hydropower and renewable energy resources like solar, and wind is an attractive power source option because it is renewable, clean, affordable, easy to deploy off the national grid. This makes renewable energy a key source for sustainable energy development among the poor majority and especially in rural health facilities. One challenge Ghana faces is the rapid population growth rate of 2% per annum. This demands that Ghana needs to over-expand its electrical generation resources to meet this rate and high demand. With 47% (14.29 million) of the population live in the rural areas by 2019 and only 52% (7.6 million people) having access to electricity in the rural area, the deficit is also expected to grow in proportion to the growing demand. The expansion plans by the Government of Ghana estimate that by 2026, the electricity demand will increase threefold to about 4,200 MW (28,000 GWh). The current peak load demand by 2019 is estimated to be 20,000 GWh, leaving a deficit of 8,000 GWh [35], [50], [51].

Although the Ministry of Energy has planned to invest about USD 1.4 to 2.6 billion in renewable energy, it still falls short according to the anticipated peak power demand of 28,000 GWh by 2030 and the Ghanaian National Commission for UNESCO, which also estimates that an estimated $9 billion was needed to be raised by 2019, as investment capital for renewable energy development and finance Ghana’s 10-year renewable energy program.

In response, the government of Ghana has put up the Scaling-up Renewable Energy Program in Ghana Investment Plan (SREP-Ghana IP) comprising (i) the renewable energy micro-grids and stand-alone solar photovoltaic systems, (ii) the solar photovoltaic-based net-metering with energy storage systems, (iii) the utility-scale photovoltaic or Wind power generation project and (iv) the technical assistance to scale-up renewable energy. The SREP-Ghana investment program provided USD 40 million as part of a cost-sharing or equity model as a financing strategy to unlock financing opportunities for accelerating sustainable energy development in Ghana using renewable energy resources and innovative financing strategies like pay-as-you-use models. The SREP-Ghana Investment plan further requested an additional USD 190 million amount to make a USD 230 million budget with contributions from the government of Ghana, the African Development Bank, the International Finance Corporation (IFC), the private sector, and other development partners, investors, financiers, and beneficiaries. Further, the government of Ghana through the Ministry of Energy has developed two 10-year phases; phase 1 - up to 2019 and phase 2 - up to 2026. However, although it is still uncertain as to how to source the funding for phase 2, the Ministry of Energy has set ambitious renewables targets as given in Table 1 but is uncertain with the financial investment sources for phase 2 [52].

However, the implementation of these renewable energy projects will not come without any challenges. Some transformative impacts and renewable energy outcomes for implementing renewable energy projects are that renewable energy projects will support low-carbon technologies and pathways, which reduce energy poverty, increase energy security, increase the supply of renewable energy, increase access to energy-efficient cook stoves, explore new resources for renewable energy programs roll-out to help reduce air pollution and climate change by avoiding greenhouse gas (GHG) emissions [52], [53].

Using renewable energy, Ghana can enhance its socio-economic development through a low-carbon energy development pathway alongside the existing large hydropower generation and renewable energy systems that currently only contribute a marginal 0.3% to Ghana’s installed capacity despite having a large renewable energy potential base. The government of Ghana is committed to achieving the UN SDG 3 and 7 which emphasizes health well-being and energy provision and attaining sustainable energy development and sustainable health systems by scaling up the deployment of renewable energy solutions. Since most rural health facilities are in remote places, off the national grid, exploring renewables would not just reduce air pollution to reduce respiratory diseases and greenhouse gas emissions. To achieve this, adequate capacity building on renewable energy systems, and enabling investment of about USD 9 billion will be needed to finance the second phase (2020-2030) [2], [52], [53], [54].

Some common observations in the three case studies concerning renewable energy deployment and investment for rural health facility electrification are that:

While these observations cannot be used to draw any solid conclusions in specific case study countries, the findings can support policy formulation and strategic planning, decision making, and overall, improve sustainable health systems in the selected case study countries. Research significance, policy implication, and limitations

The findings of this study can help decision-makers to make informed decisions that are evidence-based, replicate, or adopt public-private investment strategies capable of breeding new and innovative financing business models. Further, decision-makers can leverage existing policies or propose policy formulation to scale up renewable energy technologies in rural health centres [50], [51].

Although the top five killer diseases in Africa are lower respiratory tract infections, HIV/Aids, diarrhoeal diseases, Ischaemic heart disease, and parasite diseases (Malaria), these will differ from one country to another depending on the investment policies that have been placed by their governments [49], [50]. Renewable energy provides a solution for powering medical equipment in rural health facilities, demonstrating its potential to enhance health system resilience and improve healthcare service delivery

This study is limited to evaluating the social impact of renewable energy usage in health systems in Kenya, Rwanda, and Ghana using credible secondary data to analyses the social impact qualitatively without using primary data that would help validate the stated demographic and mortality data. Further, it is recommended that future studies should quantify the exact greenhouse gas emission reduction that can be realized using renewable resources in rural health facilities. Quantifying the impact of renewable resources in the selected case studies over a long period with a relatively larger sample can lead to better conclusions on sub-Saharan Africa. To demonstrate the benefits of renewable energy deployment, control experiments can also be done to derive some evidence-based lessons learnt from those with and without renewable energy investment interventions.