With several pharma companies announcing 'promising' results and efficacy data of their Covid-19 vaccine candidates over the last few weeks, anticipation is that an effective vaccine will soon be available for public use following regulatory approvals.
For several months, governments and health experts globally have been brainstorming on how to streamline and finalise vaccine management systems -- including storage, transportation and administration -- besides identifying the priority population that will be the first to get the vaccine shots.
In India, the central government has formed a special taskforce to oversee administration of Covid-19 vaccine(s), whenever it is ready for public use. However, vaccinating a large country with a huge population is always a task fraught with challenges, more so in the midst of a raging pandemic that has infected close to 1 crore people in the country and killed at least 1.37 lakh.
Experts have already pointed out that storage of Covid-19 vaccines in cold chains can be a major challenge because several vaccine candidates require storage temperatures between -50 degrees Celsius and -70 degrees Celsius, a range our cold stores aren't designed to handle.
As per government data, India has close to 28,000 cold store units, a decent figure, but majority of vaccines that are used in India and for which our cold stores were developed and designed, are stored at temperatures ranging from 2 degrees Celsius to 8 degrees Celsius.
While vaccine storage and cold chain management is a pan-India concern, an associated challenge that is of specific concern in remote and rural areas is the unavailability of reliable electricity supply at several primary health centres (PHCs).
Union health ministry's latest data on rural health infrastructure show that nearly 5 per cent PHCs in rural areas (795) do not have electricity supply.
On an average, a rural PHC serves 35,567 people. This means, over 2.82 crore people in rural India are dependent for health services, including routine immunisation, on PHCs that do not have power supply.
Globally, the International Renewable Energy Agency (IRNEA) estimates that nearly 1 billion people rely on health facilities without electricity supply and most of them are in rural areas.
In a recent study, experts at the University of North Carolina, US, analysed 1,29,557 health facilities spread in 78 low-and-middle-income countries and found that 59 per cent of them did not have reliable electricity supply.
Why PHCs are vital for successful vaccination
In India, PHCs are grassroot-level government-run health centres that are responsible for providing last-mile health services and carrying out immunisation drives. They are the nearest health facility for the people and effectively serve as the first point-of-contact between the government and society, especially in rural areas, for any public health intervention.
The role of PHCs is critical in India's immunisation programme. Once a vaccine is manufactured, it is transported from the manufacturer/supplier to the state or regional vaccine store. From there, the vaccine is distributed to districts, which in turn send them to community health centres (CHCs) and primary health centres (PHCs).
The CHCs and PHCs are generally equipped with cold chain facilities to store vaccines before they are used on ground. On the day of immunisation, the auxiliary nurse midwife (ANM) of each sub-health centre (SHC) under a PHC is issued vaccines in kits that are specially designed to ensure vaccines' temperature is maintained right to the point of usage.
Under this system, PHCs play a vital role in ensuring last-mile temperature requirements for vaccines to remain safe. This role is likely to remain crucial even during the mass vaccination for Covid-19, whenever a vaccine gets regulatory approvals.
The power imbalance
Though the overall figure of PHCs without electricity supply (5 per cent) may appear to be low, what is of concern is that these PHCs are concentrated in a handful of states-mostly those with poor rural health infrastructure.
In Jharkhand, 55 per cent PHCs in rural areas do not have electricity. Apart from it, there are six states where more than 10 per cent rural PHCs are functioning without electricity.
These include: J&K (18.6 per cent), Uttarakhand (14.4 per cent), Arunachal Pradesh (12.9 per cent), Odisha (12.6 per cent), Nagaland (11.3 per cent) and Uttar Pradesh (10.7 per cent).
In context of vaccines, continuous and reliable electricity supply is crucial to ensure management of cold chains where vaccines are stored to retain their optimum efficiency.
While just 5 per cent rural PHCs don't have any electricity supply, recent reports have shown that several PHCs that are connected with electricity supply, suffer regular and long power cuts and voltage fluctuations--factors that can endanger vaccine safety and potentially even damage medical equipment.
A 2017 report of the Council on Energy, Environment and Water revealed that nearly 48 per cent of the 147 randomly surveyed PHCs in Chhattisgarh were power-deficit.
"A vast majority (90 per cent) of PHCs connected to grid reported frequent power outages between 9am and 4pm (main operating hours for hospitals), while 28 per cent PHCs reported regular voltage fluctuations," the report said.
It added that of the PHCs that were connected to the power grids, 55 per cent reported power cuts between 12pm and 4pm -- their busiest hours.
This was despite the fact that Chhattisgarh itself is a power-surplus state.
Need for energy-efficient hospitals
Over the past several months, the coronavirus pandemic has tested the resilience of India's public health infrastructure. The PHCs and CHCs have been instrumental in serving as grassroot units to test and quarantine people for Covid-19, besides carrying out door-to-door awareness drives.
For any mass vaccination drive to be successful in India, it is important to ensure that PHCs have reliable basic infrastructure, especially 24-hour electricity and water supply. However, electrification of PHCs in remote and rural areas remains a challenge due to limited resources and rough terrain, especially in hilly states.
The challenge of terrain was also revealed in the Union health ministry's latest report on rural health infrastructure, which shows that 8.2 per cent of rural PHCs are still not connected to all-weather motorable roads.
In six states, this figure is more than 15 per cent, and in Arunachal Pradesh it is the highest (25.7 per cent).
This apart, one in every four government sub-health centre (SHC) in rural India (26.2 per cent) is not connected with electricity supply. In Jharkhand, 65.7 per cent of rural SHCs don't have power supply, while the figure in Bihar is 64.5 per cent, and in Assam and Odisha it is 62.3 and 47.5 per cent, respectively.
The absence of reliable electricity and water supply at these grassroot health centres has a cascading effect on the quality of services provided there and a negative impact on the morale of health workers posted in such remote areas.
To overcome the challenges of electrification in rural areas, several state governments have now started investing in renewable sources of energy (like solar photovoltaic cells) to run PHCs. The idea is to make them self-sufficient in terms of meeting their energy requirements.
Energy demands of health centres in rural areas can broadly be categorised into two: (1) to run appliances, and (2) to perform daily duties like OPD, administration work etc.
Since availability of reliable electricity supply in rural areas is limited, it is important that authorities concerned adopt an energy-efficient approach to meet these two requirements.
Apart from exploiting the potential for solar electrification, it is also important that the appliances used at these health centres (including cold chains for vaccines) are energy efficient and the buildings are designed or retrofitted in such a manner that the overall energy consumption of rural PHCs and sub-centres can be brought down.
The health ministry's data show that buildings for nearly 900 PHCs and 34,000 SHCs in rural areas across India are yet to be constructed.
Furthermore, as of July 1, 2019, the ministry estimated that there was a shortfall of 2,865 CHCs, 8,764 PHCs and 43,736 SHCs in rural areas.
All these yet-to-be constructed hospitals and health centres in rural India provide governments a chance to conserve energy, and make grassroot health centres self-sufficient and energy efficient.
In its 2017 report on PHCs in Chhattisgarh, the Council on Energy, Environment and Water had found that solar rooftop systems in PHCs were able to effectively meet their electricity needs for lighting, refrigeration, water-pumping, and even provide power for advanced medical equipment.
"About 22.4 per cent of power-deficit PHCs currently rely on solar as backup to run cold chain equipment," the report said, adding that overall, 89 per cent PHCs equipped with solar rooftop systems reported reduced electricity costs.
Access to electricity has a direct effect on delivery of public health services in remote areas.
Last year, in a study on rural PHCs in Gujarat, researchers from the National University of Singapore found that availability of electricity "significantly improved" the operational capacity of health facilities as it increased availability and functionality of a wide range of essential devices and equipment.
The study, published in the Journal of Health, Population and Nutrition, said access to electricity was critical in increasing the probability of children receiving critical vaccinations and pregnant women receiving antenatal care.
"The probability of a functioning deep freezer, ice-lined refrigerator, cold box, and vaccine carrier increased significantly by 6.5%, 5.2%, 5.8%, and 6.6%, respectively," the study said on its analysis of the impact of a rural electrification scheme on access of health services.
In this context, as governments gear up to chart their post-pandemic development strategy, it is only prudent that the buildings that house our public hospitals are imagined and designed to minimise energy needs and maximise energy efficiency.
(This article is written as part of the Centre for Media Studies-BEEP media fellowship 2020 on energy efficiency.)
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