The Malawi Government, through the Ministry of Health, has been building up its health service delivery system to address the needs of treatment and care of patients.  Health services are delivered through the following levels:

·       Community level: Community Health Workers act as a bridge between the Ministry of Health and the community. They conduct community-based health education services, immunizations and mosquito net distribution and re-treatment, among other activities at a health post.

·       Health Centre level: There are health centres built in the communities and these are centres where patients are treated for minor illnesses. Uncomplicated obstetric cases (deliveries) are also done at this level. All complicated cases are referred from this level to the district hospital. The health workers at a health centre are medical assistants and nurses/midwives.

·       District Hospitals: These health facilities are staffed by doctors, paramedics and nurses and are located in each of Malawi’s 28 districts.

·       Central Facilities: patients with complicated illness are referred from the district centre to Central Hospitals where specialists are found. There are five centrally managed hospitals in the country, in addition to the Central Medical Stores.  

There are two main health service providers in Malawi and these are the Malawi Government and the Christian Health Association of Malawi (CHAM). The government health facilities are responsible for about 60% of the health delivery while the CHAM accounts for about 35% of the health service delivery. Private individuals and organisations serve the remainder of the population.

Energy represents the third largest cost in the health care service sector behind staff wages and medicines, hence it is recognized as a major cost area. Energy consumption in hospital buildings exhibit several characteristics including: (1) air-conditioning and hot water systems operate 24 hours a day year round, making back-up machines necessary, (2) multi-function services required such as surgery, diagnostic, healing, monitoring, food preparation and laundry, (3) some specialized medical treatment equipment consumes significant electricity such as MRT/I, X-ray, etc., and (4) weather, operation, and user behaviour affect the cost and consumption.  Hospital facility managers find it challenging to identify the energy inefficiencies in their buildings, because the sector lacks measured energy use data for major hospital end uses, such as cooling, heating, lighting, and plug loads. Historically, when stakeholders have supported the Ministry of Health to compare alternative energy efficiency investments for various end-use systems, their benchmarks have been limited to end-use estimates derived from modelling.

Hospitals and hospital buildings are large consumers of energy, which they use in many different ways that reflect their unique energy requirements. They have high potential for energy savings, exhibit specific energy ‘signatures’, and alterations to system performance usually have an impact on other operations. 

In Malawi, health services and health outcomes continue to be severely impacted by unreliable energy services.  About 95% of Malawi’s electricity needs are provided by hydropower, with total installed capacity of approximately 373MW (with about 20% lost during transmission).  Electricity supply is much less than demand resulting in deficient and unreliable supply, with no supply or recurrent brownouts and black-outs characterizing many health facilities. Only 10% of the Malawian population has access to electricity, with coverage of only 1% in rural areas.  Power interruptions in Malawi can be frequent and prolonged, particularly during the rainy season (November to April), mainly due to siltation, flooding or washout of sections of the transmission or distribution system Conversely, load shedding, the practice of scheduled rotating blackouts to conserve power, is common during the dry season. When medical equipment is used in real-time it must be highly available. Backup power is an essential prerequisite to keeping a system running when the supply of electrical power is unstable or unreliable.

Hospitals and other health facilities are large energy consumers, and much of their consumption is due to the increasing energy intensity of hospital-specific equipment. Users and their equipment affect the energy balance in hospitals and influence cost-effective options to optimize energy performance while maintaining quality in the delivery of health services. Hospital construction and heating, ventilating and air-conditioning (HVAC) systems are relatively better documented compared to knowledge of actual power and energy consumption of the equipment and energy consumption patterns in modern hospitals.  In Malawi, there is a dearth of accessible information about energy usage, load patterns, and energy efficiency opportunities in large hospital and health facility settings. 

In hospitals, it is the staff and patients’ use of equipment and lighting which largely drives the demand on the electricity grid, through direct energy demand and through the need to dissipate waste heat by the heating, cooling and ventilation systems.  Most hospital-specific equipment is the domain of medical professionals, not engineers or architects. Without more detailed knowledge of equipment usage, engineers resort to standardized values and/or nominal electrical power ratings for sizing and designing. In large and complex hospitals, these practices can lead to suboptimal sizing of the electrical, heating and cooling systems, and missed opportunities for storing and recycling waste heat, improving energy efficiency measures, and designing cost-effective energy back-up systems.

In Malawi, energy-consuming equipment is divided into three main categories in central hospitals:

• Medical technical equipment (MTE)

• Building equipment (BE)

• Information, computer, telecom (ICT) equipment

Medical Technical Equipment: may be divided into large and small MTE, and non-electrical surgical instruments, etc. In large MTE, one finds medical imaging equipment (MIE), including Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), Computer Tomography (CT), and X-ray and fluoroscopes for diagnosis. These are large, expensive items housed in special rooms, usually with connections for water cooling to supplement air cooling. Notably, biochemical laboratories have large equipment types which are not MIE.  The other sub-category of smaller medical technical equipment (SMTE) has a much longer and more varied list including monitors, analyzers and therapeutic devices. These are smaller air-cooled devices located in many rooms throughout the hospital, which reject their waste heat to the room air. These devices have short startup times and draw much less power, but in a much greater quantity than large MTE.

Building Equipment: is typically autoclaves, decontaminators, washing machines, ventilated hoods, fume cupboards, lighting, and safety cabinets. Much of this equipment has traditionally been integrated in the building’s walls and floors and integrated with the building’s HVAC systems such as heating supply and the ventilation ductwork for air exhaust.

ICT Equipment: more and more MTE include ICT devices, but the category ICT equipment here is limited to computers and laptops, screens and servers in server rooms without direct clinical functions. Server rooms are an especially large consumer of both electrical and cooling energy in modern hospitals.

In light of the rapid investment in renewable energy in health facility settings, particularly solar PV, UNDP and UNICEF, in collaboration with the Ministry of Health, Department of Energy, the Electricity Supply Commission of Malawi (ESCOM) and the Malawi Energy Regulatory Authority (MERA) commissioned in 2018 an energy assessment of health facilities in 39 representative sites to take stock of the state of deployment of renewable energy technology, review management arrangements and capacity for operations and maintenance, and to inform recommendations for the development of a long-term master plan and management framework to guide the deployment of possibly thousands of solar PV installations in health facilities across Malawi.  The final report is expected in June 2018.  Some of the preliminary findings of this energy assessment of health facilities include:

a)    Ministry of Health and Population, in collaboration with the Department of Energy, MERA and ESCOM would benefit from additional capacity to develop an effective strategy to manage the installed base of solar power systems and the influx of incoming systems financed by various development partners.

b)    There is a wide range of existing RE infrastructure installed in health facilities, but an absence of functional national, district or zonal management systems, including governing the operation and maintenance of equipment to ensure that the full value of these systems is realized.

c)    There remains large unmet demand for energy services in health facilities, including ancillary structures such as staff quarters, as well as untapped opportunities to supply energy services to surrounding communities through, for example, solar water pumping, and household connections.

d)    Electrical loads and load distribution in health facilities are not well balanced, reflecting the finding that pre-installation assessments and data management protocols are not in place, including to monitor performance and trigger maintenance actions.

e)    The majority of solar PV roll-out to date has been managed under a truncated two-stage process of procurement and installation, rather than reflective of a master plan for energy services in health facilities, informed by pre-assessments, facility audits to determine building renovations prior to installation, protocols for design specifications and quality assurance, commissioning, and long-term arrangements for maintenance and operation.

f)     There is an urgent need to strengthen inter-departmental coordination between the Ministry of Health, Department of Energy, ESCOM, and MERA, as well as intra-departmental collaboration to support delivery of energy services within the health sector.

g)    Additional support would be beneficial from DoE and MERA to strengthen the application of technical standards and regulatory mechanisms for stand-alone and hybrid solar power plants, and for energy efficiency requirements in public sector facilities.