By Annika McGinnis

Video documentary by Andrew Aijuka

• Moyo district in northwestern Uganda, bordering South Sudan, has one of the lowest rates of electricity access and vaccination in the country
• Three rural health centres in Moyo district received solar power systems in September in a new project funded by the German development agency, GIZ
• The solar systems have resulted in increased safe births, better security and communication, technology charging services, and reliable power for staff
• Covid-19 dealt a blow to sales of off-grid solar power in Uganda as sellers and technicians struggled to move to rural locations during lockdowns. From January-June 2021, solar lighting sales fell to their lowest level in the past three years.
• The Moyo district budget for solar purchases has tripled in the past three years to 115.5 million shillings ($33,100) in the current budget. Still, this amount could only purchase similar solar power systems and refrigerators for around two of the district’s 28 health facilities. More resources are needed for electrification of rural health.

 

When Baatio Agnes felt her first labor pains, she left her house and walked 6 kilometers to the nearest health facility to give birth to her first child. 

She was just 17 years old. Three years later, and pregnant again, the resident of Moyo district in northwestern Uganda was again planning for the long walk. This time, it would be 15 kilometers on mountainous roads to reach the nearest health centre 3, the lowest level of a health clinic in Uganda that has a maternity ward.

But the night had fallen when she went into labor. In the darkness, Agnes was forced to move to her closest health centre 2, a more basic outpatient clinic where births are allowed only in cases of emergency. For years, the health centre in Abeso village near the border with South Sudan had operated without any source of electricity – making night births difficult and dangerous as health workers relied on small torch lamps or candles to illuminate the mother and baby.

But this time, Agnes was in luck. With a new state-of-the-art solar power system, the Abeso health centre supplied unwavering light through the long night of labor, until the moment when she welcomed her young son into this world. Today, her baby is three months old and healthy. 

 

The Abeso clinic is one of three rural health centres in Moyo district that received solar power systems in September in a new project funded by the German development agency, GIZ. In an area with some of the lowest levels of electricity access and vaccination in the whole country, district leaders and health workers are hopeful that the now-reliable light and power systems will advance health services for the more than 7,000 people who live in this remote area. 

Patrick Drama, the Moyo district energy focal person, said the district responded to a competitive call for proposals from GIZ that were eligible to eight countries in Africa to win the bid. He said Moyo district is particularly vulnerable. The main electricity grid, with power supplied from the dams on the Nile River in Jinja, reaches only a radius of about 5 kilometers along the main road in Moyo district, leaving the majority of households and institutions without power. Out of the 15 health centre 2s in Moyo, only three are on-grid, according to Drama. 

Many of the district’s health centers are located in mountainous rural communities along the South Sudan border, treating mobile populations of Ugandans, refugees, and South Sudanese nationals who cross the border to access treatment, according to Gard Oguma, the in-charge nurse at Afoji health centre II, located just 3 kilometers from the borderline. This mobile nature of the population affects vaccination, along with power shortages: When the gas-powered refrigerators run out of gas, vaccines spoil or have to be transported long distances to another health centre, where patients may not be able to go. 

According to a 2019 assessment by the Ministry of Local Government, Moyo district had an immunization coverage of just 54.6 percent, far below the national target of 90 percent. This includes childhood vaccines that target diseases such as polio, measles, yellow fever and hepatitis B. The in-charge nurses anticipate that the solar-powered refrigerators they will receive in March or April will change that. Along with the set of vaccines for infants, the fridges will also allow the health centres to start Covid-19 immunizations, Oguma said.

Gbari health centre II in Metu subcounty is a one-hour drive from Moyo town through a mountainous terrain of forests and grasslands. After kilometers of wilderness, a small group of grass-thatched huts appears in the distance. Soon after, an old stone building emerges, hosting a new crop of solar panels that glitter in the midday sun. 

This health centre is a bedrock in the community as the next closest facility is 12 kilometers away, costing 15-20,000 Uganda shillings ($4.30-$5.70) to reach on a motorbike – a rate most people cannot afford, said Fiona Maliama, a midwife at the health facility.

She said the solar system has greatly improved service delivery.

“Those days when they would bring a mother for delivery, they even didn’t have small torches, so they came in darkness, and you as a health worker you needed to bring your torch from home to come and help them in the night. After when the mother has delivered, you’d go with your torch and leave them in darkness,”

fiona Maliama, midwife

Without light to see ahead, the scorpions and snakes that live in the old clinic’s walls would bite people as they walk in the night. Maliama said it also impacted the health of newborns.

“In that darkness, even the baby may not be able to look for the breast of the mother. And in Uganda here it is mandatory that breastfeeding is supposed to be initiated within the first hour of delivery. If you don’t do that, the nutritional status of the baby will be affected just starting from that time,” the midwife said.

In the first month with power, Maliama conducted four deliveries – many more than before, when she would conduct up to two in a month. This means more people are choosing safe deliveries at the hands of health personnel, which is important to prevent complications like neonatal sepsis and maternal and perinatal deaths, she said. 

The trend is the same for all types of health emergencies. In the past, people would fear coming at night, or they would be told to return in the morning – when often the sickness had worsened, Maliama said. But in October after the light had been installed, she was able to stabilize and transfer a mother with excessive bleeding at night. In Afoji, the nurse Oguma said he has been able to respond to night calls including a child with convulsions and a patient with snake bites.

The health centres have already seen other cascading benefits, including increased security, technology charging services for community members, and reliable power in the staff quarters, where existing small solar systems were rehabilitated. Communication has also improved since staff are able to charge their phones, radios, and computers. This improves service delivery since clinicians rely on their ability to call other hospitals and health facilities to refer and transfer patients in need, said Oguma. 

In Abeso, teachers at the primary school, which has no power, charge their phones at the health centre. The facility also frequently supplies vaccines to the higher-level health facility since its own fridge was spoiled, said Idrifua Joseph, the in-charge nurse at Abeso health centre 2.

Oguma said the benefits of the solar system cascade to both the community and the health facility staff. 

“We see the community get 24-hour services. We serve them without any problem,” he said. “There was great happiness when they heard the solar system is coming, and when it was installed, most of them came physically; they wanted to see if it was true if this solar system was there. And when they saw the light on, they were so grateful.”

Energy from the sun: a growing industry in rural Uganda, with need for enabling policies 

Electricity access in rural areas in Uganda has greatly expanded in the past two decades, from only 3 percent in 2000 to 50 percent in 2020. But the country’s northern West Nile region has consistently lower rates than both the urban and rural averages countrywide. According to the most recent Uganda National Survey Report, 39 percent of West Nile residents had access to electricity in 2020. Just 1.6 percent of those households were connected to grid electricity, while 37 percent used a solar kit or a solar home system. 

 

Since its inception in 2001, the Rural Electrification Agency has been tasked to take power into rural areas. Drama, the district energy focal person, said that in recent years, the government’s “vision and understanding of energy has changed,” from a focus on supplying power for manufacturing industries to reaching the “end-user” at the household level. After 2015, decentralized energy departments were created in the ministry to manage power distribution in districts across the country. The government also mandated that all sub-county headquarters be connected to the national grid, he said.

Sometimes extending the main grid into remote areas with poles and power lines ends up with higher service costs for rural communities, and increasing off-grid solar is a better option, Drama said.

According to the Uganda National Survey Report 2019/20, the main reason households in West Nile were not using grid electricity was that the grid was not available or was too far from their households. For almost a fifth of households, the main reason was the expense of the initial connection.

While Uganda is increasing its hydropower capacity with the Isimba dam that started generation in 2019 and the Karuma dam that is expected to be commissioned in 2022, demand for grid power is actually decreasing. Grid connections fell from 22 percent in 2017 to 19 percent in June 2020, while solar connections increased from 18 to 38 percent in the same three-year period. 

74 percent of government health facilities had a solar panel, an increase from 66 percent in 2016. Almost half (48 percent) of facilities had access to electricity, up from 31 percent three years earlier. 

Uganda National Survey Report 2018/19

However, sales of off-grid solar-powered refrigerators, vital in providing health services such as keeping vaccines cold, remain low in Uganda, according to recent Global Off-Grid Solar Market Reports produced by GOGLA, the global association for the off-grid solar energy industry.

Drama said the main challenge is not the lack of resources, but enough investment and awareness in maintenance of solar power systems. Every government health center is supposed to be equipped with a solar power system, but often the people at the health centres “have not been equipped with knowledge in how to maintain these solar systems,” which fall into disrepair. The old systems were also installed during a time when less power was needed, so now the batteries are unable to withstand the increased usage, he said.

 

A 2017 USAID analysis of the off-grid energy sector in Uganda identified several continuing challenges to the growth of the sector, including difficulty for small-scale solar operators to obtain loans, lack of finance for rural households to be able to purchase solar systems, lack of certifications for solar products and services, new and unclear tax policies, and a limited reach of trained technicians to perform repairs and maintenance in rural areas. 

The report recommended improving knowledge among government ministry officials, bank officials, and telecommunications officials; increasing the supply of solar home systems and improving distribution networks; and supporting both access to capital for solar companies and access to finance for solar buyers. 

 

Covid-19 also dealt a blow to sales of off-grid solar power, especially as sellers and technicians struggled to move to rural locations during lockdowns. However, while the use of solar home systems dropped during Covid as compared to before the pandemic, the use of solar kits slightly increased, according to the Uganda National Survey Report 2019/20.

From July-December 2020, solar lighting sales in Uganda started to recover from the initial drop after the pandemic began, according to the most recent GOGLA report. But from January-June 2021, sales fell again by 27 percent to their lowest level in the past three years, as the second wave of Covid-19 and the stringent lockdown imposed by the government affected the economy.

In East Africa, while all the three countries of Uganda, Kenya, and Tanzania all saw a dip in off-grid solar lighting sales at the beginning of the pandemic, Kenya’s sales have doubled in the past three years to be more than three times the sales of Uganda and Tanzania combined, according to GOGLA. Conversely, Uganda and Tanzania’s sales have not increased significantly.

“Regarding policy, there’s still a need to make things better for the solar sector,” said Rolex Muceka, an energy advisor at GIZ in Uganda. “I know there are no VATs [value-added taxes] on some of the products, but the government is still charging it on other components like inverters and so on. I think even some of the components like solar water pumping – you find VAT is not removed for those kinds of things. 

“Maybe I think the government needs to check on some of those policies so it can encourage more private sector players to go into this field and overcome the risk. Most of these companies are in the urban areas, yet those who need the service most are in rural areas, and reaching out to them is quite difficult. It’s good for the government to create policies to help the private sector reduce this kind of risk to increase on their profits.”

An increase in government funds for rural health, but not yet enough 

The three Moyo health centres are a good start. However, many more rural health facilities are in dire need of power, Drama said. The district’s original proposal included 7 vulnerable centres, but funding was only available for 3. Now, if more health centres in the district want to acquire similar power systems, they must budget and purchase them themselves. 

In the past three years, health has steadily increased as a percentage of the total local government budget, which has also expanded. In the 2019-2020 fiscal year, out of the 25.9 billion Uganda shillings ($7.4 million) budget for Moyo district, health was allocated 3.7 billion shillings (about 14 percent). This increased in 2020-2021, when health was allocated 19 percent. In the current 2021-2022 fiscal year, out of 44.6 billion shillings for the district, health was given 20 percent: 9.1 billion shillings ($2.6 million).

The three solar systems for the Moyo health centres were acquired from All in Trade Ltd., a Kampala-based company that sells renewable energy systems. They each cost the donor between around 27 and 30 million shillings each ($7,200-$8,600), and the three solar fridges were an additional 25,000 euros, or about 100.1 million shillings, according to Timotheus Torner, the GIZ development advisor in Moyo. 

 

This is a huge amount compared to the annual budget for each facility to provide healthcare services: In the most recent 2021-2022 budget for Moyo, each health centre II was allocated just 5.1 million shillings (about $1,500) for the year. 

The budget to purchase solar batteries, inverters, and other accessories across the district has tripled in the past three years to 115.5 million shillings ($33,100) in the current budget. Still, this amount could only purchase similar solar power systems and refrigerators for around two of the district’s 28 health facilities, without including the usual maintenance costs. The three GIZ-funded solar systems were an addition to this government funding.

To help the district sustain the solar systems, GIZ conducted a user training of health centre staff to perform simple maintenance tasks, and the team is currently developing a training manual, said Lukia Nabawanuka, GIZ energy advisor in Uganda. But if there is need for any repairs, the staff must call the company to send in a technician from Kampala. 

After the warranty period, the district health management committee will have to allocate a budget to cater for any issues, said Oguma. 

Currently, 80 million shillings – representing 0.9 percent of the current annual health budget – are designated for sustaining the solar systems at all the 28 Moyo health facilities. Although funds for solar have almost doubled over the past three years, these funds cannot cover maintenance of all the health centres’ solar systems, especially replacement of batteries, Drama said. 

Muceka agreed: “The biggest challenge that requires budgeting is after five years when you need to change the battery – does the health centre or district have the budget? It’s really a challenge, and I’m not sure if we have a solution for that.”

“We can see this where some health centres have access to the grid but cannot pay because they are a government health centre,” he added. “Government needs to allocate more money for health centres for electricity because it’s an essential service for medical services. There also needs to be more awareness at a district level, so during budgeting, these things are not overlooked.”

Lighting the way for healthier communities 

Since the first Covid-19 lockdown was installed in March 2020, the midwife at Abeso clinic has never once left the village, even to travel to the Moyo town centre. 

The mountainous terrain, poor roads, and the lack of almost any phone network in the villages make the residents of this area extremely isolated. To receive SMS text messages, the in-charge nurse Idrafua has to attach his phone to a reused plastic bottle that he has tied to a specific point on his bedroom wall. Calls still don’t come through. 

Along with improving phone networks, Idrafua pleads for a new clinic motorcycle to allow the health workers and community members to more easily move between towns. 

In Abeso, village chairman Angozu Edgar Guerson implores for the health centre 2 to be upgraded to a health centre 3, when he says they can acquire a microscope to be able to conduct laboratory tests. 

And for Drama, he hopes that similar solar systems can in the future be installed in local schools – another proposal the district had originally submitted to GIZ, which did not go through. 

“The low performance in school, we felt that this could be a result of teachers not preparing lessons because they don’t have lighting systems,” he said. “And we felt that if there is power in this school, students who are near to the school can come back and study. And teachers could prepare tests, print out tests and frequently check the learning of the learners.”

One Sunday, Robert Drichi, a farmer from Abeso, was lounging at the health centre staff quarters. For himself, his family of three children, and his neighbors, the coming of the solar system has been a beacon of progress and relief in the community. He said the light recently saved one of his friends who was ensnared at night in a locally made trap for a wild animal. 

 

Oguma also told the story of a child with convulsions who arrived in the middle of the night – to find steady power and a team of staff ready to treat him. Solar, he said, is lighting the way for healthier communities. 

“That was around 2 a.m. From us to the hospital in Moyo is very far, but because of this, because the power service was there, there was light, staff are there, and the fear of the staff have come out, so they came and we served them. The child was discharged.”

This story was covered as part of the Clean Energy Wire (CLEW) fellowship. Text story, data visualizations, photos, some videos, and video editorial by Annika McGinnis; main video concept and production by Andrew Aijuka; animations by Tito Winyi.