Building power-ful health systems: the impacts of electrification on health outcomes in LMICs

Figures & data

Table 1. Search strategy for database searches.

Strategy	Keywords
Strategy #1	electrification OR electricity OR renewable energy OR clean energy OR solar energy OR solar power OR solar electricity OR photoelectric cells OR solar technology OR wind energy OR windmills
Strategy #2	health OR healthcare delivery OR health services OR access to health services OR maternal health OR Emergency Obstetric Care (EmOC) package OR child health OR vaccination OR health facilities OR quality of care OR COVID-19
Strategy #3	Strategy #1 AND strategy #2

Figure 1. PRISMA flowchart of the study selection process.

Table 2. Characteristics of the included studies. N. S: not specified.

Study	Study type	Country(s)	Primary objective(s) of the study	Source of electricity	Type of electrical grid	Health facility(s) level	Rural/urban/both	Outcome(s) measured
Chen et al., 2019 (22)	Case-control study	India	Examining the effects of a rural electrification project on the core components of health systems in that area	N. S	N. S	Primary	Rural	Service Availability Service readiness management and finance
Javadi et al., 2020 (23)	Quasi-experimental study	Ghana and Uganda	Capturing changes in service availability and readiness in health facilities following the implementation of off-grid solar electrification project	Solar	off-grid	primary	Rural	Service Availability quality and safety of care management and finance
Apenteng et al., 2018 (24)	Randomised controlled trial	Uganda	Evaluating a novel strategy, solar-powered oxygen delivery, which concentrates oxygen from ambient air using solar energy compared to the previous method of oxygenation using cylinders	Solar	N. S	Tertiary	urban	Service Availability quality and safety of care
Howie et al., 2020 (25)	Quasi-experimental study	Fiji and Gambia	Development and assessment of the reliability, usability and costs of a newly powered oxygen concentrators	Solar	N.S	Multi-level	N. S	Service readiness management and finance
Kumar et al., 2014 (26)	retrospective survey	India	Exploring the effects of supply-side factors on the volume of delivery care provided at Indian health facilities	N. S	N. S	Primary	rural and urban	Service Availability
Mbonye et al., 2007 (27)	cross-sectional survey	Uganda	Investigating the availability of emergency obstetric care (EmOC) and factors related to maternal deaths, including the availability of electricity, in Uganda	N. S	N. S	Multi-level	rural and urban	Service Availability
Mbonye & Asimwe, 2010 (28)	cross-sectional survey	Uganda	Determining the availability and access to essential maternity care and health system factors related to maternal health in Uganda	N. S	N. S	Multi-level	rural and urban	Service Availability
Morrissey et al., 2015 (29)	quasi-experimental study	Sierra Leone	Assessment of a newly implemented hybrid solar power system to support the electricity needs of a pediatric department in a district hospital in Sierra Leone	Solar	off-grid	secondary	rural	Service Availability Service readiness
Mubyazi et al., 2012 (30)	qualitative cross-sectional study	Tanzania	Describing the supply-related drivers of motivation and performance of HWs in administering intermittent preventive treatment of malaria during pregnancy in Tanzania	N. S	N. S	Primary	Rural	Service readiness management and finance
Owili et al., 2019 (31)	Cross sectional study	Kenya, Malawi, Namibia, Rwanda, Tanzania and Uganda	Exploring the determinants of quality of antenatal care in sub-Saharan Africa	N. S	N. S	Multi-level	rural and urban	Quality and safety of care
Swanson et al., 2017 (32)	retrospective survey	DRC	Examining the challenges that arose in implementing an intervention included. The training of health personnel to perform antenatal ultrasound screening and to refer women identified with high risk. Pregnancies to hospitals for appropriate care	Solar in addition to other sources	N. S	Secondary	Urban	Service readiness
Turnbull et al., 2016 (33)	quasi-experimental study	Uganda	Implementing a solar-powered oxygen delivery system for the treatment of paediatric pneumonia.	Solar	Off-grid	Tertiary	Urban	Service readiness management and finance

Table 3. Risk of bias assessment for experimental studies.

	Risk of bias domain (High, low, unclear)
Study	Random sequence generation	Allocation concealment	Selective reporting	Blinding (participants and personnel)	Blinding (outcome assessment)	incomplete outcome data	Other sources of bias
Javadi et al., 2020 (23)	Low risk of bias	NA	Low risk of bias	N.A	N.A	Low risk of bias	Low risk of bias
Apenteng et al., 2018 (24)	Low risk of bias	Low risk of bias	Low risk of bias	High risk of bias	High risk of bias	Low risk of bias	Low risk of bias
Howie et al., 2020 (25)	High risk of bias	NA	Low risk of bias	NA	NA	Low risk of bias	Low risk of bias
Morrissey et al., 2015 (29)	Unclear	NA	Low risk of bias	NA	NA	Low risk of bias	Low risk of bias
Turnbull et al., 2016 (33)	Unclear	NA	Low risk of bias	NA	NA	Low risk of bias	Low risk of bias

Table 4. Quality assessment for non-experimental studies.

Number of stars
Study	Selection	Comparability	Outcome	Overall score
Chen et al., 2019 (22)	4	0	3	7/9 (Good quality)
Kumar et al., 2014 (26)	5	0	3	8/9 (Good quality)
Mbonye et al., 2007 (27)	5	0	3	8/9 (Good quality)
Mbonye & Asimwe, 2010 (28)	5	0	3	8/9 (Good quality)
Mubyazi et al., 2012 (30)	4	0	3	7/9 (Good quality)
Owili et al., 2019 (31)	5	0	3	8/9 (Good quality)
Swanson et al., 2017 (32)	0	0	0	0/9 (Unsatisfactory quality)

Chen, Y. J., Chindarkar, N., & Xiao, Y. (2019). Effect of reliable electricity on health facilities, health information, and child and maternal health services utilization: Evidence from rural Gujarat, India. Journal of Health, Population and Nutrition, 38(1), 1–16. https://doi.org/10.1186/s41043-019-0164-6

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Javadi, D., Ssempebwa, J., Isunju, J. B., Yevoo, L., Amu, A., Nabiwemba, E., Pfeiffer, M., Agyepong, I., & Severi, L. (2020). Implementation research on sustainable electrification of rural primary care facilities in Ghana and Uganda. Health Policy and Planning, 35(Suppl._2), ii124–ii136. https://doi.org/10.1093/heapol/czaa077

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Apenteng, B. A., Opoku, S. T., Ansong, D., Akowuah, E. A., & Afriyie-Gyawu, E. (2018). The effect of power outages on in-facility mortality in healthcare facilities: Evidence from Ghana. Global Public Health, 13(5), 545–555. https://doi.org/10.1080/17441692.2016.1217031

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Howie, S. R., Ebruke, B. E., Gil, M., Bradley, B., Nyassi, E., Edmonds, T., Boladuadua, S., Rasili, S., Rafai, E., Mackenzie, G., Cheng, Y. L., Peel, D., Vives-Tomas, J., & Zaman, S. M. (2020). The development and implementation of an oxygen treatment solution for health facilities in low and middle-income countries. Journal of Global Health, 10(2), 1–10. https://doi.org/10.7189/jogh.10.020425

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Kumar, S., Dansereau, E., & Carlo, W. A. (2014). Supply-side barriers to maternity-care in India: A facility-based analysis. PloS One, 9(8), e103927. https://doi.org/10.1371/journal.pone.0103927

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Mbonye, A. K., Mutabazi, M. G., Asimwe, J. B., Sentumbwe, O., Kabarangira, J., Nanda, G., & Orinda, V. (2007). Declining maternal mortality ratio in Uganda: Priority interventions to achieve the millennium development Goal. International Journal of Gynecology & Obstetrics, 98(3), 285–290. https://doi.org/10.1016/j.ijgo.2007.05.019

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Mbonye, A. K., & Asimwe, J. B. (2010). Factors associated with skilled attendance at delivery in Uganda: Results from a national health facility survey. International Journal of Adolescent Medicine and Health, 22(2), 249–256. https://doi.org/10.1515/IJAMH.2010.22.2.249

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Morrissey, B., Conroy, N., & Estelle, A. (2015). G260(P) Effect of solar panels on in-patient paediatric mortality in a district hospital in Sierra Leone. Archives of Disease in Childhood, 100(Suppl 3), A114–A114. doi:10.1136/archdischild-2015-308599.253

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Mubyazi, G. M., Bloch, P., Byskov, J., Magnussen, P., Bygbjerg, I. C., & Hansen, K. S. (2012). Supply related drivers of staff motivation for providing intermittent preventive treatment of malaria during pregnancy in Tanzania: Evidence from two rural districts. Malaria Journal, 11(1), 1–14. https://doi.org/10.1186/1475-2875-11-48

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Owili, P. O., Muga, M. A., Mendez, B. R., & Chen, B. (2019). Quality of care in six sub-Saharan Africa countries: A provider-based study on adherence to WHO’s antenatal care guideline. International Journal for Quality in Health Care, 31(1), 43–48. https://doi.org/10.1093/intqhc/mzy105

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Swanson, D., Lokangaka, A., Bauserman, M., Swanson, J., Nathan, R. O., Tshefu, A., McClure, E. M., Bose, C. L., Garces, A., & Saleem, S. (2017). Challenges of implementing antenatal ultrasound screening in a rural study site: A case study from the Democratic Republic of the Congo. Global Health: Science and Practice, 5(2), 315–324. https://doi.org/10.9745/GHSP-D-16-00191

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Turnbull, H., Conroy, A., Opoka, R. O., Namasopo, S., Kain, K. C., & Hawkes, M. (2016). Solar-powered oxygen delivery: Proof of concept. The International Journal of Tuberculosis and Lung Disease, 20(5), 696–703. https://doi.org/10.5588/ijtld.15.0796

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