Hospital focus group findings
Ramtha and Jerash hospital focus groups contributed to RE4R project research through discussions of four key themes including energy use, energy waste, renewable energy audits or tenders, and energy awareness and capacity-building. The discussions assessed the acceptance and willingness of hospital staff to transition to a sustainable energy system. While the hospital is not responsible for paying the electricity and fuel bills, both staff and management expressed a strong interest in energy conservation and sustainable energy projects that contribute to better and efficient healthcare. Ramtha and Jerash hospitals share various similarities in their approach and perspective towards greening their energy systems, in parallel they share specific differences due to their diverse contexts.
Energy use
The managerial staff at both hospitals mentioned that the Ministry of Health established a fuel committee to eliminate fuel theft onsite. For quality and quantity assurance, the ministry also has contracts in place with three certified fuel companies (Manaseer, Total and Jo Petrol), which supply the two hospitals directly.
The hospitals are not fully aware of their level of electricity consumption. Their main concern is providing safe uninterrupted services, free of power outages, for patients. Both hospitals in Ramtha and Jerash have seen occupancy rates and electricity use increase in recent years: in Ramtha public hospital, the occupancy rate increased from 50 per cent to 63 per cent (of hospital beds) in 2013–18; Jerash hospital saw occupancy rise from 40 per cent in 2011 to 70–80 per cent in 2018. The high rise in the occupancy rate at Jerash hospital is due to it being the only public hospital in Jerash governorate.
Rapid increases in the number of patients, due to the growing population, caused energy costs at Jerash hospital to jump by 37 per cent between 2015 and 2018. This influx of patients affected Ramtha prior to 2015, but thereafter patient levels have been more affected by outbreaks of conflict, border restrictions and the gradual reduction of skirmishes near the border. In addition, Médecins Sans Frontières (MSF) closed its 42-bed unit in 2018 as the number of emergency intensive care patients dropped. In order to maintain healthcare services and the efficiency of medical equipment during power outages (due to pre-announced maintenance), both hospitals have diesel generators – two at Ramtha Hospital and five at Jerash Hospital.
Energy waste
The burden of the Syrian crisis has impacted the delivery of healthcare in Jordan, where the sector had to rapidly respond to emergencies. Public hospitals lacked the space to accommodate extra inpatients, therefore new buildings and facilities were constructed, or old buildings upgraded and retrofitted. The increase of patients has directly affected the amount of time that air-conditioning and heating systems can be used.
To circumvent these challenges, the Ministry of Health issued summer and winter guidance to all public hospitals and primary healthcare centres to improve energy efficiency, including measures such as setting the correct temperatures on air-conditioning or heating, and closing windows while these systems are in operation. In regard to oversight, a Ramtha public hospital official stated that, ‘General hospital inspections are not the most efficient, instead there is a greater need for digitized coordinated efforts.’ While in Jerash hospital, staff pointed out that general energy inspections have been identified as an essential factor in changing hospital staff behaviour towards energy waste.
Renewable energy audits and tenders
The Ministry of Health is aware of the positive economic, social and health impacts renewable energy initiatives can have on Jordan’s hospitals. However, there is currently no department mandated to carry out audits or issue tenders for energy efficiency and renewable energy. It is good practice for public entities to go through an energy audit before an energy tender can take place. Neither Ramtha nor Jerash hospitals have had an energy audit. Private companies that specialize in the implementation of energy systems usually face institutional impediments when looking to take part in such schemes. Conversely, a lack of understanding of existing policies and bureaucratic procedures among private sector companies often causes delays. In addition, approvals are required from the Ministry of Energy and Mineral Resources and the Ministry of Finance. These two ministries have an important role to play in facilitating any energy investments and accounting for energy cost savings and redeployment in future.
Staff at the two hospitals showed great interest in potential renewable energy installations and suggested the utilization of rooftops and parking lots. Staff at both hospitals believed that savings made from investing in renewable energy can provide a better environment for healthcare workers and patients. These savings can potentially cover some hospital needs such as investment in new medical equipment and patient beds.
The private sector can be a key partner for public entities in overcoming conventional energy challenges. This collaborative approach could provide a great learning initiative for hospital staff that would enable them to be part of the project from the beginning. The hospital staff of each location had different preferences in terms of installation and maintenance of a potential renewable energy system. Staff at the Ramtha public hospital prefer that a private company installs and maintains the renewable energy system for at least a couple of years. Conversely, staff at Jerash hospital would prefer that the hospital’s O&M team is responsible for the system and is involved from the beginning.
Energy awareness and capacity-building
The shift to using renewable energy in public buildings requires the desire to change for a sustainable future. Hospitals will likely support renewable energy ventures that include and consult them, and where investments will help in the development of more sustainable and improved services. Ideally, there should be an accreditation system, which can certify the hospitals that adopt sustainable applications and practices. The lack of knowledge on the most appropriate solar technology for each hospital was evident in discussions. Hospital staff members noted that before any projects take place it would be best to launch a renewable energy awareness campaign that shares the potential positive impact of transitioning to a renewable energy system.
Hospital staff members noted that before any projects take place it would be best to launch a renewable energy awareness campaign that shares the potential positive impact of transitioning to a renewable energy system.
Both hospital focus groups showed that the adoption of a renewable energy system would be particularly desirable from the point of view of power reliability. However, hospitals are dealing with other potentially more urgent environmental and service issues, such as medical waste disposal and water conservation through the repair of leaking taps and pipework. For a greater impact on economic, social and institutional conditions, it is clear that other essential sectors – water, sanitation facilities and waste management – should be addressed at the same time. Future investments could include the following environmental projects: water efficiency measures; solid and pharmaceutical waste management; and green infrastructure, including improved outdoor areas as part of patient-centred care.
Overcoming the challenges for public healthcare facilities
Data availability and accuracy
Any renewable energy investment in the Ministry of Health’s public buildings requires comprehensive information and a set of approvals prior to implementation. The accumulation of unpaid electricity bills from prior years has made it difficult for the ministry to distinguish between power consumption and cost, which is essential for calculating potential and actual savings. Data availability on energy and total usage is sparse, and gathering it can be a complex procedure, due to technicalities associated with public buildings (these have different bill payment arrangements, with some being rented). It can also be difficult to define the energy bill for separate parts of a hospital as in most cases different units are linked to one or sometimes two meters.
Suggested approach: Comprehensive accounting of fuel use and costs is needed. For example, smart metering for different clinics and buildings would help to identify areas of highest consumption. The same approach could be taken for water use.
Since the focus groups took place, the South Amman wheeling project has come online offering an innovative model for accounting and redistribuition of savings. In 2018, the Ministry of Finance and Ministry of Health signed an agreement stating that at least 50 per cent of savings would be returned to the Ministry of Health to allow it to improve health services in the mentioned facilities. Each of the 33 hospitals and health centres in the South Amman project prepared a list of their needs to improve services for patients. Annual savings from electricity costs should cover these expenses. It has not been possible to monitor how the project has functioned to date, as the KfW project was closed once the plant became operational at the end of 2020.
Institutional challenges
Renewable energy investment in Jordan requires greater cooperation and collaboration from different respective institutions, including national bodies, such as the Ministry of Energy and Mineral Resources and the Ministry of Finance, and grid connection approvals. Improved coordination between parties (e.g. Ministry of Health, Ministry of Public Works and Housing, and Ministry of Planning and International Cooperation) could alert a project to infrastructural issues prior to implementation and before any disruptive building maintenance. For example, better coordination could have avoided the need to remove and re-install the solar water heating system in Al-Mafraq Hospital (see Chapter 4).
Suggested approach: Formalize the Inter-Ministry Committee to enable clear channels of communication between different government bodies and utility companies. Unified regulatory and policy guidelines for public buildings will be essential to pursue the development of renewable energy initiatives. For example, practical options for the repayment of electricity bill debts could be set out by the utilities regulator, Energy and Minerals Regulatory Commission (EMRC).
Patient digital information glitches
A digital information system, Hakeem, was rolled out in 2009 to enhance data availability and accessibility in public health entities. Hakeem is a national patient information system that registers inpatients and outpatients in a health sector database. This enables patient information to be accessed anywhere. Power outages affect the utilization and efficiency of Hakeem as during this time staff must revert to manual records, which increases the potential for inaccuracy.
Suggested approach: Transitioning to more stable renewable energy will help ensure the reliability of access to these systems.
Audits and investments
Audits for energy efficiency and solar potential are essential to ensure safety and quality control. Few comprehensive energy audits have been carried out on Ministry of Health buildings. Some hospitals and ministry buildings have recently instigated minor energy efficiency measures to minimize energy loss, where an official government expenditure policy requires equipment procurement (e.g. of lighting or air-conditioning) to be in line with energy efficiency standards.
Suggested approach: Forming a small group of individuals among hospital staff and management, who can inform and engage with the audit, will help flag issues and improve the quality of data. Comprehensive audits (ideally covering energy and water efficiency, renewable energy potential and waste) could be conducted as a package across facilities, and take into consideration the results of any previous project audits. These would reveal both behavioural and equipment-related changes that could save money and reduce payback periods. These audits could then be used in tenders for renewable energy and other types of procurement, or for the contracting of services.
Technical challenges and the condition of buildings
The Ministry of Health has expressed concern over the lack of space in hospitals for the installation of solar and PV panels as well as building structure problems, where roofs cannot withstand extra weight due to their age. Several options can be considered for future installation spaces, such as the roofs of car parks and empty rooftops that pass the audit as well as wheeling projects.
Responsibility for repair and maintenance of solar systems is also problematic. In the case of Al-Mafraq Hospital, the plumbing system was known to be outdated and prone to leaks prior to project implementation, but its repair or replacement was beyond the scope of the project funding. Many hospitals and clinics are old and in need of repair. This can have an impact on the effectiveness of upgrades, such as solar water heaters that must be connected to existing plumbing systems.
General repair of public hospital and clinic buildings (unless rented) is the responsibility of the Ministry of Health, while larger upgrade contracts may come under the responsibility of the Ministry of Housing and Public Works. Where solar projects are not part of a more holistic upgrade and responsibility for their operation is unclear, subsequent building repairs can impair or reduce the value of a project.
Suggested approach: Ideally, solar system ownership should be transferred to the Ministry of Health at project completion with clear lines of responsibility at the hospital level for maintenance – including for the hospital O&M team and the installers. If ownership is unclear, it is less likely that care will be taken to coordinate repairs and maintenance, taking into account the value of the system.
