12 Jan How to design and implement national oxygen road maps for oxygen scale up: Case Study from Ethiopia
Authors: Habtamu S Tolla, UNICEF; Yakob S Ahmed and Daniel G Bursa, Ministry of Health, Ethiopia
Ethiopia is a low-income country with 110 million people, the second populous in Africa. While Ethiopia achieved the Millennium Development Goal (MDG) child survival target early in 2012, child mortality remains high. In 2019, there were 55 child deaths per 1,000 live births, far above the Sustainable Development Goal (SDG) target of 25 by 2030. There are many reasons child deaths remain so high, but one is the limited access to medical oxygen in health facilities.
A 2015-16 study revealed that only 98 of Ethiopian health centers did not have oxygen while 35% of referral facilities did not have oxygen in their pediatric in-patient departments. Further, 55% of these departments in referral facilities did not have pulse oximeters nor were there pulse oximeters in the health centers surveyed. In subsequent assessments made in 2017-18, where pulse oximetry and oxygen were available, clinical use was low. For example, only 10% of patient medical records included an SpO2 measurement. COVID-19 has further exacerbated the lack of oxygen access as supplies are redirected from neonatal and child health services to COVID-19 treatment facilities.
In 2016, with support from partners, the Ethiopian Ministry of Health (MOH) designed and implemented a comprehensive oxygen and pulse oximetry scale up road map, which resulted in significant improvements in oxygen availability and clinical use. This case study highlights the road map development process and its implementation in Ethiopia so that other countries can benefit from what was learnt as they plan their own oxygen access plans.
SEVEN KEY STEPS
The MOH and partners followed the seven steps below to develop the oxygen road map:
1. Baseline assessment: The MOH and Clinton Health Access Initiative (CHAI) conducted a comprehensive oxygen ecosystem assessment targeting multiple stakeholders – including 400+ facilities, subnational health administration units, MOH, central medical store, private sector and partners. Major focuses were:
- Identifying who is doing what on oxygen
- Identifying oxygen availability and supply challenges
- Identifying barriers around policy, procurement, distribution, and financing
2. Coordination mechanism: following the baseline assessment, a national oxygen ad-hoc task force was established to advise the MOH on designing the road map and its subsequent implementation. The task force was led by the Maternal, Neonatal and Child Health Directorate and the Medical Services General Directorate at the MOH and included all relevant units within the MOH and various partners.
3. Demand forecasting: oxygen demand quantification was conducted using a CHAI tool after collecting facility data on bed capacity and oxygen type distribution. Five-year oxygen needs were estimated with the required supply source and related accessories needed. In addition, costs related to capital investments and operations with particular focus on maintenance were estimated for five years.
4. Desk reviews: the task force reviewed relevant global and local policies – and implementation tools such as the Integrated Management of Neonatal and Childhood Illness training modules, Emergency Obstetric and Neonatal Care, Basic Emergency Obstetric and Neonatal Care documents and Integrated Pharmaceuticals Logistics System – to understand the content of the oxygen supply system. Furthermore, research on hypoxemia diagnosis, oxygen therapy and oxygen supply sources were reviewed. Global and local experts were also consulted.
5. Setting the strategy (road map) interventions: The task force formulated the draft scope of the strategy, and its key strategic interventions, based on the baseline assessment and demand forecast. The scope of the strategy was initially focused on child health but later expanded to include maternal health oxygen indications, surgical needs, and other adult medical needs. Therefore, key strategic objectives were set to cover setting up the policy environment and coordination, oxygen supply chain, financing and health care worker development.
6. Consultations: a broad range of stakeholders were involved in the development of the national road map. These included various government offices particularly regional health bureaus, the Ethiopia Procurement Supply Agency, the Ethiopia Food & Drug Administration, and senior clinicians working in facilities. In addition, key global and local partners, professional societies, and private gas producers were involved in workshops as well as one-on-one consultations where needed. The consultations were carried out with the intention of acquiring data from these stakeholders and ensuring their engagement for implementation funding and ongoing support.
7. Launching and implementation kick-off: after a series of reviews by the task force and presentation to MOH leaders, the road map was launched on 24 November 2016 in the presence of senior MOH officials, key partners, donors, and the private sector.
FIVE STRATEGIC OBJECTIVES
The Ethiopian oxygen road map had clear strategic objectives designed to accelerate oxygen availability and clinical use through addressing barriers identified by the assessments.
- Policy basis, decision, and coordination support to health facilities: Key activities included defining and setting standards for better and optimized oxygen sources at various levels of care; guidance on biomedical staffing; and developing maintenance Standard Operating Procedures and training guides for biomedical engineers and technicians, and clinicians.
- Design, develop and roll out of Supply Chain Management System and logistics: Key planned activities were focused on how health facilities will manage refill, fleets and different innovations including aggregate refilling at lower-level facilities.
- Establish a mechanism for maintenance of oxygen equipment and spare parts: The road map has aimed to introduce better ways of managing maintenance data, labor, managing spare parts and service information as well as managing workplace, tools, and testing equipment.
- System for building capacity of health workers on appropriate utilization: Key interventions planned were training of clinicians on oxygen therapy and basic equipment care; training of biomedical engineers on maintenance and improving managers’ awareness of oxygen supply system management.
- Financing: Ensuring sustainable budgeting was crucial for realizing the rollout of the strategy and ensuring sustainable supply of oxygen. The MOH had planned to allocate a budget as well as mobilize additional resources from partners to fund the roll out.
Pre-COVID-19 road map accomplishments
Infrastructure expanded to improve oxygen production capacity
- More than 10 PSA plants were established through different financing modalities including a Public-Private Partnership.
Procurement systems strengthened
- MoH and Central Medical Store included oxygen equipment such as concentrators, cylinders, pulse oximeters, and accessories in ongoing and revolving (Revolving Drug Fund) procurements.
- National specifications for oxygen plants, oxygen concentrators, and pulse oximeters.
- MOH-allocated budgeting for the procurement of oxygen therapy devices (3,000+ concentrators and 5,500+ pulse oximeters).
Implementation tools designed
- Oxygen therapy training manuals for clinicians.
- Maintenance and repair for biomedical engineers and technicians focusing on cylinders, concentrators, and pulse oximeters.
- Audio-video materials on maintenance of oxygen supply system designed and distributed.
- Many clinicians working in pediatric in-patient departments and neonatal intensive care units at hospitals were trained.
- Biomedical engineers and technicians working in hospitals were trained on the maintenance of oxygen devices.
Availability and clinical use by end of 2019
- Use of pulse oximeters to diagnose hypoxemia improved from 21% to 91% and oxygen therapy increased from 57% to 83%.
COVID-19 preparedness and planning
The road map has significantly contributed to a smooth take-off and response during the earlier phase of the COVID-19 pandemic.
There was an oxygen task force before COVID-19 and although inactive, it was easy to reconvene to quickly develop a short-, mid-, and long-term oxygen supply strategy for the COVID-19 response. Pre-COVID-19 experience of oxygen systems quantification and assessment helped to quickly quantify COVID-19 oxygen and equipment need. In addition, a respiratory equipment inventory in 83 COVID-19 treatment centers throughout the country was conducted, which informed the redeployment of oxygen systems.
The existence of trained biomedical engineers and training materials on the maintenance of oxygen systems were critical for the initial maintenance campaigns and subsequent roll outs. Furthermore, with established MOH and private sector engagement, private sector contributions and capacity were quickly capitalized.
Existing government procurement systems had experience where the Ethiopia Pharmaceuticals Supply Agency was able to quickly procure pulse oximeters, oxygen cylinders, and concentrators although there were initial market shortage challenges. Building on existing experience, missing tools such as standard operating procedures for piping and a PSA plant management manual were developed to further enhance oxygen supply to cope with the COVID-19 need.
A few months into the pandemic, Ethiopia was able to improve oxygen production capacity from less than 1,200m3/hr (cubic meters per hour) to more than 3,250 m3/hr.
Partners had limited awareness of oxygen program support, which resulted in low attendance at task force and consultative meetings. In addition, lack of reliable data on national hypoxemia prevalence and bed capacity at various levels of the health system were challenging in setting oxygen demand forecasts.
Funding constraints for the procurement and training of health care workers limited the scope and speed of the road map implementation. Furthermore, lack of a national monitoring system for oxygen supply chains and hypoxemia case management posed a challenge to track the wider impact of road map implementation. In addition, efforts to include oxygen-related indicators into the Health Management Information System (HMIS) were not successful.
From the review of the Ethiopian oxygen and pulse oximeter scale-up road map development process, and its subsequent implementation, we can draw the following lessons: