13 Dec Oxygen for every child who needs it: the Nigeria Oxygen Implementation Project
In 2015 we started the Nigeria Oxygen Implementation Project with the ambition of ensuring that every unwell child will receive oxygen therapy if they need it.
Earlier work in Papua New Guinea, Laos and Malawi, had shown that improving access to pulse oximetry and oxygen in hospitals could save lives – deaths from childhood pneumonia had dropped by around one-third. However, we also knew that improving an oxygen system required much more than just introducing equipment. In addition to appropriate equipment and regular maintenance, an effective oxygen system also requires skilled and motivated healthcare workers, supportive hospital and government policies, and a financing mechanism to keep it affordable and sustainable for both patients and hospitals.
We started working with 12 secondary-level hospitals in south-west Nigeria, and quickly learned the challenges that hospitals were facing with oxygen therapy. One hospital director described oxygen as his “biggest headache”, telling us that they spent millions of Naira on oxygen cylinders every month but still did not have oxygen available when it was needed. And, oxygen was expensive for patients: costing up to 2400 naira (USD $120) per day – adding to the financial pressures that cause many poor families to refuse treatment and discharge their children early.
Among hospitals that had some oxygen supply, we found it was prioritized for the operating theatre, and much of the equipment was broken or faulty. We found dozens of oxygen concentrators that were blowing air (not oxygen) or were donated second hand with incorrect electrical specifications for Nigeria. Technicians told us that they were frustrated by the piles of broken equipment for which they could not get replacement parts. Nurses and doctors told us that pulse oximeters were used rarely outside of the operating theatre, and none of them had received guidelines or training about hypoxaemia (low blood oxygen) or oxygen therapy.
But, there was also hope and enthusiasm. Frontline healthcare workers understood the importance of oxygen therapy for a sick newborn or child, and they desperately wanted better systems to provide it. Between 2015 and 2018 we worked with technicians, healthcare workers and administrators, to establish solar-powered oxygen systems using oxygen concentrators and low-pressure piping to individual beds. We introduced protocols and conducted practical group training (based on newly released WHO guidelines), and helped hospitals to establish multi-disciplinary oxygen quality-improvement teams who would be able to address all the practical challenges with oxygen provision.
The results have been encouraging, with rapid uptake of pulse oximetry resulting in better detection of hypoxaemia, improved use of oxygen and decreased pneumonia mortality. Our recent report in Lancet’s EClinicalMedicine emphasized the importance of pulse oximetry for all sick children – highlighting that it is common (22% of hospitalized neonates, 10% of hospitalized children), deadly (increasing risk of death 7-fold), and difficult to detect using clinical signs alone. Our recent report in PLoS Medicine describes how things improved in the 12 participating hospitals following introduction of pulse oximetry and improved oxygen: better oxygen care practices (universal oxygen access and >90% oxygen coverage for hypoxaemic individuals); reduced pneumonia mortality (~50% reduction).
The Nigeria Oxygen Implementation project has been a team effort, led by Prof Adegoke G Falade at the University College Hospital Ibadan, with technical support from Murdoch Children’s Research Institute/University of Melbourne, and funding from the Bill and Melinda Gates Foundation. We have worked closely with state and federal governments, and the Clinton Health Access Initiative (CHAI) team, to contribute to writing the new Nigerian oxygen clinical guideline, oxygen policy, and oxygen scale-up strategy. Our team has also contributed to global efforts through the Every Breath Counts alliance, United for Oxygen coalitions, consultative meetings and technical advisory groups (WHO, UNICEF, Unitaid).
While the Nigeria Oxygen Implementation project has ended, our work is not finished. In response to ongoing demand for technical support from hospitals and governments, we have established a local non-profit organisation (Oxygen for Life Initiative) to continue working towards ensuring that every unwell child will receive oxygen therapy if they need it.
Authors: Hamish R Graham (@GrahamHamish), Ayobami A Bakare, Trevor Duke, Adegoke G Falade