Financial Implications of Tariffs for Medical Oxygen on Rwandan Public Hospitals' Finance Management During the Coronavirus Epidemic.

In Rwanda, provider reimbursements for oxygen are based on the duration of patient consumption at a fixed hourly tariff rate. This study sought to assess whether the current insurance tariff in Rwanda was adequate to cover the costs of oxygen used in oxygen therapy and to explore alternative tariff models.The assessment found that hospitals make a marginal surplus from low volume flow rate patients and incur losses from patients who require high volume flow rates. In high volume nonspecialized hospitals with a large pool of patients consuming medical oxygen, low flow rate usage patients (e.g., neonates) tend to subsidize high flow usage patients (surgery), if the number of patients consuming low flow oxygen is higher than the latter. The study found that the current tariff was sufficient before the exponential surge in demand for high flow usage during the peak of the COVID-19 pandemic. A variable tariff that factors both the duration (hours) and the volume (liters) used during the therapy may require more work but better reflects the cost of consumption in each ward. A case-based payment model provides a standard pricing framework based on the patient's diagnosis, intervention, and intensity of treatment.This study highlights the need for a transition from the time-based tariff structure to a case-based or volume-based tariff to incentivize sustainable production and provision (supply) of medical oxygen services at health facilities in Rwanda. Social health insurance reimbursement tariffs for medical oxygen need to reflect both duration and volume of consumption because oxygen therapy varies based on intervention, disease severity, patient age, length of stay, and responsiveness to treatment.

The prevalence of hypoxemia among pediatric and adult patients presenting to healthcare facilities in low- and middle-income countries: protocol for a systematic review and meta-analysis.

BACKGROUND: Hypoxemia is a severe condition associated with high rates of mortality, particularly in low- and middle-income countries (LMICs) with poor access to oxygen therapy. Despite its clinical significance, there have been few studies to describe the burden of hypoxemia. Thus, the primary objective of this study is to systematically describe the prevalence of hypoxemia among pediatric and adult patients in low- and middle-income countries. METHODS/DESIGN: Standard systematic review methods will be used. Bibliographic databases (MEDLINE, EMBASE, CINAHL) will be searched from 1998 onwards. The search strategy aims to identify studies that have measured peripheral blood oxygen saturation (SpO2) in children and adults presenting to health facilities in LMICs. Studies will be included if oxygen saturation measurements by pulse oximetry were measured. No studies will be excluded based on study design though patients recruited from intensive care units and post-operative care will be excluded. The primary outcome is the prevalence of hypoxemia on presentation to the healthcare facility. We define hypoxemia on the basis of SpO2 measurements, and use a threshold of SpO2 less than 90% at sea level though allow for a lower threshold for studies conducted at higher altitude and where justified. Standardized tools will be used to extract data on number of patients with SpO2 measurements, number of patients with hypoxemia, patient population characteristics, and study characteristics. Quality of the included studies will be assessed using the "Checklist for Prevalence Studies" developed by the Joanna Briggs Institute. If there are enough studies to do so, we will conduct meta-analysis using a random effects model to estimate prevalence of hypoxemia and conduct subgroup analyses by age and disease groups. DISCUSSION: Hypoxemia is a critical condition and understanding the burden of hypoxemia may support decision-making in LMICs to deploy pulse oximeters and oxygen treatments more efficiently to address diseases and patient populations with the highest burden. Previous studies on hypoxemia prevalence have focused too narrowly on a few diseases or specific patient populations (e.g., pneumonia in children under five) whereas any effort to improve access to oxygen requires understanding of the potential demand for oxygen for all diseases and population groups. Governments, UN agencies, donors, and NGOs are investing strongly to improve oxygen systems in LMICs. Effective oxygen system planning requires estimation of oxygen need, informed by robust data on hypoxemia prevalence and admission patterns at all the levels of the health system. This study aims to fill that gap by providing comprehensive estimates of hypoxemia prevalence. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019136622.

Improved oxygen systems at hospitals in three Nigerian states: An implementation research study.

INTRODUCTION: Hypoxemia is a life-threatening condition and is commonly seen in children with severe pneumonia. A government-led, NGO-supported, multifaceted oxygen improvement program was implemented to increase access to oxygen therapy in 29 hospitals in Kaduna, Kano, and Niger states. The program installed pulse oximeters and oxygen concentrators, trained health care workers, and biomedical engineers (BMEs), and provided regular feedback to health care staff through quality improvement teams. OBJECTIVE: The aim of this study is to evaluate whether the program increased screening for hypoxemia with pulse oximetry and prescription of oxygen for patients with hypoxemia. METHODOLOGY: The study is an uncontrolled before-after interventional study implemented at the hospital level. Medical charts of patients under 5 admitted for pneumonia between January 2017 and August 2018 were reviewed and information on patient care was extracted using a standardized form. The preintervention period of this study was defined as 1 January to 31 October 2017 and the postintervention period as 1 February to 31 August 2018. The primary outcomes of the study were whether blood-oxygen saturation measurements (SpO2 ) were documented and whether children with hypoxemia were prescribed oxygen. RESULTS: A total of 3418 patient charts were reviewed (1601 during the preintervention period and 1817 during the postintervention period). There was a significant increase in the proportion of patients with SpO2 measurements after the interventions were conducted (adjusted odds ratio [aOR] 5.0; 4.3-5.7, P < .001). Before the interventions, only 13.7% (95% confidence interval [CI]: 12.2-15.3) of patients had SpO2 measurements and after the interventions, 82.4% (95% CI: 80.7-84.1) had SpO2 measurements. Oxygen administration for patients with clinical signs of hypoxemia also increased significantly (aOR 5.0; 4.2-5.9, P < .001)-from 22.8% (95% CI: 18.8-27.2) to 77.9% (95% CI: 73.9-81.5). CONCLUSION: Increasing pulse oximetry and oxygen therapy access and utilization in a low-resourced environment is achievable through a multifaceted program focused on strengthening government-owned systems.

Program evaluation of an ORS and zinc scale-up program in 8 Nigerian states.

BACKGROUND: In Nigeria, diarrhea is the second leading killer of children under five. Between 2012-2017, the Clinton Health Access Initiative, Inc. (CHAI) and the Government of Nigeria implemented a comprehensive program in eight states aimed at increasing the percentage of children under five with diarrhea who were treated with zinc and oral rehydration solution (ORS). The program addressed demand, supply, and policy barriers to ORS and zinc uptake through interventions in both public and private sectors. The interventions included: (1) policy revision and partner coordination; (2) market shaping to improve availability of affordable, high-quality ORS and zinc; (3) provider training and mentoring; and (4) caregiver demand generation. METHODS: We conducted cross-sectional household surveys in program states at baseline, midline, and endline and constructed logistic regression models with generalized estimating equations to assess changes in ORS and zinc treatment during the program period. RESULTS: In descriptive analysis, we found 38% (95% CI = 34%-42%) received ORS at baseline and 4% (95% CI = 3%-5%) received both ORS and zinc. At endline, we found 55% (95% CI = 51%-58%) received ORS and 30% (95% CI = 27%-33%) received both ORS and zinc. Adjusting for other covariates, the odds of diarrhea being treated with ORS were 1.88 (95% CI = 1.46, 2.43) times greater at endline. The odds of diarrhea being treated with ORS and zinc combined were 15.14 (95% CI = 9.82, 23.34) times greater at endline. When we include the interaction term to investigate whether the odds ratios between the endline and baseline survey were modified by source of care, we found statistically significant results among diarrhea episodes that sought care in the public and private sector. Among cases that sought care in the public sector, the predictive probability of treatment with ORS increased from 57% (95% CI = 50%-65%) to 83% (95% CI = 79%-87%). Among cases that sought care in the private sector, the predictive probability increased from 41% (95% CI = 34%-48%) to 58% (95% CI = 54%-63%). CONCLUSIONS: Use of ORS and combined ORS and zinc for treatment of diarrhea significantly increased in program states during the program period.

Increasing coverage of pediatric diarrhea treatment in high-burden countries.

BACKGROUND: Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc. METHODS: We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions. RESULTS: Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21-23%) to 48% (95% CI = 47-50%) and program states in Nigeria, from 38% (95% CI = 32-40%) to 55% (95% CI = 51-58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies. CONCLUSIONS: Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.