Strategies for Oxygen Ecosystems in Middle-Income Countries: A Review and Case Study from Lebanon.

The COVID-19 pandemic led to a surge of critically ill patients and a sudden increase in the need for oxygen treatment worldwide. Pre-existing gaps in oxygen systems became apparent, and governments, multilateral agencies, and other partners scrambled to increase the production, supply, and use of oxygen to meet this need. The importance of an oxygen ecosystem that is appropriate for the local context became clear. This review describes strategies for oxygen ecosystems in middle-income countries, with specific experiences from Lebanon, following the authors' extensive assessment of the country's oxygen ecosystem, on behalf of the government and UNICEF. In the assessment, fifteen governmental hospitals were visited and evaluated using the UNICEF Oxygen System Planning Tool, discussions were held with key stakeholders, and documents were reviewed. An optimal oxygen ecosystem needs to take into consideration the production of oxygen and delivery to facilities, the maintenance system within facilities, and the clinical use of oxygen. Lebanon, a lower-middle income country in the Middle East, is contending with an extensive economic crisis affecting the health system. Eighteen recommendations for strengthening the oxygen ecosystem in Lebanon that are relevant for other middle-income countries include the establishment of a National Oxygen Committee, installation of additional oxygen plants, strengthened systems for maintenance and electricity supply, increased production, procurement and supply chain resilience, improved training and human resources, the use of data collection and regular information to guide the ecosystem, and integration of oxygen into the rest of the health system.

Decentralizing oxygen availability and use at primary care level for children under-five with severe pneumonia, at 12 Health Centers in Ethiopia: a pre-post non-experimental study.

BACKGROUND: Pneumonia is the leading infectious cause of death in children worldwide, accounting for 15% of all deaths in children under the age of five. Hypoxemia is a major cause of death in patients suffering from pneumonia. There is strong evidence that using pulse oximetry and having reliable oxygen sources in health care facilities can reduce deaths due to pneumonia by one-third. Despite its importance, hypoxemia is frequently overlooked in resource-constrained settings. Aside from the limited availability of pulse oximetry, evidence showed that healthcare workers did not use it as frequently to generate evidence-based decisions on the need for oxygen therapy. As a result, the goal of this study was to assess the availability of medical oxygen devices, operating manuals, guidelines, healthcare workers' knowledge, and skills in the practice of hypoxemia diagnosis and oxygen therapy in piloted health centers of Ethiopia. METHODS: A pre-post non-experimental study design was employed. An interviewer-administered questionnaire was used to collect primary data and review medical record charts. A chi-square test with a statistical significance level of P < 0.05 was used as a cut-off point for claiming statistical significance. RESULTS: Eighty one percent of healthcare workers received oxygen therapy training, up from 6% at baseline. As a result of the interventions, knowledge of pulse oximetry use and oxygen therapy provision, skills such as oxygen saturation and practices of oxygen therapy have significantly improved among healthcare workers in the piloted Health Centers. In terms of availability of oxygen devices (e.g. cylinders, concentrators, and pulse oximeters) in the facilities, seven (58%) facilities did not have any at baseline, but due to the interventions, all facilities were equipped with the oxygen devices. CONCLUSIONS: Given the prevalence of pneumonia and hypoxemia, a lack of access to oxygen delivery devices, as well as a lack of knowledge and skills among healthcare workers in the administration of oxygen therapy, may represent an important and reversible barrier to improving child survival. Therefore, scaling up clinician training, technical support, availability of oxygen devices, guidelines, manuals, strengthening maintenance schemes, and close monitoring of healthcare workers and health facilities is strongly advised.

Changes in the availability of medical oxygen and its clinical practice in Ethiopia during a national scale-up program: a time series design from thirty-two public hospitals.

BACKGROUND: Oxygen therapy is a lifesaving treatment, however, in Ethiopia, oxygen is not readily available in many healthcare facilities. In 2015, the Federal Ministry of Health launched a national roadmap to increase access to oxygen. This study aims to evaluate whether availability of oxygen and its clinical practice in public hospitals of Ethiopia changed during the time the roadmap was being implemented. METHODS: Between December 2015 and December 2019, a multifaceted approach was undertaken to increase access to oxygen in public facilities in Ethiopia. The activities included formation of new policies, development of guidelines, procurement and maintenance of oxygen equipment, and training of healthcare workers. To evaluate whether access and use of oxygen changed during this period, facility-based surveys were conducted between December 2015 to December 2019. Primary data, including medical record reviews, were collected from 32 public hospitals bi-annually. A chi-square test that claimed P < 0.05 used to assess the statistical significance differences. RESULTS: The study was conducted in 32 public hospitals of Ethiopia, where capacity building and technical support interventions implemented. Of these 32 facilities, 15 (46.9%) were general hospitals, 10 (31.2%) were referral hospitals, and 7 (21.9%) were primary hospitals. Functional availability of oxygen has shown a statistically significant increase from 62 to 100% in the pediatric in-patient departments of general and referral hospitals (p-value < 0.001). Similarly, functional availability of pulse oximetry has shown a statistically significant increase from 45 to 96%. With regard to clinical practices, the blood oxygen saturation (SpO2) measurement at diagnosis increased from 10.2 to 75%, and SpO2 measurement at admission increased 20.5 to 83%. CONCLUSIONS: Based on the intervention results, we conclude that multifaceted approaches targeting policy, healthcare workers' capacity, increased device procurement, and device maintenance programs with on-site mentorship, can improve the availability of medical oxygen and pulse oximetry, as well as clinical practice of oxygen therapy in health facilities. Therefore, ensuring device availability along with regular technical support and close follow-up of healthcare workers and facilities are critical, and these interventions should be scaled further.

Use of pulse oximetry during initial assessments of children under five with pneumonia: a retrospective cross-sectional study from 14 hospitals in Ethiopia.

BACKGROUND: Hypoxemia, a fatal condition characterized by low concentration of oxygen in the blood, is strongly associated with death among children with pneumonia. Ethiopia's Federal Ministry of Health launched its first National Oxygen and Pulse Oximetry Scale-up road map to improve access and utilization of pulse oximetry and oxygen. This study aimed to describe the use of pulse oximetry during the initial patient assessment among children under five diagnosed with pneumonia and serves as a benchmark to measure progress of the road map. METHODS: The study design was an observational study using retrospective review of patient medical records at 14 hospitals. Medical records of 443 children age 0-59 months with a primary diagnosis of pneumonia were randomly selected for review. The primary outcome was whether an arterial blood oxygen saturation (SpO2) measurement was recorded in the patient's medical record at the initial assessment. RESULTS: Overall, 10% (95% confidence interval CI = 4%-22%) of patient medical records had a SpO2 measurement. Admitted patients were more likely to have a SpO2 measurement recorded in their medical records than patients treated in the outpatient department (P<0.01). Among admitted patients, 19% (95% CI = 8%-38%) had a SpO2 measurement compared to 3% (95% CI = 1%-11%) of patients treated in the outpatient department. CONCLUSION: In Ethiopia, patients under five with a primary diagnosis of pneumonia are rarely screened for hypoxemia with a pulse oximeter, and hypoxemia may be severely underdiagnosed. Much needs to be done to improve the routine use of pulse oximetry.