This post is part of our Every Last Breath: Oxygen blog series.
Oxygen is indispensable in treating patients with Covid-19 and pneumonia. Yet data on oxygen equipment in health facilities has encouraged us to think that oxygen is far more widely available and accessible than it actually is.
Now a study in Nigeria shows how a more sophisticated approach to measuring oxygen availability may help us understand – and address – catastrophic bottlenecks in oxygen accessibility.
A new paper pre-published under the GSK-Save the Children partnership by practitioners and academics from Nigeria, the UK, Australia, the USA and Sweden, has given us a unique insight into oxygen availability and use in Nigeria. It shows that our current approach to measuring oxygen access, which is based on having of an oxygen source in health facilities, falls short of indicating actual access to and use of oxygen on patients, particularly children.
The research team looked at oxygen availability across 58 facilities in Ikorodu, Lagos State – an urban state with a population of around 15 million people. Oxygen is a key tool in reducing pneumonia deaths by up to 35% in children. Yet the equipment in most of the 58 facilities inspected was found to be lacking or not working properly.
The study found that even when facilities officially had oxygen available, there were fundamental shortcomings in the availability of functioning pulse oximeters (which detect hypoxaemia, that is, low levels of oxygen in blood), in the availability of functioning oxygen equipment, and in the training of health workers to use the equipment and of maintenance staff to upkeep and repair equipment.
Seeking Care, Needing Oxygen
When a critically ill patient attends a health facility, staff need to assess whether their oxygen saturation levels are too low, using a pulse oximeter. The study found that oximeters were found in all secondary health facilities but none of the government-run primary health centres. And in private primary care facilities oximeters were generally in the outpatients clinics and not in paediatric wards. Only one-third of all oximeters found were functional, all at private primary health facilities. In most of these facilities, the use of oximeters was rare. None of the oximeters were suitable for use on children.
Staff knowledge and use of oxygen was also found to be lacking, with less than a quarter of staff reporting having received training on oxygen and under a third of staff able to identify the core functions of pulse oximetry or levels of oxygen saturation that warranted oxygen therapy.
All secondary health facilities and all private facilities had an oxygen source, but only half of primary health centres did. Only 12% of oxygen sources were functional. Oxygen demand had increased sevenfold between the beginning of 2020 and November of the same year, from 70 to 500 cylinders per day in Lagos. Oxygen was located in a single ward in almost all facilities where it was present, meaning its availability for patients (and particularly children) was extremely limited.
This means that while availability of oxygen may have been recorded at 59% across facilities, the actual level of availability for children, based on the use of an oximeter to detect hypoxaemia, and the availability of functioning oxygen source, was less than 10%.
What Next?
In early 2021, to increase oxygen availability, Nigeria announced a $17m fund for nationwide oxygen plants. Yet the entire diagnostic and treatment cycle needs to be improved. What indicators could be using to truly understand availability and access to oxygen in low resource settings?
We need to:
- Switch the focus from equipment to patient access, to understand whether those who need oxygen actually receive it. To calculate this, we need to know the proportion of people with hypoxaemia who receive oxygen therapy, and the proportion of critically unwell patients who are screened using pulse oximetry.
- Know the proportion of wards with oxygen sources and delivery.
- Understand the cost of oxygen for patients, as well as facility expenditure on oxygen equipment and maintenance.
What this study shows is that national and international statistics on oxygen availability do not give us a clear indication of actual access, particularly in low resource settings, rural areas, facilities where the cost of oxygen is too high for families, and when equipment is inadequate for children.
If we are to address the issue of access to oxygen, we need to start by going deeper into understanding the challenges. It is not enough to know that an oximeter or oxygen source exist. We need to know whether the equipment is appropriate for the context, that it is kept in safe and working order, that there is .sufficient power supply to use it when needed, and that maintenance staff can maintain and repair the equipment when necessary. Staff need to have been trained to identify when and how to use oxygen equipment, and to monitor and report oxygen usage.
Now more than ever, it’s critical we understand – and urgently address – the challenges to patients’ access to oxygen.
Read the full paper Measuring oxygen access: lessons from health facility assessments in Nigeria.
