Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria

Abstract

The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure ‘oxygen access’. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO2 documented) and negligible in private facilities (2%, 3/177) and primary health centres (<1%, 2/608). We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. However, triangulation of existing data suggested that no facilities were equipped to meet minimum oxygen demands. We highlight the importance of a multifaceted approach to measuring oxygen access that assesses access at the point-of-care and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.

Quality of care for children with acute respiratory infections in health facilities: a comparative analysis of assessment tools

“…Appropriate oxygen administration and monitoring of oxygen saturation are cost-effective measures for the management of pneumonia, and yet access to oxygen therapy is not a current standard indicator in the integrated GAPPD [ 2 , 19 ]. There is a need for more high-level data on oxygen use and monitoring to ensure that access to oxygen supply is being delivered in an effective manner [ 20 , 21 ]. Affordable access to uninterrupted oxygen supply should be a key indicator included in any assessment of standard ARI/pneumonia management.…”

Cost-effectiveness and sustainability of improved hospital oxygen systems in Nigeria

“…Our primary outcomes were (i) the proportion of children and neonates who were screened with pulse oximetry and (ii) the proportion of children and neonates with hypoxaemia (SpO 2 <90%) who received oxygen therapy. These outcomes were selected to be consistent with our primary stepped wedge trial analysis,26 and reflective of a patient-centred approach to measuring oxygen access 7…”

“…However, broken equipment is ubiquitous in many low-resource settings raising questions of how maintenance practices can be improved and sustained 17–19. We know that oxygen equipment and supplies are major costs for health systems, individual facilities and patients,7 17 20 21 but there are few data to support cost-effectiveness analyses or decisions 22–24…”

Hypoxaemia prevalence and management among children and adults presenting to primary care facilities in Uganda: a prospective cohort study

“…[6][7][8] However, despite WHO primary care guidelines encouraging pulse oximetry screening for young children with respiratory illness, 9 pulse oximetry availability and use in primary care settings is rare. [10][11][12] Previous studies in Africa and Asia-Pacific regions have shown that very few HCWs in primary care facilities have pulse oximeters or are trained to use them, even though it is a simple and acceptable technology. [10][11][12][13][14][15] The COVID19 pandemic has brought overdue public urgency and awareness of the longstanding need to strengthen pulse oximetry and oxygen systems in healthcare facilities in low-and middle-income countries (LMICs) -but we have limited data to guide implementation in primary care settings.…”

“…[10][11][12] Previous studies in Africa and Asia-Pacific regions have shown that very few HCWs in primary care facilities have pulse oximeters or are trained to use them, even though it is a simple and acceptable technology. [10][11][12][13][14][15] The COVID19 pandemic has brought overdue public urgency and awareness of the longstanding need to strengthen pulse oximetry and oxygen systems in healthcare facilities in low-and middle-income countries (LMICs) -but we have limited data to guide implementation in primary care settings. [16][17][18][19][20][21][22] Limited data suggests that pulse oximetry performed by primary care healthcare workers (HCWs) is feasible and can improve clinical decision-making and referral outcomes.…”