Measuring Oxygen Access: lessons from health facility assessments in 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 four key domains to consider when measuring oxygen access.Use8/58 (14%) of facilities had a functional pulse oximeter for detecting hypoxaemia (low blood oxygen level) and guiding oxygen care. Oximeters were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%), or operating theatre (4/27, 15%), not suitable for children, and infrequently used.Availability34/58 (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.CostOxygen was free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13000 ($36 USD) and 27500 ($77 USD) naira, respectively.Patient accessNo facilities were adequately equipped to meet minimum oxygen demands for patients. We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data.We highlight the importance of a multi-faceted 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.SUMMARY BOXOxygen access is poorly understood and the most commonly used metrics (e.g. presence of an oxygen source) do not correlate well with actual access to patients.Pulse oximetry use is a critical indicator for the quality of oxygen services and may be a reasonable reflection of oxygen coverage to patients with hypoxaemia.Oxygen, and pulse oximeter, availability must be assessed at the point-of-care in all major service delivery areas, as intra-facility oxygen distribution is highly inequitable.Minimum functional requirements for oxygen sources must be assessed, as many oxygen concentrators and cylinders may be present without being in working order.

Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation

“…Despite their potential for reducing mortality, pulse oximeters are rarely available in frontline facilities in low-income and middle-income countries 6 10–12. Indeed, our survey of 58 Lagos health facilities in 2020 found pulse oximeters in none of the primary health facilities, 56% (15/27) of private health facilities and exclusively on the paediatric ward of three secondary health facilities 13…”

“…Save the Children, in collaboration with LGA leaders, purposively selected seven government PHCs as ‘flagship’ facilities for the programme, targeting government facilities that have greatest need (Annex 1). Each PHC was then matched based on geographical location to a private health facility, which had consented to take part in the programme during the formative phase and provides care for children under-5 years of age 13. We also included the two government secondary care facilities.…”

“…A biomedical engineer will conduct annual oxygen and pulse oximetry equipment checks, including the location, use, functionality and maintenance. A baseline assessment of existing equipment was conducted during the formative research phase (January–August 2020) and the full methods reported 13…”

Strengthening Oxygen Systems in Asia and the Pacific: Guidance Note

“…Our proposal is that these should holistically assess access by examining the entire oxygen service delivery chain-including oxygen production and procurement, oxygen supply at the points of care, how oxygen is used (particularly pulse oximetry coverage), and costs to patients and the health system (Figure 8, Table 2). 75 Integration of better oxygen access indicators in health facility surveys and health information systems assists facility staff, administrators, policy makers, and funders understand the "supply" and "use" gap and guide investment decisions (Case Study 7).…”