ministry of health national scale up of medical oxygen

Ministry of Health

National Scale up of Medical Oxygen Implementation Plan

2018-2022

NOVEMBER 2018

TABLE OF CONTENTS TABLE OF CONTENTS ......................................................................................................................................................... 1

LIST OF TABLES................................................................................................................................................. 2 LIST OF FIGURES ............................................................................................................................................... 2 LIST OF ACRONYMS ........................................................................................................................................... 3

FOREWORD ........................................................................................................................................................................... 4 ACKNOWLEDGMENTS ........................................................................................................................................................ 5 EXECUTIVE SUMMARY ...................................................................................................................................................... 6 1.0 INTRODUCTION AND BACKGROUND ............................................................................................................. 8

1.1 HYPOXEMIA AND CONDITIONS ASSOCIATED WITH HYPOXEMIA ............................................................................... 8 1.1.1 Surgery / Obstetrics ........................................................................................................................ 8 1.1.2 Emergency care ............................................................................................................................... 8 1.1.3 Disease management ...................................................................................................................... 8

1.2 DIAGNOSIS AND TREATMENT OF HYPOXEMIA ..................................................................................................... 9 1.3 EVIDENCE FOR THE IMPACT OF INCREASING ACCESS TO OXYGEN ............................................................................. 9 1.4 OVERVIEW OF OXYGEN SUPPLY MODELS ........................................................................................................ 10

2.0 SITUATION ANALYSIS ...............................................................................................................................................11

2.1 CURRENT OXYGEN AVAILABILITY AND UTILIZATION ............................................................................................ 11 2.2 CURRENT SUPPLY MODEL IN UGANDA ............................................................................................................ 14 2.3 CURRENT MAINTENANCE MODEL AND FUNCTIONALITY ....................................................................................... 15 2.4 CURRENT TRAINING AND KNOWLEDGE LEVELS OF HEALTH CARE WORKERS .............................................................. 15

3.0 OBJECTIVES OF THE SCALE UP PLAN ..................................................................................................................17 4.0 IMPLEMENTATION STRATEGY .............................................................................................................................17

4.1 QUANTIFICATION OF OXYGEN NEED ............................................................................................................... 17 4.2.1 Expanding oxygen production capacity ......................................................................................... 20 4.2.2 Improvement of oxygen logistics ................................................................................................... 21 4.2.3 Implementation guidelines for facilities ........................................................................................ 21 4.2.4 Procurement ................................................................................................................................. 21 4.2.5 Diagnostics and supply of consumables ........................................................................................ 22 4.2.6 Training of health care workers .................................................................................................... 22

5.0 COORDINATION MECHANISMS .............................................................................................................................24 6.0 IMPLEMENTATION TIME FRAME .........................................................................................................................26 7.0 FINANCING ....................................................................................................................................................................29 8.0 MONITORING AND EVALUATION .........................................................................................................................33

8.1 THEORY OF CHANGE .................................................................................................................................. 33 8.2 PERFORMANCE MONITORING FRAMEWORK ................................................................................................... 34

9.0 APPENDICES.................................................................................................................................................................36

ANNEX 1: DETERMINING PREVALENCE OF HYPOXEMIA ............................................................................................ 36 ANNEX 2: QUANTIFICATION ASSUMPTIONS IN THE OXYGEN SUPPLY MODEL ................................................................. 37

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List of Tables Table 1 Oxygen Supply Models ................................................................................................... 10 Table 2 Recommendations for oxygen equipment in the National Medical Equipment Policy ........ 12 Table 3 Availability of oxygen equipment based on current inventory .......................................... 13 Table 4 Cylinders supplied through NMS 2014 ............................................................................. 14 Table 5 - Quantification of estimated oxygen utilization nationally at public facilities .................. 18 Table 6 Oxygen Generation Capacity in Uganda, with majority of the plants running at 50% capacity ..................................................................................................................................... 18 Table 8 Key roles and responsibilities .......................................................................................... 24 Table 9 Implementation time frame ............................................................................................ 26 Table 10 Annual costing of CAPEX, OPEX and distribution for the national oxygen system ............ 29 Table 11 Notes to Table 10........................................................................................................ 31 Table 12 Quantification of cylinder needs .................................................................................... 31 Table 13 Performance Metrics .................................................................................................... 34

List of Figures Figure 1 Oxygen supply models............................................................................................................. 11 Figure 2 Oxygen supply and availability in public and private health facilities, 2016 ..................... 11 Figure 3 Medical oxygen equipment in public and private health facilities ......................................... 12 Figure 4 Sources of oxygen concentrators at both public and private health facilities in Uganda ... 13 Figure 5 Manufacturers of Oxygen Concentrators in both public and private facilities in Uganda .. 13 Figure 6 Estimated lead times for refilling of oxygen cylinders across various levels of care ............... 14 Figure 7 Oxygen quantification calculation graphic ..................................................................... 18

Figure 8 Proportion of consumption fulfilled by production after 5 and up to 10 years, m3/month .. 19

Figure 9 Key points to consider for scaling up access medical oxygen in Uganda ................................ 20

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List of Acronyms CME DHIS2 DHMT DHO EMS GoU HITWG HMIS HSS HUMCs HCIV ICCM IRC MMTWG MNCH NDA NMS NRH PNFP PPPH RRH SCM TWG VHT UHMG UNICEF

Continuing Medical Education District Health Information Software version 2 District Health Management Team District Health Office Emergency Medical Services Government of Uganda Health Infrastructure Technical Working Group Health Management Information System Health System Strengthening Health Unit Management Committees Health Centre IV Integrated Community Case Management International Rescue Committee Medicines Management Technical Working Group Maternal, Newborn and Child Health National Drug Authority National Medical Stores National Referral Hospital Private non-for-profit Public-Private Partnership in Health Regional Referral Hospital Supply Chain Management Technical Working Group Village Health Team Uganda Health Marketing Group United Nations Children’s Fund

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Foreword

Medical oxygen is a lifesaving commodity, the lack of which can lead to severe complications and death. The government has made great strides in increasing access to medical oxygen by increasing the manufacturing capacity through the installation of oxygen plants at all Regional Referral Hospitals. As the country moves towards improving the supply of medical oxygen countrywide, there is need for a coordinated framework within which associated interventions will be implemented.

The National medical oxygen scale up implementation plan articulates a holistic approach to improving demand and supply of medical oxygen in Uganda. Specifically, the plan aims to put in place coherent and harmonized implementation of key interventions to achieve an optimal medical oxygen supply model. This will be done by leveraging various programs for which medical oxygen is a key therapeutic element.

The plan focusses on four main objectives: (i) to provide policy basis to direct decision making to scale up medical oxygen supply; (ii) to secure maintenance of medical oxygen equipment and supply of spare parts through the regional workshops and the National Medical Stores; (iii) to provide a framework for training of Health Workers and Biomedical Engineers/Technicians in rational use, operation, care, handling and basic maintenance of oxygen therapy equipment; and (iv) to provide an advocacy instrument to secure funding to support medical oxygen scale up interventions.

The scale up plan outlines the key strategies to realize an optimal supply model, including: increasing manufacturing capacity, establishment of guidelines on training and supervision, development of a dedicated procurement and distribution system for oxygen equipment and accessories, maintenance and repair system, coordination and financing arrangements, and a monitoring and evaluation framework.

In-order to achieve the targets set out in the plan, both public and private sector partners need to jointly collaborate in the promotion of all components of the plan through established linkages at the national and sub national level.

I urge all stakeholders to join hands and ensure that the required resources are mobilized through this plan to significantly improve access to medical oxygen, especially in the higher levels of health care nationwide.

For God and my Country,

Dr. Diana Atwine PERMANENT SECRETARY

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Acknowledgments

The National medical oxygen Scale up Plan is a result of joint efforts of the Ministry of Health, Development partners, Civil Society and implementing partners.

The Ministry of Health wishes to acknowledge the contributions of various organizations that supported the process, both financially and technically. Appreciation goes to those individuals who took part in reviewing the earlier editions and whose tireless efforts produced the final document for approval.

It is hoped that the National plan for scaling up access to medical oxygen in Uganda will guide safe delivery and rational use of medical oxygen across all levels of the health care delivery system and contribute to reduction of morbidity, disability and mortality.

Dr. Henry G. Mwebesa Ag. Director General Health Services

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Executive Summary

The ability to detect and treat hypoxemia is critical to patient care, especially for the management of emergency conditions in adults, children, neonates and maternal health. In our health care system, functional oxygen supply should be available in all hospitals and HCIVs in both the public and private sectors. However, access remains limited due to challenges in procurement, distribution and capacity to properly use, operate and maintain oxygen delivery and therapy devices.

There are three main oxygen supply models: use of cylinders, concentrators and oxygen generators/plants. Oxygen concentrators are the main form of oxygen supply in Uganda; however, the unreliable hydroelectricity grid power supply limits effective use of oxygen concentrators and the lack of pulse oximeters limits diagnosis to support optimal utilization of oxygen.

Oxygen cylinders are the back-up solution for concentrators when power is not available and they are the primary oxygen source for the operating theatres and ICUs. However, transportation of cylinders, limited availability of cylinders at all levels of health care, and their functionality remain a challenge. With respect to oxygen generators/plants, there are currently 17 medical oxygen plants (Mulago National Referral Hospital - 3 and RRHs - 14) to service the needs of the public health facilities.

Maintenance of the existing oxygen equipment in the public sector is conducted by Biomedical Engineers/Technicians from Regional Medical Equipment Maintenance Workshops located at the RRHs and Kampala for the Central region. However, the capacity to maintain oxygen equipment is limited due to the conflicting needs of other medical equipment also requiring repairs.

In addition to the structural barriers mentioned above, lack of knowledge among health workers in the use, operation, care, handling and basic preventative maintenance of oxygen therapy equipment contributes to low levels of utilization and reduced durability of oxygen equipment.

This National medical oxygen Scale up Plan aims to increase availability and utilization of oxygen in higher level facilities along four main objectives:

Objective 1: To provide a national strategic framework to guide scale up of medical oxygen supply and utilisation

Objective 2: To secure maintenance and replacement of oxygen therapy and diagnostic equipment through the regional workshops and the National Medical Store

Objective 3: To provide a framework for training of staff in health facilities on rational use of oxygen and basic maintenance of oxygen therapy equipment

Objective 4: To provide an advocacy instrument to secure funding to support oxygen scale up interventions

The following need to be done to establish optimal conditions for increased oxygen supply and use:

i) The distribution system for supply and delivery of oxygen cylinders has to be improved by enhancing the transport capacity of NMS, JMS and other approved service providers.

ii) The MoH has to develop guidelines for training Health Workers on hypoxemia detection, oxygen utilization and routine maintenance

iii) The capacity of the regional referral hospitals should be enhanced to properly operate and manage the oxygen plants

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iv) The MoH needs to develop and establish a centralized procurement system for purchase of oxygen equipment and spare parts to leverage economies of scale and maintain appropriate spare parts within the supply system.

v) A coordination framework should be established at the national level for harmonizing oxygen supply scale up and use.

vi) Production capacity has to be increased by expanding the capacity of the existing oxygen

plants in the 14 Regional referral hospitals or by entering into Public Private Partnerships

(PPPs) to meet the increased medical oxygen demand expected to surpass the current

generation capacity from 2022 onwards.

In order to ensure high equipment uptime and utilization, it is essential that health workers are trained in the clinical use of oxygen and pulse oximetry and the day-to-day maintenance and care of oxygen equipment. Trainings on the use of oxygen and pulse oximetry should be conducted in each HCIV and hospital as part of Continuing Medical Education (CME) and included in pre-service training for nurses, midwives and doctors where it is not the case yet. Furthermore, building in-house capacity in maintenance and repair within hospitals and the regional workshops is crucial, as dependence on external agents to service equipment may lead to high costs, delays to respond to maintenance call outs and long equipment downtime.

Improving oxygen supply and utilization at national level is a long term process. The timeline for implementation of this plan will depend on available funding and infrastructure; prerequisites that need to be in place in a facility. Establishing and maintaining the system mentioned above will require additional investments by both hospitals and central government. Funding the above activities will require a concerted effort between national and local stakeholders, development partners and the private sector. It is anticipated that major systems improvements should commence in 2018 with a fully functioning oxygen system in place by 2022.

Monitoring and evaluation shall be based on available facility utilization data from individual hospitals, NMS, JMS and the MOH. The Health Infrastructure Department will be responsible for building and maintaining an inventory of available equipment. In addition, regular surveys will be conducted to assess knowledge growth and clinical practice.

The Directorate of Clinical Services in the Ministry of Health will coordinate the implementation of this plan by working closely with partners and various technical working groups of the Ministry of Health to ensure an integrated and harmonized response.

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1.0 Introduction and Background

1.1 Hypoxemia and conditions associated with hypoxemia

Lack of oxygen in the blood (hypoxemia) is a life-threatening condition, typically caused by an underlying illness or injury. It can result in a lack of oxygen in the tissues (hypoxia) and therefore increases the risk of death if left untreated. The ability to detect and treat hypoxemia is critical to

patient care, especially for children and neonates. Hypoxemia most often occurs in three areas1: emergency care, surgery and disease management.

1.1.1 Surgery / Obstetrics

Oxygen is regarded as an essential drug in the perioperative setting as there are many reasons why patients are prone to hypoxemia in the perioperative period, for example: airway manipulations and

obstructions; inadequate breathing; the effect of drugs; and/or equipment failure2. Oxygen should be routinely given during and after anaesthesia as various techniques may lead to cardiovascular depression and reduced oxygen delivery.

1.1.2 Emergency care

Immediate oxygen therapy is a basic life-saving intervention in all significantly traumatized patients, to be carried out even before any attempt to diagnose the underlying injury. The main objective of doing so is to ensure sufficient oxygen to patients to reduce the risk of tissue hypoxia until surgery or other interventions can be performed. For example, treating hypoxaemia and hypotension are the most important factors in the prevention of secondary brain injury after traumatic brain injury.

1.1.3 Disease management

In disease management, the prevalence of hypoxemia varies by age group and underlying disease: • Neonates (0-1 month old): In low resource settings, hypoxemia occurs in ~20% of all

neonates3. Conditions such as prematurity, birth asphyxia (i.e. infants requiring resuscitation), sepsis, and pneumonia are all associated with hypoxemia.

• Children (under-15 years of age): It is estimated that 6% of all children under-15 years of age

admitted to a hospital are hypoxemic4. The prevalence of hypoxemia in severe pneumonia,

the leading cause of childhood mortality, is 13%5 with some studies finding hypoxemia in up

to 80% in severe cases and 100% in very severe cases6. While approximately 1 out 3 cases of childhood hypoxemia is due to a lower respiratory tract infection, other conditions also contribute significantly to the burden, including severe malaria (~4%), malnutrition (~5%) and meningitis (~5%).

• Adults: The predominant causes of hypoxemia in adults are chronic obstructive pulmonary

disease (COPD), acute asthma, and pneumonia. Little data is available to estimate the

prevalence of hypoxemia among adults; however, some studies estimate that ~9% of adults

admitted to hospitals in Sub-Saharan Africa are hypoxemic7. 1 Trevor Duke, Rami Subhi, Oxygen: a scarce essential medicine

2 WHO Model List of Essential Medicines for Children 6th List(Amended August 2017)

3 Subhi R, Adamson M, Campbell H, Weber M, Smith K, Duke T; Hypoxaemia in Developing Countries Study Group. The prevalence of hypoxaemia among ill children in developing countries: a systematic review. Lancet Infect Dis. 2009 Apr;9 (4):219–27.

4 S Junge et Al. The spectrum of hypoxaemia in children admitted to hospital in The Gambia, West Africa

5 Duke T et al. - The prevalence of hypoxemia among ill children in developing countries.

6 Basnet et al., Hypoxemia in children with pneumonia and its clinical predictors, Indian J Pediatr 2006; 73 (9) : 777-781

7 Foran et al. Prevalence of undiagnosed hypoxemia in adults and children in an under-resourced district hospital in Zambia. Int J Emerg Med (2010) 3:351–356

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1.2 Diagnosis and treatment of hypoxemia

The ability to quickly detect and treat hypoxaemia is critical to patient care. While the gold standard for measuring oxygen saturation is blood gas analysis, it is invasive and expensive. Detection of

hypoxaemia based on clinical signs is not reliable due to unreliable sensitivity and specificity8,9 with

the practice. The World Health Organization (WHO) advocates for pulse oximetry as the most cost-effective method for detecting and monitoring hypoxaemia (e.g., saturation level of <90%) in

hospitals10 in low resource settings. When diagnosed, hypoxemia can be treated with a very high rate of success via oxygen therapy. The WHO recommends the use of oxygen for emergency care, perioperative settings and hypoxemia

treatment11 12 13. In Uganda, oxygen and peripheral oxygen equipment are considered vital with

HCIV as the lowest recommended level of use.14 The current Uganda Clinical Guidelines (2016) recommend oxygen treatment for a number of diseases including pneumonia, other severe respiratory infections, complications of severe malaria, new-born resuscitation, trauma, poisoning

and anaphylactic shock.15 This means that oxygen and its associated equipment should be available at lower level health facilities.

1.3 Evidence for the Impact of increasing access to oxygen

Several studies and experiences from other countries have shown that it is possible to improve oxygen supply and therapy in resource-limited settings given appropriate support for training on case management and maintenance of equipment: In Egypt, oxygen concentrators were successfully

introduced into small hospitals16. In Papua New Guinea, pneumonia mortality decreased by 35%

after the introduction of an improved oxygen system17. In Malawi, introduction of oxygen

concentrators in all district hospitals saw a fall in pneumonia case fatality rates from 18.6% to 8.4%18 of total admitted pneumonia patients. While most research on hypoxemia has been in paediatric pneumonia, the positive impact of (targeted) oxygen therapy for neonatal conditions and in trauma

and surgery patients of all age groups is widely accepted.19

8 Weber M, et al. Predictors of hypoxemia in hospital admissions with acute lower respiratory tract infection in a developing country. Arch. Dis. Child. 1997; 76(4):310-314.

9 Lodha et al. Can clinical symptoms or signs accurately predict hypoxemia in children with acute lower respiratory tract infections? Indian Pediatrics, 2004, Volume 41, pp 129-135

10 WHO. Oxygen Therapy for Children. 2016.

11 Campbell H et Al. Global initiatives for improving hospital care for children: state of the art and future prospects.

12 World Health Organization. Integrated management for emergency and essential surgical care (IMEESC) tool kit. 2010.

13 World Health Organization. Surgical care at the district hospital. 1st ed.. WHO; Geneva, Switzerland: 2003

14 Uganda Ministry of Health. Essential Medicines and Health Supplies List for Uganda (EMHSLU), 2016

15 Uganda Ministry of Health, Uganda Clinical Guidelines, 2012

16 Dobson M, Peel D, Khallaf N. Field trial of oxygen concentrators in upper Egypt. Lancet. 1996;347:1597–9.

17 Duke T et al. Improved oxygen systems for childhood pneumonia. Lancet, 2008, 372(9646):1328-1333.

18 Enarson P M, et al. Development and implementation of a national programme for the management of severe and very severe pneumonia in children in Malawi.PLoS Med 2009

19 Duke T et al. The clinical use of oxygen in hospitals with limited resources. WHO, 2012

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1.4 Overview of Oxygen supply models

There are three main modes for oxygen supply commonly used in Uganda as shown in Error!

Reference source not found. (and described further in Table 1 below): cylinders, concentrators and

oxygen plants.

Table 1 Oxygen Supply Models

Model Cylinders Concentrators Central Source

(portable & storage) (Bedside & Portable) (Liquid & PSA O2

generator/plant)

Description High pressure gas is supplied Oxygen enriched gas is Oxygen is provided via a via portable canisters (typically supplied by entraining air large central source on-site, 7,500L) and delivered to health from the environment and most often in addition to a facilities, which must exchange removing nitrogen via manifold or network of the empty cylinders pressure swing absorption copper pipes

(PSA)

Use case(s) • Facilities without a reliable • Facilities with a • Large facilities with power source or in close reliable power source reliable infrastructure proximity of a plant (or backup) and skilled technicians

• Deliver medium-high • Deliver low output • Deliver high output output flow; well-suited flow (~5L/min); well- flow and pressure; for all 3 application areas suited for disease well-suited for all 3 management but too application areas

low for emergencies

Main • No need for electricity or • Can ensure • Can ensure continuous advantages highly skilled technicians continuous supply at supply at high pressure

• Low capital investment

•

low running cost • Most cost effective

cost One concentrator can system for larger

serve up to 4 beds facilities

Main • Supply is highly dependent • Requires access to • High capital investment disadvantages on supplier availability uninterrupted power • Requires access to

• Cost of transport can lead • Service and supply of reliable and sufficient to budget constraints spare parts should be power source

• System is highly sensitive

•

foreseen • Need for skilled to leakage Relatively low output technicians and

• Cylinders are potentially often insufficient for

•

adequate infrastructure

hazardous (explosion risk) emergency care (ICU) System is potentially

hazardous

Peripheral • Pressure regulator & • Humidifier • Cylinders incl. equipment gauge • Nasal prongs/catheter peripheral equipment

necessary • Flowmeter

• Humidifier • Nasal prongs/catheter

• Cylinder Key

Manufacturers • Oxygas • DeVillbiss • OGSI

(exemplary) • Oxygen Uganda • AirSep • Oxymat

• Mulago Hospital • Ozcan Kardesler

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Figure 1 Oxygen supply models

2.0 Situation analysis

2.1 Current oxygen availability and utilization

The majority of public and private not-for-profit facilities in Uganda do not have sufficient availability of oxygen and pulse oximeters. The last Uganda Services Availability and Readiness assessment

showed that only 36% of facilities offering services for chronic respiratory diseases had oxygen.20 Even when oxygen delivery and therapy equipment are available it is often not properly maintained,

leading to frequent non-functionality and thus inconsistent supply. In a recent assessment21 of oxygen systems availability, out of 78% of facilities providing some form of oxygen supply (either through concentrators or cylinders), only 47% of the oxygen supply equipment was operational (See Figure 2). The proportion of oxygen systems availability was even lower when facilities were assessed on availability of diagnostic equipment. Availability dropped further when assessment looked at staff trained on oxygen equipment (also shown in Figure 2), which was lowest at general hospital and HCIVs compared to regional referral hospitals.

Figure 2 Oxygen supply and availability in public and private health facilities, 2016

129

78%

47%

23%

15%

# Total facilities % Providing O2 % with operational O2 % with operational O2 % with operational O2, in ped ward & POx in ped ward POx, & trained staff in ped ward

20 Uganda Services Availability and Readiness Assessment 2013 (n=106)

21 Assessment on oxygen equipment in public and private health facilities in Uganda, Clinton Health Access Initiative 2016

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Oxygen is often treated as a scarce resource, restricted to operating theatres, most-critically-ill

patients, and emergencies. A verbal autopsy study found that only 4% of children who died from

pneumonia received oxygen therapy.22

In 2016, Oxygen concentrators were the main form of oxygen supply in Uganda (Figure 3). An

inventory by the health infrastructure department showed that 100% of hospitals and 84% of

HCIVs had at least one oxygen concentrator available; however, only 17% of RRH, 30% of GHs and

45% of HCIVs had a sufficient number of concentrators in accordance with the National Medical

Equipment Policy.

Figure 3 Medical oxygen equipment in public and private health facilities

Cylinders

Concentrators

Generator plant

Other

1% 3%

39%

57%

The National Medical Equipment Policy recommends a minimum level of equipment for the different

levels of the health care as indicated in Table 2. In addition, unreliability of grid power limits the

functionality of oxygen concentrators. Further, the lack of pulse oximeters (see Table 3) limits

correct diagnosis and monitoring of hypoxemia, thus inappropriate or irrational use of available

oxygen equipment is not uncommon.23

Table 2 Recommendations for oxygen equipment in the National Medical Equipment Policy24

Type of Recommended number of Recommended Recommended number of

hospital oxygen therapy apparatus25 number of pulse oximeters concentrators

NRH 78 85 52

RRH 51 23 13

GH 14 5 9

HCIV 6 2 2

HC III 2 0 0

22 Kallander, K et al., Delayed care seeking for fatal pneumonia in children aged under five years in Uganda. Bulletin of the WHO 2008

23 Medical Equipment Inventory of 31 HC IVs, 10 GHs and 6 RRHs, Health Infrastructure Department, MOH, 2015

24 National Medical Equipment Policy, Ministry of Health, 2009

25 One Oxygen Therapy Apparatus is composed of an oxygen cylinder 15-50kg, oxygen regulator, adaptor for humidifier bottle, humidifier bottle, oxygen cannulas (adult and paediatric) and a carrying case

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Table 3 Availability of oxygen equipment

Oxygen concentrators Pulse oximeters

Level Availability26 Sufficient Average # Availability28 Sufficient Average # availability27 availability29

RRH (n=6) 100% 17% 11 67% 0% 3.3

GH (n=10) 100% 30% 4.6 50% 0% 0.9

HCIV (n=31) 84% 45% 1.6 6% 3% 0.2

A significant proportion of oxygen concentrators are donations (see Figure 4) and DeVilbiss

brand dominates the market30(see Figure 5).

Figure 4 Sources of oxygen concentrators at both public and private health facilities in Uganda

Figure 5 Manufacturers of Oxygen Concentrators in both public and private facilities in Uganda

AirSep Other 19% 26%

Longfian 3%

DeVilbiss Longfei 43%

9%

Oxygen cylinders are the primary oxygen source for the theatre and ICU where higher flow rates are required and are the back-up solution when power is not available. Over 3000 cylinders were

26 % of facilities with at least one oxygen concentrator

27 Cold Chain Inventory, UNEPI, Ministry of Health 2014

27 % of facilities with sufficient number of oxygen concentrators according to National Medical Equipment Policy

28 % of facilities with at least one pulse oximeter

29 % of facilities with sufficient number of pulse oximeters according to National Medical Equipment Policy


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supplied by NMS in 2014 to 29 different facilities, mostly regional referral hospitals, averaging 112 cylinders per health facility.

Table 4 Oxygen supplied using Cylinders through NMS in 2014

Type # of facilities Oxygen Average Average31

by level that supplied [m3] volume of O2 volume of O2

received supplied to supplied by O2cylinders facilities Health care

serviced [m3] level [m3]

National Referral Hospital 1 7,898 7,898 7,898

Regional Referral Hospital 13 15,653 1,204 1,118

General Hospital 7 810 116 6.5

HCIV 8 45 5.6 0.3

Total 29 24,406

2.2 Current supply model in Uganda

The public sector is currently served by 17 medical oxygen plants (3 at Mulago NRH and 14 at RRHs)). Oxygen supply to peripheral public health facilities is currently managed by the National Medical Stores (NMS) while in some cases the health facilities deliver and pick cylinders from the regional plants at their own cost. NMS was sourcing oxygen from Mulago hospital and was using one dedicated truck that picks up cylinders from the facilities, fills them at Mulago hospital and returns them to the facilities, transporting a maximum of 50 large cylinders at a time. This poses a challenge, as oxygen must be transported separately from other commodities. Using a single truck with a limited number of cylinders makes it difficult to optimize oxygen distribution. The refill frequency

took longer than 3 months for the majority of health facilities32, as illustrated in Figure 6 below. At present, there is no robust mechanism for the existing public sector plants to distribute oxygen to facilities in their respective catchment area, despite the ever-growing demand. Occasionally, NMS continues to supply hospitals with medical oxygen from Oxygas (a private manufacturing company) in order to take advantage of a cylinder rental arrangement when oxygen is purchased from Oxygas.

Figure 6 Estimated lead times for refilling of oxygen cylinders across various levels of care

Note: The “Other” category includes all periods longer than every 3 months

31 This is based on the total number of health facilities by level.


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All the 14 RRHs currently have functional 15m3/hr oxygen plants (with the exception of Mbarara,

which is 10 m3/hr) which have the capacity to operate as regional plants to serve health facilities in their catchment area. However, public health facilities have to incur the pick-up costs of oxygen as the NMS transport system for oxygen does not have additional capacity especially due to lack of cylinders of its own.

Oxygen supply in the private sector is mostly organized via the Joint Medical Store (JMS). JMS supplies private not-for-profit hospitals (PNFP) with oxygen concentrators and peripheral oxygen equipment like regulators and pulse oximeters. Cylinders are leased to facilities from Oxygas or Uganda Oxygen. PNFP are responsible for the transport of their cylinders to and from these two private oxygen companies in Kampala. In addition several private hospitals have invested in small oxygen generation plants. There is limited data available regarding how many such plants exist and their capacity.

2.3 Current maintenance model and functionality

Maintenance of oxygen equipment in the public sector is conducted by the 12 regional workshops (Kabale, Fort Portal, Hoima, Arua, Gulu, Lira, Soroti, Mbale, Mubende, Moroto, Jinja and Central/Kampala) that are located at the RRHs and Kampala for the central region and are supervised by the Health Infrastructure Department. However, these regional workshops are faced with significant challenges due to shortage of personnel, inadequate funding and unavailability of spare

parts.33 The supply of these spare parts (regulators for oxygen cylinders, filters, valves for oxygen concentrators) lies within the responsibility of NMS. However, due to the large variety of manufacturers and systems, not all spare parts are readily available.

JMS provides maintenance service to mission hospitals, through a full-service agreement for a flat fee, or on a case by case basis. The same situation was found at JMS in that available spare parts do not always match the existing equipment and the maintenance budgets at the health facilities are often very inadequate.

According to the latest hospital and HCIV census, only 37% of the health facilities had a budget line

item for routine maintenance and repair of medical equipment. Schedules for maintenance of any

medical equipment were observed in 13.4% of the facilities surveyed.34

2.4 Current training and knowledge levels of health care workers

In addition to the structural barriers mentioned above, a lack of knowledge among health workers about the diagnosis of hypoxemia, utilization of oxygen and ongoing maintenance of equipment contributes to low levels of utilization and reduced lifespan of oxygen equipment. A study showed only 42% of children under- 5 with respiratory cases were screened using pulse oximetry during routine care, and among those with an SpO2 reading of less than 90%, only 22% were given oxygen

therapy35. Only 62% of health workers were knowledgeable on the use of a pulse oximeter and less than 50% knew the operations and basic routine maintenance protocols for oxygen therapy equipment. 33 Health Infrastructure Department, Ministry of Health, 2015

34 Hospital and HC IV Census Report 2015, Ministry of Health

35 The Study was conducted by the Ministry of Health in collaboration with the Makerere School of Public Health and the College of Health sciences and Clinton health Access Initiative

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3.0 Objectives of the Scale up Plan

This plan aims to increase the availability and utilization of oxygen in higher level facilities along four main objectives:

Objective 1: To provide a national strategic framework to guide scale up of oxygen supply and utilisation


Objective 3: To provide a framework for training of staff in health facilities on rational use of oxygen and basic maintenance of equipment


4.0 Implementation Strategy

4.1 Quantification of oxygen need

Oxygen should be available in hospitals and HCIVs in all areas where seriously ill patients are managed: neonatal, paediatric and adult (medical, surgical, obstetric) wards, operating theatre and emergency department. Uganda has ~330 facilities that are supposed to have functioning oxygen supply with a total of ~24,000 beds.

Assuming utilization of oxygen based on clinical assumptions, nationally, at least 124,348 m3 per month would be needed as of 2019 to fulfil the oxygen need of all public facilities from HCIV, GH,

RRHs and the NRH36.

Key parameters used in quantifying total oxygen need (see

36 PNFP facilities were not included in this quantification but the same methodology can be applied to this sub sector.

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Figure 7):

1. Number of hypoxemic cases o Number of beds per ward o Hypoxemia prevalence per ward o Bed turnover ratio (factor of bed occupancy rate and average length of stay)

2. Oxygen litres/m3 required per ward o Number of hypoxemic cases per ward o Oxygen litres consumed per case

3. Total estimated need per facility o Sum of the oxygen litres/m3 consumed in all wards

4. Total consumption at the national level o Summation of the total estimated need for all facilities that administer oxygen

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Figure 7 Oxygen quantification calculation graphic

Table 5 - Quantification of estimated oxygen utilization nationally at public facilities

Level of Number of Estimated theoretical need of Total Estimated theoretical need

care facilities oxygen per facility (m3/month), of oxygen per level of care 2019 (m3/month), 2019

HCIV 180 265 47,700

GH 5337 750 39,750

RRH 14 2,053 28,742

NRH 1 8,156 8,156 TOTAL 124,348

This estimated need will be fulfilled using a combination of oxygen supply options (supply mix); either through concentrators, cylinders or oxygen generators (plants).

Current oxygen production capacity from the existing public plants:

Parameters used to determine production capacity

i) Oxygen plant capacity/size (m3/hr)

ii) Oxygen plant operating days per month (i.e. 5 days per week) iii) Number of filling hours per day (i.e. 16 hours per day)

Table 6 Oxygen Generation Capacity in Uganda, with majority of the plants running at 50% capacity (16 hours per day, 20 days per month)

Production # of # of days/ Avg monthly production Capacity (m3/hr) hours/day month (m3/month)

Mulago 60 16 20 19,200

Mbarara 10 24 30 7,200

Regional referral 15 16 20 62,400 hospital Plants (13)

Total Production 88,800 m3

The current oxygen production capacity should be able to fulfil the existing demand. However, it is assumed that the current oxygen demand/utilization is low, partly from a lack of clinical knowledge, but more so as a result of a lack of availability, quality and the reliability of both factors. Figure

37 This figure includes Butabika national referral hospital whose oxygen consumption was modelled at the level of a general hospital.

19

8Error! Reference source not found. indicates the proportion of current production potential as it relates to use, alongside projected production and use.

Figure 8 Proportion of consumption fulfilled by production after 538 and up to 10 years, m3/month

Estimated demand 2028

124,348 m3/month

Demand

Estimated current oxygen

use: 22,089 m3/month

Production Current 16 hours per day Maximum plant prodution capacity plant production capacity (optimized operation for 24hr/day for 30

88,800 m3/month days per month ) - 201,600 m3/month

Regardless, it is imperative that actual oxygen use, and the uptake thereof, is appropriately captured in Health Management Information Systems (HMIS) over time to assess and evaluate the efficacy of a system. While not addressed in this scale-up plan, data on oxygen usage should be captured at the patient and facility level and fed into the HMIS on a regular basis to ensure that supply adequately meets actual demand on the ground.

4.2 Scaling up oxygen: Setting up an optimal oxygen supply model

Oxygen is a vital commodity for hospitals and HCIVs. Ensuring reliable, quality supply is therefore the primary objective for a national supply model – with cost effectiveness as a secondary objective – to ensure sustainability. In order to ensure reliable supply, oxygen demand needs to be addressed systemically and the supply model needs to be backed up by maintenance, training, financing, organization etc. (see Figure 8).

38 The investment for distribution break-even is set at 5 years as per MOH’s medium-term investment framework, with a project life of 10. See sections below for more details.

20

Figure 9 Key points to consider for scaling up access medical oxygen in Uganda

Manufacturing Logistics Implementation guidelines Procurement

capacity • Cylinder supply • Best model per HF level • Uniformity/standardization of

• National plants • Cylinder delivery • Ward organization equipment and procurement

• Private plants • Ordering process • Staff methods

• PPP ventures • Training • Bulk procurement

Diagnostics and Consumables Maintenance and supply of Guidelines on oxygen use and

• Pulse oximeters spare parts training of health workers

• Nasal prongs • Regional equipment workshops • Clinical use of oxygen and oximetry

• Pulse oximeter probes • Framework/maintenance and everyday care of equipment

• Cylinders and oxygen regulators contracts • Regular equipment maintenance

• NMS & JMS for users and technicians

Financing Coordination Monitoring and Evaluation

• Capital investment • National • Usage monitoring via HMIS

• Operations and maintenance committee • Mentorship/supervision for assurance of quality of care

• Transportation facilities & • Regional • Oxygen assessment tool

delivery of cylinders committees • Annual visits by oxygen teams and QA department

• Consumables and spare parts (incl. NDA, UNBS, etc.)

Though oxygen can be supplied through cylinders, concentrators or central oxygen generators, the ideal supply model combines these three options in the supply mix to ensure both continuity of supply and cost effectiveness. At the national level, several structures will be improved or established to provide optimal conditions for scale up of medical oxygen supply and use.

4.2.1 Expanding oxygen production capacity

The planned plants for Mulago RRH will only serve the needs of that hospitals and not the rest of the country. If there is increased detection of hypoxemia and utilization of oxygen at general hospital and HCIV level, and the actual demand outstrips what has been quantified, additional oxygen supply will be needed to meet this increase in demand. This could be achieved by an additional large size plant to fill this gap or the procurement of concentrators, large-size cylinders and related equipment (generators and spare parts) and necessary additional/peripheral equipment to ensure transportation/ administration. The options for increased generation capacity are:

1. Government/MoH expanding the capacity of each of the 14 plants at RRHs from 15m3/hr to 30m3/hr.

2. Government/MoH expanding capacity by installing one big oxygen plant at a central location or installing 1 to 4 regional plants to serve a number of districts within optimal distances from the plant.

3. Government / MoH leveraging existing management and supply chain systems by twinning some of the existing plants in a strategic manner (those with excess near-by demand)

4. Construction of new high capacity plants in facilities with very high demand

21

5. Signing PPP ventures with private companies.

4.2.2 Improvement of oxygen logistics

The current system of delivering oxygen cylinders to peripheral facilities using one truck is a major bottleneck to ensure reliable supply of oxygen at health facility level in the public sector. While construction of oxygen plant at RRHs has reduced distances to carry cylinders to the health facilities, additional trucks are needed to ensure timely delivery of cylinders to all HCIVs and hospitals.

With the additional plants, access has increased and transport costs can be reduced to optimal

levels. An ideal model of distribution would be a centrally managed system with regional centres

using an informed push39 system following a hub-and-spoke routing structure.

NMS and JMS will be responsible for managing a centralized ordering system for all public and PNFP facilities respectively. NMS will ensure transportation of cylinders from all oxygen plants at the RRHs to peripheral public facilities. Health facilities will be responsible for placing orders for oxygen cylinder refills (see Table 8 for roles and responsibilities). The transportation cost will be met from the medical supplies credit line managed by the distributing entities (i.e. NMS, JMS).

The private sector may also be able to benefit from shorter distances to the nearest oxygen plant but they shall be required to pay for the medical oxygen and meet the transportation costs.

4.2.3 Implementation guidelines for facilities

Implementation guidelines need to be developed to provide the appropriate peripheral equipment and structures to ensure successful implementation. Specific topics to be addressed in the implementation guidelines are:

i) Quantification of oxygen needs • Monthly demand • Appropriate supply mix

ii) Assurance of adequate supply of requisite spares and consumables for oxygen equipment iii) Clinical practice guidelines including pulse oximetry iv) Guidelines on operation and management of oxygen plants in public facilities

4.2.4 Procurement

The technical capacity of the MoH will be enhanced to enable preparation of specifications, procurement and installation planning. This will ensure cost effectiveness and quality of equipment. High capital investments like oxygen plants will not be made without prior consultation with the Ministry of Health Planning, Procurement and Health Infrastructure Departments. Centralised procurement process will be most preferred in order to maximize the benefits of economies of scale: driving down costs, standardization of designs, layout, equipment, spare parts, and quality standards.

39 A push system is a commodity distribution system in which the personnel or entity that issues health commodities and supplies determines the quantities to be issued as opposed to a pull system in which the personnel or the health facility staff who receive the supplies determine the quantities to order.

22

4.2.5 Diagnostics and supply of consumables

4.2.5.1 Pulse oximetry

Pulse oximetry is the best way to detect and monitor hypoxemia. Hand held pulse oximeters should be available in all facilities with oxygen equipment. Pulse oximeters should also be procured following target product profiles, based on determined use-case scenarios, taking into consideration both clinical need and health care level, to ensure quality and reliability of the equipment.

4.2.5.2 Oxygen equipment and consumables

In many facilities, oxygen equipment cannot be used because an accessory (e.g. pressure regulators, flowmeters, filters) or consumables (e.g. oxygen masks) are missing. Integrating these important components into the existing supply chain will simplify the ordering process for facilities and help avoid supply chain issues.

4.2.5.3 Maintenance and supply of spare parts

Building capacity in maintenance and repair within hospitals and the regional workshops is crucial, as dependence on external agents to service equipment may lead to high costs and long delays. Regular planned preventive maintenance (i.e. daily/weekly/monthly maintenance by the equipment users and Biomedical Engineers/Technicians) will be carried out to avoid equipment break down, expensive repairs and equipment down-time.

Maintenance of oxygen equipment and continuous, dependable supply of spare parts is the responsibility of the MoH Health Infrastructure Department, NMS/JMS and the regional maintenance teams.

Enhancing the capacity of the existing structures (NMS/JMS employees and regional maintenance teams) will be undertaken through training relevant stakeholders so as to help increase functionality of existing oxygen equipment and prolong the lifespan of new equipment. Health facility technicians and clinical staff will be trained on routine maintenance protocols to build in-house capacity for assured sustainability.

To ensure adequate maintenance of equipment, it is estimated that the regional workshops will need additional funding to service oxygen equipment, inclusive of consumables and spare parts (see Table 10). As this would account for >10% of their current yearly budget, an increase in overall budget will be required to ensure sufficient maintenance. Where the regional workshops are not fully functional, hospitals should be given the flexibility to enter into a separate maintenance plan with a private provider.

4.2.6 Training of health care workers

In order to ensure appropriate utilization of oxygen and longevity of available equipment, it is essential that health workers are trained in the use of oxygen, pulse oximetry and the day-to-day maintenance and care of oxygen equipment. Trainings on the use of oxygen and pulse oximetry

23

should be conducted at each HCIV and hospital as part of Continuing Medical Education (CME) covering the following elements:

i) Overview of hypoxaemia for clinicians ii) Detection of hypoxaemia

iii) Usage of pulse oximetry iv) Oxygen equipment and how it works v) When and how to administer oxygen

vi) Patient and caregiver education vii) Equipment care, maintenance and safety

viii) Supply chain management for oxygen at health facility level ix) Medical record keeping and data management

All these elements should be included in pre-service training for nurses, midwives and doctors where it isn't the case yet.

24

5.0 Coordination Mechanisms

A functioning oxygen supply system relies on three professional groups:

1) Clinicians who recognize and treat patients with hypoxemia 2) Engineers/Technicians who keep the equipment running 3) Administrative officers who ensure an ongoing supply and availability of spare parts

The Health Infrastructure Technical Working Group and the Hospital Technical Working Group (TWG) will have overall responsibility for coordinating and monitoring activities implemented under this plan. These TWGs will bring together clinical, technical and Biomedical Engineering and administrative experts.

Additionally, activities implemented under this plan will be integrated into the work of Regional Performance Teams at each regional referral hospital, comprising of the same expertise, to support the clinical, technical and training aspects including feedback to and coordination with the national level technical working groups.

Within the Directorate of Clinical Services, a designated oxygen focal person shall be identified at or above the level of Senior Medical Officer to ensure coordination of MOH response across the various programs and technical working groups.

5.1 Institutional framework

Table 7 Key roles and responsibilities

Institution/Implementing Roles and responsibilities

agent

National level

Ministry of Health (Health • Provide policy framework to guide implementation of activities Infrastructure Department, • Monitor progress against national indicators to improve access to Pharmacy Division, Child oxygen therapy

Health) • Coordinate different stakeholders and collaborate with other sectors to extend reach of interventions

• Develop guidelines, job aids and training materials for improving diagnosis and oxygen utilization

• Secure resources for scaling up interventions.

National Medical Stores • Ensure the appropriate distribution of medical oxygen to public health facilities across the country

• Procure high-quality diagnostic and medical oxygen therapy

equipment, including all requisite spares and consumables

Joint Medical Stores and other • Ensure the appropriate distribution of medical oxygen to private health private distributors facilities across the country

• Procure high-quality diagnostic and medical oxygen therapy equipment, including all requisite spares and consumables

• Maintain devices through various contract mechanisms if/where

applicable

Civil society • Support advocacy efforts to help secure buy-in and resources for implementation of the scale up plan

Implementing Partners • Mobilize funding and resources to fill implementation gaps

• Facilitate information exchange and coordination at different

stakeholder levels

25

• Provide technical assistance and capacity building in the implementation of oxygen scale up interventions (including but not limited to quantification, procurement, distribution, maintenance and

research)

National Drug Authority • Adoption of standard target product profiles

• Assurance of compliance with standards by suppliers/wholesalers.

Regional level

Regional Performance • Coordinate different stakeholders and collaborate with other sectors at

Monitoring teams regional level to extend reach of oxygen scale up interventions

Regional Workshops • Conduct regular maintenance and repair of medical equipment including oxygen equipment

Regional Referral Hospitals • Produce medical oxygen for onsite use and refill oxygen cylinders from health facilities within their catchment area.

• Operate and manage oxygen plants

• Budget for maintenance of oxygen plants through the annual planning

processes

District level

District Health Teams • Support development of micro-plans to support the scale up of oxygen utilization interventions

• Facilitate dialogue and buy-in of oxygen interventions at district level

• Monitor the use and access to oxygen therapy, equipment use and

maintenance

Health Facility level

Hospital Directors, Medical • Quantify medical oxygen required by facilities Superintendents and • Budget for maintenance of medical oxygen equipment and procure

Health facility In-charges pulse oximeters through annual planning processes

• Ordering and storage of oxygen equipment

• Conduct training of health facility staff through CMEs on detection of hypoxemia and appropriate administration of oxygen and management of equipment

• Conduct routine detection of oxygen saturation using pulse oximetry

especially in neonatal, paediatric, maternal and emergency/theatre wards

• Ensure access and optimum use of medical oxygen for patient care using available delivery systems

• Document oxygen utilization in patient files

26

6.0 Implementation Time Frame

Improving oxygen supply and utilization on a national level is a long term process. The time frame for implementation of this plan will depend on available funding and requisite health infrastructure at all levels.

Table 8 Implementation time frame

No. Objectives and Main activities Output Lead Year 1 Year 2 Year 3 Year 4 Year 5

2018 2019 2020 2021 2022

Objective 1: To provide a national strategic framework to guide scale up of oxygen supply and utilisation

O1.1. Establish a coordinating mechanism for the Oxygen scale up HITWG, Hospital TWG, MCH Cluster, MOH and

plan to provide decision support on technical specifications PPPH TWG, National new-born partners

for oxygen equipment purchases and installations, diagnostic steering committee, SBWG and

tools, quantification MMTWG.

O1.2. Periodic reviews to provide updates/progress on oxygen Meeting resolutions MOH and

scale up activities and to address unforeseen gaps or modify partners

assumptions

O1.3. Develop and maintain a database of the national oxygen Database of oxygen supply and MOH and

equipment inventory and the oxygen equipment supplier equipment Partners

landscape.

O1.4. Procure additional plants, cylinders, regulators, concentrators At least 3 additional oxygen plants RRH & HL

and related equipment for health facilities installed. Additional cylinders and HFs MoH/

concentrators at all higher levels MoFPED

procured following inventory and

quantification exercises

O1.5. Procure additional distribution vehicles and distribute Oxygen distribution system per NMS/

cylinders or outsource distribution to 3rd party region MoFPED O1.6. Develop operational guidelines for ordering oxygen and Operational guidelines for ordering MOH and

distributing oxygen across the country oxygen NMS and

partners

O1.7. Operate oxygen supply equipment at the respective higher Functioning oxygen supply systems RRH &

level facilities in line with MOH guidelines higher

level HFs

27


2018 2019 2020 2021 2022

O1.8. Conduct annual supervision of oxygen plants and document Documented successes, challenges MOH and

successes, challenges and improvements. and improvements in access to RRHs

oxygen


O2.1. Conduct periodic inventory of oxygen equipment Regional workshop reports Regional

Workshops

O2.2. Routine servicing of equipment including procuring spare Maintenance reports Regional

parts workshops

O2.3. Leverage existing district and regional supervision Districts and regional reports DHTs,

mechanisms to conduct periodic audits on oxygen equipment RPMTs,

functionality regional

workshops

O2.4. Maintain a database of routine spare parts of oxygen Database of spare parts and MOH, NMS

equipment as well as suppliers to source from suppliers and

partners

Objective 3: To provide a framework for training of staff in health facilities on rational use of oxygen and basic maintenance of equipment

O4.1. Conduct regional oxygen utilization trainings for all higher Trained health workers MOH and

level health facilities (prioritizing regions where oxygen plants Partners

have been set up and are running)

O4.2. Update and maintain training resource materials on Updated resource materials MOH and

diagnosis, management and routine maintenance of oxygen partners

equipment

O4.3. Leverage existing training avenues to advocate, sensitize and Trained health workers MOH and

train health workers on hypoxemia diagnosis, oxygen therapy partners

management and routine maintenance of equipment O4.4. Update and maintain a database of trained/technical Database of trained health workers MOH and

maintenance trainees/personnel partners


O4.1. Continuous dissemination of the National Scale-up of Medical Increased involvement of

Oxygen Implementation plan and engagement of all stakeholders and resource

stakeholders. commitments

O4.2. Advocate for increased investment in the national oxygen Evidence of increased investment MOH and

28


2018 2019 2020 2021 2022

system partners

O4.3. Leverage different funding avenues by sharing investment Funded proposals MOH and

proposals to bridge funding gaps partners

29

7.0 Financing Establishing and maintaining the system mentioned above will cost an estimated investment of 20.5Bn UGX (USD 4.3M) in the initial year (2018) and annual

costs of ~5.9 Bn UGX (USD 1.5M) per year (see Table 10). The costs below are estimates and therefore may vary during actual implementation depending on

oxygen consumption trends. Funding these costs will require a concerted effort between national and local stakeholders, development partners and the

private sector. Table 9 Annualized costing of CAPEX, OPEX and distribution for the national oxygen system

Investments (CAPEX) YEAR 1 UGX (USD) YEAR 2 UGX (USD) YEAR 3 UGX (USD) YEAR 4 UGX YEAR 5 UGX TOTAL (UGX) TOTAL (USD)

(USD) (USD) Oxygen plants 11,634,455,368 0 0 0 0 11,634,455,368 3,081,975

Concentrators 4,210,330,896 0 0 0 0 4,210,330,896 1,115,319

Voltage regulators for concentrators 217,683,200 0 0 0 0 217,683,200 57,664

Cylinder & Accessories 0 1,577,597,416 1,577,597,416 1,577,597,416 1,577,597,416 6,310,389,664 1,671,626

Piping for RRH 0 922,610,000 1,383,915,000 0 0 2,306,525,000 611,000

CAPEX Totals 16,062,469,464 2,500,207,416 2,961,512,416 1,577,597,416 1,577,597,416 24,679,384,128 6,537,585

Sub Total CAPEX 24,679,384,128 6,537,585

Investments (Distribution)

Distribution Cost Subtotal 1,336,486,521 1,360,866,162 1,389,041,731 1,421,518,399 1,453,972,512 6,961,885,325 1,844,208

Distribution totals Sub Total 6,961,885,325 1,844,208

Distribution

Investments (OPEX)

Plant Operations Cost Subtotal 1,525,562,560 1,525,562,560 1,525,562,560 1,525,562,560 1,525,562,560 7,627,812,800 2,020,613

Clinical Training Cost Subtotal 240,000,000 240,000,000 240,000,000 240,000,000 240,000,000 1,200,000,000 317,881

Servicing and routine maintenance 803,123,473 125,010,371 148,075,621 78,879,871 78,879,871 1,233,969,206 326,879

of oxygen equipment (5% CAPEX)

Concentrator power 556,250,890 556,250,890 556,250,890 556,250,890 556,250,890 2,781,254,450 736,756

Coordination 5,000,000 5,000,000 5,000,000 5,000,000 5,000,000 25,000,000 6,623

OPEX totals 3,129,936,923 2,451,823,821 2,474,889,071 2,405,693,320.80 2,405,693,321 12,868,036,456 3,408,751

Sub Total OPEX 12,868,036,456 3,408,751

Total annual costs 20,528,892,908 6,312,897,399 6,825,443,218 5,404,809,135.80 5,437,263,249

GRAND TOTAL 44,509,305,909 11,790,545

30

Table 10 Notes to Table 10

Oxygen plants This investment has been covered by Government of Uganda. Total hospital based plants in place are 17, installed at an average unit cost of $186,000.

Oxygen Costing for procurement of oxygen concentrators is based on the following NACME standards. Unit cost of concentrators a concentrator taken as the unit cost in 2018 of the most used brand in the country :

No. NACME standard

Total concentrators

NRH 1 85 85

RRH 14 23 322

GH 53 5 265

HC IV 180 2 360

TOTAL 1,032

Oxygen Cylinders Procurement of 5,072 cylinders by 2022 to support a sub-national cylinder based oxygen distribution system; unit cost of large (6.8m3) cylinder with accessory kit is UGX 1,544,162 (USD 409). Quantification is based on NACME standards for large cylinders. The GOU emergency medical services policy envisions 1 basic life support or Type B ambulance per population of 100,000 people which gives a target of 383 ambulances in total, and each with an allocation of 2 small-sized (“E”) cylinders. This translates into an additional 766 emergency transportation cylinders that should be procured for ambulances. Procurement of 383 small /E cylinders for ambulances/pre-hospital care by 2022 is not catered for in this document as this will be costed as part of the national EMS plan.

Piping Costs The calculation used a unit cost of USD 47,000 per regional referral hospital for cylinder banks (4-cylinders) with piping for up to eight (8) outlets. Total cost is for 13 regional referral hospitals excluding Mbarara regional referral hospital with 40% piping completed in 2019 and the remaining 60% piping completed in

2020.

Distribution costs at Market rate for distribution of health commodities is based on mileage and averages to $2.50 US per km sub national level travelled assuming an outsourcing model. Inputs into the costing piece include this rate, the total number

of refills (thus the total # of cylinders that need to be moved), but taking the following into consideration:

• Only 50% of cylinders will have to be moved • 60 cylinders is the maximum payload of the cylinder transport truck

• Average distance travelled by these cylinders is 30 km

Plant Operations Estimates based on annual costs per hospital for:

• labour (plant operators and stores staff),

• power,

• maintenance including routine servicing,

• stores stationery,

• communication costs and

• staff welfare.

Clinical Training Costs of reaching 68,000 facility-based health workers through on job training and mentorship

Servicing and routine This has been costed at 5% of CAPEX costs in one year

maintenance of

oxygen equipment

Concentrator power Using 300watts for each concentrator – number of hours – 8h, cost of power per KWH -2.4 units per day with a unit cost of power of UGX615.3.

Coordination Includes costs of technical working group meetings, review meetings and supervision

Table 11 Quantification of cylinder needs (large – 6.8m3)

No. NACME standard Total cylinders

NRH 1 78 78

RRH 14 51 714

GH 53 40 2120

HC IV 180 12 2160

TOTAL 5,072

32

7.1 Funding Gap

By the end of 2018, the government of Uganda will install three additional oxygen generation

plants with a total capacity of 60m3/hr. The government of Uganda has already installed 15m3/hr

oxygen plants in 13 regional referral hospitals and one (1)10m3/hr plant in Mbarara regional referral hospital bringing government of Uganda’s investment towards increasing oxygen production capacity to 11.6bn Uganda shillings (USD 3.1M). Government of Uganda’s overall target commitment to 2022 is 20.0bn Uganda shillings (USD 5.3M).

MOH Partners are encouraged to utilize this momentum to address the remaining gap currently estimated 11.84bnUsh (USD 3.14M) for optimization of current resources, further increasing oxygen supply availability/production, maintenance and distribution capacity in order to achieve scale up. Health facility managers are also encouraged to dedicate a portion of their capital development funds and essential medicines budget to procurement and maintenance of oxygen and associated equipment.

Estimated cost Target Funding commitment - GoU Funding Gap

(2018 – 2022) -UGX (2018 – 2022) -UGX (2018 – 2022) -UGX

Capital Investments 24,679,384,128 18,151,311,264 6,528,072,864

Distribution Costs 6,961,885,325 2,875,490,911 4,086,394,414

Operating Costs 12,868,036,456 11,643,036,456 1,225,000,000

TOTAL 44,509,305,909 32,669,838,631 11,839,467,278

33

8.0 Monitoring and evaluation

It is essential to monitor and evaluate the activities and inputs set forth in this scale-up plan to track progress, identify and address issues, and measure successes. The performance monitoring framework lays out a set of indicators to track key outputs and outcomes on an annual basis, if not more frequently. Government of Uganda will also adapt international standards and targets on oxygen systems as these become available for developing countries.

8.1 Theory of Change

Activities

Construct 3 additional oxygen plants

Purchase/outsource new trucks for transportation

Revise clinical guidelines on hypoxemia

Centralize procurement process

Train additional oxygen equipment maintenance staff

Train providers on oxygen equipment, pulse oximetry, and basic maintenance

Develop distribution guidelines, guidelines for operation and management of oxygen plants

Establish repair workshops and supply of spare parts

Establish national coordination teams and regional performance teams

Outputs Outcomes

O2 production capacity expanded Increased access, use and

availability of oxygen

Improve oxygen logistics

Reduction in mortality related to hypoxia

Improved provider knowledge of oxygen therapy and pulse oximetry

O2 procurement/spares centralized

Improved maintenance system

34

8.2 Performance Monitoring Framework The performance monitoring framework takes advantage of the records, databases, and other existing

structures already in place or to be created as part of this scale-up plan to monitor and evaluate

progress via key indicators selected below. Indicators under Service Provision are the only indicators

that will need to be tracked using additional, dedicated resources not already in place.

Table 12 Performance Metrics

Objective Indicator Baseline Mid Term Target Data Source

(2018) (2020) (2022)

Policy basis Coordinating mechanisms NA Established Established Policy review

and decision established

support for

National database of oxygen NA In-progress Established Database review

oxygen supply

equipment inventory

established

Maintenance % of HCIV/hospitals with NA 70% 100% Database of

and supply of recommended number of oxygen supply

equipment functional cylinders and and equipment

concentrators

% of national and regional 90% 100% 100% Database of

referral facilities with a self- oxygen supply

contained oxygen plant and equipment

consistently operating to meet

facility demand

# of additional distribution 0 3 5 Records/audit

vehicles procured or outsourced

in the past year

% of HCIV/hospitals with at least NA 50% 100% District/regional

one functional cylinder or reports

concentrator in each of the

following key wards: paediatric,

maternity and theatre

% of HCIV/hospitals with at least NA 100% 100% District/regional

one functioning pulse oximeter reports

in each of the following key

wards: paediatric, maternity and

theatre

% of HCIV/hospitals with a 30% 60% 90% Database of

sufficient supply of spare parts oxygen supply

and equipment

Staff training Training resources and NA In-progress Completed Records/audit

guidelines updated (clinical,

biomedical)

% of relevant staff in NA Training records

HCIV/hospitals (nationwide) 50% 80%

who have received

general/refresher trainings on

oxygen therapy and diagnosis in

the past year

Number of new maintenance 0 80 100 Database of

personnel trained in the past trainees

year

Service % of patients in HCIV/hospitals Not TBD TBD HMIS (Patient

Provision OPD who get a pulse oximetry Available records)

35

Objective Indicator Baseline Mid Term Target Data Source (2018) (2020) (2022)

reading

% of hypoxemic patients in NA TBD TBD HMIS (Patient HCIV/hospital treated with records)

oxygen

Funding Government funding committed 6Bn 10bn 20Bn Budget review to scale up oxygen supply

% of overall cost to scale up NA 30% 30% Budget review oxygen supply contributed by

partners

36

9.0 Appendices

Annex 1: Determining prevalence of hypoxemia

Hypoxemia prevalence is calculated by averaging the results of various hypoxemia prevalence

studies40 in developing countries. Almost no data were found for hypoxemia among adults, so these numbers are best guestimates based on literature and expert interviews

Tab.15: Prevalence of hypoxemia globally and in Africa GLOBAL

Age Group Disease Global Burden Global Burden Global Prevalence Hypoxemia Prevalence Hypoxemia Prevalence Proportion of Hypoxemia

2012, M 2012, % of total 2012, M (%) 2012, M Total (%)

Neonatals (0-1month) Preterm birth complications 1.0 35% 93 23% 21 13%

Birth asphyxia and birth trauma 0.7 24% 63 27% 17 10%

Neonatal sepsis and infections 0.4 15% 40 10% 4 2%

Lower respiratory infections 0.1 5% 13 19% 2 1%

Other Diseases* 0.6 21% 54 11% 6 4%

TOTAL 2.9 100% 263 19% 50 30%

Children (<15) Lower respiratory infections 1.0 19% 88 12% 11 6%

Diarrhoeal diseases 0.7 14% 71 2% 2 1%

Malaria 0.5 10% 49 4% 2 1%

Meningitis 0.2 4% 20 5% 1 1%

Protein-energy malnutrition 0.2 4% 20 5% 1 1%

Iron-deficiency anaemia 0.0 0% 27 4% 1 1%

Other Diseases* 2.5 49% 285 6% 16 10%

TOTAL 5.2 100% 561 6% 33 20%

Adults (>=15) Ischaemic heart disease 7.3 15% 164 - 0%

Stroke 6.7 14% 140 - 0%

Chronic obstructive pulmonary disease 3.1 6% 89 22% 20 12%


Trachea, bronchus, lung cancers 1.6 3% 39 8% 3 2%

Other Diseases* 27.2 57% 1,443 4% 58 34%

TOTAL 47.9 100% 1,920 4% 84 50%

ALL AGE GROUPS TOTAL 55.88 2,744 6% 168 100%

AFRICA By

Age Group Disease Disease Burden Burden Disease Prevalence Hypoxaemia Prevalence Hypoxaemic Patients Proportion of Hypoxemia

2012, Million 2012, % of total 2012, Million By Disease (%) 2012, ~Million Total (%)

Neonatals (0-1month) Preterm birth complications 0.3 31% 29 23% 7 14%

Birth asphyxia and birth trauma 0.3 30% 28 27% 8 16%

Neonatal sepsis and infections 0.2 17% 16 10% 2 3%


Other Diseases 0.2 16% 16 11% 2 4%

TOTAL 1.0 100% 95 20% 19 39%

Children (<15) Lower respiratory infections 0.5 17% 44 12% 5 11%

Malaria 0.5 17% 46 4% 2 4%

Diarrhoeal diseases 0.4 14% 37 2% 1 2%

Protein-energy malnutrition 0.1 5% 14 5% 1 1%

Meningitis 0.1 5% 13 5% 1 1%

Iron-deficiency anaemia 0.0 8 4% 0 1%

Other Diseases 1.2 35% 119 6% 7 14%

TOTAL 2.9 94% 280 6% 17 35%

Adults (>=15) HIV/AIDS 0.9 17% 51 4% 2 4%


Stroke 0.4 8% 11 - 0%

Ischaemic heart disease 0.3 6% 9 - 0%

Chronic obstructive pulmonary disease 0.1 1% 5 22% 1 3%

Other Diseases 3.2 55% 193 4% 8 16%

TOTAL 5.4 96% 285 4% 12 26%

ALL AGE GROUPS 9.3 660 7% 47 100%

40 Subhi R, Adamson M, Campbell H, et al. The prevalence of hypoxaemia among ill children indeveloping countries.

37

Annex 2: Quantification assumptions in the Oxygen supply model

Table 16: Oxygen utilization per ward

Hospital ward % of total hospital size Hypoxemia Oxygen need prevalence by ward per patient per

ward [L]

Neonatal ward 15% 20% 2,160

Pediatric ward 20% 6% 6,480

Adult ward 55%41 4% 12,960

Surgery 5% 100% 2,880

Emergency care / ICU 5% 100% 7,200

Table 17: Number of facilities by level of care

Level of Care (LOC) # of facilities Bed Capacity Oxygen supply mix

NR Hospital 1 1347 100% plants, (Distribution 30% cylinders, 70% piped)

RR Hospital 14 330 100% plants (Distribution 100% cylinders, no piping at this time)

General Hospital 47 130 60% concentrators, 40% cylinders

HCIV 168 40 80% concentrators, 20% cylinders

41 53% if no ICU existent

38

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ministry of health national scale up of medical oxygen

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