Ministry of Health National Scale up of Medical Oxygen Implementation Plan 2018-2022 - NOVEMBER 2018
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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
1
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
2
List of Acronyms
CME Continuing Medical Education
DHIS2 District Health Information Software version 2
DHMT District Health Management Team
DHO District Health Office
EMS Emergency Medical Services
GoU Government of Uganda
HITWG Health Infrastructure Technical Working Group
HMIS Health Management Information System
HSS Health System Strengthening
HUMCs Health Unit Management Committees
HCIV Health Centre IV
ICCM Integrated Community Case Management
IRC International Rescue Committee
MMTWG Medicines Management Technical Working Group
MNCH Maternal, Newborn and Child Health
NDA National Drug Authority
NMS National Medical Stores
NRH National Referral Hospital
PNFP Private non-for-profit
PPPH Public-Private Partnership in Health
RRH Regional Referral Hospital
SCM Supply Chain Management
TWG Technical Working Group
VHT Village Health Team
UHMG Uganda Health Marketing Group
UNICEF United Nations Children’s Fund
3
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
4
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
5
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
6
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.
71.0 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
81.2 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
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
10Figure 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
11Oxygen 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
3%
1%
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
12Table 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
30 Assessment on oxygen equipment in public and private health facilities in Uganda, Clinton Health Access Initiative 2016
13supplied 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.
32
Assessment on oxygen equipment in public and private health facilities in Uganda, Clinton Health Access Initiative 2016
14All 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
1516
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 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 equipment
Objective 4: To provide an advocacy instrument to secure funding to support oxygen scale up
interventions
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.
17Figure 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
18Figure 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
37This figure includes Butabika national referral hospital whose oxygen consumption was modelled at the level
of a general hospital.
198Error! 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
Current 16 hours per day Maximum plant prodution capacity
Production 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).
38The 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.
20Figure 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
215. 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.
39A 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.
224.2.5 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
23should 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.
245.0 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
266.0 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
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