Introduction Improving hospital oxygen systems can improve quality of care and reduce mortality for children, but we lack data on cost-effectiveness or sustainability. This study evaluated medium-term sustainability and cost-effectiveness of the Nigeria Oxygen Implementation programme.Methods Prospective follow-up of a stepped-wedge trial involving 12 secondary-level hospitals. Cross-sectional facility assessment, clinical audit (January–March 2021), summary admission data (January 2018–December 2020), programme cost data. Intervention: pulse oximetry introduction followed by solar-powered oxygen system installation with clinical and technical training and support. Primary outcomes: (i) proportion of children screened with pulse oximetry; (ii) proportion of hypoxaemic (SpO2 <90%) children who received oxygen. Comparison across three time periods: preintervention (2014–2015), intervention (2016–2017) and follow-up (2018–2020) using mixed-effects logistic regression. Calculated cost-effectiveness of the intervention on child pneumonia mortality using programme costs, recorded deaths and estimated counterfactual deaths using effectiveness estimates from our effectiveness study. Reported cost-effectiveness over the original 2-year intervention period (2016–2017) and extrapolated over 5 years (2016–2020).Results Pulse oximetry coverage for neonates and children remained high during follow-up (83% and 81%) compared with full oxygen system period (94% and 92%) and preintervention (3.9% and 2.9%). Oxygen coverage for hypoxaemic neonates/children was similarly high (94%/88%) compared with full oxygen system period (90%/82%). Functional oxygen sources were present in 11/12 (92%) paediatric areas and all (8/8) neonatal areas; three-quarters (15/20) of wards had a functional oximeter. Of 32 concentrators deployed, 23/32 (72%) passed technical testing and usage was high (median 10 797 hours). Estimated 5-year cost-effectiveness US$86 per patient treated, $2694–4382 per life saved and $82–125 per disability-adjusted life year-averted. We identified practical issues for hospitals and Ministries of Health wishing to adapt and scale up pulse oximetry and oxygen.Conclusion Hospital-level improvements to oxygen and pulse oximetry systems in Nigerian hospitals have been sustained over the medium-term and are a highly cost-effective child pneumonia intervention.

Background: Oxygen is an essential medical therapy that is poorly available globally. We evaluated the quality of oxygen therapy in 12 secondary-level Nigerian hospitals, including access to oxygen equipment, equipment functionality, healthcare worker knowledge and appropriateness of use. Methods: We conducted a three-part evaluation of oxygen access and use involving: (1) facility assessment (including technical evaluation of oxygen equipment), (2) clinical audit (children and neonates admitted January 2014-December 2015) and (3) survey of healthcare worker training and experience on the clinical use of oxygen (November 2015). Results: Oxygen access for children and newborns is compromised by faulty equipment, lack of pulse oximetry and inadequate care practices. One hospital used pulse oximetry for paediatric care. Eleven hospitals had some access to oxygen supplies. Testing of 57 oxygen concentrators revealed two (3.5%) that were 'fit for use'. Overall, 14.4% (3708/25 677) of children and neonates received oxygen some time during their admission; 19.4% (1944/10 000) of hypoxaemic children received oxygen; 38.5% (1217/3161) of children who received oxygen therapy were not hypoxaemic. Conclusions: Oxygen access for children in Nigerian hospitals is poor, and likely results in substantial excess mortality. To improve oxygen access for children globally we must focus on actual provision of oxygen to patients-not simply the presence of oxygen equipment at the facility level. This requires a systematic approach to improve both oxygen (access [including equipment, maintenance and affordability]) and oxygen use (including pulse oximetry, guidelines and continuing education).

Background Oxygen reduces mortality from severe pneumonia and is a vital part of case management, but achieving reliable access to oxygen is challenging in low and middle-income country (LMIC) settings. We developed and field tested two oxygen supply solutions suitable for the realities of LMIC health facilities. Methods A Health Needs Assessment identified a technology gap preventing reliable oxygen supplies in Gambian hospitals. We used simultaneous engineering to develop two solutions: a Mains-Power Storage (Mains-PS) system consisting of an oxygen concentrator and batteries connected to mains power, and a Solar-Power Storage (Solar-PS) system (with batteries charged by photovoltaic panels) and evaluated them in health facilities in The Gambia and Fiji to assess reliability, usability and costs. Results The Mains-PS system delivered the specified ≥85% (±3%) oxygen concentration in 100% of 1-2 weekly measurements over 12 months, which was available to 100% of hypoxaemic patients, and 100% of users rated ease-of-use as at least ‘good’ (90% very good or excellent). The Solar-PS system delivered ≥85% ± 3%) oxygen concentration in 100% of 1-2 weekly measurements, was available to 100% of patients needing oxygen, and 100% of users rated ease-of-use at least very good. Costs for the systems (in US dollars) were: PS$9519, Solar-PS standard version $20 718. The of oxygen for a standardised 30-bed health facility using 1.7 million litres of oxygen per year was: for cylinders 3.2 cents (c)/L in The Gambia and 6.8 c/L in Fiji, for the PS system 1.2 c/L in both countries, and for the Solar-PS system 1.5 c/L in both countries. Conclusions The oxygen systems developed and tested delivered high-quality, reliable, cost-efficient oxygen in LMIC contexts, and were easy to operate. Reliable oxygen supplies are achievable in LMIC health facilities like those in The Gambia and Fiji.

BACKGROUND:Improving oxygen systems may improve clinical outcomes for hospitalised children with acute lower respiratory infection (ALRI). This paper reports the effects of an improved oxygen system on mortality and clinical practices in 12 general, paediatric, and maternity hospitals in southwest Nigeria. METHODS AND FINDINGS:We conducted an unblinded stepped-wedge cluster-randomised trial comparing three study periods: baseline (usual care), pulse oximetry introduction, and stepped introduction of a multifaceted oxygen system. We collected data from clinical records of all admitted neonates (<28 days old) and children (28 days to 14 years old). Primary analysis compared the full oxygen system period to the pulse oximetry period and evaluated odds of death for children, children with ALRI, neonates, and preterm neonates using mixed-effects logistic regression. Secondary analyses included the baseline period (enabling evaluation of pulse oximetry introduction) and evaluated mortality and practice outcomes on additional subgroups. Three hospitals received the oxygen system intervention at 4-month intervals. Primary analysis included 7,716 neonates and 17,143 children admitted during the 2-year stepped crossover period (November 2015 to October 2017). Compared to the pulse oximetry period, the full oxygen system had no association with death for children (adjusted odds ratio [aOR] 1.06; 95% confidence interval [CI] 0.77-1.46; p = 0.721) or children with ALRI (aOR 1.09; 95% CI 0.50-2.41; p = 0.824) and was associated with an increased risk of death for neonates overall (aOR 1.45; 95% CI 1.04-2.00; p = 0.026) but not preterm/low-birth-weight neonates (aOR 1.30; 95% CI 0.76-2.23; p = 0.366). Secondary analyses suggested that the introduction of pulse oximetry improved oxygen practices prior to implementation of the full oxygen system and was associated with lower odds of death for children with ALRI (aOR 0.33; 95% CI 0.12-0.92; p = 0.035) but not for children, preterm neonates, or neonates overall (aOR 0.97, 95% CI 0.60-1.58, p = 0.913; aOR 1.12, 95% CI 0.56-2.26, p = 0.762; aOR 0.90, 95% CI 0.57-1.43, p = 0.651). Limitations of our study are a lower-than-anticipated power to detect change in mortality outcomes (low event rates, low participant numbers, high intracluster correlation) and major contextual changes related to the 2016-2017 Nigerian economic recession that influenced care-seeking and hospital function during the study period, potentially confounding mortality outcomes. CONCLUSIONS:We observed no mortality benefit for children and a possible higher risk of neonatal death following the introduction of a multifaceted oxygen system compared to introducing pulse oximetry alone. Where some oxygen is available, pulse oximetry may improve oxygen usage and clinical outcomes for children with ALRI. TRIAL REGISTRATION:Australian New Zealand Clinical Trials Registry: ACTRN12617000341325.

Background: Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria. Methods: We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not). Findings: Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming similar to 3500 L of oxygen per admission. Interpretation: Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children. (C) 2019 Published by Elsevier Ltd.

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Objective To identify and describe interventions to improve oxygen therapy in hospitals in low-resource settings, and to determine the factors that contribute to success and failure in different contexts.Methods Using realist review methods, we scanned the literature and contacted experts in the field to identify possible mechanistic theories of how interventions to improve oxygen therapy systems might work. Then we systematically searched online databases for evaluations of improved oxygen systems in hospitals in low- or middle-income countries. We extracted data on the effectiveness, processes and underlying theory of selected projects, and used these data to test the candidate theories and identify the features of successful projects.Findings We included 20 improved oxygen therapy projects (45 papers) from 15 countries. These used various approaches to improving oxygen therapy, and reported clinical, quality of care and technical outcomes. Four effectiveness studies demonstrated positive clinical outcomes for childhood pneumonia, with large variation between programmes and hospitals. We identified factors that help or hinder success, and proposed a practical framework depicting the key requirements for hospitals to effectively provide oxygen therapy to children. To improve clinical outcomes, oxygen improvement programmes must achieve good access to oxygen and good use of oxygen, which should be facilitated by a broad quality improvement capacity, by a strong managerial and policy support and multidisciplinary teamwork.Conclusion Our findings can inform practitioners and policy-makers about how to improve oxygen therapy in low-resource settings, and may be relevant for other interventions involving the introduction of health technologies.

Background Oxygen is a life-saving, essential medicine that is important for the treatment of many common childhood conditions. Improved oxygen systems can reduce childhood pneumonia mortality substantially. However, providing oxygen to children is challenging, especially in small hospitals with weak infrastructure and low human resource capacity. Methods/design This trial will evaluate the implementation of improved oxygen systems at secondary-level hospitals in southwest Nigeria. The improved oxygen system includes: a standardised equipment package; training of clinical and technical staff; infrastructure support (including improved power supply); and quality improvement activities such as supportive supervision. Phase 1 will involve the introduction of pulse oximetry alone; phase 2 will involve the introduction of the full, improved oxygen system package. We have based the intervention design on a theory-based analysis of previous oxygen projects, and used quality improvement principles, evidence-based teaching methods, and behaviour-change strategies. We are using a stepped-wedge cluster randomised design with participating hospitals randomised to receive an improved oxygen system at 4-month steps (three hospitals per step). Our mixed-methods evaluation will evaluate effectiveness, impact, sustainability, process and fidelity. Our primary outcome measures are childhood pneumonia case fatality rate and inpatient neonatal mortality rate. Secondary outcome measures include a range of clinical, quality of care, technical, and health systems outcomes. The planned study duration is from 2015 to 2018. Discussion Our study will provide quality evidence on the effectiveness of improved oxygen systems, and how to better implement and scale-up oxygen systems in resource-limited settings. Our results should have important implications for policy-makers, hospital administrators, and child health organisations in Africa and globally. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12617000341325 . Retrospectively registered on 6 March 2017.

BACKGROUND:Hypoxaemia is a common and potentially fatal complication of many childhood, newborn and maternal conditions but often not well recognised or managed in settings where resources are limited. Oxygen itself is often inaccessible due to cost or logistics. This paper describes implementation of oxygen systems in Lao district hospitals, clinical outcomes after 24 months and equipment outcomes after 40 months postimplementation. METHODS:A prospective field trial was conducted in 20 district hospitals, including 10 intervention hospitals that received oxygen concentrators and 10 control hospitals. Equipment outcomes were evaluated at baseline, 12, 24 and 40 months. Clinical outcomes of children under 5 years of age with pneumonia were evaluated using a before-and-after controlled study design with information retrospectively collected from medical records. RESULTS:Fourteen (37%), 7 (18%) and 12 (34%) of 38 concentrators required repair at 12, 24 and 40 months, respectively. The proportion of children discharged well increased in intervention (90% (641/712) to 95.2% (658/691)) and control hospitals (87.1% (621/713) to 92.1% (588/606)). In intervention hospitals, case fatality rates for childhood pneumonia fell from 2.7% (19/712) preintervention to 0.80% (6/691) postintervention with no change in control hospitals (1.7% (12/713) preintervention and 2.3% (14/606) postintervention). CONCLUSION:Medium-term sustainability of oxygen concentrators in hospitals accompanied by reduced case fatality for childhood pneumonia has been demonstrated in Lao PDR. Significant local engineering capacity to address multiple causes of equipment malfunction was critical. The ongoing requirements and fragile structures within the health system remain major risks to long-term sustainability.

Oxygen is an essential medicine for the treatment of pneumonia, the leading cause of death in children under five worldwide. Yet, providing a sufficient and reliable supply of oxygen is a major challenge for many health facilities in the developing world, particularly in paediatric care units. The cost-effectiveness of oxygen concentrators versus compressed gas cylinders as a source of oxygen in low-resource health facilities has been demonstrated, but evidence of their long-term functionality is scarce. The Biomedical Engineering Department at the Medical Research Council Unit in The Gambia manages and maintains 27 oxygen concentrators at several sites across the country, and has kept electronic records of all preventive maintenance checks and repairs on these devices since 2006. Through a retrospective analysis of these maintenance records, the objective of this study was to assess the long-term reliability and maintenance needs of oxygen concentrators in a low-income setting with biomedical engineering technologist support. We found that the majority of concentrator repairs are low-cost and require a low experience level to complete. We estimate that the useful lifespan of oxygen concentrators in low-resource settings could reasonably exceed 7 years provided a system is in place for routine preventive maintenance. We conclude the paper with additional insights on the broader support ecosystem required to manage and maintain oxygen concentrators in low-resource settings.

Four different medical oxygen system configurations are presented and compared across a wide range of criteria relevant to low-resource settings. Two systems make use of power when available to generate and store oxygen for later use; the others use a backup battery bank (grid- or solar-charged) during power interruptions. Some system designs have been realized as prototypes with some field experience, and others are still conceptual. The results of this review and analysis have implications for future work involving the evaluation, development, and prototyping of alternative oxygen supply systems for settings with poor grid power and limited financial and technological resources.

The use of oxygen concentrators for the supply of medical oxygen in developing countries is increasingly becoming an alternative to conventional compressed gas cylinders, which are expensive to refill and logistically challenging to transport. Oxygen is important for obstetric, surgical, and an aesthesia care, as well as for the effective management of many diseases including severe sepsis, malaria, and pneumonia. One major obstacle to the effective use of oxygen concentrators in resource poor settings is the need for a constant power supply. An assessment of power availability in three health centres in The Gambia is presented, which highlights the issue of intermittent electricity supply for real health centre settings in a developing country. A battery-powered oxygen delivery system is also presented, which is charged from an intermittent grid power supply. This oxygen system will be beneficial in areas with little or intermittent electricity supply, such as The Gambia, where oxygen is in short supply.

Oxygen therapy is essential in all wards, emergency departments and operating theatres of hospitals at all levels, and oxygen is life-saving. In Papua New Guinea (PNG), an effective oxygen system that improved the detection and treatment of hypoxaemia in provincial and district hospitals reduced death rates from pneumonia in children by as much as 35%. The methods for providing oxygen in PNG are reviewed. A busy provincial hospital will use on average about 38,000 l of oxygen each day. Over 2 years the cost of this amount of oxygen being provided by cylinders (at least K555,000) or an oxygen generator (about K1 million) is significantly more than the cost of setting up and maintaining a comprehensive system of bedside oxygen concentrators (K223,000). A district hospital will use 17,000 l per day. The full costs of this over 2 years are K33,000 if supplied by bedside concentrators, or K333,000 plus transport costs if the oxygen source is cylinders. In provincial and district hospitals bedside oxygen concentrators will be the most cost-effective, simple and reliable sources of oxygen. In large hospitals where there are existing oxygen pipelines, or in newly designed hospitals, an oxygen generator will be effective but currently much more expensive than bedside concentrators that provide the same volume of oxygen generation. There are options for oxygen concentrator use in hospitals and health centres that do not have reliable power. These include battery storage of power or solar power. While these considerably add to the establishment cost when changing from cylinders to concentrators, a battery-powered system should repay its capital costs in less than one year, though this has not yet been proven in the field. Bedside oxygen concentrators are currently the 'best-buy' in supplying oxygen in most hospitals in PNG, where cylinder oxygen is the largest single item in their drug budget. Oxygen concentrators should not be seen as an expensive intervention that has to rely on donor support, but as a cost-saving intervention for all hospitals.

Introduction Acute respiratory infection, principally pneumonia, remains the leading cause of death in young children worldwide. (1-3) Case management of pneumonia is a key component of the WHO Integrated Management of Childhood Illness strategy and is integral to the achievement of the fourth UN Millennium Development Goal: reducing under-5 mortality by two-thirds by 2015. (4) WHO guidelines for the management of pneumonia include antibiotic therapy, appropriate use of oxygen and general supportive care. Oxygen is needed to treat hypoxaemia, a life-threatening feature of very severe pneumonia resulting from impaired lung function. Medical oxygen, which is potentially life-saving, is in limited supply in the developing world, although the extent and nature of the problem are not well documented. (5) A situational analysis has shown that in the Gambia most health facilities have inadequate oxygen availability and that the factors that are important for ensuring oxygen supplies differ between facilities. (6) Oxygen concentrators have been proposed as an answer to the high cost and logistical problems associated with oxygen cylinders, the traditional method of supply. (7) However, there is a risk that the technology might be misapplied, compromising care. (8) The suitability of concentrators for the developing world is still in question, and a realistic appraisal of the role of concentrators in different contexts is needed, along with user-friendly guidance to assist decision-making. In this report, we analyse the options available, suggest a decision-making algorithm and present a software tool we have produced to analyse options and costs in a range of different contexts. Methods A health needs assessment framework was used to define issues that surround oxygen treatment in the Gambia and the options for improving it. (9-11) In this study we evaluated the two supply options, cylinders and concentrators, in terms of their cost, how well they work and their sustainability. Functionality assessment We first analysed the functionality of cylinders and concentrators. Data were collected in 2004-2007 and analysed in 2005-2008. We used semi-structured interviews with two instruments: the first was developed by one of the authors (SEH) specifically for a case study of failed oxygen concentrators in the Gambia, (6) and the other was adapted and validated by one of the authors (SEH) for a local study of oxygen use (8) from a WHO health facility assessment tool. Interviews were undertaken throughout the Gambia with health-care staff, administrators, policy-makers and others with relevant knowledge. Details of the instruments, interviewees and other aspects of methods used are described elsewhere. (6,8) In addition, we collated the international operational experience of our multi-disciplinary team of investigators, assessed the operational experience gained in the Gambia so far and reviewed others' published experience. The findings of the functional assessment were incorporated along with the cost analyses described below, into a decision algorithm. Cost modelling To provide comparative costs in different contexts, we broke down and costed each option by using the ingredients approach and applied a decision-analytic model to flame the alternative components, (12,13) taking into account capital and running costs, the scale of consumption and the context. We constructed a decision algorithm to identify the most cost-effective option for a range of circumstances. These results were incorporated into an options analysis tool developed on Microsoft Access software (Microsoft Corporation, Redmond, WA, United States of America), and the tool was applied to data from a previous situational analysis of Gambian health facilities.6 We used costs in 2007 and exchange rates of 22.66 dalasi per United States dollar (US$) and US$1.977 per United Kingdom pound on 24 December 2007. …

In Brief Oxygen for the treatment of sick patients in tropical countries is in very short supply. Oxygen concentrators, which filter nitrogen from atmospheric air to produce 90% oxygen, have considerable potential to meet this need. However, being produced mainly for North American and European home use, many concentrators may not be well suited to use in challenging tropical conditions. This report gives a detailed evaluation of 11 models of oxygen concentrator on the basis of the information supplied by their manufacturers. The aim of the survey was to identify concentrators specified to operate in the heat and humidity of tropical countries and to identify which would be most suitable based also on their cost-effectiveness, energy efficiency, and maintenance requirements. Six of the 11 models surveyed were specified to operate at up to 40°C and 95% relative humidity. The highest ranking models for performance, cost, and energy efficiency were from one manufacturer, AirSep, which was the only manufacturer to produce independent data showing successful use of their concentrators in a tropical country. Oxygen for the treatment of sick patients in tropical countries is in very short supply. Oxygen concentrators, which filter nitrogen from atmospheric air to produce 90% oxygen, have considerable potential to meet this need. However, being produced mainly for North American and European home use, many concentrators may not be well suited to use in challenging tropical conditions. This report gives a detailed evaluation of 11 models of oxygen concentrator on the basis of the information supplied by their manufacturers. The aim of the survey was to identify concentrators specified to operate in the heat and humidity of tropical countries and to identify which would be most suitable based also on their cost-effectiveness, energy efficiency, and maintenance requirements. Six of the 11 models surveyed were specified to operate at up to 40°C and 95% relative humidity. The highest ranking models for performance, cost, and energy efficiency were from one manufacturer, AirSep, which was the only manufacturer to produce independent data showing successful use of their concentrators in a tropical country.

Objective To compare oxygen supply options for health facilities in the Gambia and develop a decision-Making algorithm for choosing oxygen delivery systems in Africa and the rest of the developing world.Methods Oxygen cylinders and concentrators were compared in terms of functionality and cost. Interviews with key informants using locally developed and adapted WHO instruments, operational assessments, cost-modelling and cost measurements were undertaken to determine whether oxygen cylinders or concentrators were the better choice. An algorithm and a software tool to guide the choice of oxygen delivery system were constructed.Findings In the Gambia, oxygen concentrators have significant advantages compared to cylinders where power is reliable; in other settings, cylinders are preferable as long as transporting them is feasible. Cylinder costs are greatly influenced by leakage, which is common, whereas concentrator costs are affected by the cost of power far more than by capital costs. Only two of 12 facilities in the Gambia were found suitable for concentrators; at the remaining 10 facilities, cylinders were the better option.Conclusion Neither concentrators nor cylinders are well suited to every situation, but a simple options assessment can determine which is better in each setting. Nationally this would result in improved supply and lower costs by comparison with conventional cylinders alone, although ensuring a reliable supply would remain a challenge. The decision algorithm and software tool designed for the Gambia could be applied in other developing countries.

In Papua New Guinea (PNG), the most common cause of death among children under 5 years of age is pneumonia. Children with severe pneumonia need antibiotics and oxygen but oxygen shortages are common owing to the cost and complex logistics of transporting it in cylinders. Detection of hypoxaemia using clinical signs can be difficult, especially in highly pigmented children in whom cyanosis is difficult to recognise. Pulse oximetry is the most reliable, non-invasive way of detecting hypoxaemia. However, most hospitals in PNG do not have pulse oximetry. We proposed that the installation of a reliable, sufficient and cheap supply of oxygen in hospitals coupled with the use of pulse oximetry would make a significant difference to child survival rates in PNG. Oxygen concentrators, which extract oxygen from ambient air, were installed in the children's wards of five hospitals during 2005. Pulse oximeters were also introduced to enable better detection of hypoxaemia. This paper describes the technical aspects of this programme: the equipment used and the rationale behind choosing it, the installation, commissioning and testing processes. The ongoing training of clinical and engineering staff as well as two follow-up evaluations are described.