Ethiopia’s Oxygen ecosystem during the Covid-19 pandemic; a lesson and experience to share.

Ethiopia’s Oxygen ecosystem during the Covid-19 pandemic; a lesson and experience to share.

Yakob S Ahmed, Amanual Lulu, Ministry of Health

?Introduction: Oxygen is considered an essential medicine by the World Health Organization (WHO) and has been included in its Model List of Essential Medicines under general anesthetics for nearly 40 years. On September 2016, the Ministry put forth the National medical oxygen and pulse oximeter scale-up roadmap with good progress and many pitfalls. Unparalleled pre pandemic investment in oxygen ecosystem demonstrated a contest during the COVID-19 pandemic. During the initial phase of the pandemic, most of the cases were asymptomatic and the treatment centers were able to manage cases without any tension. As new strains of the virus emerged and the cases snowballed it was difficult for the already fragile oxygen supply system of the country to catch up with the growing demands of oxygen and this became evident during the second wave of the pandemic.

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Background: It is estimated that Ethiopia will require 4700 large cylinders per day (1385 M3/Hr) by 20212. However, this estimate didn’t put into consideration for such type of pandemic as supplemental oxygen therapy is recommended for all severe and critical COVID-19 cases with 10 L/M and 30 L/M, respectively. And hence, this has created a huge mismatch between oxygen production and demand. As of May 5, 2020, the actual oxygen production was 1515, and the demand during similar time was 2628 M3/Hr. the supply chain system was terrible leading to a huge traffic queue of trucks with empty cylinders in few older oxygen-producing private plants because of lack of comprehensive location information for each plants. Private oxygen plants are the major source of oxygen in the country accounting for 81.1 % of the national oxygen production, public 13.9 % and PPP accounts for 5%, and which most being located in Addis Ababa, SNNPR, Amhara, and Oromia regions. There are about a little over 30 public and private oxygen plants in Ethiopia but they are only functioning at 55% of their potential capacity. This is mainly due to weak management of plants, shortages of spare parts, frequent light interruption, and limited technical capacity from experts.

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Purpose: Revitalizing the oxygen ecosystem during the pandemic was crucial. We have aimed doubling national medical oxygen production, reduction of plant downtime by half, decreasing turnaround time for hospital oxygen deliver with an hour, establishment of emergency safety stock of oxygen and improving hypoxia detection capacity by 2/3.

Interventions: The interventions were designed in a way to respond to the second wave of pandemic that occurred in late January 2021, highlighted the need for vigilant monitoring of oxygen demand and production at a national level. We have tested so many small scale and large scale interventions. Here below are the most common ones

1.?????Establish a national oxygen governance system: Accordingly, a team was established at MoH to provide technical support to the national COVID case management effort. The major objectives of the team were advising MoH to improve the oxygen ecosystem during the pandemic in terms of policy, strategy, guidance and resource mobilization. ?This team was able to identify national oxygen plants, functional/nonfunctional, Installed/uninstalled, private/public with extensive inventory. Meetings private plant owners and managers to increase their production capacity and extending daily working hours. Monitor maintenance of nonfunctional plants, Facilitating installation of uninstalled plants and mobilizing funding for procurement of new plants. Forecast oxygen demand, cylinder demand, concentrators demand, and respiratory therapy equipment’s demand. The team helped to guide the procurement team on the basic specifications needed in the oxygen ecosystem. The team was primarily based in MoH and report to the medical services director general.

2.?????Public private partnership and multisector approach: Ministry of health recognized the contribution of private sectors in the early weeks of the pandemic to mitigate the challenges posed in by the increment of oxygen demand by both the essential health service and the response to the COVID-19 pandemic. Joint planning of oxygen demand and setting a joint goal to improve oxygen production capacity and working hours of production site helped us to agree on bridging the gap between potential and actual production capacity. With a continuous harmonized follow up the national team able to make 5 private oxygen plants functional which add 15% of production capacity. A national guide was prepared to inform harmonized oxygen production, distribution and use among public and private facilities. During a hilarious second wave of COVID pandemic the national oxygen revitalization team tested an innovative approach to use oxygen producers from steel production sector with quick adjustments. This effort helped us to cover 50% Addis Ababa oxygen demand in two days’ time. The steel production factories filled more than 40,000 large cylinders and saved more than 15 million ETB.

3.?????Maintenance campaigns and monitoring of oxygen production/distribution centers: After comprehensive inventory of the national oxygen ecosystem Ministry of health has provided financial and technical support to maintain four nonfunctional hospital owned plant in different part of the country. During the inventory campaign the team discovered six uninstalled and non-commissioned plants. Later after the inventory these plants installed and made functional. This effort added additional 25% production capacity. With the help of developmental partners like Gates and CHAI a medical-grade PSA oxygen plant with central piping was installed at Millennium makeshift treatment center. Central piping with the manifold system was also put into place in St. Peter Hospital and Field treatment center, later St. Peter supplied with oxygen plant from Check republic government donation. Recently additional 9 plants are in the pipeline from global fund and government funded projects. The national maintenance campaign able to maintain more than a thousand respiratory therapy equipment’s saving more than 20 million ETB. The inventory and maintenance campaign was organized by the national team and almost all private and public biomedical engineers engaged in the campaign. Oxygen forecast, use, production and distribution monitoring format was developed and shared with all facilities. A regular report being collected and facility specific feedbacks were being given

4.?????Establishment of central oxygen safety stock: During the second wave of the pandemic hospital oxygen delivery turnaround time was extended by 2 -3 hrs. This is because of the emergency raging of one of the highest producing private plant. During this time stock out of oxygen at COVID treatment centers were every day experience. Taking care of the emergency stock out was addition burden in the national COVID response. The national oxygen revitalization team came up with an idea of establishing a central oxygen safety stock for emergency management. The center was established by the MoH in Millennium compound on April 16, 2021. Management protocol prepared and endorsed. Emergency oxygen request form prepared and shared with facilities, focal team established and orientation was provided to hospitals. With this effort we able to respond to any emergency crises happened in all treatment center. This Addis Ababa experienced was later extended into regions. Until recently the national safety stock team able to deliver more than 5000 cylinders to facilities to respond to emergency stock out.

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Results: Even though the COVID-19 pandemic has negative impacts on the health system and health care delivery, oxygen has become the center of attention that created a favorable condition for making such kind of huge investment and commitment from the Ministry and other stakeholders. It was made possible to improve the production, distribution and rational use capacity more than any time in the health sector history.

??????I.?????????National medical oxygen production capacity improved by 110% (1515 to 3258 cubic meter per hour) as of September 18, 2021.

????II.?????????Average working hours of both public and private oxygen plants were improved from 9hrs/a day to 19hrs/day which contributed a lot for both production and distribution capacity

??III.?????????Average Oxygen refill turnaround time of treatment centers were improved by 3hrs after oxygen mapping and health facility matching made by the national oxygen revitalization team.

?IV.?????????In two years’ time with procurement and ?donations 4000 (20L size) and 4150 (≥ 40L size) cylinders,1281 concentrators, 748 pulse oximeters, and 630 Mechanical ventilators have been distributed to health facilities providing COVID-19 service.

???V.?????????During the pandemic, the Ministry of Health has also reshuffled budget and used it to provide both technical and financial support to public hospitals’ oxygen plants, central piping of oxygen system, procurement of spare parts and training on the rational use of oxygen at health facilities

?VI.?????????Recently we have more than 35 oxygen plants with 80% functionality and 9 new oxygen plants on pipeline.

VII.?????????Four hospitals had a central oxygen piping system in the past two years.

VIII.?????????National oxygen reporting and monitoring system established. Regular monitoring and supportive supervision visits had been going on in the past two years.

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Takeaways from oxygen ecosystem improvement efforts

1.?????Improved government funding and partners engagement

2.?????Oxygen is considered as a vital medical supply unlike other time

3.?????Private sector should take the lead on oxygen production and distribution while government should take a role to improve rational use

4.?????Governance at all level is important to achieve set goals

5.?????Building maintenance capacity at local level can help plants up and running for a reasonable amount of time

6.?????Improving quality of clinical care have a direct effect on improving oxygen ecosystem. ?