A new approach to Oxygen provision
Our long-term goal is to help reduce mortality from hypoxaemic illnesses, especially in children where the mortality is currently the worst. This means supplying oxygen in the places where it is most needed - the periphery.
Others have made some important advances in supplying oxygen, these champions have been paediatricians and engineers working in referral hospitals. In some of these settings large oxygen plants have been a good solution. But cylinder oxygen is prohibitively expensive where the distribution network is large and includes remote/rural areas. Oxygen concentrators have shown a lot of promise. However, they do need maintenance and repair, and without it they often last only months instead of years. The level of skill needed is only moderate – and does not need a fully-trained biomedical engineer – but it does go far beyond just changing filters. Health workers are busy people with very specific training, and they have rarely been able to take up the maintenance and repair challenge. Biomedical engineers are rare and almost never seen outside major hospitals.
Take pneumonia as an example and as one of the key high-mortality childhood conditions that needs oxygen. Probably half the children who develop and die from pneumonia in Africa are never even seen by a health worker at any level. Their parents either do not recognise the severity of the disease, or know that the local health facility will be unable to treat it. Among the cases that are seen in the health service, many are misdiagnosed and sent home. Others are told they should be transferred to a facility with oxygen, but the challenges that this raises are insurmountable and the child rarely even starts the journey. Sadly, of those who do, a few perish on the way, already having disease too severe to withstand the rigours of the trip without oxygen. The proportion who do make it to a referral centre is unknown, but even though referral hospitals are also the first port of call for the city-dwellers living around them it is unlikely to be more than a few percent of those who need oxygen to survive.
This is not a criticism of the existing efforts of the hard-working paediatricians, nurses and engineers at referral hospital level. However, it is a recognition that even reducing mortality in such hospitals to zero would have relatively little impact on overall pneumonia mortality.
We envisage a self-sustaining business model for the provision of oxygen supplies, based on FREO2 OxyLink and including re-supply of spare parts. At the district level, we are engaging local entrepreneurs to create businesses which are paid by the local health facility to guarantee a supply of oxygen. These businesses will maintain, repair and if required replace the equipment. At the national level, we will provide the initial training and equipment, and arrange the supply of spare parts, consumables and replacement machines to the franchisees at a low but sustainable price. The funding of individual health facilities will allow for a range of options. Some may be funded from the national health budget, perhaps with the addition of funds from the growing international interest in pneumonia by INGOs and other agencies. Individual health facilities could even be supported by community groups in high-income countries.
One key aspect is that the day-to-day running of the process will not depend on fully trained biomedical engineers. Our ‘oxygen technicians’ will be trained, competent, and supported in the installation and maintenance of oxygen devices only. Before being trained for this work they will have been local motorcycle or car mechanics, electricians, or other relevant tradespeople.
Another important feature of the operation is the ‘swap and go’ approach to maintenance. Instead of wasting a good deal of a technician's time in travel, routine maintenance will be programmed at the district centre and machines due for work will be collected on a regular ‘milk run’ including multiple health facilities. At each, the machine needing work will be replaced by a newly-refurbished one. This way the work can be done much more efficiently by a centre-based technician – who may even only need to work part time as a result. Similarly, a machine that fails will be rapidly replaced by a refurbished one from stock, minimising down-time for the clinic. Doing all the repair and maintenance work in the district centre means that all the needed tools and spares will always be close at hand.
Our aim: 100% availability of oxygen so that any child who needs oxygen, gets it.
