Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria

The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure ‘oxygen access’. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO2 documented) and negligible in private facilities (2%, 3/177) and primary health centres (<1%, 2/608). We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. However, triangulation of existing data suggested that no facilities were equipped to meet minimum oxygen demands. We highlight the importance of a multifaceted approach to measuring oxygen access that assesses access at the point-of-care and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.

Characterising hospitals’ suitability for medical officer internship training in Kenya: analysis of the Kenya Harmonized Health Facility Assessment

Background Kenya has significantly expanded its medical school numbers and internship training hospital numbers to address its workforce gap. The majority of newly accredited internship hospitals are first-level referral/district hospitals, which are considered to have shortage of staff, medications, have limited service capacity and are described as “not organized for training purpose”. Using data from the Kenya Harmonized Health Facility Assessment (KHFA) 2018, we characterise the readiness and capacity of 61 internship hospitals to understand whether they are suitable to provide internship training for medical doctors. Methods We used secondary data from KHFA 2018, which sampled 61 out of all 74 internship hospitals in Kenya. Comparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall readiness and capacity index was calculated as the mean of 12 domain-specific scores for each facility. We compared the readiness and capacity of each domain and overall between Level 4 small hospitals, Level 4 large hospitals and Level 5 & 6 hospitals. Results The average overall capacity and readiness index is 69% for all internship training centres. Hospitals have moderate capacity and readiness (over 60%) for most of the general domains, though there is huge variation between hospitals and only 29 out of 61 hospitals have five or more specialists assigned, employed, seconded or part-time - as required by the national guideline. Quality and safety score was low across all hospitals with an average score of 40%. As for major specialties, all hospitals have good readiness and capacity for surgery and obstetrics-gynaecology, while mental health was poorest in comparison. Level 5 & 6 facilities have higher capacity scores in all domains when compared with Level 4 hospitals. Conclusion Major gaps exist in staffing, equipment and service availability of Kenya internship hospitals. Level 4 hospitals are more likely to have a lower readiness and capacity index, and should be reviewed and improved to provide appropriate and well-resourced training for interns and to utilise appropriate resources to avoid improvising .

Facility assessment and qualitative analysis of health worker perspectives on neonatal health in Malawi

Objectives The “Integrating a neonatal healthcare package for Malawi” (IMCHA#108030) project conducted mixed-methods to understand facility-based implementation factors for newborn health innovations in low-resourced health settings. The objective of the two datasets was to evaluate: (a) capacity of quality newborn care in three districts in southern Malawi, and (b) barriers and facilitators the scale up of bubble continuous positive airway pressure (CPAP), a newborn health innovation to support babies with respiratory distress. Data description The Integrated Maternal, Neonatal and Child Quality of Care Assessment and Improvement Tool (version April-2014) is a standardized facility assessment tool developed by the World Health Organization (WHO) that examines quality as well as quantity and availability. The facility survey is complemented by a qualitative dataset of illustrative quotes from health service providers and supervisors on bubble CPAP implementation factors. Research was conducted in one primary health centre (facility assessment only), three district-level hospitals (both) and a tertiary hospital (qualitative only) in southern Malawi. These datasets may be used by other researchers for insights into health systems of low-income countries and implementation factors for the roll-out of neonatal health innovations as well as to frame future research questions or preliminary exploratory research on similar topics.

Assessing the Current States of Logistics Management and Training on Family Planning Services in Nigerian Healthcare Facilities

Background: Management of Family planning (FP) commodities is a significant problem that is not limited to compromising the quality of FP services but also results in economic burden especially in developing countries. Some facilities may have ample FP commodities while others have a shortage if FP logistics are managed poorly. Hence, assessing the FP commodities logistic management is relevant to inform decision-makers. Methods: This survey was a cross-section study of 763 public primary and secondary healthcare facilities in Nigeria. The study involved facility assessment and quantitative interview of key personnel in each facility, using a structured questionnaire. The study was conducted from May to July 2019. The data collected were analysed with IBM-SPSS version 25.0. Descriptive statistics were performed, Chi-Square and linear logistics regression were used to establish significant associations; p<0.05 was considered significant. Results: About half (51.4%) of primary and 33.5% of secondary healthcare facilities were not using forms for reporting FP supplies. Also, 23.8% of primary and 18.8% of secondary facilities waited for more than two months before receiving orders. The facilities have an average of 2-3 trained personnel on FP services. FP staff who were trained had their last training over a year ago (primary-31.9%); secondary-37.4%). Secondary facilities were 2.102(95% CI:1.567–2.820) times more likely to use log forms, 1.845(95% CI: 1.076–3.165) times more likely to have cold chains, and 4.785(95% CI: 3.207–7.139) more likely to have trained staff on insertion and removal of implants than primary facilities (p<0.05). Conclusion: We advocate that the government and donor agencies carry out urgent interventions such as regular supply of contraceptives, regular training of FP service providers, provide sufficient manpower, carry out regular monitoring and evaluation of FP services and create awareness on the need to use FP services among grassroots citizens.

Characterization and distribution of medicine vendors in 2 states in Nigeria: implications for scaling health workforce and family planning services

Background In 2014, Nigeria issued the task-shifting/sharing policy for essential health services, which aimed to fill the human resource gap and improve the delivery of health services across the country. This study focuses on the characteristics, spread, and family planning (FP) stocking practices of medicine vendors in Lagos and Kaduna, assessing the influence of medical training on the provision and stocking of FP services and commodities by vendors. Methods We conducted a census of all Patent Medicines stores (PMS) followed up with a facility assessment among 10% of the mapped shops, utilizing an interviewer-administered questionnaire. Bivariate analysis was conducted using the Chi-square test, and multiple logistic regression was used to estimate the adjusted odds ratio (OR) and confidence intervals (CI) for the test of significance in the study. Results A total of 8318 medicine shops were enumerated (76.2% urban). There were 39 shops per 100,000 population in both states on average. About half (50.9%) were manned by a medicine vendor without assistance, 25.7% claimed to provide FP services to > 2 clients per week, and 11.4% were not registered with the regulatory body or any professional association. Also, 28.2% of vendors reported formal medical training, with 56.3% of these medically trained vendors relatively new in the business, opening within the last 5 years. Vendors utilized open drug markets as the major source of supply for FP products. Medical training significantly increased the stocking of FP products and inhibited utilization of open drug markets. Conclusion Patent and Proprietary Medicines Vendor (PPMVs) have continued to grow progressively in the last 5 years, becoming the most proximal health facility for potential clients for different health services (especially FP services) across both Northern and Southern Nigeria, now comprising a considerable mass of medically trained personnel, able to deliver high-quality health services and complement existing healthcare infrastructure, if trained. However, restrictions on services within the PPMV premise and lack of access to quality drugs and commodities have resulted in poor practices among PPMVs. There is therefore a need to identify, train, and provide innovative means of improving access to quality-assured products for this group of health workers.

Measuring Oxygen Access: lessons from health facility assessments in Nigeria

ABSTRACTThe COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure “oxygen access”. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe four key domains to consider when measuring oxygen access.Use8/58 (14%) of facilities had a functional pulse oximeter for detecting hypoxaemia (low blood oxygen level) and guiding oxygen care. Oximeters were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%), or operating theatre (4/27, 15%), not suitable for children, and infrequently used.Availability34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward.CostOxygen was free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13000 ($36 USD) and 27500 ($77 USD) naira, respectively.Patient accessNo facilities were adequately equipped to meet minimum oxygen demands for patients. We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data.We highlight the importance of a multi-faceted approach to measuring oxygen access that assesses access at the point-of-care, and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.SUMMARY BOXOxygen access is poorly understood and the most commonly used metrics (e.g. presence of an oxygen source) do not correlate well with actual access to patients.Pulse oximetry use is a critical indicator for the quality of oxygen services and may be a reasonable reflection of oxygen coverage to patients with hypoxaemia.Oxygen, and pulse oximeter, availability must be assessed at the point-of-care in all major service delivery areas, as intra-facility oxygen distribution is highly inequitable.Minimum functional requirements for oxygen sources must be assessed, as many oxygen concentrators and cylinders may be present without being in working order.

Implementation status of national tuberculosis infection control guidelines in Bangladeshi hospitals

In response to the World Health Organization (WHO) recommendation to reduce healthcare workers’ (HCWs’) exposure to tuberculosis (TB) in health settings, congregate settings, and households, the national TB control program of Bangladesh developed guidelines for TB infection prevention and control (IPC) in 2011. This study aimed to assess the implementation of the TB IPC healthcare measures in health settings in Bangladesh. Between February and June 2018, we conducted a mixed-method study at 11 health settings. The team conducted 59 key-informant interviews with HCWs to understand the status of and barriers impeding the implementation of the TB IPC guidelines. The team also performed a facility assessment survey and examined TB IPC practices. Most HCWs were unaware of the national TB IPC guidelines. There were no TB IPC plans or committees at the health settings. Further, a presumptive pulmonary TB patient triage checklist was absent in all health settings. However, during facility assessment, we observed patient triaging and separation in the TB specialty hospitals. Routine cough-etiquette advice was provided to the TB patients mentioned during the key-informant interviews, which was consistent with findings from the survey. This study identified poor implementation of TB IPC measures in health settings. Limited knowledge of the guidelines resulted in poor implementation of the recommendations. Interventions focusing on the dissemination of the TB IPC guidelines to HCWs along with regular training may improve compliance. Such initiatives should be taken by hospital senior leadership as well as national policy makers.