Can’t breathe: Why thousands of Kenyan patients are dying
An oxygen production machine at Nakuru Level Five Hospital.
What you need to know:
- Most critically ill patients in the country requiring specialised ICU or HDU care are referred to Level 5 hospitals.
The country has only 70 PSA oxygen plants.
Kenya has only 239 medical engineering technologists and 256 medical engineering technicians.
A new report by the African Population and Health Research Center (APHRC) has warned that increasing input costs in the production and distribution of medical oxygen is the reason the country is losing thousands of patients who are in dire need of the life-saving commodity in public health facilities.
The study was done in eight counties in Nairobi, Eastern, Rift Valley, Nyanza, Western, Coast, North Eastern and Central parts of Kenya.
According to the researchers, most critically ill patients in the country requiring specialised ICU or HDU care are referred to Level 5 hospitals or the national referral hospitals as the lower levels of the health system, from health centres to dispensaries hardly have any access to medical oxygen.
In April last year, President William Ruto flagged off 20,620 medical oxygen cylinders to aid counties in what he said was transforming the healthcare system.
President Ruto then announced that the Global Fund through Amref Medical had donated funds amounting to 41.7 million dollars to support oxygen supply and comprehensive infrastructure improvement.
"This covers refill of compressed and cryogenic oxygen, acquisition of tanks and cylinders, installation of high volume Pressure Swing Absorption (PSA) oxygen generation plants and the piping and installation of manifolds as well as oxygen outlets to health facilities," the head of state said.
However, APHRC researchers told Nation that their findings show an increase in tariffs on electricity and fuel prices as well as over-reliance on imported cylinders as it exposes purchasers to the impact of fluctuating foreign exchange rates and disruptions in the global supply chain is making the cost of medical oxygen unbearable.
The researchers were also shocked to find that a year later after President Ruto’s promise, the country has only 70 PSA oxygen plants.
Medical oxygen
“Most of these facilities have inpatient wards but not all have a regular supply of medical oxygen, with many of them relying on the county teaching and referral hospitals to supply them via oxygen cylinders.
Notable innovations with the potential for replication and scalability include the creation of a WhatsApp forum in one county to facilitate the collation of a weekly oxygen consumption report from all health facilities within the county,” they said.
The report notes that 89 percent of the 70 PSA plants are not operating at optimum capacity due to obsolete technology, lack of capacity to regularly maintain and service plants, failure to factor in population increases in planning and historical failure to list oxygen as an essential medicine.
The study further established that Kenya has only 239 medical engineering technologists and 256 medical engineering technicians bringing this to a total of only 495 experts.
“Nairobi has 28 medical engineering technologists, Eastern-43, Rift Valley-33, Nyanza-13, Western-25, Coast-38, North Eastern-3, Central-19 while at the national level, we have only 37,” the lead researcher told Nation.
“Nairobi also has only 4 medical engineering technicians, Eastern has 49, Rift Valley-71, Nyanza-9, Western-11, Coast-68, North Eastern-4, Central-19 while at the national level, the country has 21,” she said while urging county and national government to prioritise making medical oxygen available in all health facilities.
The study which was done in seven counties around the country established that the predominant form of medical oxygen is produced via pressure swing adsorption (PSA) technology, given the relative affordability of the initial installation costs of PSA technology compared to medical liquid oxygen (LOX).
PSA plants
They however cautioned that PSA plants incur heavy routine operational and maintenance costs.
“An overall assessment is that at least the county teaching and referral hospitals (Level 5) have a more or less adequate supply of medical oxygen, based on the presence of intensive care units (ICUs) and high dependency units (HDUs) which require regular and predictable supply of medical oxygen,” the report noted.
This means that the impending withdrawal of donor funding and subsequent uptake of these costs by the county governments coupled with rising input costs raises concerns about the potential transfer of these expenses to patients.
It is why experts are now concerned that the convergence of factors such as limited credit access and an unfavourable business environment create significant obstacles to the establishment of local enterprises and facilities for oxygen production and manufacturing of oxygen consumables.
While releasing the findings of their study done in all counties around the country on Monday, Maurine Ng’oda who is the lead researcher highlighted that to cover the increasing expenses associated with changes in input costs, gas-producing companies have found it necessary to raise the prices of their products.
She pointed out that the establishment of PSA plants involves substantial expenses and significant upfront investments.
Pending bills
“Medical oxygen suppliers in Kenya have also reported delays in receiving payment for their services, thereby contributing to the mounting pending bills within the health sector,” she told Nation in an interview adding that medical oxygen continues to remain neglected and receives little priority in county budgets.
The researchers explain that despite Covid-19 highlighting the critical importance of medical oxygen, it has remained largely un-prioritized by county governments.
For some of the counties, medical oxygen projects are occasionally referenced in the Annual Development Plans (ADPs) and County Integrated Development Plans (CIDPs) while for most of the counties, medical oxygen is not budgeted for as it is currently funded by donors such as Amref Health Africa, they pointed out.
Ms Ng’onda said that health financing in the country is primarily through government funding and out-of-pocket expenditures.
“While donor funding has played a significant role (58 per cent) in Kenya’s health sector development budget, a concern within the health sector is the withdrawal of donor funding - anticipated that more than 30 programs will have to transition to domestic financing by 2030,” she said noting that health sector budgets at the county level make up a substantial portion of the total budgetary allocation which is approximately 24 per cent of the counties’ total budget.
According to the findings, current expenditures account for a greater proportion of the health sector allocations (89 percent), leaving little fiscal space for development expenditures such as the purchase of medical oxygen.
At the national level, recurrent expenditures still account for a greater proportion of the health sector expenditures despite the increases in the wage bill.
APHRC also highlights that apart from inadequate staff, health institutions across the country have inadequate knowledge and technical expertise required for the running and maintenance of medical oxygen equipment and plants.
The researchers now urge the national government to urgently increase the level of investments towards extending and increasing medical oxygen infrastructure.
“This should be done with equity in mind, so that far-flung rural counties are not overly disadvantaged, nor the more populous counties under-served by available medical oxygen services,” Ms Ng’onda said.
They are also of the view that investments in extending electricity connection to health facilities at the appropriate voltage must be prioritised.
“Some facilities are stuck with equipment they cannot operate because of low electrical power voltage should be prioritized.
This is why they are of the view that a national plan or roadmap on medical oxygen is urgently needed to specify the measures and investments that the national and county governments will take to ensure that gaps in the production, supply and utilization of medical oxygen are addressed.
APHRC urges the government to review its policy on taxation so that it is aligned with low investments in medical oxygen.
“The taxation policy should encourage, rather than stifle investments in medical oxygen equipment and other supplies.
A major recommendation in this regard is zero rating of all equipment and accessories bought by or supplied to public health facilities for medical oxygen,” they highlight.
What is the cost of medical oxygen in Kenya?
It costs about Sh108 million to set up an oxygen plant in the country and this includes the plant house, cylinders, personnel and trucks.
The price of 6.8 cubic metre cylinder of oxygen (a “J” cylinder) enough to treat an adult for roughly a day including transport costs is Sh2,500 though this varies from one facility to another.
However, according to Air Liquide, the comparison of prices between countries varies because production costs vary.
Additional costs can include a cylinder deposit fee of about Sh40,000, a monthly cylinder rental fee of about Sh2,800 as well as paying to transport cylinders to the gas companies depot.
In 2022, the Ministry of Health disclosed that medical oxygen availability in public hospitals around the country was as low as 16 per cent.
“In a recent survey of emergency care centres across the country, over 30 per cent of the facilities did not have a regular supply of oxygen.
Close to 90 per cent of those with oxygen did not have piped oxygen in the emergency department and delivered oxygen directly from the tanks to the patient,” the government said.
Access to Medicine Foundation, pipeline intra-hospital oxygen distribution networks are helpful to supply oxygen at high pressure to equipment such as anaesthetic machines and ventilators or directly connected to patients with a flow-meter and tubing.
The experts add that a key advantage of pipeline systems is that they allow the distribution of oxygen to multiple patients simultaneously and obviate the need for handling and transporting heavy cylinders between hospital wards.
