Breathing Life into Mali’s National Medical Oxygen System
Dr. Brehima Traoré teaches a group of nurses and midwives at the Yirimadio clinic how to use the center’s new oxygen machines.
Imagine: your young daughter has been sick with pneumonia for several days. Her breathing is becoming increasingly difficult, and you know she needs to go to the hospital for more intensive treatment. Depending on whether you live in a low-income country or a high-income country, your child’s health outcomes could be very different, based on access to a crucial tool: medical oxygen. In high-income countries, oxygen is readily available at every stop in the health system: in the ambulance, at the clinic, in the hospital, and in the operating room. In many low-income countries, however, this life-saving resource is a rarity. A 2018 study found that an average of only 61% of hospitals in low- and middle-income countries surveyed had access to medical oxygen in their operating rooms.
The difference in oxygen access has long contributed to a gap in health outcomes and child mortality rates between rich and poor countries. Oxygen is essential for treating childhood pneumonia – which kills 800,000 under-five children each year, primarily in low-income countries, making it one of the leading causes of child mortality.
Medical oxygen is a critical treatment for patients facing respiratory failure, including patients hospitalized with severe cases of COVID-19. Low blood oxygen levels (medically, hypoxemia) have been found to be correlated with COVID-19 mortality; in a small study by the Mayo Clinic, 68.63% of COVID-19 patients with suboptimal blood oxygen levels did not survive.
Disparities in oxygen access came into sharp focus in Mali at the start of the COVID-19 outbreak, at which point, to Muso’s knowledge, none of Mali’s national secondary referral hospitals had oxygen equipment available for hospitalized patients, and most had limited intensive care units and few ventilators. Muso acted rapidly to respond to these and other health system gaps that rendered patients vulnerable to routine illnesses prior to the pandemic, and would only prove worse for health outcomes should the country face a surge of COVID-19 cases. Partnering with the Malian government, we are diligently working to reinforce access to medical oxygen within our direct service sites and across the national health system, delivering oxygen equipment to key community health centers and district referral hospitals, and training facility staff on its use to improve access to this necessary resource across the health system in the long term.
Through an in-kind donation, we procured 54 multi-patient oxygen concentrator machines which will reach patients at referral hospitals in five regions of the country, which together serve 17 million of Mali’s 19 million citizens. In addition to oxygen concentrators, Muso and our partners are distributing 50 pulse oximeters, used to measure blood oxygen levels; 50 newborn mannequins to practice neonatal resuscitation; 5,000 nasal tubes for adults; and 5,000 nasal tubes for children across the national health system. To ensure every district hospital in the country has this oxygen capacity, Muso is partnering with UNICEF to reinforce, strengthen, and expand Mali’s national medical oxygen system in all regions of the country.
Dr. Traoré demonstrates use of portable oxygen for patients transported by ambulance.
Muso’s Learning and Innovation team developed a new training curriculum to support long-term use and maintenance of the equipment by clinical staff, which was first trialed through the deployment of four oxygen concentrator machines in Muso’s direct service sites. The equipment was installed at the Bankass District Hospital and the Yirimadio and Bankass Community Health Centers, as well as the ambulances and motorcycle ambulances, bringing oxygen access to the community care level for the first time. To build this curriculum, we adapted and translated from global best practices, including training materials developed by Dr. Hamish Graham for the Nigeria Oxygen Project along with World Health Organization guidelines and recommendations. Training modules subjects include hypoxemia diagnosis and pulse oximeter use, oxygen use, and maintenance of oxygen therapy equipment. To rapidly equip staff at hospitals across the country with these tools, Muso established a system of “cascading trainings,” starting with a training for health professionals within the Ministry of Health, who will then go on to educate regional and district level staff. These trainings will additionally support the government to spearhead data collection on oxygen equipment usage, critical to facilitating iterative learning processes and the long-term success of the system.
Mali’s national oxygen system may have grown and strengthened during a time of crisis, but Muso’s goal was to build a system that outlasted the pandemic. Sourcing equipment was necessary to bolster the system, but the core of the system’s continued utility is the regular training, accompaniment, and monitoring designed to support proper equipment usage and maintenance and ensure quality care in district and regional hospitals. Together, this strengthened system will enhance patient care on a number of fronts:
Oxygen as a COVID-19 Therapy:
As COVID-19 —the impetus for this new health system capacity— continues its spread in Mali, more patients will have access to one of the most vital therapies for this uncured disease. Patients within COVID-19 units at six hospitals in Bamako, designed for support and isolation, also now have access to medical oxygen.
Treating Childhood Pneumonia:
The need for a national oxygen system in Mali began long before the pandemic. We worked with the government to design the national medical oxygen system in a way that would strengthen the foundation of the country’s health system long after the last case of COVID-19 is detected. For example, the training of providers on the oxygen system will also support patients’ access to therapies for diseases like pneumonia. While Muso Community Health Workers can treat mild cases of pneumonia at the community level, more severe cases must be referred for clinical care. Historically in Mali, children whose cases were severe enough to reach this level were more likely to die because of insufficient oxygen supplies and capacity at the clinic. With the introduction of the oxygen system, clinicians at the community health center in Muso’s rural sites have shared promising reports of improved child health outcomes. One shared,
“Several children suffering with hypoxemia in the setting of severe pneumonia have recently been evacuated from the Tori community health center to the Bankass district hospital. We found that because they received oxygen therapy during the ambulance ride, their oxygen saturation was improved even before arriving at the district hospital.”
Benefitting Neonatal Resuscitation:
Bolstering the national oxygen system has also leveraged opportunities to improve in national standard practices for newborn resuscitation. While medical oxygen can be used in some cases of newborn hypoxemia, there are now improved techniques to revive newborns suffering from asphyxiation. As part of the national oxygen system deployment, Muso is integrating newborn resuscitation best practices into the training curriculum, and is equipping each district hospital with newborn mannequins. This additional training will position the oxygen we distribute to have more reach and capacity to treat more COVID-19 patients, and additionally leverages an opportunity to train providers across the nation, who care for millions of people, on best practices for how to save babies.
Creating a just global health system necessitates early, equitable access to care for all. Whether riding in an ambulance through the hills of San Francisco or on a moto ambulance through rural Mali, a patient should have equal access to oxygen equipment, and a provider prepared to deploy it. Mali’s upgraded national oxygen system, built in partnership by the Malian public sector actors, Muso, and UNICEF, will bring this ideal one step closer to reality, and will help patients across Mali breathe a little easier.