The Independent (Kampala)

16 December 2012

Uganda: Delays Hit Mulago's New Oxygen Plant

Experts propose ways to ensure poor maintenance does not kill off Sh3 billion venture

If fuel shortage causes a stampede at the fuel pumps, imagine a patient on a hospital bed, gasping for breath, and needing urgent resuscitated with emergency oxygen. Unfortunately, if that patient is at Uganda's National Referral Hospital at Mulago in Kampala, the reservoir is sometimes dry and cylinders by the patient's bed empty.

Such patients often die, says Dr. John Omagino, the director of the Uganda Heart Institute at Mulago, who does not want to even imagine what happens in the other underfunded hospitals away from the capital.

Omagino has performed open heart surgeries and other complicated procedures and has seen patients die because of lack of oxygen. He says a human being dies in just six minutes if they are deprived of oxygen which is a faster death than if they are injured severely in the stomach or have their limbs cut off.

"In this institute, there are no debts, failure to buy oxygen means death to the patients," he says.

Dr Omagino is among several leaders at the hospital who are determined to end the oxygen shortages. First, they must ensure that a new oxygen manufacturing plant is up and running. That would end the laborious and expensive process of importing it from neighbouring Kenya. Secondly, Dr Omagino hopes, the new plant will produce enough oxygen to supply even the hospitals outside the capital. Finally, he hopes the new process will cut out the use of cylinders that need to be refilled as the oxygen will be pumped directly to patients at point of need.

"We cannot continue depending on a vehicle that travels about 700 miles to bring us oxygen. One time the vehicle broke down thrice and many patients died," Omagino says.

The hospital has contracted a Chinese company, China Sinopharm, to build the oxygen plant and the Heart Institute is launching a medical compressed gas plant and vacuum extraction pump. Together, these interventions are expected to supply the three gases the hospital needs most; oxygen, medical air, and nitrous oxide.

But not everything is going according to plan. Construction of the oxygen plant that should have been ready by Nov.20 is still going on and a new commissioning date has not been made. Even before it is commissioned, however, there are claims that the new plant is too small. Part of the concern appears to be a result of the specifications of the new plant.

New capacity:

Mulago has been using large cylinders of a about 6.8 cubic meters, which is equivalent to about 340 jerry cans of 20 litres each. The cylinders of the new plant are far smaller, at 0.04 cubic meters or about two 20-litre jerry cans of gas each.

Edward Kataaha, the Senior Hospital engineer, explains that despite contrary claims, the capacity of the new plant is adequate. He says it can produce up to 60 cubic meters of oxygen per hour, which is about nine of the big cylinders it has been buying.

The numbers regarding oxygen usage are tricky, as they involve money, vested interests, and secrecy. However, an official at the hospital revealed that on average, the hospital uses 200 of the 6.8 cubic meter cylinders supplied by British Oxygen Company (BOC) Kenya or about five cylinders per ward per day. That would amount to just about half of the oxygen used or 2720 cubic metres of oxygen.

However, Mulago buys 5,492 cubic metres or 5.5 million litres of oxygen every two weeks. The oxygen is pumped into a tank rented from (BOC) which is refilled on a running contract.

Based on the capacity figures given by Kataaha, the new plant would require 45 hours or six days of eight hours each to produce oxygen that would serve the hospital for two weeks at current consumption. Not bad at all, especially if the gases projected to be produced by the Heart Institute are factored in. However, if indeed the hospital requires the 5,492 cubic metres of oxygen that BOC has been supplying, then the new plant is way too small.

Dr Charles Ibingira, the dean school of Biomedical Sciences at Makerere University says the plant's capacity should not be a concern because it can be increased. But even if the question of capacity is resolved, other concerns remain, including the unreliable electricity supply. The hospital must also evaluate whether, apart from saving lives by ensuring a more stable supply of medical gases, there is any net financing gain.

Cost implications:

On whether there is a net financial gain or not, Dr. Lawrence Kaggwa, a former executive director of Mulago Hospital for 12 years, says his team realized as early as 2002 realised that oxygen producing industries were failing to meet the hospital's oxygen needs.

"Oxygen production and distribution was an oligopoly," Kaggwa said, "The hospital would admit about 1, 800 patients, run 20 theatres, facilitate the intensive care units. It needed oxygen at all times."

To meet the rising need for oxygen, his managers weighed three options; getting oxygen concentrators for some theatres and wards; buying a concentrator or plant to produce the gases on a large scale, or to import liquid oxygen.

Kaggwa said after sending a team of engineers to Nairobi and Zambia hospitals, the management decided to import liquid oxygen as it was the technology they deemed fit to supply oxygen to the central pipe system.

"Although the cost of importing seemed high, the tank would be refilled in Nairobi without maintenance costs."

But Billbest Bakirese, a senior planner at the hospital says the supply chain started getting clogged when National Medical Stores (NMS) took over the procurement of drugs and sundries in 2010. Deliveries of the oxygen started to delay and cylinders on the wards were insufficient. The stock outs made the hospital rethink oxygen costs.

David Nuwamanya, the principal hospital administrator says management approved procurement of the new plant in May 2011 and a contract was signed in June 2012 to kick start the installation of the plant in lower Mulago next to the liquid oxygen tank.

Byarugaba says China Sinopharm International Corporation was contracted to build the plant at US$1.08 million (Shs 2.9 billion), a big undertaking from the hospital's 2012/2013 capital development budget of 5.02 billion.

"The cost of setting up the plant is almost equivalent to the cost of importing oxygen for about three to four years," Byarugaba because, he says, the hospital spends between Shs 700 to 800 million annually on oxygen imports. The hospital pays BOC alone Shs 480 million per year. It is hoped that once the new plant is operational, that money will be saved.

Dr Ian Clarke, the Chairman International Medical Group and owner of the top-ranked International Hospital of Kampala, is not so sure.

"If it is a public private partnership, then the company will produce enough oxygen for Mulago and also supply other private health facilities," he says. But, he says, if the plant remains under government management, it will break down due to poor maintenance.

Byarugaba says China Sinopharm, which is contracted to install the plant and maintain it under guarantee for 10 years, has already subcontracted a local company for the job.

But Dr Ibingira agrees with Dr Clarke that to get the most out of the new plant, its managers must ensure regular checks and tests to prevent infections and contamination from bacteria from the neighbouring sites.

The oxygen house needs good air flow and environment hygiene from pollution sources like waste gas, anaesthesia gas, and the hospital air-vent of vacuum system. The incinerator, a road and generator are too close to the plant. In Mulago, it is not unusual for new life to be born in such a hostile environment. One hopes, however, the new plant can survive in it.

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