At the heart of Nairobi's bustling Upper Hill area, sits Kenyatta National Hospital (KNH) - the oldest hospital in Kenya.
The public referral hospital, founded in 1901, has recorded major milestones over the years, but it has not been without mishaps.
Perhaps its greatest challenge is the irony of the hospital's lack of a functioning oxygen plant.
A damning report lays bare the challenges that have dogged the 1,800-bed hospital. For more than 20 years, the oxygen plant KNH boasts of has not functioned. If it did, the current medical oxygen shortage would have been unheard of. The shortage has forced the hospital to scale down some of its operations to cater to critically ill Covid-19 patients.
If it were functional, the oxygen plant, paid for by taxpayers, would have produced 2,500 litres per minute. But as a 2018 assessment report indicates, it is "currently out of service". The report recommends increased access to oxygen and pulse oximetry.
"There is no oxygen plant at KNH. The old one here broke down in 2015 and has never been repaired. That is why we have been surviving on BOC bulk cylinders," a doctor at the hospital anonymously tells HealthyNation.
Last week on April 6, a circular to staff read: "Following national challenges on the availability of oxygen as a result of the Covid-19 pandemic, the hospital is experiencing very low hospital-wide oxygen pressure to drive our machines. This has affected all our theatres, intensive care units (ICUs), and Mbagathi infectious diseases unit ."
It added: "The supplies of oxygen to the hospital from BOC Kenya are getting diminished by day. The purpose of this letter is to recommend temporary suspension of theatre electives as we monitor the situation in the course of the day."
Lack of piping
A day later, KNH's chief executive officer Evanson Kamuri sent a statement to newsrooms saying they had just received a top up of 3,000 litres of oxygen to run the hospital.
KNH has experienced an increase in oxygen use due to the pandemic. Over the past year, said Dr Kamuri, the average consumption of oxygen had sharply risen from 4,000 to 8,000 litres per day due to an increase in the number of patients requiring ventilator support and critical care. "These are high oxygen dependent units," he added.
But HealthyNation has learnt that if the plant was functioning, KNH would not have relied on BOC Kenya Ltd for the supply of the essential medicine.
It costs about Sh108 million to set up an oxygen plant which includes the plant house, cylinders, trucks and personnel. Kisii Level Five Hospital, for instance, installed its plant for Sh22 million. The country has 73 such plants across counties.
And it is not KNH alone that is facing oxygen shortage. Although public hospitals boast of oxygen cylinders, patients who direly need the commodity cannot access it due to lack of piping.
For families who have lost their kin due to unavailability of the oxygen the current crisis rekindles bitter memories. One such family is that of former Matungu MP Justus Murunga. According to his son Eugene Murunga, the MP could have been saved had there been oxygen at the local hospital.
Oxygen saves lives. Its provision is a critical component of emergency respiratory resuscitation around the world, and it consequently features on the World Health Organization's (WHO) list of essential medicines.
Oxygen therapy is not just used for pneumonia and other lung diseases. It is also crucial for treating various non-respiratory conditions that result in an abnormally low concentration of oxygen in the blood (hypoxaemia), such as sepsis, severe malaria, trauma and cardiovascular diseases. It is equally essential for surgical care and anaesthesia.
Yet, a study published in February last year showed that only two of 11 health facilities in rural Kenya had oxygen equipment and nine facilities had at least one concentrator or cylinder.
According to the study published in the journal Paediatric Pulmonology, most of the facilities suffered power outages of up to seven times per week.
"The median duration of the power outage was 17 minutes and the longest was more than six days," said the study.
Covid-19 isolation centres
While the majority of people with Covid-19 have mild symptoms, 14 per cent will need oxygen in hospital and five per cent will need mechanical ventilation in intensive care. Yet, across counties many hospitals and dedicated Covid-19 isolation centres have reported oxygen shortages.
Kenyatta University Teaching, Referral and Research Hospital (KUTRRH), Murang'a, Kitui and Nyeri counties are among counties that have made trips to collect oxygen from steel manufacturer Devki after the company announced it would give it for free.
With Covid-19 cases shooting through the roof, the demand for medical oxygen has outstripped the country's supply.
Health Cabinet Secretary Mutahi Kagwe said Kenya is facing a severe shortage of oxygen despite the country having 880 tonnes of medical oxygen, up from 410 tonnes last year.
"The situation at the moment is such that the industry is completely stretched," he said.
Medical oxygen is a regulated commodity that must be at least 82 per cent pure and generated by an oil-free compressor. It can come from oxygen concentrators and cylinders.
Oxygen is regulated as a pharmaceutical drug. Companies have to register with the local medical authority to produce it. Thus the businesses require more stringent systems to test the oxygen for impurities and record its journey, so that it can be recalled if there is an issue.
Unlike industrial cylinders, medical cylinders are completely emptied and cleaned every time they are refilled. Some former employees say these extra steps explain why medical oxygen costs more.
Oxygen sources include cylinders, filled with either liquid or gaseous oxygen, or on-site oxygen generation. Oxygen gas cylinders come in a wide variety of sizes.
They can be used to provide oxygen directly to the patient or to power a centrally located manifold system. Gas cylinders are generally refilled by transporting them to an oxygen depot that is supplied with oxygen from a larger oxygen generation plant.
Liquid oxygen tanks are typically larger, weighing at least 55kg and standing more than 0.75m in height. They provide the supply for a centrally located oxygen piping system. Liquid oxygen tanks are usually stationary and are filled by a provider using a filling truck.
Sluggish investment and poor delivery of oxygen are some of the issues any counties relying on transporting oxygen in compressed gas cylinders, as is generally done in poorer countries, face. As a result, oxygen in sub-Saharan Africa tends to be at least five times more expensive than in Europe and North America.
The price of a 6.8 cubic metre cylinder of oxygen (a "J" cylinder), enough to treat an adult for roughly a day, including transport, costs Sh2,489 in Kenya. (Air Liquide said comparisons of prices between countries were "unfair" because production costs vary.)
Additional costs can include a cylinder deposit fee of about Sh40,000, a monthly cylinder rental fee of about Sh2,706, and paying to transport cylinders to the gas company's depot.
Last year, as Covid-19 hit and the country had just recorded 7,577 cases and 159 deaths, medical oxygen, a commodity seen as a simple treatment, was scarce. Now, a year later, with 141,365 cases and over 2,276 deaths, Kenyan health facilities are still grappling with the same problem: an acute shortage of the oxygen.
But what is medical oxygen? How is it different from air?
Commonly, medical oxygen is administered in facilities like hospitals and clinics. It is used during anaesthesia, first aid resuscitation for emergencies, life support for patients who cannot breathe on their own, and oxygen therapy.
"A lot of attention has been focused on the lack of ventilators. Although the mechanical device is coveted for its ability to push life-saving oxygen deep into damaged lungs to help patients breathe, the lack of oxygen itself is equally worrying, given that it is an essential medicine also needed to run a ventilator," Dr Bernard Olayo, founder of Hewatele, an innovative oxygen supply company, tells HealthyNation.
Dr Olayo says a prescription is necessary to order oxygen.
So, why the shortage?
Service interruptions due to outstanding balances is a frequent cause of oxygen stockouts, as the government often processes payments slowly. In addition, whereas many county hospitals say they own oxygen cylinders, if the oxygen is not piped, it is as good as not being available.
"When you are sick, medical oxygen is prescribed as a drug. It also comes with different gadgets for giving it," says Dr Benjamin Wachira, assistant professor of emergency medicine at Aga Khan University, Nairobi.
"In some private hospitals, oxygen flows from the walls. But, many facilities do not have piped oxygen."
Many public facilities were not built with the oxygen piping. This has continued to date, despite the piping being a standard, says Dr Wachira.
Secondly, according to Dr Wachira, many public hospitals were not designed and built as compact units where all departments are housed in one building.
"The departments are spread out across many acres of land, making it very expensive to pipe such a facility," he says.
A recent survey of emergency care centres across Kenya found 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.
As a result, many hospitals operate on a tank system. "If you have a facility with 15 patients needing oxygen at the same time, you need 15 different tanks. This is neither practical nor affordable for facilities or patients," says Dr Wachira, the current president of the African Federation for Emergency Medicine.
Monopoly and greed
Further, in Kenya, many rural hospitals lack supplementary oxygen equipment, adequate supply chains for oxygen cylinders and reliable electrical power needed for oxygen delivery.
According to the WHO, oxygen therapy is recommended for all severe and critical Covid-19 patients. For these reasons, the Path's Kenya country oxygen report 2018 says, Covid-19 treatment health facilities should be equipped with pulse oximeters, functioning oxygen systems including single-use oxygen delivery interfaces.
"When Covid-19 hit, we bought the big things like ventilators and forgot the small things like oximeters. It is like having tea in a kettle without a cup to drink it," says Dr Olayo.
He says the shortage and high costs are driven by monopoly, greed and logistics. "Even if you eliminate corruption, our market is still inefficient. At any point there are eight to nine middlemen," he says.
Until recently, Kenya depended almost entirely on BOC for medical oxygen cylinders. BOC has received criticism for having higher prices, inconsistent delivery services, requiring additional deposits for cylinders, and not providing oxygen in case of an outstanding balance.
Competition now exists in the form of government-operated oxygen plants (such as those provided through the Managed Equipment Service programme) as well as private-sector suppliers (such as Crown Gases, Noble Gases and Oxyplus) or partnerships (such as Hewatele).
Through the three plants installed in Siaya, Nakuru and Nairobi's Mama Lucy hospitals between 2014 and 2018 to supply 200 health facilities across the counties with affordable oxygen, Dr Olayo hopes to avoid the painful choices he faced as a young doctor because of a lack of oxygen.