Emily Headrick, Clinical Technical Advisor, FHI 360
Graciela Avila Cacavelos, Consultant, PSI
Kayla Stankevitz, Technical Advisor for Health Information Systems, FHI 360

“Do you remember a year ago, when all we had was a WhatsApp group to ask questions of each other and send pictures of the oxygen purities?”Rodrigo Romero, head of the Paraguay Ministry of Health´s Medical Gas Department offered this poignant reflection during the opening remarks of an event hosted in March by the USAID-supported Meeting Targets and Maintaining Epidemic Control (EpiC) project to celebrate the launch, training, and validation of the country’s first digital oxygen maintenance tracking system. 

Medical oxygen has always been a scarce resource. While it is an essential medicine, particularly to stabilize and save the lives of neonates, intrapartum and postpartum women, surgical patients, and patients with cardiopulmonary diseases, it is not produced, distributed, or administered like other medicines. The ability to administer oxygen as a medicine requires that multiple components of the oxygen ecosystem — including infrastructure, human resources, and consumables — are functionally available. The COVID-19 pandemic was the world’s first experience with a massive spike in worldwide demand for medical oxygen and resulted in a grave lesson: The oxygen ecosystem in almost every country — high income and low income alike — needed significant investment.

When hospitals full of hypoxemic COVID-19 patients ran out of oxygen, it was assumed that the problem was each facility’s inability to produce enough oxygen. In many places, this assumption resulted in the purchase of more oxygen-producing equipment like pressure swing adsorption (PSA) plants or oxygen concentrators but little other action. In 2022, the EpiC project conducted a comprehensive oxygen ecosystem assessment with the Ministry of Health (MOH) in Paraguay and determined that, with current assets, the country had the capacity to produce more than enough oxygen to meet its demands. The bottlenecks lay in other components of the oxygen ecosystem, particularly the ability of the MOH Logistic Directorate (DIGGIES) to track and manage the functional availability and maintenance needs of the PSA plants located around the country. 

Putting data to work

While advanced technology to monitor medical oxygen exists, there are disadvantages in relying on proprietary software. District Health Information Software 2 (DHIS2) is a free, open-source data management system that can be adapted to meet a range of requirements and is used to support EpiC activities around the world. After weighing the options, the MOH/DIGGIES team and EpiC embarked on the construction of a novel DHIS2-based system to monitor PSA plants and oxygen production in Paraguay. 

In August 2022, the MOH-EpiC working group initiated the design process by defining the system requirements, or the type of information needed to properly monitor the functioning of PSA plants and oxygen production and consumption. By November, basic functionalities were agreed upon, and a team led by EpiC started the design in coordination with Health Information Systems Programme (HISP) Colombia. Because PSA plants are fairly new in Paraguay, the gathering of requirements was a learning process for the team and required several weeks of discussions. By December, the initial version of the system had been presented to the MOH and installed on an MOH server for review. Between December 2022 and February 2023, the MOH team reviewed the system and provided feedback to the design team on the components and functionalities, adding new requirements and trying the system internally to ensure proper functioning. In March, a validation workshop was conducted in Asunción, with participation from three public hospitals (INERAM, the referral hospital for respiratory diseases; Itaugua National Hospital, the biggest specialized hospital within the public sector; and Barrio Obrero Hospital, a smaller maternal and child care hospital in Asunción), PSA plant operators, maintenance chiefs, and administrative and managerial staff, who were trained on the use of the tool and provided feedback about the system and its features. Following the validation workshop, the design team and MOH worked jointly on the suggested changes to produce the final version.

Sustainability through simplicity

The DHIS2-based oxygen monitoring system is projected to greatly improve strategic resource management for the oxygen ecosystem and result in significant cost savings due to improved monitoring of waste and adherence to recommended maintenance schedules defined in the standard operating procedures (SOP) currently under development by EpiC. The input requirements from plant operators — who were engaged and involved in building this system from the start as it directly affects their day-to-day work — is minimal. The DHIS2 interface can be continuously adapted, modified, and updated as new requirements become relevant or needed, and the MOH has already voiced interest in expanding this product to monitor liquid oxygen (LOX) systems and inventory management systems for oxygen-related equipment and consumables.

EpiC recognizes that no country, government, or group of health system leaders should rely solely on ad hoc mechanisms like WhatsApp groups to respond to a crisis like pandemic oxygen shortages ever again. However, this collaboration is a testament to the fact that advanced, expensive, high-tech solutions are not always necessary to meet immediate needs when it comes to the oxygen ecosystem. The optimization of a free, sustainable, adaptable, and open-source system challenged the EpiC team to imagine, innovate, and offer a “best of all worlds” platform for the MOH of Paraguay to strengthen their oxygen ecosystem — and their health system — for years to come.

A free, open-source, global good

The challenges of information availability experienced in Paraguay are not unique. In fact, the COVID-19 pandemic has shown that many countries are unable to get site-level data in a timely manner to understand and optimize medical oxygen system performance. In response, EpiC is preparing to release the metadata for the Paraguay medical oxygen tracking system as an example that other countries can quickly adapt and deploy for use in their context.

Featured Image: PSI’s Claudia Castellan facilitates the validation and launch of the DHIS2-based oxygen tracking system for hospital administrators, PSA plant operators and Ministry of Health officials in Asuncion, Paraguay in March 2023. Photo Credit: Emily Headrick, FHI 360