OXYGEN GENERATION PLANTS: Saving lives beyond COVID-19
25 the first time, the government has functioning oxygen plants in the country. This places the health system better prepared for any future pandemic, including the resurgence of COVID-19 in the event it returns. Minister of Health Lizzie Nkosi takes us through the significance of this development.
MEDICAL OXYGEN IS A LIFE-SAVING ESSENTIAL MEDICINE
Medical oxygen is a life-saving essential medicine for a wide range of medical issues which may quickly worsen if left untreated. The COVID-19 pandemic highlighted the importance of medical oxygen and the importance of establishing in-country production for medical oxygen to cater for our needs. As a ministry we had, before the COVID-19 pandemic, realised how little oxygen we had available in the country, but no one could have anticipated the surge in the need for oxygen that came with the COVID-19 pandemic.
The second wave of the pandemic, had us all looking for medical oxygen support as export embargos meant the quota allowed for export from our neighbours was significantly reduced. South Africa had embargos on export of commodities, including oxygen. Mozambique wanted to help but we (ministry) did not have the type of oxygen cylinders that could be refilled in Mozambique and brought into the country. The country currently utilises 3 315 oxygen cylinders of which only 1 250 are owned by government, the rest are rented from our suppliers (Afrox and Elcor). The ministry learnt during this period that you cannot have a single source for oxygen; if your one supplier fails to deliver, then lives will be lost. Elcor was added as a supplier of oxygen during the second wave of COVID-19.
OXYGEN GENERATION PLANTS
During the COVID-19 second wave we worked very closely with the private sector and other ministers including the minister of Finance to increase our access to oxygen. We sent requests to all parties for support in establishing in-country oxygen generation.
The Luke Commission (TLC) were the first to build and operationalise a plant in the country, which is the largest plant in Southern Africa constructed outside of government. The TLC started building in 2021 and the plant is operational. The plant at TLC was initially meant to be smaller, but was scaled-up with financial support from the Kirsh Foundation (of E12 million) and by FNB Foundation. As government, we had started talking to all our partners about the need to generate more oxygen in-country, the ministry tried to establish a plant at the Lubombo Referral Hospital (LRH), but this works stalled as we were in the middle of the pandemic and were unable to access the required technical teams for the work. We ended up installing a liquid oxygen tank to provide oxygen at LRH, Raleigh Fitkin Memorial (RFM) Hospital, and Mavuso COVID-19 Centre (supported by Right to Care, USAID funded SA organisation). Médecins Sans Frontières (MSF), who have extensive experience working in emergency settings and supporting us to combat the HIV/AIDS and TB pandemic confirmed that they would be able to construct two oxygen plants to service the Shiselweni Region.
One oxygen plant at Nhlangano
Health Centre and the second one at Hlatikhulu Government Hospital,which would be able to supply other facilities in the region including Matsanjeni Health Centre, as oxygen cylinders were also provided for. These plants began operating in 2022 and cost E10 million to construct.
The plant at Nhlangano Health Centre uses electricity, but has a generator only dedicated to the plant in the event of power shortage. When oxygen is in low demand, the oxygen plant idles, when demand increases, the plant increases its generation capacity to meet the required needs.
The plant at Hlathikhulu Government Hospital also has a dedicated generator with solar energy planned to be brought in the short-term with support from UNICEF. Hlathikhulu Government Hospital is a regional hospital and has a large children’s ward, maternity, and neonatal ward, and a dialysis service, and thus it is important it is able to have quick access to oxygen as per its needs.
The United States (US) Government brought in 400 oxygen concentrators with MSF also bringing in a consignment to fill the gap. These concentrators were distributed mostly to the Mavuso COVID-19 Centre, and Shiselweni Region. Smaller numbers were brought in by other partners that were distributed across care points, such as the Malagwane COVID-19 Centre, and private facilities. Of the 85 ventilators used at the height of the response, 70 were donated by the Taiwan Government.
REGULATION AND CERTIFICATION
All essential commodities, including oxygen and other medical gases, are regulated by the Ministry of Health using guidelines and frameworks as provided for by the World Health Organisation (WHO). The Ministry of Health remains the custodian of policy direction, guidance and monitoring of health set standards by global bodies including the WHO. There is a need to ensure that the entity has quality certifications for medical oxygen so in the unlikely event of harm to a patient, the ministry should be covered.
Below are a few examples, but the list of quality certifications goes up to 10.
1. ISO 13485: medical devices quality management systems
ISO 1524-2: regulators for use with medical grade gases
Valid certificate of a quality management systems (ISO) 13485, ISO 9001
4. BS EN/SAN MGPS standards certificates 2. 3.
5. ISO 14971: medical devices risk management
6. Need to ensure that oxygen purity >92 per cent
Ensure internal and external quality assurance protocols available and are being implemented
ISO 14644: for clean rooms and associated with controlled environments. We would require an environmental assessment report to ensure they meet required standards. 7. 8.
OXYGEN PLANTS DANGEROUS
Oxygen plants are dangerous facilities, they need to be placed appropriately with a large source of water readily available onsite in case of fire. This is especially required if a plant is producing for distribution and not just to meet its facility needs.
In 2021, the ministry established the Oxygen Technical Working Group (TWG) comprising of various experts to advice the ministry on how best to improve access to medical oxygen for all people in Eswatini. The team has worked tirelessly, conducted assessments alongside our health workers and developed a comprehensive National Medical Oxygen Operational Plan (ENMOOP) 2023-2025 with the overall goal to ensure access to medical oxygen for all people in Eswatini and ensure effective use to save lives by the year 2025. The TWG recommended that to prevent loss of lives, oxygen needed to be closer to the health facilities and that the country should not rely on one source of oxygen. The recommended national medical oxygen supply model is to implement regional oxygen hubs with PSA oxygen generation plants as the main source and bulk liquid oxygen tanks as a back-up. In addition, the operational plants already mentioned (one at TLC, two in the Shiselweni Region) the following are under construction to align to the recommended model:
● Mbabane Government Hospital – oxygen plant supported by WHO to supply the facility that sees over 20 000 patients per month. The plant is expected in-country by the end of May.
● Central Medical Stores – oxygen plant supported by the Global Fund to supply facilities in the Manzini region. The plant is expected in-country by the end of May.
● RFM – bulk liquid oxygen tank to supply the facility that sees over 12 000 patients a month and provide refills to its network of Nazarene clinics in Manzini.
● Lubombo Referral Hospital – oxygen plant supported by Government to supply facilities in the Lubombo Region.
Different scenarios have been modelled to estimate our oxygen needs, in normal and not normal (surge) situations and mitigation measures put in place. Figure 1 below shows the current oxygen production capacity and demand (in litres) during a no COVID-19 surge). )LJXUH Current oxygen production capacity and demand (in litres) during a no COVID-19 surge
)LJXUH , below shows the current and planned oxygen production capacity and demand (in litres) during a surge. The oxygen demand are theoretical calculations estimated for surge; they are calculated using the number of beds, hypoxemia prevalence and oxygen )LJXUH a surge
Current oxygen production capacity and demand (in litres) during
KEY PLAYERS APPLAUDED
As a ministry, we would like to appreciate Afrox and Elcor who, even during trying times, rose to the occasion and worked around the clock to deliver oxygen to our facilities. Our sincerest thanks goes to the Dairy Board who re-engineered their plant to be able to produce medical oxygen to supply government when availability was low.
We would also like to thank the investment from government and partners. government created so many isolation and high care spaces in public health facilities across the country, which included bringing in oxygen concentrators and setting up reticulation to bring oxygen to the patient’s bed even at the Mavuso COVID-19 Centre; we thank the Ministry of Commerce, Industry and Trade for the amazing cooperation which enabled us to setup liquid oxygen tank and piping to run oxygen to patients at Mavuso. Our partners, the
flow rates. The 123 974 486 litres of oxygen demand gap will be mitigated with increasing frequency of liquid oxygen refill. If we are ever faced with another pandemic that requires a surge production of oxygen, liquid oxygen will be brought in.
Republic of China (Taiwan) brought in ventilators and oxygen cylinders when all countries had banned their export; these were distributed to public and private facilities. The US Government supported TLC to provide COVID-19 care, oxygen concentrators and masks. MSF for oxygen plants and cylinders and the Kirsh Foundation for filling every gap we came across along the way, from rapid tests, testing platforms, ICU beds, ultra cod fridges, antibiotics, antiretrovirals, etc.
OXYGEN MILESTONE
For the first time, we have functioning oxygen plants in the country. As government we have a responsibility to ensure that our health system is ready for any future pandemic including the resurgence of COVID-19 in the event it returns. In-country generation of oxygen and decentralisation of oxygen hubs to the region will ensure access to this life saving commodity as required to avoid unnecessary loss of lives.