Article Text

Solar-powered oxygen, quality improvement and child pneumonia deaths: a large-scale effectiveness study
  1. Trevor Duke1,2,
  2. Francis Pulsan2,
  3. Doreen Panauwe3,
  4. Ilomo Hwaihwanje4,
  5. Martin Sa'avu5,
  6. Magdalynn Kaupa6,
  7. Jonah Karubi6,
  8. Eleanor Neal7,
  9. Hamish Graham7,8,
  10. Rasa Izadnegahdar9,
  11. Susan Donath10
  1. 1Intensive Care Unit, and Centre for International Child Health, Department of Paediatrics, University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
  2. 2Discipline of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
  3. 3Department of Paediatrics, Wabag General Hospital, Wabag, Enga Province, Papua New Guinea
  4. 4Department of Paediatrics, Goroka General Hospital, Goroka, Eastern Highlands Province, Papua New Guinea
  5. 5Department of Paediatrics, Mendi General Hospital, Mendi, Southern Highlands, Papua New Guinea
  6. 6Department of Paediatrics, Mt Hagen General Hospital, Mt Hagen, Western Highlands Province, Papua New Guinea
  7. 7Infection and Immunity, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
  8. 8Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
  9. 9Bill and Melinda Gates Foundation, Seattle, Washington, USA
  10. 10Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
  1. Correspondence to Professor Trevor Duke, Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia; trevor.duke{at}


Background Pneumonia is the largest cause of child deaths in low-income countries. Lack of availability of oxygen in small rural hospitals results in avoidable deaths and unnecessary and unsafe referrals.

Method We evaluated a programme for improving reliable oxygen therapy using oxygen concentrators, pulse oximeters and sustainable solar power in 38 remote health facilities in nine provinces in Papua New Guinea. The programme included a quality improvement approach with training, identification of gaps, problem solving and corrective measures. Admissions and deaths from pneumonia and overall paediatric admissions, deaths and referrals were recorded using routine health information data for 2–4 years prior to the intervention and 2–4 years after. Using Poisson regression we calculated incidence rates (IRs) preintervention and postintervention, and incidence rate ratios (IRR).

Results There were 18 933 pneumonia admissions and 530 pneumonia deaths. Pneumonia admission numbers were significantly lower in the postintervention era than in the preintervention era. The IRs for pneumonia deaths preintervention and postintervention were 2.83 (1.98–4.06) and 1.17 (0.48–1.86) per 100 pneumonia admissions: the IRR for pneumonia deaths was 0.41 (0.24–0.71, p<0.005). There were 58 324 paediatric admissions and 2259 paediatric deaths. The IR for child deaths preintervention and postintervention were 3.22 (2.42–4.28) and 1.94 (1.23–2.65) per 100 paediatric admissions: IRR 0.60 (0.45–0.81, p<0.005). In the years postintervention period, an estimated 348 lives were saved, at a cost of US$6435 per life saved and over 1500 referrals were avoided.

Conclusions Solar-powered oxygen systems supported by continuous quality improvement can be achieved at large scale in rural and remote hospitals and health care facilities, and was associated with reduced child deaths and reduced referrals. Variability of effectiveness in different contexts calls for strengthening of quality improvement in rural health facilities.

Trial registration number ACTRN12616001469404.

  • mortality
  • health services research

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

View Full Text

Statistics from

Supplementary materials


  • Twitter @GrahamHamish

  • Contributors All authors contributed substantially to several aspects of this study. TD designed the project in collaboration with IH, JK, MK, DP and MS, who gathered the preintervention data in their provinces. FP led the clinical training in respective provinces, along with provincial paediatricians, and gathered the postintervention data. EN, HG and RI supported the design and administrative aspects of the project. Statistical analysis was done by SD and TD. The paper was written by TD, with input from SD and all authors, who reviewed and approved the final manuscript.

  • Funding This project was funded by the Bill and Melinda Gates Foundation. Project funding, which also included support for trialling the implementation of oxygen concentrators in 12 urban hospitals in Nigeria, was provided in 2014. Preparatory work for this project occurred in 2014 and 2015. Additional funding was provided by the RE Ross Trust (Victoria) for training aspects and by the National Health Department of PNG, and the Provincial Health Authorities in each province (in-kind funding with contributions by many clinical and technical staff). The funding agencies, especially the Bill & Melinda Gates Foundation and the PNG National Department of Health, have worked closely with the project leaders, with input into design and method of analysis, but the final methodology, analysis and decision to publish are independent of the funding agencies.

  • Competing interests Apart from being funded through the Bill & Melinda Gates Foundation for the conduct of this work, none of the authors have any competing interests in regard to this manuscript.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the PNG National Department of Health, The Human Research Ethics Committee of the University of Melbourne (15 43 797.1), the Provincial Health authorities in each participating province, and Church Health Services which run some of the participating health facilities.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Additional information on the method are available at and Australian New Zealand Clinical Trials Registry: ACTRN12616001469404. Additional results data are available in the online supplemental appendices.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.