Oxygen as an essential medicine
Oxygen therapy is an essential part of ending preventable deaths among newborns, children, and adults globally. The need for medical oxygen has been on the rise for more than a decade, with diseases requiring oxygen for treatment—such as pulmonary and cardiovascular disease and asthma—accounting for a larger share of the burden. In low- and middle-income countries, many health facilities are unequipped to meet the rising demand.
Almost half of all hospitals in these countries have an inconsistent supply of medical oxygen or lack it entirely. Even fewer health facilities have functional pulse oximeters—devices that measure blood oxygen levels—which help health workers to determine the need for oxygen therapy and closely monitor the required levels of oxygen concentration.
The COVID-19 pandemic has spotlighted the role of medical oxygen as a lifesaving therapy for patients struggling to breathe. Ensuring reliable supply of oxygen to adequately meet the surging demand—especially in countries where that balance is already threatened—could save lives.
Oxygen access involves an assortment of sophisticated equipment, along with accessories for measuring and administering the medicine. All of these types of equipment require training on how to use them as well as regular maintenance.
How oxygen is produced and delivered
The process to deliver oxygen is often complicated—with oxygen being produced in three primary ways. (1) Air separation units (ASUs)—often used for industrial purposes—produce highly purified liquid oxygen, which can be converted into gas and stored in cylinders or taken via tanker truck to facilities with a liquid storage tank. (2) Pressure swing adsorption (PSA) plants are stand-alone oxygen generation systems—either at central filling hubs or onsite at health facilities—that extract oxygen from the air. The oxygen can be piped directly to patients’ bedsides or stored in cylinders and administered from there. (3) Oxygen concentrators "concentrate" oxygen from ambient air and provide a continuous supply to the patients' bedsides.
Once a facility has oxygen, there are additional accessories necessary to administer oxygen therapy to patients: nasal cannula and tubing; accessories to control pressure, flow, and concentration; and pulse oximeters to monitor levels of oxygen concentration. Appropriate maintenance and use of oxygen equipment and devices requires training to biomedical engineers and health care workers to manage this delivery system.
Determining what the best oxygen generation and storage solutions are varies between and within countries. The oxygen production ecosystem in just one country can be incredibly complex and may require a mix of different business models to serve the context of each individual hospital and facility. Considerations like upfront capital, operating costs and maintenance, and infrastructure requirements will play into these decisions.
Launching a global response to oxygen shortages in the time of COVID-19
Recognizing the central importance of sustainable oxygen supply for the treatment of COVID-19, Unitaid and Wellcome led the launch of the COVID-19 Oxygen Emergency Taskforce in February 2021 as part of the Access to COVID Tools Accelerator (ACT-A). The taskforce brings together key organizations that have been working to improve access to oxygen since the start of the pandemic, including the World Health Organization, UNICEF, the Global Fund, the World Bank, the Clinton Health Access Initiative (CHAI), PATH, the Every Breath Counts coalition, and Save the Children.
Building on these efforts, partners have four key objectives as a part of an emergency response plan: measuring acute and longer-term oxygen needs in low- and middle-income countries; connecting countries to financing partners for their assessed oxygen requirements; supporting the procurement and supply of oxygen, along with related products and services; and reinforcing advocacy efforts to highlight the importance of oxygen access in the COVID-19 response. In its first year, the taskforce has achieved numerous milestones.
Procuring oxygen equipment to improve access to oxygen therapy
Members of the task force have mobilized to provide various medical devices to address urgent oxygen shortages. In May 2021, with US$20 million from Unitaid, CHAI and PATH announced a new program to procure and supply new oxygen equipment. They worked in partnership with the ministries of health in nine countries—Democratic Republic of the Congo, Ethiopia, Liberia, Malawi, Nigeria, Rwanda, Senegal, Uganda, and Zambia—to develop equipment priorities to improve equitable access to oxygen therapy across health facilities. The procurement included oxygen cylinders and accessories for the transportation, storage, and dispensation of medical oxygen. It also included other respiratory care devices, such as pulse oximeters, and equipment for facility refurbishments like piping and manifolds, which are needed to deliver oxygen to patients’ bedsides.
Interested eligible organizations were invited to submit quotes for the procurement and delivery of the oxygen equipment, and the most qualified vendors were selected. PATH and CHAI coordinated the purchase, shipping, customs, handover, and delivery to the ministries of health.
Overall, more than 300,000 pieces of oxygen equipment and supplies were procured and delivered to the nine countries, with efforts now underway to distribute them to health facilities.
MALAWI
The Malawi Ministry of Health was able to procure and deliver more than 8,000 pieces of oxygen equipment and supplies, including 1,500 oxygen cylinders, 900 oxygen therapy accessories, 150 pulse oximeters, 5,500 oxygen masks, 30 ventilator bags, and 100 patient monitors. In December 2021 , PATH and the Malawi Ministry of Health held a formal handover ceremony of this critical equipment.
After the formal handover, the Ministry of Health initiated planning efforts to distribute this oxygen equipment and supplies to numerous health facilities across the country, focusing on broad and equitable distribution across as many health facilities as possible. In total, 74 health facilities now benefit from new cylinders, pulse oximeters, masks, and other oxygen equipment.
ZAMBIA
The Zambia Ministry of Health was able to procure and deliver more than 3,000 pieces of oxygen equipment and supplies, including 1,800 oxygen cylinders, 1,080 oxygen therapy accessories, and 411 pulse oximeters. In December 2021, PATH and the Zambia Ministry of Health held a formal handover ceremony of this vital equipment. At the ceremony, Zambia’s Minister of Health, Ms. Sylvia T. Masebo MP, affirmed, “We are grateful for this donation” as “we are in dire need of this kind of medical equipment.” The Ministry of Health is now focusing on the dispersal of the equipment and supplies to numerous health facilities across the country. Like Malawi, the approach in Zambia is about equitable distribution of the vital oxygen equipment and supplies to as many health facilities as possible—in total, they are being delivered to more than 90 hospitals and health centers—to maximize access to oxygen therapy across the country’s population.
Additionally, under a global memorandum of understanding with Air Liquide and Linde, the Ministry of Health, with support from CHAI, is coordinating with Linde (through AFROX Zambia) and other partners to improve the use of liquid medical oxygen within the country. Working with urgency, the government, partners, and AFROX set up a functional system to optimize the use of available medical oxygen to ensure it would be available at health centers to meet demand. This work stabilized oxygen supply in the seven initial hospitals, and efforts are underway to ensure that additional hospitals equally have sufficient oxygen for patient care. They are also working to build a framework for local contractual agreements—in line with standard public procurement practices—which could form the basis of longer-term purchasing deals by governments and global agencies that fund access to medical oxygen to avoid supply shortages.
UGANDA
The Uganda Ministry of Health procured and delivered over 8,400 oxygen equipment and supplies towards their pandemic response, including 2,362 oxygen cylinders, 1,040 cylinder accessories, 300 pulse oximeters, 10,500 oxygen masks, 80 patient monitors, 190 mechanical ventilator and high flow oxygen consumables, as well as install power generators for oxygen plants and oxygen manifolds for intensive care units at seven facilities. In December 2021, the CHAI Uganda Country Director and his team formally presented the procured equipment to the Ministry of Health. The equipment was received by Dr. Jane Ruth Aceng, the Minister of Health, and handed over to the National Medical Stores.
CHAI continues to work in partnership with the Ministry of Health and National Medical Stores to equitably distribute this oxygen equipment and supplies to numerous health facilities across the country, including support to fill the new cylinders prior to distribution.
Having appropriate, sufficient oxygen equipment and supplies is critical to ensuring access to lifesaving oxygen therapy. However, these equipment procurement efforts are just an initial step to strengthening long-term oxygen systems.
Beyond procurement: Creating sustainable oxygen systems
Procuring oxygen equipment was a key part of the global emergency response to COVID-19. To ensure the longevity of this investment, country decision-makers need to prioritize long-term access to oxygen therapy as an integral part of health systems strengthening beyond the pandemic response. This should include understanding current and future needs, coordinating with key stakeholders, setting up a strong policy framework, building functional infrastructure across facilities, and ensuring sufficient human capacity to manage oxygen supply and delivery. PATH and CHAI, together with the Every Breath Counts coalition, have been supporting a number of low- and middle-income countries in their work to improve reliable oxygen access over the last two years.
A key first step is having strong data to make evidence-based decisions for strengthening oxygen systems. Part of this is understanding the gap between the current availability of respiratory care equipment compared to the forecasted need—like was done in the Democratic Republic of the Congo, Liberia, Malawi, Senegal, and Zambia. Country decision-makers can use this data to inform national policy development, equipment procurement and repair, and trainings for hospital staff on medical oxygen.
Another important part of strengthening oxygen systems is collaboration with all key oxygen stakeholders, including government, manufacturers and distributors, civil society, health departments, donors, and implementers. This ensures oxygen planning and scale-up are well coordinated across the various actors who are critical to keeping the system operational and effective. Key examples of this stakeholder coordination are in Zambia—in their hosting of a national COVID-19 oxygen summit—and in Lao PDR and Malawi—in the development of their national oxygen roadmaps.
A national roadmap or strategy for oxygen provides one central framework to push forward oxygen efforts in the country and outlines a national vision for oxygen access. For example:
- In the Democratic Republic of the Congo, the National Roadmap for Scaling Up Medical Oxygen and Pulse Oximeters envisions universal access to medical oxygen and pulse oximeters so no patient ever admitted to a health facility ever dies due to lack of oxygen.
- In Liberia, the National Roadmap to Increase Access to Medical Oxygen in Liberia aims to increase access to medical oxygen through coordinated implementation and resource mobilization.
- In Malawi, the National Medical Oxygen Ecosystem Roadmap seeks to reduce morbidity and mortality from hypoxemia and ensure oxygen is available to treat all who need it.
- In Nigeria, the National Strategy for the Scale-up of Medical Oxygen in Health Facilities targets to reduce mortality and morbidity from hypoxemia by addressing gaps in oxygen access.
- In Zambia, the National Medical Oxygen Strategic Plan aims to provide safe, affordable, and timely respiratory care services to all Zambians.
These plans help identify and invest in appropriate long-term solutions for oxygen delivery. Funding must cover not only initial procurement, but also costs related to equipment and infrastructure maintenance as well as continued training and advocacy. Multiple countries have already developed or are currently developing such planning documents.
Strong oxygen systems require a sufficient mix of oxygen equipment and infrastructure, whether it is liquid oxygen, PSA plants, or cylinder distribution networks. The needs will differ for each country and context, should be informed by available data, and consider supplemental costs for spare parts and accessories. In Vietnam, the results of their biomedical equipment survey informed additional efforts to increase liquid oxygen and supply sources for provinces most in need. In Kenya, assessments of respiratory care equipment led to the repair of over 20 equipment, including oxygen concentrators, patient monitors, and electrical suction devices, and 5 PSA plants as well as the extension of oxygen piping infrastructure in two hospitals. In Cambodia, data from facility assessments of 122 facilities were used to secure funding for 42 PSA plants, and an analysis of PSA operational costs provided valuable insight for mapping out sustainable financing plans to keep these plants functional and cost-efficient.
Part of what is critical for strong oxygen systems is sufficient human capacity for biomedical engineers to maintain oxygen equipment and for health care workers to administer oxygen therapy. For example, in India, the Ministry of Health and Family Welfare (MOHFW) and PATH trained more than 9,160 health officials, health care providers, and oxygen equipment operators across the country in the maintenance of oxygen devices and clinical use of oxygen. And with support from CHAI, the MOHFW carried out two series of national PSA repair and maintenance trainings to 12,000 technicians. The Democratic Republic of the Congo Ministry of Health, in collaboration with PATH, developed an updated guideline for the use of medical oxygen. Together, they also trained 175 health care providers and 44 biomedical engineers on the use and routine maintenance of ventilators. In Ethiopia, building from previous efforts, the Ministry of Health and CHAI trained 762 health care workers and 189 biomedical engineers and technicians at referral and general hospitals on standard medical oxygen therapy and oxygen device maintenance. They also adapted the standard oxygen therapy training manual into an online training for health staff across the country to access more readily.
These and other country efforts to scale up the necessary components of an oxygen delivery system are a strong start—but more needs to be done to ensure sustainable access for many years to come.
The path forward for oxygen
The COVID-19 pandemic has highlighted the limited availability of oxygen therapy across the globe. Over the last two years, countries have made great strides in improving access to oxygen as a critical treatment for COVID-19—both by increasing immediate procurement and distribution of oxygen equipment and by propelling action toward long-term oxygen systems. The world must maintain this momentum to ensure these gains are not lost.
Translating the pandemic response into long-term, high-quality respiratory care services will require more efforts to build a sustainable, underlying oxygen ecosystem. This ecosystem will require systems to keep oxygen equipment up and running for its full lifetime and systems that consistently provide health workers with the right tools, processes, and practices to save lives. At health facilities, this means improving diagnostics through routine pulse oximetry screening for all patients in need and strengthening platforms that continuously reinforce good clinical practices. Across the health system, this means driving equitable oxygen access down into lower-level health facilities and strengthening oxygen business models through coordinated supply partnerships. These efforts must be supported by sustainable financing channels and guided by strong data systems to serve health facilities at scale. Through such initiatives, strengthened health systems will be able to address non-COVID needs for oxygen and be better prepared for future pandemics and oxygen crises when they happen.
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Photo captions:
Malawi: (1) Formal handover ceremony for the oxygen equipment (cylinders) from PATH to the Malawi Ministry of Health; (2) Oxygen cylinders being stored in a Ministry of Health warehouse before distribution to health facilities in Malawi; (3) Inspecting equipment delivered to Malawi as part of ACT-A procurement efforts. Photo credit: PATH.
Zambia: (1) Formal handover ceremony for the oxygen equipment (pulse oximeters) from PATH to the Ministry of Health in Zambia; (2) Zambia Minister of Health Ms. Sylvia T. Masebo MP tests the new pulse oximeters during formal handover ceremony for the oxygen equipment; (3) CHAI staff touring an AFROX oxygen plant in Zambia; (4) Conducting a delivery of medical oxygen cylinders in Zambia. Photo credit: PATH and CHAI.
Uganda: (1) Formal handover ceremony for the oxygen equipment from CHAI to the Ministry of Health in Uganda; (2) A truck filled with cylinders to be distributed to health facilities throughout Uganda; (3) CHAI delivers oxygen supplies to the Minister of Health in Uganda. Photo credit: Tanzi Media Ltd.