Audrey Battu, Senior Director, Essential Medicines, Clinton Health Access Initiative 
Dennis Walusimbi, Program Manager, Clinton Health Access Initiative Namibia  
Ayush Gupta, Senior Associate, Markets, Clinton Health Access Initiative 

Hypoxemia, or low blood oxygen, can be a life-threatening condition without access to supplemental medical oxygen for treatment. The prevalence, impact, and management of hypoxemia in Namibia is influenced by the country’s health care infrastructure, access to medical care, and prevalence of diseases that lead to hypoxemia. Despite concerted health system strengthening efforts, the country’s health care system still faces resource constraints, limited access to care in rural areas, and a high burden of diseases such as HIV, tuberculosis (TB), and malaria, which can complicate or contribute to respiratory conditions leading to hypoxemia. In 2022, the country recorded more than 17,000 malaria cases, 172,256 COVID-19 cases with 4,103 deaths, and 8,604 TB cases, all of which require oxygen for treatment.  

The COVID-19 pandemic exposed critical shortcomings in Namibia’s oxygen delivery system. Facilities currently rely on four sources of medical oxygen: (1) oxygen-generating pressure swing adsorption (PSA) plants located on site at health facilities; (2) liquid oxygen (LOX) produced off site, trucked to facilities, and stored in cryogenic tanks; (3) oxygen cylinders procured and delivered from local suppliers; and (4) oxygen concentrators used within hospitals. 

LOX has several advantages compared to other sources of medical oxygen. It can be efficiently stored in large amounts, reducing transportation and waste costs. LOX is stored at lower pressure and is often a safer option compared to use of oxygen cylinders in hospital wards. Despite its promise, the deployment of LOX in low- and middle-income countries (LMICs) like Namibia has been limited due to high production costs, high rental fees for tanks and related equipment, and a monopoly held by LOX suppliers. This has created a market trap in which low volume and higher pricing make LOX less appealing to ministries of health (MOHs). 

A cylinder filling station attached to an oxygen-generating PSA plant at Onandjokwe District Hospital. Photo by Ayush Gupta, Clinton Health Access Initiative. 

Between March 2023 and March 2024, the Meeting Targets and Maintaining Epidemic Control (EpiC) project, funded by the United States Agency for International Development (USAID), undertook a comprehensive assessment to explore investment opportunities for LOX in Namibia. The assessment outcomes and strategic recommendations for enhancing the country’s medical oxygen ecosystem are presented here.

The assessment included the following activities:   

  • Stakeholder Engagement: Engaged with both demand and supply stakeholders to understand the current landscape and needs. 
  • On-Site Assessments: Conducted on-site assessments of 18 health facilities.  
  • Consultations: Held consultations with the country’s oxygen supply stakeholders to evaluate the supply chain and infrastructure. 
  • Quantification: Conducted a quantification analysis of medical oxygen needs in 28 health facilities to assess their current and potential oxygen systems. 
  • Cost Analysis: Performed a cost analysis of existing oxygen systems in health facilities to identify inefficiencies and potential areas for investment. 
  • Detailed Report: Produced a comprehensive report documenting the current situation and investment options for improving oxygen supply. 
  • Feasibility Assessment: Assessed the technical feasibility for local production of medical-grade oxygen at a privately owned industrial air separation unit (ASU) in the country. 

The assessment identified several critical issues, including: 

  • Oxygen Distribution: Inconsistent supply from PSA plants and high costs of LOX tank refills and asset rentals. 
  • Maintenance: Many PSA systems outdated, have ongoing maintenance challenges, and lack capacity and optimal purity and pressure levels to meet current demand. 
  • LOX Import Costs: LOX imported from South Africa, leading to high delivery and distribution costs. 
  • Infrastructure: Challenges in maintenance of medical gas piping systems and inadequate oxygen outlet coverage. 
  • Procurement and Logistics: Stock-outs and disruptions in oxygen cylinder supply. 
A quantification exercise found that the total monthly oxygen need across the 28 facilities is equivalent to ~13,600 J-size cylinders. 

The quantification exercise estimated the total monthly oxygen need across 28 priority health facilities at 97.14 million liters, equivalent to approximately 13,600 J-size cylinders. The oxygen needs are spread evenly across the country, highlighting the importance of a robust and widely distributed supply system.

Strategic Recommendations 

The collaboration between the Government of Namibia and the EpiC project has been instrumental in identifying and addressing some of the challenges in the oxygen supply system in Namibia. While the local production of LOX is crucial for affordability and economic viability, optimizing existing PSA operations and medical piping systems is essential for overall sustainability. Based on the assessments and analysis, EpiC discussed the below recommendations with the government to build a stronger and sustainable oxygen market in Namibia: 

  • Replacing or repairing old PSA plants 
  • Investing in new plants with higher capacity filling stations 
  • Establishing local production of medical-grade LOX to reduce reliance on imports and lower costs 
  • Applying a hub-and-spoke model to improve distribution efficiency using high-demand facilities as hubs to supply nearby spoke facilities 
  • Collaborating with local suppliers to localize solutions and reduce costs 
  • Revisiting and updating PSA maintenance contracts to ensure proper functioning and longevity 
  • Repairing or upgrading medical gas piping systems in facilities to enhance centralized oxygen delivery 
  • Ensuring adequate biomedical engineering support through training at the facility and regional level 

We are excited about the recommendations concerning system costing and intend to use the findings to advise facilities on optimizing their oxygen production and storage solutions. We would welcome the opportunity to collaborate with health partners on implementing other recommendations, provided that additional implementation funds become available.

MHSS representative

The Government of Namibia intends to use the findings and recommendations from the assessment to advise facilities on optimizing their oxygen production and storage solutions. Hopefully health partners and stakeholders will seize this opportunity and collaborate with the Government of Namibia on implementing these critical recommendations. 

Featured image: Liquid oxygen tank at Walvis Bay District Hospital. Photo by Ayush Gupta, Clinton Health Access Initiative.