Irene Obiero, Country Support Manager, Clinton Health Access Initiative
Phyllis Chituku, Program Manager, Clinton Health Access Initiative 
Dr. Terence Carter, Senior Technical Advisor, Clinton Health Access Initiative
Audrey Battu, Senior Director, Clinton Health Access Initiative

Medical oxygen is a life-saving commodity used in the management of hypoxemia—abnormally low levels of oxygen in the blood. Hypoxemia can occur as a symptom of chronic disease or serious health conditions, as well as during surgery and during birth. 

Compared to most of sub-Saharan Africa, South Africa has an abundance of resources when it comes to the supply of medical oxygen. South Africa is home to three major oxygen manufacturers – Afrox, Air Products, and Air Liquide – that produce and supply liquid oxygen within South Africa and for neighboring countries. Additionally, a small number of pressure swing adsorption (PSA) plants produce oxygen gas, and oxygen cylinders filled by air separation units (ASUs) or PSA plants, are used to supply oxygen to patients. With this set-up, South Africa should have been well positioned to meet the threefold increase in demand for oxygen during the COVID-19 pandemic. However, the lack of oxygen infrastructure in health facilities, coupled with gaps in the medical oxygen supply chain led to supply shortages of this precious commodity as demand for oxygen surged. During the first two years of the pandemic, in 2020 and 2021, the excess deaths in South Africa were estimated at 292.3 per 100,000 people.1 The majority of these deaths (85%-95%) were attributed to COVID-19, while the remaining 5%-15% were attributed to overwhelmed health services.2

Using liquid oxygen (LOX) as a main source of medical oxygen can be a game changer in scaling up access to cost-effective medical oxygen in sub–Saharan Africa. Given South Africa’s ample liquid oxygen production, the priority was to foster the use of LOX as the primary source for medical oxygen, where it was logistically and infrastructurally feasible, and to establish PSA plants and oxygen cylinders as sources for medical oxygen in regions that were out of the reach of LOX supply sources.

Oxygen cylinder bank connected to a manifold. Photo by Clinton Health Access Initiative for EpiC.

Interventions

In 2022, the Meeting Targets and Maintaining Epidemic Control (EpiC) project was funded by the United States Agency for International Development (USAID) to propose interventions that would scale up access to medical oxygen, particularly LOX, in South Africa. EpiC’s objectives were twofold: (i) to understand the key barriers of medical oxygen use by public health facilities and formulate the appropriate oxygen use solutions for these hospitals, emphasizing the use of LOX where possible, and (ii) to provide support to the national government to enhance its oversight of LOX suppliers to keep them accountable to the contract prices of LOX and delivery terms of the national tender.

Key Findings

Facility assessments in 106 facilities in 34 districts across 6 provinces found that LOX use was hindered by distance from ASUs, poor road infrastructure, and infrastructure gaps within health facilities. EpiC’s site visits found old and outdated piping systems, limited piping in wards, inadequate oxygen access points (wall-mounted outlets) in wards, and inappropriately sized bulk LOX tanks that led to wasted LOX (through off-gassing), making it expensive for health facilities to refill. Other barriers to oxygen access and use included an unreliable power supply hindering oxygen production by PSA plants, as well as the lack of training and support for the maintenance of oxygen equipment, leading to the neglect and break down of equipment that is critical for the provision of oxygen therapy.

Even with substantial LOX production capacity in South Africa, LOX is not uniformly accessible across the country. The selection of a supplier for LOX is the responsibility of the National Treasury, which publishes a national medical and industrial gases tender every three years and has historically awarded a three-year LOX supply contract to one supplier. Health facilities that are close to the awarded supplier’s ASUs benefit from unconstrained supply and low prices, while facilities that are farther away are subjected to significant price hikes to account for the distance that the supplier covers during LOX deliveries as well as the need to use compressed cylinder oxygen. Compressed cylinder oxygen is more expensive and unable to meet high oxygen demand such as was needed during the COVID-19 pandemic. Since South Africa is one of the larger countries in Africa, there is a significant price escalation for many health facilities that are geographically disadvantaged.

There was significant political will within the National Department of Health (NDOH) to expand the use of LOX in South Africa’s health sector. In 2023, in a huge win for competitive market shaping, the national tender for industrial and medical gases was – for the first time – awarded to two suppliers (Afrox and Air Liquide); with Afrox contracted to supply LOX to five out of nine provinces, and Air Liquide to supply the other four provinces. This was crucial for scaling up access to LOX, as it brought more ASUs within reach of rural and remote health facilities, reduced transport costs for suppliers, and increased competition within this market, thus keeping prices low.

Proposals to Scale up Access to Oxygen

Following the facility assessments, EpiC developed a comprehensive report on oxygen use solutions for public health facilities bearing in mind their available infrastructure, distance from ASUs, and availability of trained staff to maintain oxygen equipment. EpiC provided detailed recommendations to the NDOH, including:

  • Customizing bulk LOX tank sizes according to health facility consumption patterns to minimize loss of oxygen by oversized tanks.
  • Clustering LOX bulk tanker deliveries to enable single delivery routes by large tankers to a cluster of hospitals in a single trip.
  • Regular monitoring of oxygen consumption trends to inform decision-making on the appropriate oxygen sources for health facilities.
  • Prioritizing the procurement and installation of medical devices and equipment for the provision of oxygen therapy, such as medical gas piping systems.
  • Prioritizing oxygen infrastructure within NDOH’s infrastructure budget and advocating with provinces to dedicate a budget line to oxygen. While the bulk tank installation costs are borne by the supplier, the oxygen reticulation and wall mounted oxygen outlets at the bedside are the responsibility of the Department.

To enhance supplier transparency and accountability, EpiC worked with both NDOH and the National Treasury to develop a supplier monitoring system to track oxygen supply and use. This will help suppliers adhere to the national tender terms and any relevant quality standards, as well as identify and troubleshoot supply chain bottlenecks.

You can read further details about the EpiC South Africa project’s efforts to explore oxygen supply solutions in this summary brief.

Featured image: A 15-ton Afrox-supplied liquid oxygen tank. Photo by Clinton Health Access Initiative for EpiC.

References:

  1. Wang, Haidong; Paulson, Katherine R.; Pease, Spencer A.; Watson, Stefanie; Comfort, Haley; Zheng, Peng; Aravkin, Aleksandr Y.; Bisignano, Catherine; Barber, Ryan M.; Alam, Tahiya; Fuller, John E. (10 March 2022). “Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21”. The Lancet. 399 (10334): 1513–1536. doi:10.1016/S0140-6736(21)02796-3. hdl:11573/1621634. ISSN 0140-6736. PMC 8912932. PMID 35279232.
  2. Moultrie, Tom; Dorrington, Rob; Laubscher, Ria; Groenewald, Pam; Bradshaw, Debbie (23 February 2021). “Correlation of excess natural deaths with other measures of the COVID-19 pandemic in South Africa” (PDF). Burden of Disease Research Unit, South African Medical Research Council. p. 1. Retrieved 26 March 2021.