Mirwais Rahimzai, Technical Director, FHI 360
Jane Makepeace, Program Officer, FHI 360
Medical oxygen is a vital medicine used in many health care settings, including surgery, trauma, heart failure, asthma, pneumonia, and maternal and child care. It’s also essential for pandemic prevention, preparedness, and response, and for fighting tuberculosis. There are four primary modalities for supplying oxygen to hospitals, each with its own advantages and disadvantages. Health facilities choose the most appropriate oxygen source based on several factors including oxygen demand, cost, supply chains and availability of infrastructure, electricity, and skilled personnel.
In 2020, a rapid facility-level assessment of 670 hospitals across 30 countries conducted by the Meeting Targets and Maintaining Epidemic Control (EpiC) project — funded by the United States Agency for International Development (USAID) — revealed critical shortages of oxygen as well as gaps in capacity to administer oxygen to patients with COVID-19 and pneumonia. The assessment found that no facility was equipped to meet the oxygen demand, and oxygen was too expensive for most patients to afford.
To address these gaps, the World Health Organization (WHO) is supporting countries to develop national oxygen frameworks to increase access to medical oxygen. The WHO hosted its first Road to Oxygen Access meeting from May 14–16, 2024 in Dakar, Senegal. This meeting brought together WHO Member States, UN agencies, nongovernmental organizations, donors, and academic professionals to discuss medical oxygen access and oxygen ecosystems worldwide.
During the meeting, the WHO presented the national oxygen scale-up roadmap template, developed for Member States’ use in developing evidence-based, inclusive, and costed plans for increasing access to medical oxygen. The roadmap was discussed, and attendees voted on the scope together. The meeting’s plenary and breakout sessions focused on discussion and idea-sharing around effective partnerships, costing and sustainable financing, workforce development, technical aspects of oxygen systems, and measuring impact and outcomes. Sessions also focused on policy, regulations, and guidelines for developing and maintaining sustainable access to medical oxygen. This meeting provided an invaluable opportunity for global oxygen stakeholders to come together and solidify their commitment to increasing access to medical oxygen beyond the context of the COVID-19 pandemic. Discussions inspired several key themes and important points to carry into subsequent oxygen ecosystem development steps for WHO Member States.
Representatives from EpiC attended this meeting in Senegal as invested members of the global oxygen community. Since early 2022, EpiC has supported 24 countries to improve their medical oxygen ecosystems, including procuring and installing physical infrastructure such as tanks and medical gas piping systems; training facility staff to maintain and repair oxygen systems; training clinical staff to safely administer oxygen to patients; and developing sustainability plans to ensure long-term supply and availability of oxygen. Eight countries are also receiving market shaping support to influence and create markets for more sustainable and affordable access and pricing to liquid medical oxygen.
Key Takeaways
The Road to Oxygen meeting was an opportunity for the WHO to present their new national oxygen framework tool and for member states and implementing partners to review it and provide feedback. The following key takeaways emerged throughout the meeting.
Continue national oxygen scale up roadmap discussions
The COVID-19 pandemic triggered significant investment in strengthening the oxygen ecosystem in low- and middle-income countries (LMICs). This investment has been essential but not sufficient. It is important that Member States take on a stewardship role in planning and coordinating investments in the infrastructure, operation, and maintenance of oxygen systems, and do so in collaboration with key stakeholders including the private sector. The National Oxygen Scale Up Roadmap template shared by the WHO has the potential to assist countries in much needed national level planning.
Rightsize medical oxygen solutions
A large part of the meeting conversation focused on oxygen-generating pressure swing absorption (PSA) plants as a means of medical oxygen supply. However, an optimal oxygen setup at any given health facility would depend on multiple internal and external factors. Liquid oxygen (LOX) systems have not been as widely used as PSA plants. Since the COVID-19 pandemic, however, many donors and health facilities are seeing the value and benefits that LOX systems provide: lower electricity bills, more straightforward maintenance, and large output of oxygen for the amount of space required. While transportation and a supply chain are required to maintain a LOX system, the long-term costs and benefits are remarkable.
A small primary care facility may need a concentrator, while a larger, more rural hospital with poor road connectivity may prefer an oxygen producing plant on site. Electricity would be a determining factor for both. A national hospital with a smaller satellite facility located in urban areas may opt for LOX with the capability to serve the surrounding health facilities with filling cylinders, known as a hub-and-spoke model. There is no one size fits all solution. Various oxygen supply combinations exist for facilities to ensure the availability and affordability of medical oxygen in their specific context.
Engage stakeholders early
An oxygen ecosystem is just that — an ecosystem with many moving parts and varied participants that must be harmonized for the health and longevity of the ecosystem. It is never too early to integrate stakeholders from all along the supply chain into oxygen setup development planning. During the Road to Oxygen Access meeting, several countries shared that when the Ministry of Health looped in other relevant government ministries, they were able to receive tax breaks, energy discounts, rapid commodity regulation approvals and import/transportation support in advance of the oxygen system being in place. The same proactive approaches to private sector entities such as oxygen vendors, transporters, and academic institutions produced similar results with cost savings and adherence to timelines and scopes. Partnerships are key for strengthening all components of a medical oxygen system. Engagement with the private sector to ensure there is access to high quality oxygen at reasonable prices is also critical and requires knowledge of the national and regional oxygen market and prolonged engagement and follow-up with possible vendors and contributing stakeholders.
Plan for sustainability from the outset
Three central points emerged throughout EpiC’s work and appeared continually over the three-day meeting:
- Financial Planning. Setting up separate budget lines dedicated to oxygen procurement and determining where the funds will come from internally — exclusive of donor support — is essential for sustainability.
- Human resource capacity. Capacity building of clinical and non-clinical staff to produce, distribute, and manage medical oxygen ensures durability of the oxygen system.
- Maintenance. Routine maintenance requires timelines, budget, procurement for replacement parts, and trained biomedical engineers capable of performing routine and emergency maintenance to keep a system running.
The WHO Oxygen Road Map Meeting was an important milestone for the global oxygen community in continuing to close the oxygen access gap by providing an opportunity for donors and WHO Member States to come together and collectively develop a comprehensive oxygen scale-up framework. EpiC encourages oxygen stakeholders to consider these key takeaways when adapting oxygen scale-up frameworks to specific country contexts. EpiC is enthusiastic and hopeful for the prospect of affordable, high quality oxygen access for all.
Featured photo: A plenary session with panelists presenting country case studies and examples of finding the need gap to assess and quantify national oxygen scale-up. Photo by WHO / MLD Design / 2024.