Access to safe oxygen will help countries breathe easier

December 1, 2017 by Lisa Smith

The ability to safely deliver medical oxygen is just as important for health facilities as having reliable electrical power and water. Yet oxygen rarely receives the same attention as these other essentials.

Oxygen delivery

Access to safe oxygen is a complex health systems problem. Photo: PATH/Eric Becker.

For a child with severe pneumonia—and every other patient struggling for breath—access to oxygen is a matter of life or death. The ability to safely deliver medical oxygen is just as important for health facilities as having reliable electrical power and water. Yet, in low- and middle-income countries (LMICs), oxygen rarely receives the same attention as these other essentials.

Safely delivering oxygen to patients takes more than oxygen itself—it requires equipment like pulse oximeters and oxygen generation and delivery devices. But even when health facilities have oxygen and devices, mismatched or broken equipment often prevents oxygen from getting to patients. While oxygen outages occasionally get media attention, planning for this lifesaving commodity is a critical challenge in LMICs every day.

That’s why PATH set out to understand how much oxygen is needed and how it’s supplied to health facilities in LMICs. Our study uncovered complex, interlocking issues that stand between oxygen and people who need it—and it exposed market failures that we are working to define and solve.

As part of that effort, PATH brought together a coalition of countries, industry representatives, and global health partners last month for the A2O2: Accelerating Access to Oxygen Convening. Over the course of three intense days, stakeholders talked through barriers to safe oxygen delivery and shared what’s working to address them. They left with a more harmonized global view—and a common path forward to improve access to safe oxygen delivery.

Andi Saguni speaking at a podium, with an infographic showing access to oxygen across the Indonesian health system behind him.

Dr. Andi Saguni, director of the Health Service Facility Directorate for the Indonesia Ministry of Health, shared his country’s ASPAK database, which tracks access to oxygen across the many islands of Indonesia. Photo: PATH/Spike Nowak.

Here are our top three takeaways from the A2O2 convening:

#1: Coordinate countrywide: clarify who does what

It takes coordination across the entire health system to get enough oxygen where it’s needed when it’s needed—without it, stock-outs and equipment problems are common. Getting the right people to engage with the issue, decide on a course of action, and act on the problem is extremely difficult—but not impossible, as a number of countries at the A2O2 convening demonstrated:

  • Roadmap for oxygen access: Ethiopia and Nigeria have national oxygen delivery roadmaps, which track existing access and options for short- and long-term scale-up efforts. The roadmaps aim to increase awareness, prioritize oxygen among disparate groups, and lay out ambitious next steps.
  • Data to inform deployment: India and Indonesia have standards for required medical devices and routinely collect data about device availability in order to estimate supply gaps, spend money efficiently, and supply appropriate safe oxygen delivery devices.

#2: Sustain supportive systems: better information for better decisions

In many LMICs, safe oxygen delivery devices are purchased (and donated) at all levels of the health system. Without a centralized policy or strategy, most countries end up using many brands and models of devices in their health facilities. Maintaining and stocking supplies and spare parts for so many devices is complicated—and so is training staff to use and maintain them. Inconsistent information about device and procurement specifications, past purchase prices, and terms and conditions for after-sales services make purchasing decisions even more complex.

The A2O2 convening showcased some ambitious efforts to balance agile and informed decision-making with coordinated management of all available devices—purchased and donated:

  • Coordinated ordering: Indonesia created the e-Katalog, an online system to manage supplier agreements, negotiate prices, and procure medicines and medical devices. Health facilities can procure supplies independently, but products are vetted by the national procurement agency, Lembaga Kebijakan Pengadaan Barang Jasa Pemerintah (LKPP).
  • Centralized resources: India’s National Health Systems Resource Centre (NHSRC) has developed centralized information resources to support government procurement of safe oxygen delivery supplies. This includes a central repository for device technical specifications, access to past purchase prices to inform future supplier negotiations, and a national public-private partnership for device maintenance.

#3: Focus on financing: get the most out of every dollar

Most LMICs use domestic resources to pay for safe oxygen delivery devices, and they understandably select the lowest-priced products. As a result, higher-quality firms that may offer better after-sales services can’t compete with those offering lower purchase prices. Once devices are in facilities, however, resources to operate them are limited—which leads to poorly maintained devices and inconsistent access to safe oxygen.

“Safe oxygen delivery is a complex health systems issue.”

Given budget constraints, it is important for countries to make the most efficient use of available funds. A2O2 participants discussed methods for improving budgeting practices, including alternative ownership models:

  • Total cost of ownership: Stakeholders agree that purchasers need better tools for estimating the total cost of a device over its lifespan (similar to a tool for cold chain equipment) and that total cost-of-ownership estimates can help set expectations for short- and long-term oxygen costs.
  • Ownership models: While most countries prefer to own medical devices, Kenya has trialed a leasing program for sets of essential medical devices, including oxygen plants. The Managed Equipment Services program was organized nationally with seven-year leases to provide medical devices, training, and maintenance for five departments in 98 hospitals.

Next steps: reframing oxygen as an essential utility

Clearly, safe oxygen delivery is a complex health systems issue. While it seems obvious that oxygen saves lives, those lives represent many different health issues. In a siloed health care landscape where funding is driven by results, the benefits of oxygen are sometimes difficult to measure—and that can lead to lack of interest and underinvestment for a critical lifesaving commodity. This holds true for many other medical devices as well.

With so many efforts underway in countries to improve safe access, oxygen is a logical starting place to improve access to all essential medical devices. We need to continue elevating oxygen as a matter of life and breath and encourage a new way of looking at safe oxygen delivery that considers medical oxygen not only an essential drug and required device(s), but also a utility—as necessary as water or electricity in the provision of care.