Strengthening oxygen ecosystem for COVID-19 and beyond in India

Medical oxygen proved to be a lifesaving drug during the COVID-19 pandemic in the absence of a proven therapeutic solution for patients suffering from the infection. In May 2021, India's health infrastructure was overwhelmed by the caseload, with a lack of oxygen, manpower, drugs, and hospital beds. The most difficult challenge for the country was providing an adequate volume of medical oxygen for the most severely ill patients who were unable to breathe on their own.

PATH, with its extensive experience in respiratory care management, responded quickly and played a critical role in strengthening the oxygen ecosystem at this critical juncture. It provided technical assistance in the installation and procurement of PSA oxygen generation plants and oxygen concentrators, as well as improved their readiness.

Furthermore, in order to build capacity for long-term sustainability, PATH developed, translated, and disseminated high-quality, reliable, and ready-reference knowledge products, such as the Guidebook on Medical Oxygen Management, Oxygen Posters, Standard Operating Procedures, Checklists, Case Studies, and Success Stories on various aspects of the oxygen ecosystem.

Publication date: July 2022

Available materials

  1. English

    1. Guidebook on medical oxyogen management system 52.7 MB PDF

      PATH initiated the development of a guidebook on oxygen management systems to reduce the knowledge gaps in the medical oxygen ecosystem among health care service providers at all health facilities in India. In collaboration with the Maharashtra government, PATH created a ready reference that provided high-quality, reliable, and actionable information. Health care service providers, technicians, and other stakeholders can use this guidebook to understand the basic working, installation, repair, and maintenance of various oxygen systems, like Pressure Swing Adsorption (PSA) oxygen generation plants, Liquid Medical Oxygen (LMO) storage tanks, oxygen cylinders, and MGPS, among others. This guidebook is being adapted by at least four more states in the country.

    2. Case study: Sustaining pressure swing adsorption (PSA) functionalities: A case of SCB medical college and hospital at Cuttack in Odisha, India 488.7 KB PDF

      PATH, as the Technical Support Unit (TSU) for oxygen in the state of Odisha, provided technical assistance for the installation of two Pressure Swing Adsorption (PSA) plants of 2,000 LPM PSA and 600 LPM each, in SCB Medical College and Hospital at Cuttack. Other post-installation support, such as oxygen purity testing and certification, was also provided to the hospital authorities. This case study documents the journey of installing these two PSA plants in the hospital and how oxygen supply was sustained round-the-clock to the 173 ventilators and to the bedsides through the medical gas pipeline system (MGPS).

    3. Case Study: strengthening health systems’ capacities to operate and manage medical oxygen generation, storage and supply equipment: Lessons from the Indian state of Maharashtra 236.2 KB PDF

      This case study documents PATH's efforts in re-skilling the biomedical engineers (BMEs) and technicians working with the Health Equipment Maintenance and Repair (HEMR) division of the Indian state of Maharashtra’s health department for the operation and maintenance of oxygen systems. Engaging BMEs who manage vaccine cold chains to manage oxygen systems was an approach that had never been attempted before in the country; this was the first such initiative of its kind during the pandemic.

    4. Case study: Delivering oxygen at doorstep: A case study on Rajasthan’s oxygen concentrator banks 239.5 KB PDF

      This case study documents various aspects of establishing oxygen concentrator banks by the government of Rajasthan, their impact, and lessons learned from this intervention. This initiative was aimed at providing medical oxygen equipment to patients suffering from respiratory diseases, such as COVID-19, silicosis, COPD, etc. directly at their doorstep. This concept was envisioned to reduce the spread of COVID-19, minimize the load on medical facilities, and most importantly, reduce the loss of life due to respiratory diseases.

    5. Case Study: Strengthening peripheral systems to PSA oxygen plant—a case of Sadar Hospital, Samastipur, Bihar, India 330 KB PDF

      The case study emphasizes the importance of adhering to the standard technical specifications of various components in an oxygen ecosystem. Any inferior quality product can increase the vulnerability of the system and increase the risk to life. There are many stakeholders in the installation of a PSA plant, and each one must play their role for efficient functioning of the PSA plant.

    6. Case study: Localized solutions for installation of PSA plant—a case of Ram Sagar Mishra Hospital in Lucknow, India 251.4 KB PDF

      This case study is an insight into how PATH working alongside various stakeholders at the state, district, and facility levels, respond to challenges in the installation of PSA plants and document the lessons that it offers for similar initiatives in the country and globally.

    7. Case Study: many a twist in the tale of pressure swing adsorption plant installation at the District Combined Hospital in Pilibhit, Uttar Pradesh, India 454 KB PDF

      This case study documents PATH’s technical assistance to the District Combined Hospital (DCH) at Pilibhit in Uttar Pradesh in installing and commissioning a PSA plant and achieving oxygen self-reliance. It offers lessons that can be picked by other organizations working in the field of medical oxygen ecosystem.

    8. Case study: Moving across mountains—enabling medical oxygen availability in hard-to-reach areas 674.1 KB PDF

      This case study presents a glimpse of PATH’s experience in proving respiratory support in three of the most hard-to-reach areas across India, namely, Shimla in Himachal Pradesh, Shillong in Meghalaya, and Kargil in Ladakh.

    9. Case study: Technical assistance for procurement and installation of PSA oxygen generation plant in India 626 KB PDF

      To build captive oxygen capacity and to ensure the availability of medical grade oxygen within health facilities, on-site pressure supply adsorption (PSA) oxygen generation plants (OGPs) were installed in various health facilities during the pandemic. This case study documents the challenges PATH surmounted with support from Google and GIVE India to achieve oxygen self-reliance in various facilities in India.

    10. Case study: Strengthening capacity to effectively manage medical oxygen systems in India 408.6 KB PDF

      This case study documents the various training, capacity strengthening and upskilling activities undertaken by PATH under the Google Give India project for effective management of medical oxygen in India.

    11. Standard operating procedures (SOPs): Operation and maintenance of oxygen concentrators 801.5 KB PDF

      This document provides a detailed functioning of the oxygen concentrator (OC) and its components. This Standard Operating Procedures (SOPs) intends to bridge the knowledge and skills gap among health care facility staff by providing in-depth information on the operation and management of an OC.

    12. Standard operating procedures (SOPs): Getting accreditation of laboratory through the National Accreditation Board for Testing and Calibration Laboratories (NABL) 794.4 KB PDF

      The National Accreditation Board for Testing and Calibration Laboratories (NABL) is a constituent board of the Quality Council of India (QCI), an autonomous body setup under the Department for Promotion of Industry and Internal Trade (DPIIT), Ministry of Commerce and Industry, Government of India. The purpose of this SOP is to acquaint the users with procedures used by the NABL for specific tests and measurements based on third-party assessment and as per international standards.

    13. Standard operating procedures (SOPs): The Petroleum and Explosives Safety Organization (PESO) certification 1.5 MB PDF

      Medical oxygen is now identified as an essential medicine and has been listed by the World Health Organization. For better respiratory care case management, special attention is required to keep medical oxygen pure and safe. In this context, PESO certification is important for a health facility that is using cylinders, cryogenic tanks, compressed gas storage containers, or oxygen generation plants. PATH developed this SOP with the intention of supporting health facility administrators, clinical practitioners, procurement officers, planning staff, biomedical engineers, infrastructure engineers, and policymakers in the states and at the national level to follow the PESO certification procedure.

    14. Standard operating procedures (SOPs): Operation and maintenance of oxygen cylinders in health care facilities 598 KB PDF

      This SOP provides guidance on the safe use and operation of compressed oxygen gas cylinders in health care facilities. PATH developed this SOP with the intention of bridging the knowledge and skill gap among health care facility staff by providing in-depth information on the operation and management of an oxygen cylinder.

    15. Standard operating procedures (SOPs): Operation and maintenance of liquid medical oxygen (LMO) storage tanks 1.4 MB PDF

      PATH developed this SOP to provide step-by-step details on liquid medical oxygen (LMO) management and intends to bridge the knowledge and skills gap among health care workers in the facilities.

    16. Standard operating procedures (SOPs): Medical gas pipeline system (MGPS) 1.2 MB PDF

      The central piped medical gas system is one of the newer types of hospital plumbing systems that have been introduced to deliver different medical gases to the patient’s bedside. This SOP developed by PATH provides details on MGPS management needed for oxygen, nitrous oxide, medical air, nitrogen, carbon dioxide, vacuum, and waste anesthetic gas disposal.

    17. Standard operating procedures (SOPs): Pressure swing adsorption (PSA) plant operations and preventive maintenance by the facility management 324 KB PDF

      After the onset of COVID-19 pandemic, pressure swing adsorption (PSA) oxygen plants have emerged as a viable option and are widely used as a primary source of medical oxygen across hospitals in India. This SOP has been developed by PATH with the intention of providing details of PSA plant operations and maintenance by the facility administration. 

    18. Checklist for pre-commissioning/pre-startup review of liquid medical oxygen storage tank system 349.5 KB PDF

      Before a plant or facility is handed over for regular operations, it should be inspected, checked, cleaned, and verified for initiating operations. The objective of this checklist developed by PATH is to oversee the pre-commissioning of Liquid medical oxygen (LMO) and ensure all important activities are undertaken. 

    19. Pre-installation checklist for liquid medical oxygen storage tanks 354.1 KB PDF

      Liquid medical oxygen (LMO) is a preferred source of medical oxygen because of the purity of oxygen, zero operational cost associated, no limitation on flow rate and large storage capacity. This checklist is meant to be used by those technical staff who are managing MGPS, manifolds, PSA plans, and LMO tanks in hospitals.

    20. Checklist for pre-commissioning/pre-startup review of oxygen MGPS 330.6 KB PDF

      Patient safety is of utmost importance in the design, installation, commissioning, and operation of medical gas pipeline systems (MGPS). The system has to be operational round the clock with practically zero downtime, and its failure can be fatal if not restored at the earliest. PATH developed this checklist which is meant to be used by any technical staff member at a hospital managing MGPS, manifolds, etc.

    21. Nishtha: Compendium of case studies on oxygen systems in India 535.9 KB PDF

      This compendium is a compilation of six case studies on ramping up of oxygen infrastructure and overall oxygen ecosystem strengthening in India. These case studies are on various aspects of oxygen ecosystem, such as installation of oxygen generation plants, capacity strengthening of healthcare service providers, public private model, among others.

    22. Case study: Enabling remote Melghat’s journey to self-sufficiency in medical oxygen 173 KB PDF

      This case study from Melghat in Maharashtra’s Amravati district offers insights into the challenges faced in improving and strengthening oxygen systems in difficult-to-reach areas and highlights the collaborative efforts supported by NSE Foundation’s project CAVACH in ensuring the resilience of vulnerable populations against similar crises in the future.

    23. Case study: Breathing life into the fight against COVID-19 in the far-flung villages in Kupwara district of Kashmir 248.3 KB PDF

      These case studies from Dab Bal and Machil villages in Jammu and Kashmir’s Kupwara district offer insights into the challenges of strengthening oxygen systems in difficult-to-reach areas, isolated in the winter due to heavy snowfall, and how interventions by project CAVACH made a difference in these places.

    24. Case study: Journey of making a community health center in a hard-to-reach Kuchai self sufficient in oxygen management 249.5 KB PDF

      This case study aims to capture the collaborative efforts of NSE Foundation’s Project CAVACH and CHRI to install an oxygen generation plant in one of the most remote and hard-to-reach areas of Kuchai block in Saraikela Kharsawan district of Jharkhand, parts of which are affected by Naxalism and covered with forests and hills. It captures how the local administration and other local stakeholders were roped in to ensure a seamless installation and commissioning of the plant to mitigate challenges posed due to the remoteness of the site. The case study also captures the learnings from such an intervention.

    25. Case study: The long road to oxygen sufficiency: The experience of Sai Dhanwantri COVID-19 Hospital in Yavatmal 268.1 KB PDF

      This case study from Yavatmal district of Maharashtra narrates the challenges faced by a remote hospital set up by a local trust during the oxygen crisis of COVID-19 second wave. It also documents the generous financial support provided by NSE Foundation in strengthening the hospital’s oxygen ecosystem and saving many lives.

    26. Case study: World Bank-oxygen management in Kerala. What made the state oxygen positive? 829.1 KB PDF

      Kerala’s ability to treat COVID-19 cases is a result of the timely steps that the state government took to strengthen its medical oxygen capacities. Kerala’s initiatives offer valuable insights into building a sustainable ecosystem for medical oxygen management.

    27. Case study: Capacity strengthening of health care service providers of charitable health facilities 577.1 KB PDF

      Recognizing the vast potential and the need for further strengthening the capabilities of these charitable health facilities, PATH provided technical assistance in improving their capacities for effective respiratory and emergency care management. This narrative provides an insight into the successful initiatives of the project that equipped 62 CHFs with the knowledge and skills needed to manage existing critical care patients and prepare for future health care emergencies.

    28. Case study: Improving access to marginalized population—a case study of Little Flower Leprosy Hospital, Bihar 255.2 KB PDF

      The present document elaborates the case of Little Flower Leprosy Hospital located in Bihar, the challenges faced by it during COVID-19 pandemic, the support extended by PATH, and learnings for the future.

    29. Case study: A success story of strengthening capacities on oxygen therapy hub-and-spoke model, Gujarat 291.9 KB PDF

      This success story demonstrates the success of its hub-and-spoke approach for strengthening the oxygen management capacities in various health facilities of Gujarat.

    30. Case study: Augmenting oxygen management capacity through upskilling—a success story from Lok Nayak Jai Prakash Hospital, New Delhi 361.2 KB PDF

      This success story highlights the importance of upskilling and capacity strengthening of internal technicians and healthcare service providers within a hospital. Availability of a trained staff within the hospital reduces the dependence on external vendors and service providers.

    31. Case study: Learning resource package for medical oxygen management 233.2 KB PDF

      This success story details the need, process, and mechanisms of developing a standardized oxygen ecosystem learning resource package for trainers. This learning resource package, the first-of-its-kind for oxygen ecosystem globally, provides comprehensive learning, knowledge, and skills-building opportunity on medical oxygen management.

    32. Case study: Oxygen planner—a digital solution for COVID-19 preparedness 330.6 KB PDF

      Adequate and easy-to-use digital tools across various aspects of the oxygen management and response emerged to be a critical response requirement during the COVID-19 pandemic. One such requirement was for an immediate-term planning tool that could be used by anyone—facilities, districts, private health sector, or public health practitioners. This success story talks about such a digital tool - the O2 planner.

    33. Standard operating procedures (SOPs): Medical oxygen sample collection using tedlar bags 320.6 KB PDF

      This document provides guidance to all staff on sampling procedures and how to reduce sampling errors. The SOP includes the following components: types of gas sampling, Tedlar bag sampling procedures and precautions, and tips to reduce sampling errors. The SOP intends to bridge the knowledge and skill gap among health care facility staff by providing in-depth information on taking samples and sending them off for gas analysis at the labs.

    34. Standard operating procedures (SOPs): Use of oxygen concentrator at Health and Wellness Centre (HWC) for management of hypoxia 859.1 KB PDF

      The document details the purpose and use of an oxygen concentrator at a health and wellness centre. The SOP covers multiple components including purpose and use of an OC, need for oxygen therapy, diagnosing low levels of oxygen, clinical conditions requiring oxygen therapy, indications for placing patients on an OC, use of OC at HWC, transferring patients from HWC to higher centres and important considerations to be taken while handling OCs, etc. The SOP intends to bridge the knowledge gap among health care facility staff by providing in-depth information on the usability of OC beyond COVID-19.

    35. Technical support units for better health outcomes: Insights from USAID NISHTHA's assistance in strengthening oxygen ecosystem in India 172.3 KB PDF

      This document dives deeper into the role of these six states’ technical support units (TSUs) in strengthening the oxygen management systems, highlighting their contributions and impact on the overall oxygen ecosystem in the states. The document also captures the experience of TSUs, including both the challenges faced by them and the opportunities they came across during their collaborations with the government, private sector, and other agencies while providing the required technical assistance. Lastly, the document intends to not only illustrate the states’ unique experiences while receiving technical assistance on oxygen management but also draws out lessons from their experiences for all future health programming.

    36. Process document for setting and operationalization of oxygen skill labs 648.3 KB PDF

      This document provides the details of setting up and operationalization of oxygen skill labs. Oxygen skill labs will employ an interactive and participatory teaching mechanism for training. Different skill stations are set up to demonstrate clinical and technical oxygen management processes for trainees to better understand these processes. These skill stations can help the trainees learn by practicing skills using mannequins, models, simulation exercises, demonstration videos, and presentations.

    37. Compendium of frequently asked questions (FAQs) on oxygen ecosystem 730.2 KB PDF

      This compendium of frequently asked questions has been compiled from the audience questions that were posed during the webinar series on Oxygen Ecosystem conducted during September and October 2021. The responses are from the experts in the field and can be useful to understand various aspects of an oxygen ecosystem.

    38. Manual on conducting oxygen audits 6.4 MB PDF

      This is a reference guide that provides guidance on conducting oxygen audits with an aim to debunk the myths surrounding such audits in health facilities.

  2. English

    1. Oxygen delivery toolkit: Resources to plan and scale medical oxygen

      This oxygen delivery toolkit: Resources to plan and scale medical oxygen provides materials to help decision-makers, implementers, and advocates plan, manage, and communicate the value of scaling up oxygen delivery systems and access to oxygen and pulse oximetry.

    2. Medical oxygen posters

      PATH has created a set of eleven posters or job aids intended to support health care service providers and other personnel involved in the operation and maintenance of medical oxygen equipment, such as oxygen cylinders, oxygen concentrators, Pressure Swing Adsorption (PSA) oxygen generation plants, liquid medical oxygen (LMO) storage tanks, and medical oxygen conversion charts. These job aids provide guidelines on how to operate the equipment and the safety and mitigation measures that need to be adhered to when dealing with medical oxygen.

    3. Training module: Basics of medical oxygen management system

      The Training of Trainer module on "Basics of oxygen management system", developed by PATH, is meant for providing training to those participants who, by the end of the course, are expected to effectively oversee the oxygen ecosystem at their respective levels. This ToT module is relevant to oxygen program managers at national, state, district, and health facility levels to understand the components of medical oxygen management and use this information for informed decision making.

    4. Training module: Rational and hygienic use of medical oxygen: Personnel handling oxygen devices

      This PATH-developed module is intended to provide training to personnel handling oxygen devices in order to meet future demand for medical oxygen by understanding the components of medical oxygen management, oxygen devices, oxygen storage sources, oxygen delivery equipment, operation and maintenance, and their rational and hygienic use.

    5. Training module: Rational and hygienic use of medical oxygen: Medical and nursing personnel

      PATH has developed this module to train medical and nursing personnel on various components of medical oxygen management; COVID-19 case management with oxygen; devices used to deliver oxygen therapy to patients; and the rational use of oxygen to meet future demand for medical oxygen. This module will help in effectively overseeing the management of medical oxygen and judiciously using medical oxygen in respiratory care and COVID-19 case management.

    6. Training module: Operations and management of oxygen equipment

      One of the critical actions to improve health outcomes and save lives is to augment the public health system’s capacity to reliably deliver oxygen. The public health systems in the country have historically relied on oxygen cylinders to meet the medical oxygen demand. As a result, there were very few trained personnel who understood the complexity of integration and maintenance of newly deployed oxygen systems and knew how to manage them. This module was developed to provide training relevant to ITI trainers and biomedical engineers working at national, state, district, and health facilities to understand the operations and maintenance of oxygen or respiratory equipment.

    7. Training module: Quality testing protocol

      As states in India are rapidly setting up oxygen systems, there is a growing gap between the facilities with newly installed oxygen systems and the availability of accredited laboratories to test and certify the quality of oxygen produced from this equipment and approve them for commissioning and use. This training module developed by PATH provides training relevant to oxygen sample preparation that is critical for medical use.