When sick children arrive at primary health care (PHC) facilities, it is critical that they are appropriately screened, diagnosed, and managed, and if needed, referred to urgent care without delay.

Clinical signs alone do not detect all indicators of severe illness in children. In order for health care workers to make the right diagnosis, they must be equipped with the right tools and training, including access to and training for pulse oximeters and clinical decision support systems.

In many countries, these critical tools are not available, not functioning properly, not suited for infants who need them most, or providers lack appropriate training.

There is also no clear global guidance to help countries in choosing the best devices, nor is information available on their cost-effectiveness or their suitability in primary care.

Lacking these important devices, frontline health workers face difficulty in identifying children who require immediate medical attention. When danger signs are overlooked or not adequately addressed, children’s lives are at risk. Patients may receive medicines that they don’t need. Misuse of antibiotics, in turn, gives rise to drug-resistant superbugs.

• Pneumonia remains the leading infectious cause of mortality among children under five, claiming more than 800,000 lives every year globally, with children living in poor rural communities and urban slums being especially vulnerable. Too many cases of pneumonia go untreated or are misdiagnosed because health systems do not provide access to effective and affordable care.
• Detection and management of children at high risk of morbidity and mortality is crucial. Clinical signs alone do not detect all children with severe disease.
• Low oxygen in the blood (hypoxemia) is one of the main signs of severe illness like pneumonia. Children with hypoxemia are 5.5 times more likely to die than those without hypoxemia.
• Tools for measuring blood oxygen levels, such as pulse oximetry, are essential for alerting health workers to signs of severe disease and the need for urgent treatment.
  • Pulse oximetry identified hypoxemia in 30% of very sick children who were not identified by clinical signs alone.
  • After pulse oximetry and oxygen were provided in pediatric wards of hospitals, child deaths fell by 50%.
• Clinical decision support systems (such as clinical decision support algorithms or CDSAs) that help process patient information and symptoms through digital applications are another key piece in improving care.
  • Research studies have linked clinical decision support systems to improved quality of care, such as reduced unnecessary use of antibiotics, better communication with the child’s caregiver, higher rates of referral to hospital when needed and, most tellingly, improved recovery of children.
• Integration of pulse oximetry and CDSA use into national Integrated Management of Childhood Illness (IMCI) guidelines is an important step to ensure consistent and correct use.

TIMCI aims to improve access to affordable and appropriate tools to help health workers identify critically ill children and refer them for treatment without delay.

Between 2019 and 2024, TIMCI is working in collaboration with the governments of India, Kenya, Senegal, and Tanzania and global partners to:

• Introduce pulse oximeters and CDSAs in nearly 300 PHC facilities across the four project countries, including health care worker training and supportive supervision.
• Generate data on health impact, cost-effectiveness, and feasibility of utilization of these tools in PHC settings, helping to address evidence gaps, inform national and global guidance, increase donor engagement, and incentivize manufacturers to innovate and governments to pursue adoption and scale-up.
• Strengthen the market for next generation pulse oximeters (POs with additional features to measure respiratory rate, temperature, and/or hemoglobin), including developing a target product profile, collecting and sharing market intelligence, and conducting field evaluations.
  • With synergistic support from BMGF, PATH is strengthening the innovation ecosystem for AI and smartphone tools including a data repository and partnerships with diverse groups developing and externalizing AI products.
• Collaborate with national and global stakeholders to ensure pulse oximetry is included in IMCI/IMNCI guidelines and relevant child health policies, and develop scale-up plans for sustainable and long-term use.
• Advance access to pulse oximeters that work on all skin tones.

By making PHC service delivery more accessible, accountable, affordable, and reliable, this initiative can help establish progress toward universal health coverage targets mandated by the UN Sustainable Development Goal 3.8 by 2030.

Technical resources and tools

• Access to oxygen (A2O2) resource library, May 2023
• Oxygen financing: Global Fund opportunity, March 2023
• Technology and market landscape: next generation pulse oximeters, September 2022

Advocacy and communications resources

Fact sheets

• NEW Improving access to pulse oximeters that work on all skin tones
• Improving access to tools that detect severe illness
• Clinical decision support algorithm

Articles and media announcements

• Strengthening oxygen supply and respiratory care in Tanzania, June 2023
• Landmark oxygen resolution adopted by WHO Member States, May 2023
• Increasing access to medical oxygen: Actions to ensure sustained gains side event, May 2023
• PATH welcomes World Health Organization Executive Board decision to adopt landmark oxygen resolution, February 2023
• Integrating connected diagnostics in primary health care, February 2023
• How oxygen matters: Stories of impact across the lifespan, November 2022
• Next generation pulse oximeters have great potential to reduce maternal and child mortality, PATH and Unitaid report says, September 2022
• Procurement to patient: Increasing access to medical oxygen during the COVID-19 pandemic, June 2022
• Digital health tools to accelerate action toward child survival, November 2021
• Broken equipment and surging demand for oxygen left Tanzania hospitals in a bind, August 2021
• Expanding access to lifesaving oxygen therapy for infants and children, August 2021
• 4 principles for scaling health products, December 2020
• Pulse oximetry—from Apple Watch to equitable access, October 2020
• Ushering in a new era of pneumonia control, November 2019
• New projects aim to better identify critically ill children, July 2019