Fatal Lack of Oxygen During Pandemic Peaks Spurs Action to End Enduring Shortages

The Global Accountability Platform (COVID GAP) blog series.
February 10, 2023
By Nellie Bristol

Access to medical oxygen literally has been a matter of life and death during COVID-19 peaks and shortages have had devastating effects in many countries around the world. While specific data are difficult to come by, one study showed that vast under-resourcing in intensive care units in ten African countries contributed to high mortality rates, with one in two patients dying without receiving oxygen. In Peru, which reported the highest per capita COVID-19 death rates in the world, at least 11 Lima hospitals reported shortages, people stood in long lines for bottled oxygen, and price gouging was rampant. In addition to its importance during the pandemic, medical oxygen is critical to treatment of struggling newborns, those with pneumonia, and a variety of chronic diseases such as pulmonary disease and asthma. Yet despite its life saving potential, the oxygen production and supply chain has long been inadequate, leaving many low- and middle-income countries (LMICs) in dire circumstances.

“Health-care personnel and patients in many LMICs have experienced the medical oxygen crisis as a painful reality for many years, frustrating efforts to provide quality care, forcing choices about who to prioritize, and burdening patients with treatment costs,” experts wrote in the Lancet Global Health. “But it has taken a global respiratory disease pandemic to draw the attention of the global community.”

Among examples of renewed attention is a February 1 World Health Organization (WHO) Executive Board resolution urging countries to include medical oxygen on national lists of essential medicines and medical devices for adults and children and develop regulations and costed plans to support adequate oxygen access. The resolution requests WHO to provide needed guidelines, technical specifications, training materials, and other resources to support the program. The Board recommended adoption of the resolution by the World Health Assembly in May.

The move was applauded by PATH, which called oxygen access “a long-neglected element of health systems planning.”

“Almost half of all hospitals in low- and middle-income countries have an inconsistent supply of medical oxygen or lack it entirely,” the medical innovation organization noted. “Even fewer have functional pulse oximeters—devices that measure blood oxygen levels and help health workers to determine oxygen delivery and dosages.” While countries improved oxygen access during the height of the pandemic by increasing procurement and distribution equipment and improving long term systems, continued attention and focus is required to ensure forward momentum, said Lisa Smith, PATH Access to Medical Devices Portfolio Director. “Translating pandemic investments into sustained respiratory care services will require coordinated efforts across financing, health system and device infrastructure, operations and maintenance, clinical training, data systems, policy design, and advocacy,” the organization said, actions that can be encouraged by the WHO resolution.

Other global action toward improved oxygen access includes the September 2022 establishment of a Lancet Global Health Commission on medical oxygen security co-chaired by scholars from Uganda, Bangladesh, Australia, and the US. Commissioners will be supported by a multidisciplinary advocacy group and global network of collaborators with a focus on LMIC representation and nonacademic experts. Report publication is slated for World Lung Day (September 25) 2024 and will include multilingual policy briefs summarizing major recommendations for national, regional, and global health decision makers.

PATH’s Smith also praised this move, saying the commission is bringing together experts from around the world into a cohesive network able to collect evidence, identify gaps, and develop solutions. “We’ve had nothing like that previously,” she said in an interview.

In discussing the commission’s launch, panel members highlighted oxygen access progress forced by COVID-19, including with the aid of the Access to COVID-19 Tools Accelerator (ACT-A) Oxygen Emergency Taskforce. Through the program, they said, “many LMICs have received new oxygen technologies….to treat patients with COVID-19. However, radical improvements in underlying support structures, processes, and personnel are needed if these are to be sustainably integrated into health systems, alongside surge capacity, to achieve a long-lasting effect on lives.”

The African Union last year cited oxygen availability as a major priority and said five countries already had national plans to scale up supplies while another eight had them in the works. Remaining gaps in the supply chain include developing proper infrastructure and support personnel. “Oxygen equipment is arriving without the trained staff to operate it and the technicians to maintain it,” an AU statement said. “Most countries have oxygen equipment lying idle waiting for a spare part and/or trained technicians to repair it. Despite the availability of liquid oxygen for industrial purposes in many nations, access by public hospitals is limited by lack of critical infrastructure (e.g. piping and storage), and transportation. Governments with national oxygen plans do not have the financing needed to implement them.”

While countries themselves will need to devise their own systems, continued global support will be critical. In addition to the Executive Board resolution and the Lancet Global Health Commission, PATH’s Smith said close collaboration across global partners through platforms like the ACT-A Oxygen Emergency Taskforce will continue to be important. Co-chaired by Unitaid and Wellcome Trust, taskforce members include WHO, the Global Fund, the World Bank, Clinton Health Access Initiative, PATH, the Every Breath Counts Coalition, and Save the Children will continue to be important.

Access to oxygen is one of the critical COVID-19 response needs tracked by COVID GAP. Oxygen was included in the therapeutics pillar of ACT-A , an account for which a total of $9.1 billion has been requested since 2020, but only $1.7 billion raised. The importance of establishing public/ private collaboration in ensuring adequate oxygen supplies during a crisis was highlighted by Peru’s Alberto Valenzuela at a 2021 Duke Global Health Institute webinar. Valenzuela, then Executive Director of the Pan American and Parapan American Games Legacy Project, was called on by the government to aid in increasing access to vaccinations, oxygen, and other critical needs as the pandemic overran the South American nation.

The Duke Global Health Innovation Center is a proud partner of the COVID Global Accountability Platform (COVID GAP). The COVID GAP blog aims to provide thoughtful, timely analysis and insights on important news and developments, guided by our ongoing research, analysis, and stakeholder engagement.

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