Can COVID-19 breathe new life into medical oxygen innovations?

For patients with a range of medical conditions, from pneumonia to COVID-19, oxygen therapy can make the difference between life and death. In low-income countries, poor access to medical oxygen leads to high mortality rates for people with hypoxemia, or low blood oxygen. That resulted in over 1 million preventable deaths a year before the COVID-19 pandemic, with many more people dying needlessly because of oxygen shortages over the past 26 months. But despite being vital to every human being, oxygen doesn’t fit neatly into any given global health issue, meaning it is hard to find donors willing to invest in it. The COVID-19 pandemic changed all that. It drove a surge in demand for oxygen globally, with some countries seeing a tenfold increase over the course of a few weeks. It also drove more financing toward improving its availability in low- and middle-income countries. The ACT-Accelerator COVID-19 Oxygen Emergency Taskforce, which was launched in early 2021 to mitigate pandemic-related oxygen shortages at the country level, has delivered almost $1 billion to LMIC governments. It has asked for another $1 billion in 2022, said Leith Greenslade, a member of the task force and head of Every Breath Counts, a coalition of organizations working to reduce deaths from pneumonia. Calls for additional investment in oxygen supplies for LMICs are expected at this week’s Global COVID-19 summit. “When COVID hit, these hospitals didn’t have the basics, let alone innovations,” Greenslade said. “So many excess COVID deaths were due to lack of oxygen. That’s a scandal that’s waiting to be written. The global COVID response was late to the party with oxygen.” Now, more than two years into the pandemic, some are concerned that donor interest in medical oxygen will wane. COVID-19 raised the stakes for the global health community to fix oxygen delivery products that had been written off as unrepairable, revisit innovations that couldn’t scale, and develop new ways to address oxygen needs in low-resource settings. And moving forward, the question is whether support for those lifesaving innovations will be sustained — even as the pandemic’s urgency recedes. Innovators focused on medical oxygen in low-resource settings face some of the same financing challenges that extend across medical devices. “You get to that funding cliff,” said Patricia Coffey, a program adviser for medical devices and health technologies at PATH, a Seattle, Washington-based NGO focused on global health innovation. “You’ve got a great concept, but no one wants to fund the hard part, which is figuring out the regulatory process, finding an industry partner, doing the tech transfer, actually entering the market, and then selling it.” That reality meant many innovations developed pre-COVID-19 were not ready to be purchased at scale when they were needed most during the pandemic. That was the case for OneBreath, a medical device company focused on affordable mechanical ventilation. The COVID-19 pandemic created new funding opportunities for the company, such as a $1.4 million technical assistance grant from the U.S. International Development Finance Corporation, said Matt Callaghan, OneBreath’s founder and chief medical officer. But COVID-19 also led supply chains to fall apart, kept OneBreath’s engineers out of their offices, and led a number of organizations to experiment with developing ventilators — from smaller nonprofit groups to large corporations, including Ford, Dyson, and Tesla. Prior to COVID-19, medical oxygen was not a global health priority, Greenslade said. For example, in February 2020, the global health agency Unitaid announced a new funding mechanism for innovations to increase access to oxygen therapy. But the grants — which ranged from $500,000 to $2 million — were small compared to the larger-scale funding needed to really make a difference. Most donors continue to fund vertically, by disease area, Greenslade said. One side effect of all the global health spending related to the COVID-19 response was that it boosted medical oxygen infrastructure in low-resource settings. For example, prior to the pandemic, there were only 68 oxygen plants on the African continent, but by 2021, that number increased to 119. With better systems — and funding — in place to generate medical oxygen, there’s also an opportunity to expand the focus to innovations to deliver and conserve oxygen. Over the course of the pandemic, many of the calls for new medical oxygen innovations seem to overlook solutions that failed to scale in the past due to a lack of sustained investment. This problem repeats itself across the global health industry, said David Bell, an independent consultant in global health, diagnostics, and infectious disease. In a previous role, he worked on a modification to an oxygen mask for the treatment of pediatric hypoxemia. It halved oxygen consumption while providing a slightly higher oxygen concentration — meaning it could effectively double the number of people who could be treated from an oxygen supply. “There’s a lot of noise about oxygen, a lot of talk. But it’s all just delineating the problem, doing studies yet again to prove there’s a lack of oxygen,” he said. “People making noise know about these innovations. We don’t need to reinvent the wheel. We need to look at why these things didn’t work.” Moving forward, Bell said, he hopes to see more financing go toward adopting innovations that already exist. “So many excess COVID deaths were due to lack of oxygen. That’s a scandal that’s waiting to be written. The global COVID response was late to the party with oxygen.” --— Leith Greenslade, member, ACT-Accelerator COVID-19 Oxygen Emergency Taskforce Still, while there is value in revisiting past innovations, new solutions are also needed, Greenslade said. Health facilities in LMICs are still working with technologies that are decades old and not designed for their constraints, where unreliable power and maintenance make it difficult to supply oxygen. And incentives for existing medical oxygen manufacturers to innovate are low, since making a cheaper or more efficient product means they’ll lose money, Greenslade noted. This means it’s critical to provide support to locally developed innovations. In Malawi, the Global Health Informatics Institute, which offers training on health information technology, launched the OpenO2 initiative in August 2020. Their goal was to support repairs for oxygen concentrators, which take in air from the room, filter out nitrogen, and provide oxygen to patients who are having trouble breathing. OpenO2 converted buses into mobile workshops so engineers and technicians could visit health facilities, make repairs, and offer training to hospital staff. “We hope to demonstrate the cost you’re incurring by engaging groups like this is much lower than the cost of buying new equipment,” said Timothy Mtonga, director of the Global Health Informatics Institute. “Maybe we can change the mindset and move into more of a repair and maintenance culture — versus, if something doesn’t work, throw it away, and we’ll ask the next donor.” In November 2021, the Global Health Informatics Institute established the Oxygen Alliance to support local organizations in repairing oxygen equipment. But they are finding their requests to donors are going unanswered. While donors talk about wanting to support local innovations, emergency spending during COVID-19 went toward rapidly deployable solutions, and there’s a risk that funding for medical oxygen innovation will continue going to big international NGOs, Greenslade said. The COVID-19 pandemic has resulted in more funding for the testing, validation, and scale-up of oxygen innovations, said Steve Adudans, founder and CEO at Gear Health Systems in Kenya, and was previously CEO at Hewatele, a social enterprise focused on making medical oxygen available in remote areas. But a number of challenges stand in the way of financing for Africa-based medical oxygen innovators, he said. There is low investment appetite in research and development for medical oxygen. Limited manufacturing capacity means most prototypes must be manufactured elsewhere, or that parts must be imported for assembly, leading most funders to prefer buying finished products from the country of origin, Adudans said. Update, May 13, 2022: This article has been updated to clarify Patricia Coffey’s job title.