Addressing the urgent medical oxygen crisis in low-resource settings

Medical oxygen has been used for over 100 years and is classified as an essential medicine by the World Health Organization. It is used across many levels of the health systems to treat everything from respiratory diseases and trauma to vulnerable groups such as newborns and elderly people. But despite its importance, many low- and middle-income countries face a severe shortage of medical oxygen and the necessary infrastructure to produce and distribute it.

The COVID-19 pandemic highlighted the shortage of medical oxygen as it put huge pressure on health systems around the globe. In many LMICs, hospitals ran out of oxygen, resulting in preventable deaths and the families of patients paying high prices for scarce oxygen supplies. As of May 10, 150,000 oxygen cylinders are needed every day in LMICs to treat COVID-19 only.  

Medical oxygen is produced at plants and can be piped directly to patients or, when produced offsite, transported in smaller pressurized gas cylinders or liquid tanks, depending on a hospital’s needs and infrastructure. However, in low-resource settings, purchasing a plant or liquid tank isn’t always possible, either because of costs, poor-quality roads, seasonal conditions, or a lack of local suppliers.

“There are two types of oxygen supply. Firstly, some hospitals produce their oxygen through a generator, but that requires constant electricity. Others who don't have the capacity to produce their own, have to purchase their oxygen cylinders,” said Dr. Benoucheca Pierre, head of the intensive care unit at Hôpital Universitaire de Mirebalais in Haiti and a senior expert adviser in Madagascar for BRING O2 — a Partners In Health-led initiative that helps accelerate access to safe, reliable, and quality oxygen in Malawi, Rwanda, Peru, Lesotho, and Madagascar.

Hospitals with enough resources can connect cylinders through a network and distribute the oxygen to patients through piping. But those who can’t afford it have to put the oxygen cylinders at the patient’s bedsides, she explained. “That has a lot of risks both for the patient and for the environment,” given that it’s very flammable and the cylinders very heavy.

“I wouldn't want us to minimize the crisis that is obviously present — and even more prevalent with COVID-19 — but oxygen is life. And let's keep in mind that oxygen has a cost, but there's no price you can put on a life,” said Pierre. In a conversation with Devex, Pierre elaborated on the urgent medical oxygen crisis and the need to invest more in supply, infrastructure, and training.

This conversation has been edited for length and clarity.

Can you tell us about your experience providing oxygen for patients during COVID-19 surges as head of the intensive care unit at Hôpital Universitaire de Mirebalais in Haiti?

Haiti is a country with very limited resources and the sociopolitical situation in recent years has had a very negative impact on the health system. This has also affected the availability of medical oxygen in the country. The COVID-19 pandemic, in turn, considerably increased the consumption of oxygen by patients, making the situation especially difficult. This is a real challenge the country has to face.

At Hôpital Universitaire de Mirebalais I had to manage the COVID-19 care unit. Although the hospital had an oxygen generator, our team still had to obtain oxygen cylinders for secondary supply. So in order to deliver oxygen to the patients, some of these cylinders had to be connected with pipes through a manifold system. Others were used at the bedside of patients or to supply artificial respirators. We also had to use oxygen concentrators for patients who were receiving oxygen at a flow rate of less than or equal to 10 liters, but for those we need an almost constant source of electricity.

In your experience, what are the main challenges when it comes to improving access to oxygen?

Funding is a big issue. In order to provide a country like Haiti with oxygen infrastructure, funding is very important in order to maintain the oxygen infrastructure continuously, so that the patients don't have to pay enormous prices for it.

We also have to improve the supply chain, and make it stable around the existing oxygen ecosystem. Because right now, there are a lot of shortages and a lot of delivery issues. We also need to adopt new public policies around oxygen in countries like Haiti.

Advocacy at the international level would also be important, and even just a little investment could have enormous impacts. It’s also important to support organizations such as BRING O2 and Partners In Health in their work to develop health care capacities and services in low-resource countries.

Following the COVID-19 pandemic, what are the current needs around oxygen supply in countries such as Haiti and Madagascar?

The COVID-19 pandemic has brought the global oxygen crisis to light, but low- and middle-income countries were already facing a shortage of medical oxygen. Patients who suffered from respiratory diseases were already dying every second in these countries, simply because of the lack of oxygen. So both Haiti and Madagascar face very severe situations where most hospitals depend on oxygen cylinders for their oxygen supply, which face challenges such as shortages and constant management of logistics.

Since the pandemic, several global initiatives have been established in order to respond to the situation in low- and middle-income countries. In Madagascar, BRING O2 aims to solve the oxygen shortage by improving local biomedical and clinical capacity and by strengthening the entire oxygen ecosystem from plant to patients.

This includes providing comprehensive support for oxygen infrastructure and health care facilities. But also the assessment and maintenance of oxygen plants, installation of new oxygen concentrators, supplying oxygen cylinders, and installing new tubing and high-pressure outlets to inpatient beds. The initiative also provides training for health care professionals in oxygen administration and advice on oxygen management.

As the senior expert adviser in Madagascar for BRING O2, you led the development of the very first national standards for delivering medical oxygen to patients. Can you tell us more about this achievement?

This was a collaborative effort that involved all key players in the country's health system, including government officials and health care providers. The document will serve as a resource for training others who will spread what they’ve learned across other health facilities. It's going to have a significant impact in Madagascar because it will help ensure that patients who are dependent on oxygen have access to the medical oxygen that they need. By establishing national standards for the provision of medical oxygen, it will also help improve the quality of patient care and reduce the risk of the adverse effects associated with oxygen therapy.

However, in order to sustain and expand this impact, BRING O2 will need continued investment in infrastructure and in training and capacity building. It's also going to be important to continue to collaborate with local stakeholders to ensure that the standards remain relevant and responsive to the growing needs of Madagascar's health system.

Sadly, the reality for countries that have limited resources is quite different. There isn't a policy to manage oxygen policies and the national budget that is allocated to the health care system is really small. These countries often depend on international help and investments from other countries for what they need. That's why I always try to put an emphasis on the long term, as well as training.

What do you think is unique or special about PIH and BRING O2’s approach to oxygen ecosystem strengthening?

What I find unique about BRING O2's approach is its systemic and integrated nature. The mere supply of machines is really not enough to meet the needs. This requires education and training on the standards of medical oxygen use and how to maintain all the infrastructure providing sustained support. BRING O2 really strengthens these countries by providing both equipment and expertise on the multiple aspects of oxygen supply and use.