Will the medical oxygen industry learn a lesson from COVID-19?

The COVID-19 pandemic exposed the lack of equitable access to medical oxygen in low- and middle-income countries, particularly to medical liquid oxygen, or LOX, which is the gold standard of care. Lower-income countries found themselves scrambling to work with the gas companies that produce medical oxygen to patch together even a limited supply. In many cases, it was nowhere near enough to meet the demand, which saw an estimated 1 in 5 COVID-19 patients requiring access to medical oxygen. Now advocates are pushing for the gas industry — particularly the six gas companies responsible for producing the vast majority of LOX — to lock in the advances that were made during the outbreak, while also taking additional steps to ensure LMICs have a sustainable supply. “It is an issue we had been aware of for many years, but COVID was a window that we could use to highlight it,” Marijn Verhoef, the director of operations and research at the Access to Medicine Foundation, told Devex. In a new report, AMF lays out steps the industry can take to make access more sustainable. “Now everyone understands the issue of lack of access, what it means not to have access.” Before COVID-19, the gas industry’s focus had been on industrial gasses and not medical products. LOX sales were primarily to high-income countries. “They would say there’s no demand for our product, so we didn’t supply it,” Leith Greenslade, the coordinator of the Every Breath Counts coalition, told Devex. Because they were providing limited LOX to the global south, the companies didn’t invest in nearby production facilities. In some cases, the gap was tolerated by governments that did not craft national strategies for the supply of medical oxygen. As a result, when COVID-19 emerged, many lower-income countries lacked the connections to quickly procure supplies of LOX — and when they did, the industry didn’t have the capacity to quickly deliver the product. Around the world, there were reports of deaths that could have been prevented by access to oxygen. In Kenya, medical oxygen was only available in 16% of the country’s counties before the pandemic, according to Dr. Angela Ndaga, a public health expert with the nonprofit Amref. “Oxygen just wasn’t considered an area of need,”she told Devex. In the midst of the pandemic, Ndaga found herself spearheading an initiative to secure greater access to medical oxygen, particularly LOX. The facilities for producing LOX are easier and cheaper to maintain than systems that produce oxygen in its gas form. The project, which was part of a $41.7 million Global Fund grant, is on track to ensure that oxygen is available in each of Kenya’s 47 counties. But it was slowed, Ndaga said, because the supplies they needed were not nearby and there was little local expertise for installing and maintaining the systems. Policymakers and health care providers weren’t the only ones struggling to get ahold of the companies. “There was no relationship between the oxygen industry and global health actors,” Greenslade said. During the pandemic Every Breath Counts and AMF began organizing roundtable discussions where one of the primary goals was “to bring industry to the table,” she said. “It was introducing them to the Global Fund, to Wellcome Trust, it was starting from scratch.” Most of the companies were receptive to piecing together temporary solutions to get LOX to the places where it was missing, even as they struggled to keep their existing clients stocked. Some converted to medical LOX production from an industrial version that does not have to meet the same regulatory or purity standards. Others hit on innovative delivery methods, including airlifting LOX tankers and trailers. Despite a tenfold increase in medical LOX supply from pre-pandemic levels, the companies were still unable to meet all of the demands of LMICs during the height of the pandemic, AMF determined. Greenslade is worried that not enough is being done to consolidate those gains and address the still-existing gaps in coverage. “If we’re hit with another respiratory pandemic, I’m not confident we won’t again see a replay of the COVID oxygen tragedy,” she said. AMF has laid out six concrete steps that the companies could take to expand LOX access to LMICs over the next several years. At the top of the list is for companies to develop an access-to-medical-oxygen strategy and to integrate it into corporate documents, such as environmental, social, and corporate governance reports. “One thing we’ve learned in the last 20 years as an organization is that if there is buy-in from the top, if it’s recognized in corporate strategy and spoken about not just in corporate reports, but also ESG reports, integrated reports, that’s something that will generate momentum in the company,” said. One of the six companies, Air Liquide, did establish a strategy for improving access to medical oxygen in LMICs in 2021 and is publicly reporting on its progress. Greenslade is looking for the other five to make similar commitments. “They can look to the pharmaceutical industry,” she said. “They all have robust access to medicines teams within the companies.” Devex attempted to contact four of the companies, but only received a response from the Germany-headquartered Linde, which declined to comment. AMF is also encouraging the companies to set equitable prices, to help support a workforce and infrastructure that can maintain the medical LOX system, and to expand their reach, including by increasing local production capacity. While AMF’s focus is on what industry can do to increase access, those steps can be taken in collaboration with governments, regional bodies, and donors. Air Liquide and Linde have already set up partnerships with Unitaid and the Clinton Health Access Initiative to improve access in countries they have collectively identified as priorities. AMF plans to establish a framework for tracking ongoing industry efforts, which they plan to measure against the “performance that we would like to see,” Verhoef said. The companies “need to recognize their role in the global health architecture,” Emma Cahuzac, a researcher with AMF, told Devex. “Because they are part of it, whether they want it or not.” The World Health Assembly will keep attention on the issue, as the gathering will consider a World Health Organization resolution on increasing access to medical oxygen. While the resolution is primarily focused on WHO and its member states, its adoption could keep the focus on the need to prioritize planning for medical oxygen requirements and training more staff to implement the intervention — efforts that would be boosted by industry involvement. “The resolution will be helpful, but we will still need robust engagement with the private sector,” Greenslade said.