Guest Articles

June 2

Zachary Clemence / Ravi Doshi / Carrie Hemminger / Jayendra Kasar / Evan Spark-DePass

Learning From India: How Low- and Middle-Income Countries Can Scale up Access to Oxygen During a COVID-19 Surge

We all know that oxygen is essential for survival. But COVID-19 has highlighted the crucial importance of medical oxygen as a lifesaving therapy for patients struggling to breathe. And as India has shown, the pandemic has also revealed health systems’ limitations in supplying sufficient oxygen – and the global supply chain’s inability to respond to the massive need for medical oxygen that can arise during a crisis.

While most people with COVID-19 develop only mild or moderate respiratory symptoms, approximately 20% develop severe or critical disease that requires oxygen therapy to support breathing. Spiking cases of COVID-19 place an additional demand for oxygen, on top of the amount needed as an essential treatment for a range of other health concerns, such as severe pneumonia, newborn conditions and obstetric emergencies. We at PATH, a global organization that works to accelerate health equity, have worked for the past five years to implement a comprehensive approach to sustainably improve access to oxygen in low- and middle-income countries (LMICs).

Overall, the COVID-19 pandemic – and particularly the recent crisis in India – has made it clear that oxygen access has not received the critical attention it needs to be effective and sustainable. Indeed, it’s often overlooked in health system planning across LMICs. This is because it is both a medicine and a device—unlike other health commodities. It also has a complex delivery infrastructure, and requires proper training for health workers, sufficient data and systems for maintenance and equipment management, and substantial ongoing financial support.

And at the same time, as the pandemic has highlighted, scaling up respiratory care systems takes time, planning and long-term investment — these systems can’t be built in days or weeks. So countries like India may find themselves struggling to make up for decades of lack of investment by creating oxygen infrastructure or production capacity in a short amount of time. The current oxygen crisis in India brings a host of lessons that should be applied around the world, so that other countries don’t follow the same trajectory if they experience their own COVID-19 surges. We’ll discuss some of those lessons below.


The critical COVID-19 surge in India and the world’s response

India’s official count of new COVID-19 cases leapt from about 11,000 per day in mid-February to a daily toll that reached over 400,000 in early May. Given these rising numbers, the oxygen need for COVID-19 patients alone at the height of the surge was estimated at 17.4 million cubic meters—which is almost three times higher than before the surge, and accounts for over 60% of the COVID-19 global oxygen need. Hospitals are running out of beds, oxygen and other supplies like personal protective equipment.

While the situation has become alarmingly critical, we are seeing efforts within the country to expand access to oxygen as quickly as possible. Almost 90% of the country’s bulk liquid oxygen supply—7,500 metric tons daily—is being put to medical use, whereas healthcare facilities typically consume about 15% of the supply, leaving the rest for industrial use. The government also started an “Oxygen Express,” with trains carrying tankers to wherever they are needed—particularly from production sites in the east to hard-hit urban areas, like New Delhi and Mumbai. Where liquid oxygen isn’t a viable option, 713 on-site oxygen generation plants are being commissioned to fill the gap. Likewise, the government is releasing oxygen supplies from armed forces reserves, and the Indian Air Force is airlifting oxygen from military bases. Sports halls, stadiums and religious facilities have also been converted into makeshift treatment centers to ease the pressure on hospitals.

We have also seen an outpouring of international support. Multilateral agencies and civil society organizations, working with the government and country stakeholders, are attempting to fast-track respiratory care support to India—in the form of additional liquid oxygen, oxygen generation plants, 10-liter oxygen concentrators, hi-flow oxygen technologies (like ventilators), pulse oximeters and related accessories. Bilateral agencies in the United States, United Kingdom, France, Germany, Italy, Canada and Japan, among others, have also delivered vital oxygen devices, funding, and other forms of support to address the crisis. Grassroots efforts, such as the Oxygen for India initiative, are striving to raise funds for distributing oxygen to the patients at greatest risk, especially those who are unable to be admitted to hospitals or who cannot pay for it.


Lessons for rapidly scaling up oxygen access during a COVID-19 surge

Ensuring a reliable supply of oxygen to adequately meet the surging demand—especially in countries where that balance is already threatened—could go a long way in saving lives. How an LMIC prepares for and responds to an oxygen shortage will be highly dependent on their specific country context, and the mix of available oxygen.

Learning from India’s experience of handling a severe oxygen crisis, other countries need to be prepared to avoid a situation at a similar scale—their emergency planning efforts need to be accelerated. Surges can happen quite quickly given the right mix of factors, as we saw in India, and we still don’t know how “transferrable” this crisis is to other countries. However, increasing COVID-19 cases are already being seen across Asia, like in Nepal and Cambodia, as well as across Latin America. National governments need to explore possible solutions to increase oxygen availability quickly, without waiting until a catastrophic COVID-19 surge occurs. This should be done with the appropriate ministerial bodies and subnational governments, in coordination with multilateral agencies, civil society organizations and private industry, in order to avoid duplication of efforts and address inefficiencies that can slow response time.

An important first step is understanding current oxygen availability and existing supply gaps – to the extent that’s possible. In countries where equipment assessments have been conducted, such as Ethiopia, Malawi, Pakistan, Senegal and Zambia, or where equipment information systems exist, this data may already be readily available. Where this data isn’t accessible, another option is to rapidly assess existing oxygen infrastructure and device availability in health facilities—both functioning and nonfunctioning. In India, for example, hospitals are collecting and sharing daily oxygen supply reports with state-level officials for tracking and redistribution purposes, and some states have even developed data dashboards to see changes in real time. Additionally, the Every Breath Counts coalition has started crowdsourcing information on nonfunctioning oxygen generation plants in LMICs, with the aim of repairing these devices for future use. Once a country has a better sense of where and how oxygen is available, even at a high level, it can target its efforts to quickly expand oxygen devices and supply appropriately.

When a surge happens, there are not many options to quickly scale up access to oxygen if the necessary infrastructure is not in place. Diverting or refurbishing existing oxygen devices or supply is one way to increase access to oxygen during a shortage. India played to its strength by diverting industrial liquid oxygen, which is prevalent in the country, for medical use. However, logistical challenges—such as a lack of oxygen storage containers and transportation limitations—delayed the arrival of much of this oxygen to health facilities, especially those far from the production sites. To avoid this problem, at the first sign of a surge in COVID-19 cases, oxygen and cylinders typically used by industry should be re-routed for medical use—making sure that the relevant equipment has been appropriately cleaned, and medical oxygen purity standards are applied. Ensuring that logistics and supply systems are ready to move and store increased volumes of oxygen or related devices is also essential.

Other countries, especially in sub-Saharan Africa, do not have such existing liquid oxygen availability and infrastructure. They will likely need to prioritize other oxygen supply options, such as oxygen generation plants, oxygen concentrators, or cylinders and refilling stations. Where possible, existing stocks of functioning oxygen devices should be diverted to areas of highest need, while nonfunctioning devices are refurbished. That’s the approach taken by Build Health International, with support from the DAK Foundation: It is providing rapid assessments of broken oxygen generation plants, starting in Malawi and Burundi, then sourcing the supplies to fix them as quickly as possible, and providing the necessary training to keep them operational. India is making similar efforts. Actions like this could go a long way toward revitalizing oxygen infrastructure, instead of relying only on new procurement.

Where diverting or refurbishing existing resources isn’t possible or sufficient, countries must prioritize the procurement of oxygen equipment, such as oxygen generation plants, cylinders and/or oxygen concentrators. However, this option may be challenging, as those markets are already being strained as a result of heavy demand from countries experiencing COVID-19 crises – due to the depleted supply, this equipment may not arrive in-country until after a surge has subsided. In addition, countries may not have the available funds to procure this needed equipment quickly. However, they can make use of global funding currently available to support the actions noted above. Both the World Bank and the Global Fund have COVID-19 funding mechanisms in place that can be used to scale up oxygen access efforts in LMICs right now. There has also been a recent appeal to G7 leaders for an additional US $200 million for emergency oxygen funding that would enable the Access to COVID-19 Tools (ACT) Accelerator to respond quickly to LMICs’ requests to alleviate imminent medical oxygen shortages.

LMICs at risk for COVID-19 surges will face challenges in rapidly increasing access to oxygen when shortages occur, and they should start preparing for that immediately. It will require difficult decisions, grassroots efforts, and global coordination across multilateral, bilateral, civil society and industry stakeholders. If we want this moment to mean something, we need to act now to invest in oxygen for the short- and long-term, to save lives during COVID-19 and beyond.


Zachary Clemence is a Market Dynamics Officer, Ravi Doshi is a Market Dynamics Associate, Carrie Hemminger is a Senior Communications Officer, Jayendra Kasar is a Program Officer – Respiratory Care Management, and Evan Spark-DePass is a Market Dynamics Officer at PATH.


Photo courtesy of Navy Medicine.




Coronavirus, Health Care, Transportation
COVID-19, scale, supply chains