COVID-19 Oxygen Needs in Low- and Middle-Income Countries Have Tripled in Just Three Months – Where are Solutions?
India’s first ‘Oxygen Express’ train transports liquid medical oxygen from steel plants that produce oxygen to different parts of the country (23 April).

India’s COVID crisis has laid bare the health costs of inadequate access to medical oxygen supplies – faced by many other countries even before India’s pandemic surge began.  Already in February, WHO said that oxygen shortages to treat those seriously ill were impacting more than half a million people in low- and middle-income countries every day – with an estimated need of US$90 million to meet demand in 20 low- and middle-income countries (LMICs). Soon after, a COVID-19 Oxygen Emergency Taskforce was established “to measure oxygen demand, work with financing partners, and secure oxygen supplies and technical support for worst-affected countries.”  Meanwhile,  along with spiraling COVID cases, LMIC oxygen needs have more than tripled from less than 8 million cubic meters in late February, to more than 28 milion cubic meters today, according to the Taskforce “oxygen tracker.”

Oxygen needs: 24 February 2021
Oxygen needs: 10 May 2021









Geneva Health Files spoke to Robert Matiru, Director of Programmes at Unitaid, who also advises the WHO co-sponsored ACT- Accelerator initiative (ACT-A), to understand the logistical challenges countries face in ensuring oxygen supplies and the broader economics of access to medical oxygen.

Geneva Health Files: What has led to the difficulties in accessing medical oxygen in many parts of the world, including in India?   

Robert Matiru: It’s worth distinguishing between India and other LMICs. In India, there is a relatively well-developed health system and local oxygen supply is there, but a lack of planning for an outbreak at this scale, and limited prioritisation have resulted in oxygen not being where it is needed in the country. We are starting to see this improve now, with gas being diverted from industry and supplies arriving in parts of the country where it is needed most, helped by multilateral and bilateral responses.   

A patient, wearing an oxygen mask, sits outside Lok Nayak Jai Prakash Narayan Hospital (LNJP), New Delhi, one of India’s largest COVID treatment facilities.

For many other LMICs, the difficulties are more systemic and long-term. Even before COVID-19, oxygen supply in LMICs was inadequate. The problem is complex: tools to diagnose respiratory distress are often not well-embedded in health systems, and sustaining oxygen supplies is an expensive, long-term commitment, and equipment is poorly designed for use in low-resource healthcare settings. Oxygen concentrators are often not designed to withstand the difficult conditions found in many LMICs, oxygen piping systems needed to deliver oxygen to the bedside are lacking or often not well-maintained, and complex logistics mean oxygen cylinders don’t always reach their destination on-time. Medical oxygen [globally] is supplied by six major companies; in countries there is a lack of market competition, which often results in higher prices and access issues.  

All of these issues have been compounded by the impact of COVID-19. While oxygen is vital for the effective treatment – alongside corticosteroids – of patients with severe and critical COVID-19, access in LMICs is limited due to the cost, infrastructure and logistical barriers outlined above. In the COVID-19 response thus far, diagnostics, PPE and vaccines have been prioritised over medical oxygen, despite it being so essential.  

Robert Matiru, Unitaid

GHF: What could the international community have done to prevent such a crisis?  Were the mechanisms in the ACT Accelerator, deficient in anticipating and preparing for such a demand for medical oxygen?   

Matiru: It’s important to recognise that oxygen supply is a complicated space for the reasons highlighted in the previous response. COVID-19 outbreaks at this scale are unpredictable. Last year, global development agencies invested more than US$ 150 million in oxygen products and services for LMICs, but that is just a fraction of what is required for a comprehensive and sustainable response to address the unprecedented surge in demand for medical oxygen that we are seeing now due to COVID-19. At the end of last year ACT-A called on donor countries to invest in ten times this figure, at a minimum, for COVID-19 related annual oxygen needs in LMICs. We are far from receiving even a fraction of that. To amplify the urgency and size of the need, as well as accelerate efforts to support countries, the ACT-A Oxygen Emergency Taskforce was launched in February and is coordinating with global health partners and civil society to raise awareness and funding, plan better and ensure operational readiness to act when subsequent outbreaks occur, but also with a view to implementing resilient oxygen systems. This is already in action with O2 Taskforce partners actively supporting countries to assess and cost their context-specific needs and to access available funding through the Global Fund’s C19RM process and via the World Bank’s loan mechanism. In parallel, governments need to start prioritising oxygen as part of their COVID-19 response plans, but also for the long-term, so oxygen supply is available to those who need it.    

GHF: You have said that a lack of competition in the medical gas market has increased the costs of oxygen, and has resulted in countries having to pay a premium for an essential medicine. Can you elaborate? 

Matiru: The market is dominated by six major companies – the lack of competition between providers drives prices higher, and prices are quite variable from country to country. Certain companies dominate markets in certain countries, and across regions. This makes it hard for governments to negotiate on price and supply, particularly during times of surging demand. It’s worth noting that medical gas is not seen as hugely profitable compared to gas for industry, which is where most of these companies’ interests lie. There is little incentive to engage and supply medical oxygen, especially when there is red tape such as local regulations which can take time and cost money.  As a Taskforce, we would like industry to be part of the solution and are actively determining which market interventions are the most appropriate, high-priority and cost-effective, so that engagement with these companies is targeted and clear. A major focus of the investments the Taskforce is calling for, will need to be directed at addressing entrenched oxygen market failures. 

GHF: What should countries do domestically to prepare for demands for medical oxygen? In your assessment, why have certain countries done well on this, and why have certain countries failed on preparing for the demand for oxygen?  

Matiru: Countries need to follow the epidemiological data (which relies on having good testing in place – this is unfortunately not a given in many LMICs) and plan for surges, positioning oxygen supplies to meet anticipated demand, but also plan for the long-term. It’s important to have an appropriate mix of oxygen solutions in place that suits the country’s needs best.  

GHF: In the context of India, how quickly can international supplies rush in to help?  Have the offers of help there made a difference? 

Matiru: Other partners working on the ground, such as UNICEF, WHO, CHAI [Clinton Health Acccess Inititiative] and PATH are probably better-placed to answer this question. But as an overview – the response has been rapid and significant as reported in the media. Taskforce partners have contributed to the effort (e.g. WHO and UNICEF have supplied thousands of O2 concentrators; PATH/CHAI are helping instal PSAs (pressure swing absorption) plants and the global health community is engaging directly with the Government of India to ensure that any support meets the urgent need, and will have the intended impact. Due to the unprecedented level of demand, there are supply constraints and long lead times for certain commodities such as concentrators and PSA plants. The O2 Taskforce is working to improve supply conditions so that appropriate products and services can move as quickly as possible as cases continue to surge around the world. It is now crucial to collaborate with and support other at-risk countries in the regions and elsewhere with surge preparation to support LMICs through both the acute needs in the coming weeks and the more sustained needs we will inevitably see through this year and next. 

Adapted from the article first published in Geneva Health Files by Priti Patnaik, GHF founder and publisher.

Image Credits: Flickr, Prasar Bharati News Services, PATH ,, Unitaid.

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