The COVID-19 pandemic has increased the level of worldwide investment in respiratory care and now that cases are on the decline, countries need to develop long-term strategies to use oxygen, according to health experts.

“Severe pneumonia, sepsis, trauma complications – there are many patients that would benefit from oxygen,” explained Janet Diaz, a team lead at the World Health Organization (WHO) who spoke about oxygen redeployment on Thursday morning at the Geneva Health Forum.

Every year, 7.2 million newborns in low-and-middle-income countries (LMICs) suffer from severe pneumonia and need medical oxygen to survive. To date, fewer than one in five children actually gets it, making pneumonia the biggest infectious killer of these children.

“It is always important to think about where patients get oxygen – emergency departments, critical care areas, acute care areas – and the different populations of patients that could be oxygen candidates,” Diaz continued. “The investments made are a big win. Now we have to ask, ‘what’s next?’”

Diaz stressed that oxygen redeployment “won’t just happen.” Specific plans to integrate COVID-19 equipment into the health system will be required for the transition. She cited the first steps of this plan as creating a roadmap, entering high-level national planning with donors and engaging and training the workforce to build their capacity to properly administer oxygen to the right people at the right time.

The ACT-A Oxygen Emergency Task Force

The ACT-A Oxygen Emergency Task Force was established by UNITAID in February 2021, about a year into the pandemic, to help LMICs gain access to secure oxygen supplies and the technical support and skills to manage them – and is expected to continue to play a key role in the transition.

More than 20 United Nations and global health agencies partnered on the task force, mobilising more than $700 million in grant financing in the first year. In December 2021, the US government announced plans to infuse another $75 million for additional support of USAID’s Rapid Response efforts, which includes investment to help strengthen oxygen market systems from production to delivery.

The task force was initially focused on five key objectives, which were outlined by a UNITAID representative on Thursday: assessment of acute and long-term oxygen needs in LMICs; support and review of funding requests to the task force; procuring oxygen; increasing LMIC access to liquid oxygen, oxygen plant repairs and critical parts; and strengthening advocacy and communication efforts to highlight the importance of oxygen.

Towards the end of the first year, the task force shifted slightly to focus on identifying priority countries; coordinating action on quick wins with a special focus on monitoring pressure swing adsorption (PSA) plant repairs; and resolving supply gaps and bottlenecks.

Now, as a result of this work, many LMICs have started this year with a greater capacity to meet the needs of their citizens – those with COVID-19 and others who are suffering from respiratory diseases, the representative said.

Nigeria: Six lessons learned

Adamu Isah, a Nigerian physician who works with the country’s Save the Children program, highlighted the lessons that his country learned over the past two-and-a-half years, which he said could be translated to other LMICs.

Nigeria is a federal republic with state governments that have their own autonomous parliaments.

“When you run a program, you have to take note of this and make sure there is coordination between the national efforts and those on the state and local level or it will not be sustainable,” Isah stressed.

Nigeria’s Health Ministry established an oxygen desk where regular meetings between all engagement parties to share ideas. Now, the country is preparing to conduct a nationwide assessment to harmonize the assessments done by individual partners.

He also said Nigeria was evaluating how to ensure it could sustain its oxygen supply.

The current policy is that, for the first six months that people need oxygen in Nigeria, they receive it free of charge. But this was becoming unsustainable – the lesson being that programs need to be evaluated for their sustainability from the beginning. He said the country is now considering either looking for alternative and supplementary funding sources or asking patients to pay for some of the cost.

They also learned to document the oxygen being given to patients.

“Before COVID, no one was talking about oxygen in hospitals,” Isah said, but they quickly learned the need to document the type and amount of oxygen being given, and for what indication it was being used, to ensure proper use and also anticipate future needs.

Nigeria also understood that some people may be hesitant to give their children oxygen and therefore learned to engage religious leaders and traditional rules to promote its use.

Lastly, the country has begun to evaluate if it is better to procure oxygen devices or to develop the capability of manufacturing them in-house.

“In the days of COVID there were long delays,” Isah said. “The question is could we make our own?”

Ethiopia: A head start

When COVID struck, Ethiopia was in a better place than most LMICs due to work it had been doing since 2015 in collaboration with the Clinton Health Access Initiative (CHAI) to improve oxygen services at public hospitals, explained Rahel Belete, who runs CHAI’s Ethiopian program.

The country had already developed new policies and guidelines, procured more oxygen equipment and trained health workers to better diagnose and treat hypoxemia. By 2019, oxygen was available in 100% and pulse oximeters in 96% of in-patient pediatric departments where the program ran. Clinical practice had also improved.

Certainly, the investments the country made gave Ethiopia a head start, Belete said. However, the demand for oxygen during the pandemic far exceeded Ethiopia’s capacity, especially given the country had the fourth highest COVID-19 caseload in Africa.

There have been 470,647 infections and 7,510 coronavirus-related deaths reported in Ethiopia since the start of the pandemic, according to Reuters. Today, Ethiopia is only reporting an average of 22 new daily infections.

The pandemic propelled CHAI to look forward and consider a next phase of its oxygen roadmap, Belete explained.

The components of the new roadmap are focused on:

1. boosting the capacity of existing oxygen plants;

2. tracking and more effectively using data to inform decisions;

3. training healthcare workers to adopt standardized oxygen therapies, while at the same time ensuring staff knows how to use the systems and therapies that do exist so that they don’t end up in the junkyard;

4. making sure any new oxygen tools are standardized to make it easier to find and fund replacement parts, as well as putting a reliable maintenance program in palace;

5 sustainability – making sure the funding is in place to continue growing the program.

“It is important that we have a platform in which there can be international cohesion in the thinking, brainstorming and coordination,” she concluded.

Image Credits: Sky News, Agência Brasília , Maayan Hoffman.