PATH’s Systemic Approach for Creating Sustainable Oxygen Supply and Improving Oxygen Access During India’s COVID-19 Crisis

Introduction

Access to oxygen therapy often proves to be the deciding factor between life and death when suffering from COVID-19. Approximately 15 percent of all COVID-19 patients require oxygen support, yet many patients in low-resource settings lack access to this life saving resource.¹

During the peak of the first wave of the pandemic in India in September 2020, demand for medical oxygen increased from 800 metric tons (before the pandemic) to around 4,000 metric tons. During the peak of the second wave in May 2020, demand peaked at around 8,000 metric tons.² Although production scaled up to meet the demand, many challenges existed related to supply chain and logistics—such as storing oxygen, transporting it, and procuring the accessories needed to deliver oxygen to patients.

In this context, PATH’s work to increase access to oxygen during India’s COVID-19 second wave proved to be a promising practice. PATH played a pivotal role in strengthening the oxygen ecosystem in the country by helping with installation of oxygen generator plants, providing oxygen concentrators, and providing technical assistance in oxygen supply maintenance.

Since early 2020, PATH has provided technical assistance to almost 24 states and union territories in India, working closely with governmental and nongovernmental stakeholders engaged in procurement, deployment, operations, and maintenance of oxygen supplies. As of November 2021, it works as the technical support unit for medical oxygen to over 15 state governments directly and provides technical assistance to another nine state governments in India.

PATH also supports installation and commissioning of around 1,500 pressure swing adsorption oxygen generation plants in various capacities across the 24 states. In addition, PATH has provided over 1,100 oxygen concentrators to over 200 health facilities, with a total capacity of 10,000 liters per minute. PATH has trained 6,000 health officials, health care providers, and oxygen equipment operators across the country on installation, operations, and maintenance of oxygen devices and on judicious use of oxygen during oxygen therapy.

With technical assistance from PATH, states have improved their availability of oxygen cylinders, medical gas pipeline systems, liquid medical oxygen storage and delivery, and they have strengthened their readiness through strategy road map and oxygen management plans. This assistance has directly and indirectly contributed to improvement in the oxygen ecosystem in nearly 128,000 health care facilities across the country.

PATH staff and Barabanki district hospital officials install a VSA oxygen generator at District Hospital, Barabanki, Uttar Pradesh

Background: PATH is a global organization that works to accelerate health equity by bringing together public institutions, businesses, social enterprises, and investors to solve the world’s most pressing health challenges. With expertise in science, health, economics, technology, advocacy, and dozens of other specialties, PATH develops and scales solutions—including vaccines, drugs, devices, diagnostics, and innovative approaches to strengthening health systems worldwide.

How can you replicate or adapt this promising practice?

Optimize existing resources

As health facilities began upgrading their oxygen infrastructure, they needed support in managing the operations and maintenance of the oxygen equipment. Working with states enabled PATH to implement a two-pronged innovative approach to rapidly strengthen health systems capacity, as there was no time to create a new cadre of technicians. The first prong was training existing staff on management of oxygen systems. For example in Maharashtra, PATH trained the biomedical engineers and technicians working with the Health Equipment Maintenance and Repair division of the state’s health department in the operation and maintenance of oxygen systems. Engaging biomedical engineers who manage vaccine cold chains to manage oxygen systems was an approach that had never been attempted before in the country.

Create learning resources to manage the system

The second prong of the strategy was to make high-quality, reliable, and actionable information related to medical oxygen systems at all health facilities in the state. As a result, PATH collaborated with the government of Maharashtra to develop a guidebook³ on oxygen management systems as an immediate reference for those who need to understand the basic working, installation, repair, and maintenance of various oxygen systems. This guidebook is being adapted by at least four more states in the country.

PATH developed the Oxygen Delivery Toolkit⁴ to help decision makers, implementers, and advocates in lower-middle-income countries to plan, manage, and communicate the value of scaling up oxygen delivery systems. It also recently launched the Access to Oxygen (A2O2) Resource Library⁵ to host global and country-specific tools, guidance, data, publications, policies, protocols, and advocacy resources related to oxygen delivery systems and oxygen scale-up.

To build a knowledge-sharing community on medical oxygen management, PATH in collaboration with the World Bank organized a five-part webinar series⁶ between September and November 2021. The webinar brought together experts to share best practices, lessons learned, and expert insights for a strong oxygen ecosystem with audiences in India and other South Asian countries.

What are the lessons learned from this bright spot?

Adopt a system-wide and flexible approach

PATH adopted a system-wide approach in strengthening efforts to manage COVID-19. As part of its partnerships with governments and charitable hospitals to install respiratory care equipment, PATH assisted them in mapping vendors and procuring oxygen equipment, including identifying product specifications, assessing facility eligibility, and ensuring site readiness.

In other cases, where state governments were already procuring and installing oxygen devices through other partners, such as PM CARES (the Prime Minister’s Citizen Assistance and Relief in Emergency Situations Fund), PATH provided strategic assistance related to oxygen road map preparation, supplier sourcing, equipment installation, progress reviews, and capacity strengthening.

The healthcare workers unpack and install an oxygen concentrator for a COVID-19 Positive patient inside an isolation ward at Rural Hospital in Palghar, Maharashtra.

Work closely with governments

PATH worked with state governments to develop a long-term strategic road map for sustainable oxygen supply—going beyond COVID-19 and expanding its use for critical care, respiratory care, intensive care, and pediatric care, in effect, for comprehensive primary health care. Collaborating with various state governments enabled PATH to strengthen institutional capacity for operating and maintaining oxygen systems, to ensure sustainability of oxygen use in public health systems.

In some states where PATH already had established relationships, including Uttar Pradesh, Bihar, and Maharashtra, it introduced initiatives to strengthen the oxygen ecosystem through existing teams and made technical capabilities available to them. In other states, where PATH did not have significant engagement, it worked with funding partners to introduce the projects and obtain approval from the respective state governments to begin work.

Leverage in-house expertise effectively

PATH invested in the respiratory care program early on by strengthening in-house capacities and building a wide resource base to provide comprehensive assistance. PATH’s team has public health specialists, along with experts in medical device and engineering, monitoring and evaluation, communications, knowledge management, digital health, data and market analytics, procurement and vendor management, supply chain management, and project management, among others. PATH invested significant resources in research related to not only product development but also evidence-based programs.

How was this promising practice implemented?

Once PATH began working in a state, it coordinated with the Ministry of Health and Family Welfare and the state health departments to assist them with conducting a landscaping and needs analysis. PATH designed a response that included the following components.

Assess needs

PATH’s team members used a checklist and conducted site assessments jointly with state health officials to determine whether a facility was appropriate for setting up pressure swing adsorption oxygen generation plants and the best suited capacity of the plant. For example, sometimes the caseload and oxygen demands in facilities did not meet the size of the oxygen plant or liquid medical oxygen storage capacity allocated to it. In addition to site assessment, the team also assessed the readiness and ability of a health facility to meet prerequisites for a pressure swing adsorption oxygen plant.

Secure funding

Over 12 multilateral, bilateral, private philanthropic, or corporate organizations have worked with PATH to financially assist the country to build its oxygen ecosystem. Prominent organizations supporting PATH’s initiative in the medical oxygen space include the United States Agency for International Development, Bill & Melinda Gates Foundation, World Bank, and Google.

Strengthen capacity

Due to the public health system’s reliance on oxygen cylinders to meet demands, there was a shortage of staff at national, state, district, and subdistrict levels who understood the complexity of integration and maintenance of these oxygen systems that were being deployed and the knowledge to manage them. PATH organized orientation sessions and provided program managers with technical information to aid them. PATH’s state teams also made frequent visits to the oxygen plant sites and regularly engaged with vendors to ensure that sites were constructed to meet the desired standards. The state teams further coordinated with district health officials and other hospital authorities to streamline site preparation.

“There has been a conscious effort from our end to reach some of the most difficult locations across India which were grappling with oxygen shortage and provide the needed support. We have helped move the PSA [pressure swing adsorption] plants in smaller modules across the curving, mountainous roads in the North-East, also in Kargil, one of the remotest and most challenging terrains in the country. These are experiences which words alone cannot describe!” —Neeraj Jain, India Country Director and South Asia Director, PATH

Supplementary material

PATH’s Systemic Approach for Creating Sustainable Oxygen Supply and Improving Oxygen Access During India’s COVID-19 Crisis.pdf

Sources

Gilbert N. A year into COVID-19, medical oxygen scarcity still costing lives. PATH. March 19, 2021. Accessed November 10, 2021. https://www.path.org/articles/year-covid-19-medical-oxygen-scarcity-still-costing-lives/
PATH. Accelerating oxygen access during India’s second wave. September 14, 2021. Accessed November 10, 2021. https://www.path.org/articles/accelerating-oxygen-access-during-indias-second-wave
Department of Public Health, Government of Maharashtra. Guidebook on Medical Oxygen Management System. Government of Maharashtra; 2021. https://nrhm.maharashtra.gov.in/MH_Guidebook_Final.pdf
PATH. Oxygen Delivery Toolkit: resources to plan and scale medical oxygen. Accessed December 8, 2021. https://www.path.org/programs/market-dynamics/oxygen-delivery-toolkit
PATH. Access to Oxygen (A2O2) Resource Library. Accessed December 8, 2021. https://a2o2resources.org
PATH. Building sustainable oxygen medical systems: experiences and lessons from India’s COVID-19 response. A South Asian regional knowledge exchange webinar series. Accessed December 8, 20201. https://o2webinar2021.com/?fbclid=IwAR320wnqxY95MafM5J9txNu5tD3AQtGjxwTjNedqchmJ1G6V9SjoR78KwVM