Reducing global inequities in medical oxygen access: the Lancet Global Health Commission on medical oxygen security

Executive summary<br/>“Oxygen delayed is life denied,” COVID-19 survivor, Kenya<br/><br/>Medical oxygen is an essential medicine that has been in clinical use for over 150 years. It is required at every level of the healthcare system for children and adults with a wide range of acute and chronic conditions, and for safe surgery and perioperative care, and must be available to all who need it. The COVID-19 pandemic shone a spotlight on the longstanding inequities in access to medical oxygen globally, and the importance of this lifesaving therapy to people of all ages and in every part of the world. It was against this backdrop that the Lancet Global Health Commission on Medical Oxygen Security was launched in 2022 – to synthesise available evidence and harness expertise into concrete and actionable recommendations for governments, industry, global health agencies, donors, healthcare workforce, and researchers.<br/><br/>Our work emphasises that oxygen is a service, not just a commodity, and achieving equitable oxygen access requires a systems approach, addressing multiple domains (production, storage, distribution, supply, clinical use, coordination, regulation, financing) across multiple sectors (health, education, energy, industry, transport). Previous efforts, including the major investments in response to the COVID-19 pandemic, largely focused on the delivery of equipment to produce more oxygen, neglecting the systems and people required to ensure equipment is distributed, maintained, and used safely and effectively. Key findings from this Commission show how future investment in strengthening oxygen systems could have huge impact, saving millions of lives, accelerating progress towards the Sustainable Development Goals (SDGs), and leaving the world much better prepared for future pandemics.<br/><br/>Key findings<br/>The global need for medical oxygen is high. Each year, 373 million newborns, children, and adults need medical oxygen, including 364 million patients with acute medical and surgical conditions, and 9 million patients with long-term oxygen needs due to chronic obstructive pulmonary disease (COPD). Eighty-two percent of patients needing oxygen live in low- and middle-income countries (LMICs), with 70% concentrated in South Asia, East Asia, and Sub-Saharan Africa. Patients with acute medical and surgical needs require a minimum 1.2 billion cubic metres (Nm3) of medical oxygen annually. This need is rising, driven by population growth, unmet surgery and long-term oxygen therapy needs. Efforts to prevent oxygen need are critical, through immunisation, smoking and malnutrition reduction, improved indoor and outdoor air pollution, and climate change mitigation. During emergencies the need for oxygen can increase exponentially, putting enormous pressure on health systems. In 2021, globally an additional 52 million patients needed 1.9 billion cubic meters of oxygen to treat COVID-19.Global access to oxygen is highly inequitable with huge gaps in many LMICs despite pandemic-related investments in recent years. We found over 5 billion people, 60% of the world’s population, do not currently have access to safe, quality, and affordable medical oxygen services. In LMICs, less than one in three (30%) people who need oxygen for acute medical or surgical conditions currently receives adequate oxygen therapy, with the greatest inequities in Sub-Saharan Africa. This equates to a 70% oxygen coverage gap, which far exceeds gaps for HIV/AIDS (24%) and tuberculosis (39%) medicines. Major contributors to the oxygen access gap include: people not reaching a health facility; facilities lacking basic oxygen service capacity; missed identification of oxygen need due to lack of pulse oximetry; interrupted, unsafe, or otherwise low quality oxygen care; and the high costs of oxygen services borne by patients. Pulse oximeters and oxygen are currently available in 54% and 58% of general and 83% and 86% of tertiary hospitals, with frequent shortages and equipment breakdown causing healthcare workers moral distress as they ration care. Pulse oximeters and oxygen are practically nonexistent in primary healthcare facilities.<br/><br/>Global costs to fill the oxygen gap are large but represent a highly cost-effective investment that will have wide reaching impacts. We estimate that closing the large acute medical and surgical oxygen access gap in LMICs requires an additional $US6.5 billion annually, equating to $US32.6 billion between 2025 and 2030. This does not include the substantial cost to meet the additional oxygen needed for pandemics ($US6.8 billion for COVID-19 in 2021) or costs for long-term oxygen therapy services. The case for investing in medical oxygen is strong - it is as cost-effective as routine childhood immunization, would enable governments to make progress on eight of the nine SDG 3 goals, and reduce deaths during future pandemics.<br/><br/>National Medical Oxygen Plans are essential to facilitate investment and effectively coordinate service delivery, as outlined in the 2023 World Health Organization (WHO) Increasing Access to Medical Oxygen Resolution. Less than 30 countries have developed National Oxygen Plans to date, and we encourage all governments to do so by 2030. Governments should bring together public and private sector partners with a stake in medical oxygen delivery - including health, education, industry, energy, transport, and other sectors - to design the system and institute a governance structure that keeps all parties connected in its management. Oxygen systems must be integrated into broader national health plans and pandemic preparedness and response strategies.<br/><br/>Pulse oximetry is the gateway to safe, quality, affordable oxygen care and needs to be integrated in clinical education, guidelines, and all levels of the healthcare system. Pulse oximetry measures an essential vital sign - the peripheral blood (haemoglobin) oxygen saturation (SpO2) - that should be routinely assessed in all patients at all levels of health care. However, healthcare workers are currently poorly equipped or supported to use pulse oximeters effectively and pulse oximetry and oxygen therapy are lacking from many clinical guidelines and health curricula. We found that pulse oximetry was performed for only 19% of patients presenting to general hospitals in LMICs and almost never performed for patients presenting to primary healthcare facilities, with the greatest inequities in small and rural government health facilities and across Sub-Saharan Africa. We recognise an urgent need to make high-quality, robust pulse oximeters more affordable and better used while also working to improve their accuracy for all populations, including those with darker skin pigmentation and infants and young children.<br/><br/>Oxygen systems must be designed to suit the context, include operational costs, and be affordable to all patients. There is no one-size-fits-all national medical oxygen system. Rather, governments should define priorities and optimise their systems to suit local conditions. Most health systems and health facilities will benefit from a mixed-source oxygen supply (i.e., liquid, oxygen plant, cylinder, and/or oxygen concentrator), including reliable back-up in case of failure and to meet surges during emergencies. Operational costs account for 50 to 80% of total system costs but have received relatively little investment to date, with catastrophic consequences for the functioning, sustainability, and effective use of oxygen equipment. We particularly highlight the importance of investing in the clinical and engineering workforce. Although there are many different models for managing a national oxygen system, from fully-government- to fully private sector-run, governments should ensure that whatever system they choose, costs are not shifted to the patients. Patient and caregiver testimonies repeatedly told of punishing out-of-pocket costs and we strongly urge governments to include pulse oximetry and oxygen services in Universal Health Coverage (UHC) schemes and to pursue other strategies to minimise user fees.<br/><br/>We call for closer collaboration between the medical oxygen industry, national governments, and global health agencies. The medical oxygen industry, like the pharmaceutical industry, is an essential part of the public health and pandemic preparedness and response architecture. Governments are responsible for ensuring that medical oxygen markets function safely, competitively, and with price transparency, and that national regulations defining medical oxygen quality and safety are aligned with the updated WHO International Pharmacopoeia. Companies should adopt specific oxygen access targets and publish progress while global health agencies should regularly assess oxygen industry progress as they currently do for the pharmaceutical industry. We call on global health agencies and donors to maintain oxygen access as a global health priority, including supporting the new Global Oxygen Alliance (GO2AL) and replenishing The Global Fund with a strong oxygen access mandate. Finally, access to medical oxygen and related tools and therapies must be fully integrated into global pandemic preparedness and response architecture.<br/><br/>Accurate and timely data on oxygen systems is essential for effective decision making and oxygen service access. We found huge gaps in oxygen access data, major deficiencies in the tools we use to monitor oxygen systems and service delivery, and estimates of cost-effectiveness for different oxygen solutions and patient populations. We present two new tools to help governments, health facilities, and global health agencies make progress. These include 10 Oxygen Coverage Indicators and a national Access to Medical Oxygen Scorecard (ATMO2S), which governments should use to both plan their national oxygen systems and report progress implementing the WHO Oxygen Resolution. We also offer