There was little doctors could do when Paul Msoma was admitted to hospital in Malawi with Covid in 2021, and struggling to breathe. Kamuzu Central hospital in Lilongwe had cylinders of oxygen, but not the flowmeters they needed to administer the gas to the patients.
“Paul said, ‘I know the health workers are nice but I can see pain in their eyes when they are looking at me. There is nothing they can do, not because they don’t know how to do their job, but because they can’t connect us to oxygen,’” says Msoma’s friend, Sosten Chilumpha.
Chilumpha and other friends clubbed together and bought the equipment the hospital needed, but it was too late for Msoma, who died at the age of 44. “It was very sad,” says Chilumpha. “Paul was my best friend.”
Accessing medical oxygen was a major challenge during the pandemic. The key, and often fatal, complication of Covid is depletion of oxygen in the blood. A study of 64 hospitals in 10 African countries found that half of the Covid patients who died never received oxygen.
Since the pandemic, increasing the continent’s oxygen security has become a priority for African governments and global health organisations to prepare for future health emergencies, but also to help patients with other serious conditions.
On Wednesday, the member states of the World Health Organization are expected to vote on a resolution at the World Health Assembly, which – if adopted – will urge all its members to develop national action plans to increase access to medical oxygen.
Health ministries in 12 countries, including Malawi, have already done so.
“There has been a systems change,” says Audrey Battu, the director of essential medicines at the Clinton Health Access Initiative. “Many countries realised that oxygen is needed to treat most severe diseases, even tuberculosis or HIV. Covid is just the tip of the iceberg.
“The pandemic also changed the funding landscape,” she says. “Global funders who never financed oxygen initiatives, for example the Global Fund, started putting money towards it.”
Ethiopia, the continent’s second-most populous country, is serving as a model for other states with its “oxygen roadmap”. A 2015 assessment of more than 100 hospitals in Ethiopia showed that only 45% of inpatient paediatric departments had access to pulse oximeters, while 63% of departments had oxygen. By 2019, oxygen was available in 100% and pulse oximeters in 96% of inpatient paediatric departments where the programme ran. When the pandemic hit, Ethiopia was able to respond to increased demand.
Ashenafi Beza, a senior adviser at the Ethiopian Ministry of Health, says the original plan was to increase the number of oxygen plants from two to 13. “When Covid came it accelerated the government’s efforts. Today, there are about 40 functioning pressure-swing absorption (PSA) plants producing oxygen,” he says.
Before the roadmap, “hopeless” situations were common in Ethiopian hospitals, Ashenafi says, with one in 10 inter-hospital referrals due to oxygen shortages.
“I felt desperate and helpless,” he says, recalling a time when a patient died after he was forced to refer them to a different facility as there was no oxygen in his hospital. “There is no worse feeling than losing a patient when you have the expertise and equipment to treat them, but you have to send them to a facility nearly 20 miles away because you’re short on oxygen.”
Ashenafi says that alongside public initiatives, there are now about 10 private companies producing medical oxygen in Ethiopia. Among them is Liyana Healthcare, which began supplying hospitals in 2020. The company operates an oxygen plant in Hawassa, about 170 miles south of the capital, Addis Ababa.
“Before, oxygen manufacturers were only based in Addis Ababa,” says Girma Ababi, Liyana’s CEO. “I was practising in a hospital 220 miles south of Addis but there was no supply chain to ensure a continuous supply of oxygen.”
Girma says that during times of political unrest in Hawassa roads could be closed for days at a time, hindering the supply of oxygen to his hospital. “I would see patients die in front of me,” he says. “Those were the most painful moments of my career. Lives were lost.”
Liyana supplies oxygen to 49 hospitals across the south and west. “Now, regardless of what happens between Addis and Hawassa, hospitals can get oxygen,” Girma says.
However, replicating Ethiopia’s success is not as simple as copying and pasting its policies, says Raphael Kayambankadzanja, a market dynamics officer at Path, a not-for-profit organisation focused on increasing access to new health technologies, which has been working with Malawi’s Ministry of Health.
“Malawi had a unique situation as we had no manufacturers in the country to manufacture oxygen equipment,” says Kayambankadzanja.
Before the pandemic Malawi had two functional PSA plants producing oxygen, now there are seven, with a further seven expected to open by the end of the year, Kayambankadzanja says. However, a lack of manufacturers to supply spare parts for oxygen equipment represents a challenge.
“We are now trying to strengthen the private sector, or at least stimulate it, to stock spare parts routinely,” Kayambankadzanja says, although the government’s focus is changing. “In Malawi, the government’s priorities shifted to the cholera outbreak in March last year,” he says.
Carina King, an epidemiologist at the Karolinska Institutet in Sweden and co-chair of the new Lancet Global Health Commission on Medical Oxygen, worries that as Covid is no longer a global health emergency, attentions may turn elsewhere. “During Covid we saw a huge amount of investment coming through that had never gone to oxygen before. Yet I worry that in 10 years’ time we will be speaking about lack of oxygen again.”
Habtamu Seyoum Tola, an Ethiopian doctor and Unicef researcher, adds: “On the global level, we are already seeing donor funding declining for oxygen. I have concerns about the sustainability of funding not only in Ethiopia but also in other countries in the region.”
Additional reporting by Charles Pensulo