This post is part of our Every Last Breath: Oxygen blog series.
The burden of under-five pneumonia deaths in India
India is responsible for 17% of global under five pneumonia deaths. In 2018, the number of children under-five who died of pneumonia was 127,000. That’s 14 children dying every hour from a largely preventable disease.
It’s further evidence that the social determinants of health are weighted against hundreds of millions of people in India. And that the brunt of these inequities is borne by children who are poor, vulnerable, and socially excluded.
Around 10–20% of pneumonia cases in India become severe and require hospitalisation and medical oxygen. It’s estimated that the use of medical oxygen – one of the key recommendations in the Global Integrated Action Plan for Prevention and Control of Pneumonia & Diarrhoea – could reduce childhood pneumonia-related mortality by at least 35%.
Oxygen concentrators: a solution
Hypoxaemia, caused by low levels of oxygen in blood, is a potentially fatal complication of pneumonia. It's easily treated with oxygen, which is included in the World Health Organization’s list of essential medicines and commodities. That’s why it’s vital that life-saving medical oxygen is available and accessible free-at-point-of-use for sick children who need it the most.
Where oxygen cylinders and centralised piped oxygen systems are unavailable or too expensive, oxygen concentrators are a viable and cost-effective option, with studies showing they can dramatically increase the availability of medical oxygen in poorer countries at lower costs. They draw in air from the environment and pass it through molecular sieve beds to concentrate atmospheric oxygen to the levels necessary for treating patients suffering from hypoxemia. Oxygen concentrators can be easily moved between wards, hospital rooms or health facilities to provide a sustainable and reliable source of oxygen to multiple patients.
They may run for up to five years or more, with minimal service and maintenance and their use can drastically reduce costs to patients requiring long-term oxygen therapy to just Rs.8 per day for each patient.
In resource-limited settings, two major drawbacks to using oxygen concentrators are that they need both a reliable, regular power supply and regular maintenance.
Both needs can be addressed by effective programme planning and training. In areas with frequent power failures, back-up generators are an option – though they are expensive, and the issue of fuel and maintenance can be problematic over time. For facilities with brief power failures, another option is a battery bank system that is chargeable with electricity or solar panels.
Dysfunctional oxygen concentrators in health facilities
According to the government of India’s own figures, at any one time up to one-third of equipment in health facilities doesn’t work. My experience when visiting health facilities bears that out: it’s very common to come across non-functioning equipment. The causes can range from something as minor as a blown fuse to a serious problem requiring support from a biomedical engineer or service provider.
An assessment in the State of Madhya Pradesh found that less than half of the 66,000 items of medical equipment in state-run health centres and hospitals were on an annual maintenance contract. Out of 40 oxygen concentrators listed, only 14 had a maintenance contract.
At divisional and district level in India, there is a lack of tools, spare parts, and workshop facilities to carry out repairs to basic medical equipment.
Oxygen concentrators require regular maintenance by health staff, technicians, and service providers. Trained clinical staff can handle minor problems, including cleaning filters. But in India’s hot, humid, and dusty environments, it’s very important that regular maintenance checks are done, and biomedical engineers are vital at the district level. In collaboration with the National Cold Chain Training Centre, Pune, UNICEF has run a pilot training programme for cold chain handlers on maintaining equipment in special newborn care units – including oxygen concentrators.
Government response
To address the issue of dysfunctional medical equipment in public health facilities, India launched the Biomedical Equipment Management and Maintenance Program in 2015. As of August 2018, 20 states and union territories have joined the programme (a public–private partnership). Five states and union territories are maintaining their equipment in-house using biomedical engineers or through an annual maintenance contract with the manufacturer.
COVID-19: challenge and opportunity
The present COVID pandemic is posing serous challenges on the health systems. The World Health Organization reports that around 15% of COVID-19 patients with “severe infection” will require oxygen. In India, only 0.45% of COVID-19 patients are still on ventilators, while 2.94% of them are on oxygen support, according to data from the Union Health Ministry.
State governments have responded by strengthening health facilities and oxygen delivery systems to meet the COVID challenge. Oxygen concentrators manufactured in India are being purchased in large numbers not only to augment oxygen supply in COVID hospitals but also to be installed in hotels, schools and other temporary structures identified as additional facilities for COVID cases.
Now it’s vital that we build on these initiatives. To achieve maximum use from these machines, it is essential that the Government take the following steps:
- Only buy high-quality oxygen concentrators that meet approved specifications.
- Build a minimum of two-year warranty into the procurement process and annual service contracts be established after the warranty expires. This will make sure the recommended checks are carried out and spare parts are available from the service provider/manufacturer.
- Clinical and technical staff should be trained on how to use and maintain concentrators.
It’s time for India to step up and invest more than the 1.2% GDP which it currently spends on health. Health and oxygen for all can only become a reality when health becomes an overriding political priority, something which is so challenging considering all of India’s competing priorities.
COVID-19 is having a devastating impact across the country. But in responding to the crisis, we must grasp the opportunity to build resilient health systems – including lifesaving oxygen delivery systems for the future and for every child who needs them.
