United4Oxygen
World’s First Public-Private Partnership to Increase Access to Oxygen and Pulse Oximetry
A consortium of government, industry, foundation and civil society organizations joined forces to support the Governments of Ethiopia and Nigeria efforts to scale-up access to pulse oximetry and oxygen in health facilities, with a special focus on reducing deaths among pregnant women and children under five.
The Alliance is supporting the Government of Ethiopia to implement its National Medical Oxygen and Pulse Oximetry Scale Up Road Map (2016-2020/21), and the Government of Nigeria to deliver on its National Strategy for the Scale-Up of Medical Oxygen in Health Facilities (2017-2022). Successful implementation of these flagship policies has the potential to save a lot of lives and inspire other governments to prioritize access to oxygen as part of health reforms.
An estimated three million Ethiopian women and seven million Nigerian women give birth each year to a large population of newborns. Improved access to oxygen will not only reduce maternal deaths but will also reduce newborn and child deaths, especially from respiratory illnesses like pneumonia. Each year 7,500 Ethiopian women and 18,000 Nigerian women die in pregnancy and childbirth, according to the Global Burden of Disease. A further, 109,000 Ethiopian babies and 157,000 Nigerian babies die in the first month of life. Babies who are born preterm, or who contract sepsis or pneumonia early in life are particularly vulnerable to death, as are women and children in remote communities with little or no access to health services. Pneumonia is the leading cause of death among children under five in both Ethiopia and Nigeria, claiming 180,000 children each year.
Access to oxygen in hospitals is also severely limited in Ethiopia and Nigeria. A recent study by the Clinton Health Access Initiative (CHAI) of 78 hospitals across three states in Nigeria found that only 2% had pulse oximeters and 25% of pediatric wards had functional oxygen systems. The study concluded that among the children with pneumonia who reached a health facility, 47% of non-severe pneumonia cases were missed, only 4% of severe pneumonia cases were correctly diagnosed, and just one in 10 children received the oxygen they needed.
In Ethiopia, the situation was only slightly better. 45% of hospital pediatric wards had pulse oximeters and 64% had fully functional oxygen delivery devices. However, only 14% of the hospitals studied had standard operating procedures on oxygen use or health care workers trained in oxygen therapy, and only 41% had biomedical engineers and technicians who could maintain oxygen equipment. High rates of mortality among children with pneumonia in hospital settings across Sub-Saharan Africa have also been reported in Kenya, Malawi, and Uganda, suggesting similar problems with access to medical oxygen.
The United4Oxygen partners — including Adara Development, Assist International/GE Foundation, the Bill & Melinda Gates Foundation, the Center for International Health (Royal Children’s Hospital Melbourne), the Center for Public Health and Development, Diamedica (UK), the Global Development Incubator, Gradian Health Systems, Grand Challenges Canada, Malaria Consortium, Masimo, PATH, Philips, the Pneumonia Innovations Network, Save the Children, UNICEF, University of Alberta, the US Fund for UNICEF, USAID, and the World Federation of Societies of Anaesthesiologists — will support the Governments of Ethiopia and Nigeria by:
(a) increasing the availability of pulse oximetry screening and oxygen therapy technologies in health centers and hospitals;
(b) training local staff in the use of the new technologies;
(c) establishing sustainable financing solutions for the procurement, installation and maintenance of the new equipment; and
(d) prioritizing pulse oximetry and oxygen access in the policies and guidelines of government health authorities and of the major international development agencies.
The Ethiopian Government has described the oxygen access agenda as central to their own Health Sector Transformation Plan (2015-2020) and National Newborn and Child Survival Strategy (2015-2020). Increasing access to oxygen is also critical to the achievement of the new Sustainable Development Goals relating to health and to the implementation of the new Global Strategy for Women’s, Children’s and Adolescent Health.
Following the successful implementation of the government plans, the United4Oxygen partners will promote and seek to extend the oxygen access model to other countries with high levels of maternal, newborn, and child deaths throughout South Asia and Sub-Saharan Africa. In addition to reducing maternal, newborn, and child deaths, lack of oxygen access contributes to higher death rates from cardiac arrest, acute blood loss, pulmonary edema, trauma (e.g. road traffic accidents), and unsafe surgery.
The Partnership will focus on the following activities:
1. OXYGEN ACCESS: Improve availability of functional pulse oximetry and oxygen therapy in the health centers and hospitals, particularly in maternity and pediatric wards, targeted by the governments.
2. GOVERNMENT POLICIES: Support national and sub-national governments to prioritize oxygen access as part of their health plans, and to update oxygen/pulse oximetry policies and guidelines in the context of government women’s, newborn’s, and children’s health strategies.
3. SYSTEMS SOLUTIONS: Contribute to a set of integrated oxygen solutions relevant to each target facility, including the most relevant mix of technologies, business and delivery models (PPPs, subsidies, user fees), and maintenance networks.
4. SUSTAINABLE FINANCING: Establish sustainable financing solutions for oxygen systems, with a focus on increasing country budget allocation and increased private sector financing including blended finance, venture capital, private equity, and performance-based financing.
5. HEALTH WORKER SKILLS: Improve the pulse oximetry and oxygen use skills of healthcare workers, including training on rational use of oxygen and procurement.
6. MEASUREMENT: Align global and country stakeholders around a common set of oxygen and pulse oximetry measurement indicators and incorporate key indicators into relevant routine surveys.
7. DATA: Improve national and sub-national data collection relating to mortality and morbidity caused by lack of access to oxygen as well as coverage of pulse oximetry and oxygen therapy, with a special focus on maternity and pediatric wards in health facilities.
8. INTERNATIONAL ACTION: Promote the Ethiopian and Nigerian oxygen access models, engage with industry to promote the business case for provision of appropriate oxygen delivery equipment, and support the prioritization of oxygen on the agendas of the major UN and multilateral development agencies, its inclusion in official measurement tools and more research to strengthen the evidence base for oxygen/pulse oximetry as a high-impact maternal, newborn and child health intervention.
Partner Responsibilities
Adara Development will leverage its expertise in bubble continuous positive airway pressure (bCPAP), which is a life-saving technology that can be offered in low-resource settings on infants who require advanced therapy. Oxygen delivered via nasal cannula, while critically important, is not sufficient to save an infant’s life who is suffering from respiratory distress syndrome (RDS). With bCPAP therapy, low birthweight infants have a much higher chance of survival. Adara has close to two decades experience of providing neonatal health programs in rural Uganda and has extensive training manuals, training protocols, master trainers, and training teams that will be utilized for this commitment. In addition, Adara’s long-term partner, Kiwoko Hospital, recognized as a center of excellence for neonatal care in East Africa, will advise and inform the integrated approach to the implementation of a bCPAP program.
Assist International, in partnership with the GE Foundation, will design, develop, and manage oxygen system solutions according to program design criteria established by the commitment. This includes coordinating with local health leadership to assess needs and implementation solutions at regional and local levels, determining site development requirements for building construction and power augmentation, and the procurement, logistics, and installation of all system equipment, including but not limited to high capacity oxygen generator (plants), portable compressors, cylinders, piping, with all required accessories. Assist International will coordinate with local partners to establish sustainable competency related to the operation and management of oxygen systems through training of core skills and best practices of system operations and maintenance. The fiscal commitment of Assist International is $300,000 with implementation contingent upon confirmation of additional anticipated funding partnerships.
The Bill & Melinda Gates Foundation (BMGF) will work closely with partner organizations—such as PATH and CHAI—and manufacturers to assess the suitability of oxygen concentrators and pulse-oximeters in Ethiopia. Additionally, BMGF has supported market analysis and country level strategy development for oxygen systems.
Diamedica (UK) will share expertise on sustainable and cost-effective procurement, installation and maintenance of oxygen concentrators, oxygen storage, anaesthesia and oxygen therapy related equipment including CPAP. Diamedica is committed to training medical and technical personnel to enable them to maximise the potential of our equipment, safely and economically in Ethiopia.
The Global Development Incubator (GDI) will leverage its experience with oxygen solutions in Kenya to bring the best models and knowledge in Ethiopia to support local efforts. GDI will also support the creation of a broader partnership network for medical oxygen solutions and partner with the Center for Public Health and Development and Grand Challenges Canada to scale Hewa Tele.
Gradian Health Systems will bring to this commitment a dual focus on product development for oxygen-related medical devices and training for biomedical engineering technicians. Gradian’s anaesthesia and ventilation work stations are specifically designed to succeed in rugged environments with unreliable infrastructure, including lack of electricity and medical oxygen, making them ideal complements to an effort to expand oxygen access. Additionally, with over 20 years’ experience working with and training biomedical engineering technicians across Africa and other low-resource settings, Gradian’s engineering team brings expertise in developing training materials, course work and maintenance programs that will be utilized for this commitment.
Grand Challenges Canada (GCC), funded by the Government of Canada, is dedicated to supporting Bold Ideas with Big Impact in global health. GCC will evaluate for possible support through its Transition-to- Scale program oxygen innovations that have the potential to save and improve lives of pregnant women and children under 5 years of age, including for Cesarean section and pneumonia.
Malaria Consortium will commit to test joint respiratory rate and pulse oximeter devices where possible as part of the ARIDA field trials in Ethiopia in partnership with UNICEF and feed the results into the implementation of the Government of Ethiopia’s National Oxygen and Pulse Oximetry Scale-Up Plan.
Masimo Corporation will improve availability of its Measure-Through Motion and Low Perfusion pulse oximetry and pulse co-oximetry in the health centers and hospitals, particularly in maternity and pediatric wards by developing an effective and efficient health screening model for prevention, detection, and treatment. Masimo will also contribute to improving clinical decision-making algorithms and to building a strategic service delivery model recommendation for the sustainable post-deployment support of education, training, maintenance, service, support and re-supply.
PATH will shape the global market for oxygen concentrators and pulse oximeters, promoting the Ethiopian oxygen model at the regional and global levels to stimulate strategic change in other low-resource settings, and increasing understanding of the oxygen access issue and solutions among decision-makers, health care providers, and advocates. PATH will serve as the primary liaison for suppliers of oxygen concentrators and pulse oximeters providing information on the total market size, potential business opportunities, and strategies for engagement in Ethiopia and other low-resource settings. Finally, PATH will advocate for integration and broader awareness of oxygen and pulse oximetry as lifesaving commodities within global reproductive, maternal, newborn, child, and adolescent health frameworks.
Philips will support this commitment through innovation by the Philips Africa Innovation hub and through its Community Life Center (CLC) approach to primary healthcare, which supports access to oxygen through the systemic development of locally relevant healthcare delivery systems and prioritizes infrastructure, IT, capacity building and appropriate diagnostic and therapeutic medical devices. Together with support from others such as Grand Challenges Canada and in collaboration with the Ministry of Health, Philips will drive the effort to disseminate at scale the Philips Children’s Respiration Monitor, which supports the diagnosis of childhood pneumonia and can improve access to treatment. In support of pulse oximetry, Philips will collaborate with Save the Children on the development of an affordable and robust diagnostic platform for neonates and young children.
The Pneumonia Innovations Network will mobilize its members to host a Summit in 2017 to bring the major stakeholders together to launch this commitment in Ethiopia. In addition, the Team commits to hosting at least three webinars on issues relating to this commitment during 2017 and to leverage its access to governments, UN agencies, foundations, companies and NGOs to further advance the commitment by attracting new partners, new funding and new advocacy opportunities. The Team will also serve as the central body for monitoring the commitment, reporting quarterly to the partners and annually to CGI.
Save the Children will support the Ethiopian government to improve the management of childhood pneumonia and other child illnesses, and increase child survival by 2019 by supporting the Ethiopia FMoH to implement scale-up of oxygen and pulse oximetry for child health through providing technical assistance around policies; guidelines; training program and materials; monitoring, learning, and evaluation; and advocacy efforts.
UNICEF will leverage the Every Breath Counts advocacy campaign—launched by UNICEF at the African Union Summit in January 2016—which highlights the need to increase focus on pneumonia, the single leading killer of children under five globally. The campaign has provided a platform to tackle childhood pneumonia by strengthening the relationship between immunization, nutrition, water and sanitation, climate change, the environment and child health. UNICEF and partners will continue to raise awareness of pneumonia’s impacts on the world’s children through champions, such as the First Lady of Nigeria, and will endeavor to increase both donor and government funds for the implementation of pneumonia-related programming in Ethiopia, highlighting the role that lack of oxygen plays in child and pneumonia-related mortality both in Ethiopia and globally. Additionally, UNICEF Ethiopia works with the Government of Ethiopia (GOE) to address maternal health, newborn and child health, health policy and systems, and caregiving for children. UNICEF Ethiopia is strengthening community health systems through technical assistance, financial support, and supplies for the GOE Health Extension Program (HEP). UNICEF Ethiopia will support UNICEF’s commitment as a lead partner in-country and provide technical assistance to the GOE to improve access to oxygen across Ethiopia.
The University of Alberta commits to promoting and implementing solar powered oxygen delivery, where possible, within the Government of Ethiopia’s National Oxygen and Pulse Oximetry Scale-Up Plan.
The U.S. Fund for UNICEF will support UNICEF in its commitment to mobilize resources, increase visibility, and facilitate partnership coordination as it pertains to U.S. donor engagement and grants management.
USAID will support the Ethiopian Government to rationalize routine pulse oximetry and oxygen with the larger menu of extant interventions to improve maternal and child quality of care to strengthen primary care and community level planning and service delivery.
The World Federation of Societies of Anaesthesiologists (WFSA) commits to training anaesthesia providers on pulse oximetry and oxygen provision as part of the Safer Anaesthesia From Education (SAFE) programme, and working alongside the Ethiopian Society of Anaesthesiologists as anaesthesia experts, advisers, and campaigners on relevant policies, standards and guidelines.”
The Centre for International Child Health (University of Melbourne/MCRI) will support the Government of Ethiopia’s National Oxygen and Pulse Oximetry Scale-Up Plan by providing technical assistance regarding the effective implementation of pulse oximetry and oxygen therapy. We will contribute our expertise in child health guidelines, implementation of large-scale oxygen projects (in Papua New Guinea, Laos and Nigeria), hospital quality improvement, and effective clinical training.
The United4Oxygen Alliance is in support of the United Nations (UN) Sustainable Development Goals and the Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016-2030).
Note in 2020 United4Oxygen was merged into the Every Breath Counts Coalition.
Updated September 2021