Oxygen therapy is essential for treating severe covid-19 and numerous other conditions. However, for many patients, including women, children, and newborns, this essential treatment is unavailable, resulting in millions of deaths globally.

Oxygen shortages are an indicator of health inequities within and across countries. Oxygen has been on the WHO Model List of Essential Medicines and List of Essential Medicines for Children since 2017 for treatment of hypoxemia and is also crticical for treating patients with pneumonia. However, nearly 50% of health facilities in low resource settings had inconsistent or no supply, only half had pulse oximeters, and the poorest countries had less than 20% of the medical oxygen they needed. Oxygen shortages and rising prices are reported in countries that have some of the highest numbers of child deaths due to pneumonia, such as India, Bangladesh, and Nigeria.

Severe pneumonia affects more than 22 million young children in low and middle income countries annually and is the single largest infectious cause of death among children worldwide. More than 800 000 children aged under 5 died from pneumonia in 2017 alone—that’s more than from malaria, measles, and diarrhea combined. It accounts for 15% of all deaths of children in that age group, and death rates are three times higher among children in the poorest 20% of households than in the richest. Cost is a huge barrier to treatment for low income households; oxygen to treat a child with severe pneumonia over 3-4 days costs around US$40-60. It’s estimated that better access to oxygen could save 148 000 children aged under 5 each year in the 15 countries that have the highest burden of mortality due to pneumonia. Availability of oxygen could also prevent deaths from other non-respiratory conditions that result in hypoxemia, such as sepsis and severe malaria, and is equally essential during surgical care, anesthesia, and childbirth.

Covid-19 has exacerbated health inequities among the poorest and most vulnerable, particularly among women, children, and adolescents. With health systems and supply chains under huge added stress, it has become even more difficult in some countries to get oxygen for everyone who needs it. In many hospitals, health workers have to make heartbreaking choices about who gets oxygen and who doesn’t. This is an immense moral burden for health workers, who may themselves be vulnerable, often working without adequate protection and support. Meanwhile, demand for oxygen for patients with covid-19 inevitably competes with demand for non-covid patients.

Invest in oxygen

As part of the PMNCH Health-Care Professionals Associations constituency, and in the context of the PMNCH “Call to Action on COVID-19,” we want to underline how urgent investment in medical oxygen is to ensure equitable, safe, and efficient manufacture, distribution, and supply management, and to maximize safety and support for health workers. This includes investing in oxygen concentrators to increase the availability, management, and quality of oxygen therapy available in low resource settings (when reliable electricity is available). In parallel, health system investments must be in place for the appropriate transport, set up, and storage of oxygen cylinders, as well as structural maintenance of oxygen piping to ensure the delivery of quality oxygen. These investments will strengthen health systems’ ability to provide access to maternal, newborn, child, and adolescent health services and supplies through the covid-19 response and recovery period, helping us to protect and promote the health, wellbeing, and rights of the most vulnerable.

While securing adequate supplies in every setting, we also need to ensure that healthcare facilities have the expertise and equipment in place to deliver oxygen safely and effectively. Health workers require training in emergency triage, pulse oximetry, and oxygen therapy. For infants and small children, we need to ensure the supply of suitable delivery devices, such as appropriately sized masks, nasal cannulas, and monitoring devices such as portable pulse oximeters, as well as improved laboratory facilities to monitor blood oxygen levels. There are many situations where babies may be born compromised outside of medical facilities, or there might be a need to administer oxygen during transfer to higher level of care facilities. Task shifting and task sharing could improve the capacity of low resource settings to manage these scenarios, with appropriately trained and experienced midwives and nurses authorized to administer oxygen in the absence of a medical doctor, when an adequate support system is in place.

We urge governments not to divert already limited oxygen supply away from essential needs for women, newborns, children, and adolescents. They should invest in sustainable and robust oxygen management systems during and after covid-19, guaranteeing equity in oxygen manufacture and management, and ensuring access for people on lower incomes. Equipment should be safely delivered, maintained, and stored. Providing oxygen therapy can introduce certain risks in the workplace, such as exposure to aerosols when treating patients on respiratory support. Governments should therefore provide frontline healthcare workers, notably nurses, midwives, and doctors, with adequate protective personal equipment and ensure safe working conditions. 

The availability of oxygen therapy can make the difference between life and death, and healthcare workers should not be forced to decide who should, or should not, receive it. While covid-19 has exacerbated the oxygen divide, there was already a chronic shortage. Our focus now must be on ensuring we have a sustainable supply, with equitable and safe distribution of this essential commodity at a community level. We must meet the need for oxygen without delay.  

Authors – as part of PMNCH Health Care Professional Associations constituency

Errol R Alden, president, International Pediatric Association.

Competing interests: none declared.

Franka Cadée, president, International Confederation of Midwives.

Competing interests: none declared.

Jeanne Conry, president elect, International Federation of Gynecology and Obstetrics.

Competing interests: I sit on the board of directors for two non-profit organizations: Forum Institute and Heartland Health Research Alliance. It is unpaid. They both advocate or do research on environmental exposures and newborn/maternal health.

Annette Kennedy, president, International Council of Nurses.

Competing interests: none declared.

Karen Walker, president, Council of International Neonatal Nurses.

Competing interests: none declared.

Acknowledgments: We would like to thank Ann Yates and Florence West, International Confederation of Midwives, Anne-Sylvie Ramelet, International Council of Nurses, Carole Kenner, Council of International Neonatal Nurses, and Jonathan D Klein, International Pediatric Association, for their contributions.