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Fighting for breath: time to invest in oxygen delivery systems in India

By Dr Vinod Kumar Anand, Head of Health, Save the Children India

The second highest burden of under-five pneumonia deaths in the world

In India, a child dies from pneumonia every 4 minutes. Childhood pneumonia here accounts for 14% of under-five deaths.

Amid India’s extreme contrasts in wealth and poverty, it is disadvantaged and marginalised children who are at greatest risk from deadly pneumonia. Children whose immune systems have been weakened by malnutrition, and who live in areas with high levels of air pollution and unsafe water, sanitation and hygiene services.

A recent study conducted by Save the Children revealed that the overall prevalence of acute respiratory infection among children under five years of age was more than 13%. One in ten children with pneumonia has it severely, which requires admission to hospital. As set out in the Global Integrated Action Plan for Prevention and Control of Pneumonia & Diarrhoea (GAPPD) framework, good-quality inpatient care is critical to save these children. High on the list of priorities comes far better oxygen delivery systems: it’s estimated better access to medical oxygen could reduce childhood pneumonia related mortality by at least 35%.

Picking up the warning signs: pulse oximetry is accessible and affordable

The standard non-invasive method of detecting hypoxaemia – severe and life-threatening lack of oxygen in the blood – is pulse oximetry. The World Health Organization (WHO) recommends oximetry to be used on all patients presenting or admitted with respiratory illness or exhibiting emergency signs or any signs of hypoxaemia.

It’s a straightforward intervention. Feasibility studies show that all health workers – including community health workers – can be trained to use pulse oximeters effectively. Pulse oximeters are produced in India and can cost as little as $170.

Why oxygen concentrators are the way forward

Medical oxygen must be used judiciously. It can be supplied in different ways – by cylinders, concentrators or larger oxygen plants – that each have unique advantages and disadvantages. Central piped oxygen systems are unsuitable for many district-level hospitals as they are expensive to set up and run. Oxygen cylinders are easy to use but operational costs are high.

By contrast, oxygen concentrators are less expensive. They offer a safe, reliable source of oxygen, which is more convenient and accessible than oxygen cylinders. WHO estimates a kilolitre of oxygen costs $10–30 from a cylinder, compared with just $2–8 from an oxygen concentrator.

Health facilities lack oxygen delivery systems

However, many health facilities in India’s 28 State and 8 Union Territories lack functioning oxygen delivery systems. In 2014, an assessment study by the Ministry of Health & Family Welfare, the UN Development Programme and the Norway India Partnership Initiative evaluated the key aspects of paediatric care in 13 district hospitals across 4 high burden states of India[1]. It revealed that oxygen delivery systems were inadequate and that oxygen saturation levels in patients was not monitored in district hospitals.

Findings in 2019 from Save the Children’s situational analysis on childhood pneumonia found that in the high-burden states of Uttar Pradesh, Madhya Pradesh, Rajasthan, Bihar and Jharkhand, health facilities at the district and sub-district level were under-prepared for providing inpatient care for pneumonia cases. It found that, while 80–90% of district hospitals and community health centres had a supply of oxygen, only 65% of community health centres had functional pulse oximeters. Most worrying, the study found that, as a result of inadequate training and poor record-keeping, oxygen is often poorly administered.

Government response

The Government of India launched Social Awareness and Actions to Neutralize Pneumonia Successfully (SAANS) in 2019 to strengthen the rational use of oxygen for severe pneumonia cases. The guidelines clearly recommend uninterrupted availability of oxygen delivery systems and use of pulse oximeters to ensure safe oxygen delivery. Almost all the state governments have budgeted for SAANS trainings for their health staff and for the purchase of pulse oximeters in the current year. Ensuring uninterrupted supply, functioning equipment, capacity building and supervision of health staff will go a long way to ensuring the judicious use of oxygen and pulse oximeters to save lives.

A long way to go

The speed that the COVID-19 pandemic is spreading is putting an immense burden on weak health facilities at all levels. Severe cases of COVID-19 result in pneumonia and require oxygen and other life-saving measures.

But this pandemic is also an opportunity to channel resources to strengthen oxygen delivery systems at all levels of the health system – by building the supply chain and providing the training to health workers. India is still a long way from achieving the goal – set out in the National Health Policy and Integrated Action Plan for Pneumonia and Diarrhoea – to reduce childhood pneumonia mortality from 5 to 3 deaths per 1,000 live births by 2025. Scaling up access to oxygen delivery could help address that challenge by saving hundreds of thousands of lives each year.

In crisis there is opportunity. Now is the moment for India to be strategic and, in responding to the pandemic, to build a more resilient and stronger health system for the future and for everyone.


[1] Assessment of Quality of care in hospitals in India, UNDP Newborn Project, 2014

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