09 Jul Medical oxygen and the SDGs
“Apart from oxygen, name one other essential medicine that is a topline treatment for all but one of the conditions targeted by the health SDGs?”
This was the focus of the second of three High Stakes Conversations on the role of medical oxygen and global health goals hosted by Every Breath Counts on 27 June 2024. The event, The Sustainable Development Goals (SDGs) and Access to Medical Oxygen, brought together leading experts on four health SDGs – Chinyere Ezeaka from Lagos University on newborn survival (SDG 3.2), Mike Hess from the COPD Foundation on chronic disease reductions (SDG 3.4), Arthur Kwizera from Makerere University on safe surgery (SDG 3.5), and Mike Fogarty from WHO on Universal Health Coverage (SDG 3.8). While focusing on these four SDGs, the conversation kicked off with Leith Greenslade of Every Breath Counts making a bold claim that medical oxygen is the only medicine that is recommended to treat eight of the nine health conditions targeted by the SDGs.* With almost all countries off track to achieving the health SDGs by 2030, according to the latest independent SDG report, most governments are looking for strategies to make fast progress. Medical oxygen is one of them.
“The vast majority of medical oxygen needed for surgery is in low- and middle-income countries and most othe need is currently unmet.”
Oxygen and safe surgery (SDG 3 multiple)
Arthur Kwizera, leading anesthiologist and critical care clinician from Uganda, began by outlining the massive global need for medical oxygen as part of surgical procedures, citing Lancet estimates that 30% of all diseases require surgery. However, the vast majority of this need (80%) is from patients in low- and middle-income countries, where only 20% of the global surgical workforce is located and where 50% of health facilities do not provide medical oxygen. In this context Kwizera challenged the WHO recommendation that adult patients undergoing surgery should receive 80% fraction of inspired oxygen (FiO2) during surgery and for two to six hours afterwards, as unable to be implemented in low-resource settings. It may also lead to unnecessary oxygen consumption and even harm to patients, as a review and several studies have indicated here, here, here, and here. Kwizera concluded that more conservative administration of oxygen therapy may be more lifesaving. Further, as arterial blood gas analysis is largely unavailable in low-resource settings, Kwizera recommended wide use of pulse oximetry both during and after surgery, and accelerated uptake of new non-invasive technologies like the Oxygen Reserve Index which measure oxygenation in surgical patients receiving supplemental oxygen to help clinicians manage hyperoxia and prevent hypoxia. Kwizera concluded by appealing for a greater focus on “preventive critical care,” including by wider pulse oximetry monitoring in homes to enable faster access to care and reduce the need for invasive critical care.
“The number of COPD patients is expected to rise from 480 million to 600 million by 2050, with massive implications for demand for home oxygen.”
Oxygen and chronic disease (SDG 3.4)
Mike Hess, respiratory therapist with the COPD Foundation in the United States, focused on the massive burden of chronic obstructive pulmonary disease (COPD) as a major driver of global medical oxygen need. Citing current estimates of 480 million cases of COPD, expected to reach 600 million by 2050, Hess underscored the vital role of medical oxygen in extending life and improving the quality of life for COPD patients. However, while COPD patients in high-income countries have benefited from access to home oxygen therapy from electric concentrators, cylinder deliveries, and other innoivations – most often covered by health insurance – patient popuilations living in low- and middle-income countries are largely underserved, with many undiagnosed and home oxygen markets fragile or non-existent. He concluded by calling for significant increases in investments to close access gaps for patients with long-term oxygen needs, and for new efforts to raise awareness about the need. Walking the talk, Hess unveiled plans for World Oxygen Day on 2 October 2024, where for the second time, the COPD Foundation will rally the world to come together to advocate for medical oxygen.
“Low oxygen level is the commonest cause of death in newborns.”
Oxygen and neonatal survival (SDG 3.2)
Chinyere Ezeaka, leading neonatologist from Nigeria, presented a strong case for medical oxygen access to be front and center of efforts to reduce newborn deaths, citing the many conditions that result in low levels of oxygen in the blood, including prematurity (respiratory distress), infection (pneumonia), and birth injury (hypoxic brain injury). Ezeaka stated that oxygen administration begins in the delivery room and underscored the need for well trained clinicians to administer and monitor oxygen very carefully using blenders and pulse oximeters to avoid retinopathy of prematurity (ROP) and other harms. However, as most health faclites in low resource settings lack both the technologies and the trained clinicians to operate them safely, huge investments are needed. NEST360 (Newborn Essential Solutions & Technologies) is an example of such an investment with 22 organizations working across 130 hospitals in five African countries to reduce newboth deaths. A key goal is to ensure that the Every Newborn Action Plan (ENAP) target of at least 80% of disctricts with one hospital providing Level 2 inpatient care for sick newborns including respiratory support (i.e., CPAP). Ezeaka concluded that this work needs to happen in many more countries and that resources have been developed to help countries follow the NEST360 model, including the Newborn Toolkit.
“Almost 6 in 10 people lack access to any form of UHC, and 2 billion face financial hardship paying for health services, including medical oxygen.”
Oxygen and Universal Health Coverage/UHC (SDG 3.8)
Finally, Mike Fogarty who leads primary health care at the World Health Organization (WHO) argued that while medical oxygen and pulse oximetry services should be covered by national UHC schemes, 57% of people (4.5 billion) currently lack of access to any type of UHC and 2 billion face financial hardship accessing health services, according to the latest UHC Monitoring Report. Fogarty outlined several tools to help governments prioritize which health services will be covered by UHC and these included options for medical oxygen and pulse oximetry services. He demonstrated how governments can use the WHO UHC Planning and Packages tool to ensure that medical oxygen and pulse oximetry are covered across the disease landscape and for all relevant partient populations, and encouraged the audience to register for an account and explore how the tool could be applied. Fogarty acknowledged the body of evidence that patients in many low-resource settings are being forced to pay steep out-of-pocket costs for oxygen or forgo treatment, and recommended that the access to oxygen movement raise awareness about the UHC Planning and Packages tool with national governments.
The consensus of the second High Stakes Conversation was that governments and the broader health community remain largely ignorant of the power of medical oxygen to accelerate achievement of most of the health SDGs. Although the COVID-19 pandemic raised awareness of the vital role of medicla oxygen as an essential medicine, stakeholders have been slow to act to incporporate medical oxugen into exoisting polciies and programs. With only six years left to achieve the health SDGs, this needs to change. The organizations and initiatives aligned with each of the health SDGs – EPMM/ENAP, Child Survival Action, The Global Fund, the NCD Alliance, Resolve to Save Lives, Safe Surgery, Global Campaign for Road Safety, Global Alliance on Health and Pollution, UHC 2030, and more – all need to pay more attention to medical oxygen. And the Global Oxygen Alliance (GO₂AL), a new coalition co-chaired by Unitaid and the Global Fund, is well placed to play a leading role in making these connections.
You can watch the entire conversation here.
*Strengthening medical oxygen systems can help a country reduce maternal, newborn, and child deaths (SDGs 3.1 and 3.2), deaths from HIV/AIDS, TB, and malaria (3.3), chronic disease deaths (3.4), substance abuse deaths (3.5), road traffic accident deaths (3.6), poisoning deaths (3.9), and achieve UHC (3.8).
High Stakes Conversation #2, June 2024
If you missed High Stakes Conversation #1, Access to Medical Oxygen and Respiratory Pandemics, you can watch here and read the summary here.