Scenes of relatives desperately trying to find oxygen supplies for hospitalized COVID-19 patients in India last year, alerted the world to an acute, deadly problem. Yet that was not this first time the country’s hospitals have been hit by a shortage of the life-saving gas, prompting the question of whether there will be enough supplies, when the next major health crisis hits.
In May 2021, India’s hospitals were at breaking point. The country found itself at the epicentre of the global COVID-19 pandemic, and one of the biggest challenges was providing enough medical oxygen for the sickest patients, unable to breathe unaided, as demand rose ten-fold.
By the end of April, there were just under 18 million confirmed cases, and over 200,000 deaths.
‘Out of stock’
Some hospitals posted “oxygen out of stock” signs, whilst others asked patients to search for treatment elsewhere.
As news organizations published stories about patients dying from a lack of oxygen, family members decided to take matters into their own hands, hunting for canisters that might save the lives of their loved ones.
To many observers, the crisis seemed to indicate a lack of planning on behalf of the authorities, not least because this was far from the first time that medical oxygen had been scarce during a health crisis, even during the present pandemic.
Just a few months earlier, in September 2020, the country had already found itself in a similar situation: as case numbers soared, medical oxygen production failed to keep pace, amid an exponential growth in demand.
And many people remembered that 70 children had died at a government-run hospital in Uttar Pradesh due to a lack of oxygen in 2017, when a supplier stopped delivering canisters, after complaining of unpaid bills.
India’s huge size, and the way its oxygen production industry is set up, were also identified as key factors. Only a small number of India’s hospitals have the facilities to produce the gas in-house, and the rest depend on deliveries from private companies.
Oxygen production plants are concentrated in the industrial belt of eastern India, meaning that cryogenic trucks, specially designed to carry liquid oxygen, have to travel long distances to reach regional suppliers, which transfer the gas into smaller containers for delivery to hospitals.
© UNICEF/Ronak Rami
Two workers set up the oxygen cylinders for treating patients with respiratory diseases, in India.
The Indian Government, the UN and other humanitarian organizations, responded to the emergency in a variety of ways.
Additional tankers were airlifted from abroad, tankers used for liquid argon and nitrogen were converted to carry oxygen, and the railways innovated to introduce special “Oxygen Express” trains.
Industrial oxygen was diverted from steel plants to hospitals and the procurement and distribution of oxygen concentrators was stepped up.
The UN focused on getting hold of essential equipment such as concentrators, ventilators, and oxygen-generating plants, as well as implementing other measures to reduce the rate of serious case numbers, speeding up the rollout of vaccination programmes, and improving testing facilities.
The World Health Organization (WHO) deployed over 2,600 public health specialists working on other diseases to tackle the epidemic in India, and around 820 staff members from the UN Children’s Fund (UNICEF) and UN Development Programme (UNDP) helped the authorities to monitor over 175,000 COVID-19 centres across the country.
Maintaining a steady flow
But how should India prepare for the next oxygen emergency, given the unpredictable nature of demand for the gas, in a country where the cost of producing, storing and transporting it, is higher than the cost of the product itself?
And how can better distribution be ensured, so that oxygen is available wherever it is needed, at all times, and no one is deprived of this life-saving product?
These questions were tackled in January by Ramana Gandham, Rajaji Meshram, and Andrew Sunil Rajkumar, a trio of health specialists, in a blog published by the World Bank.
Following technical assistance from the international financial institution in four Indian states – Andhra Pradesh, Meghalaya, Uttarakhand and West Bengal – as well as with the central Government authorities, the experts set out a series of options to strengthen the country’s medical oxygen policy.
© UNICEF/Vineeta Misra
A patient who may have COVID-19 waits for medical assistance at a facility in the Goregaon area of Mumbai, India.
Hike in production
They recommended a significant hike in the production of medical oxygen, a process that has already begun: more than a thousand new plants are being funded by the Government, producing 1,750 metric tons of oxygen every day, and more plants have been set up with regional and private sector backing.
The specialists recommend supporting hospitals that want to build their own plants, on site, which would reduce the problem of distribution. In some areas, such as Bihar state, companies are offered incentives, such as subsidized land or utilities, and low-interest finance, to set up plants.
Once they’re up and running, it’s important that the plants are maintained, something that has not always been the case, due to a lack of resources.
The same goes for all storage tanks and delivery systems, such as specialized trucks. Trained people are needed to run the plants, and India has launched an initiative to train 8,000 technicians capable of operating and maintaining them.
The experts found that, during the May 2021 crisis, the issue was not so much a shortage of medical oxygen, but rather the concentration of medical oxygen in eastern India, and the inability of the distribution network to ramp up to meet the ten-fold surge in demand.
One solution to this issue is the creation of “buffer storage” facilities, at strategic locations, so that oxygen can be delivered far more quickly during emergencies.
Since the last wave, the Indian Government, technical partners, and private agencies have worked closely to estimate India’s future demand for oxygen.
Many forecasting and modelling techniques have been used to develop a deeper understanding of production, demand and storage requirements.
Digital tracking systems have now been set up, to allow India’s states to ensure the delivery of oxygen at different points along the supply chain, monitor consumption and forecast demand.
In Uttarakhand, 30,000 Radio-Frequency Identification (RFID) tags have been distributed to medical oxygen suppliers and hospitals, to be affixed on oxygen cylinders. Delhi, whose hospitals were badly affected by a lack of supply during the May 2021 COVID wave, is also making use of tracking technology.
It is hoped that, by putting these measures in place, the country will be able to swiftly and effectively respond to the next health emergency, minimise deaths, and avoid a repeat of the distressing, chaotic scenes witnessed less than a year ago.
World Bank support for India
- To date, the World Bank Group has provided over $3 billion in support of India’s efforts to combat the COVID-19 pandemic. As part of this, Bank projects at the national and state level are working with India to address critical gaps in its oxygen supply systems.
- At the peak of the second wave, the Bank Group worked closely with global suppliers to facilitate the rapid purchase and delivery of 29,600 high quality oxygen concentrators for the country. The Bank also assisted with the sourcing of other oxygen-related commodities within India, such as oxygen cylinders.
- In partnership with the NGO PATH, the Bank provided targeted technical assistance to four states – Andhra Pradesh, Meghalaya, Uttarakhand and West Bengal – to strengthen their oxygen systems and build capacities. It also supported the central Government on key transport and logistics issues related to medical oxygen in India.