Abstract
Oxygen support became one of the rate-limiting steps for medical care during COVID-19 pandemic in India. The primary aim of this study was to appraise the manufacturing, supply, and distribution of medical oxygen during the pandemic. The secondary objectives were to highlight the coordination of various stakeholders to mitigate the oxygen surge and to present a critical analysis of India’s response to the emergent situation. Using an analytic approach, we have delineated India’s response to mitigate the medical oxygen surge during the distressing second peak between March–May 2021. In the pre-COVID-19 era, of the total 6900 MT of oxygen produced in India, only 1000 MT was available for medical usage, which was increased up to 19940 MT through the strengthening of in-house oxygen manufacturing, low-cost innovations, and enhanced storage facilities. High-burden states were identified, and transport was facilitated through departments of railways, defence and civil aviation. Real-time scrutiny of the oxygen supply was provided. Essential customs duties on importing oxygen and vital equipment were exempted, along with other swift decisions. National Oxygen Stewardship Program’ was initiated to build the capacity of health care workers in oxygen therapy and rational use of surplus oxygen. The pandemic overwhelmed the health system. But a coordinated multi-stakeholder approach facilitated the fight against oxygen surge. However, a comprehensive pandemic response will need more than just oxygen. This resourceful utilization offers a silver lining and facilitates the improvement of health systems and health outcomes in the long term.
Keywords: COVID-19, health equity, health management, oxygen surge, supply chain
INTRODUCTION
India has been one of the worst affected countries during the Coronavirus (COVID-19) pandemic. Like several other countries, India battled for optimal usage of medical logistics such as testing kits, hospital beds, intensive care units (ICU), ventilators, and medical oxygen (MO).[1] Oxygen was the key therapeutic agent during the COVID-19 pandemic because of the predominant respiratory manifestations of the disease.[2,3] The World Health Organization (WHO) reported that nearly 15% of COVID-19 patients required MO. The requirement varies according to the severity of the disease, with severe cases requiring intensive support with a longer hospital stay.[4,5] The shortage of MO in hospital setups of low-middle-income countries (LMICs) has been highlighted previously. In 2015, the Lancet Commission on Global Surgery mentioned that nearly one-fourth of surveyed hospitals in LMICs lacked sufficient MO supply. Before the pandemic, nine in ten hospitals in LMICs lacked access to pulse oximetry and optimal MO, while only one-fifth of needy patients could receive MO.[6]
In the past two years of the pandemic, most hospitals across India, especially those treating COVID-19, suffered an acute shortage of MO, primarily due to an unprecedented surge in oxygen demand.[5] The shortage was initially noted during the peak of the first wave of COVID-19 as MO demand peaked at 3095 MT on September 29, 2020.[7] During the second wave in 2021, the demand rocketed due to the delta variant, and the deficit escalated steeply.[8,9] The need for MO escalated several times, touching an average of 5500 MT a day by the third week of April 2021, 7100 MT in the fourth week of April 2021, and 8943 MT in early May 2021.[10] Some reports claimed that many lives were lost across the country due to MO shortage or denial.[11] The scarcity was attributed to several factors, including an unexpected surge in the number of patients, a consequent increase in the demand for isolation and ICU bed capacities in the country, and the logistic challenges in the supply chain of oxygen distribution, including the production and transport facilities.[12]
The distribution of MO is complex, with multiple stakeholders and mostly private players in the supply chain. In India, large hospitals are usually supplied MO directly by manufacturers that use tankers to transport the MO.[13] Meanwhile, medium and small hospitals rely primarily on intermediate gas agencies. The manufacturers supply liquid medical oxygen (LMO) to filling stations via tankers, and these agencies get their cylinders filled and after that, supply them to these hospitals either via “jumbo cylinders” (gaseous oxygen-GOX) or “dura cylinders” (containing LMO that expands 860 times to gaseous form).[14] India’s estimated split of liquid oxygen system (LOX) and gas cylinders system (GOX) is 70% and 30%, respectively.[15] Thus, an uninterrupted supply of oxygen through this complex distribution network during the pandemic in a country like India, with vast geographical diversities, was a herculean task.
However, foresightedness, precision in decision-making, and multisectoral participation assisted India in mitigating the oxygen surge at national and subnational levels. This acute shortage was also noticed in other LMICs and high-income countries, which overwhelmed the health systems.[16] Therefore, our primary objective was to appraise MO’s manufacturing, supply, and distribution across India during the pandemic. This review also highlights the coordination between various stakeholders to mitigate the oxygen surge and formulate long-term plans to combat similar situations. In addition, we present a strength, weakness, opportunity, and challenges (SWOC) analysis of India’s response to the emergent situation.
METHODS
Study settings
India has a semi-federal democratic governance system. The Constitution of India accords the responsibility of “health” in its states and preventing the spread of infectious diseases from one state to another concurrently with the Government of India (GoI) and the states.[17] India witnessed a high risk of the burden of COVID-19 due to its enormous population size, high population density, significant socio-economic disparities, increased migration, and a high prevalence of comorbid conditions.[18,19] The pandemic peaked multiple times, with some states experiencing increased burden and an early peak (Delhi, Kerala, Maharashtra, Tamil Nadu, Karnataka) while being more gradual and spread out in other states (Bihar, Odisha, Chhattisgarh). Till August 18, 2022, there were 44,298,864 confirmed cases, with 527,206 deaths since the detection of the first case on January 30, 2020.[20] The overall production of oxygen in the pre-COVID-19 era was approximately 6900 MT daily. The medical consumption was almost 1000 MT per day, and the industrial sector was using the rest.[21]
Data sources
The authors kept track of COVID-19 developments between January 2020 and October 2021. Initial search terms included COVID-19, oxygen surge, Liquid Oxygen, and medical oxygen to explore the notifications issued by the GoI through the Press-Information Bureau and the official websites of the Ministries involved in oxygen management. Newspaper briefings concerning steps taken by different stakeholders to manage oxygen surges facilitated the search for relevant updates on government websites. We pooled the official government communications relevant to oxygen surge management during the pandemic (e.g., public orders, circulars, advisories, guidelines, press releases, updates on official websites), guidance documents for stakeholders, excerpts from leading national and local newspapers, and relevant reports. Further information was retrieved using the standard snowball search technique. For data on COVID-19 disease burden, we used data available in the public domain (https://github.com/covid19india/data.).
Quality checks and archiving
The primary author (Moonis Mirza), a hospital administrator, curated the repository by removing duplicate documents and verifying authenticity through triangulation from government documents and websites. Data were archived chronologically according to date and with labels for easy retrieval. The quality check and relevance to the study for inclusion in the study were cross-verified by two other authors (MV, SSS), who are community medicine experts with experience in data handling and curation. Any discrepancy was resolved by a senior author (RK). Two senior authors (DKS, SR), actively engaged in micromanaging the oxygen management in their administrative positions, provided critical inputs concerning the facilitators and gaps in the direction.
Synthesis and analysis
The present scoping review was conducted between October 10 and December 20, 2021, where key events were compiled by sequencing the documents into a repository, and duplicate data were merged. Consequently, we cross-validated all the information, searched for additional information on the internet, and contacted the contributing stakeholders (like Linde and INOX, the primary MO suppliers in India) for detailed information. The WHO 2018 updated pandemic influenza risk, and impact management checklist were used to group the data into relevant themes by MM.[22] Two co-authors (MV, SSS) independently reviewed the paraphrasing and theme assignment and made suggestions as and where necessary. Subsequently, after repeated discussions among the authors, we reached a consensus to critically analyze surge management using SWOC framework.
Ethics statement
Being a secondary analysis of information available in the public domain and not involving any individual human or patient-level data, ethics approval was not sought.
RESULTS
We cataloged over 200 government circulars, notifications, and office orders concerning oxygen surge and its management that were made public between January 2020 and October 2021. Maximum notifications were communicated by the Ministry of Railways (n = 64), followed by the Ministry of Defence (n = 25), Ministry of Health and Family Welfare (MoHFW n = 20), and Prime Minister’s Office (PMO) (n = 13). The proactiveness of the response can be gauged from the fact that the frequency of critical decisions announced by the GoI broadly coincided with the peak daily rise of COVID-19 cases [Figure 1]. This multi-disciplinary coordinated response proved to be the biggest strength, as per the SWOC analysis [Table 1].
Figure 1.
COVID-19 burden and number of crucial Government decisions per day
Table 1.
Critical appraisal of the oxygen mitigation strategies during the COVID-19 pandemic in India
Internal factors | External Factors |
---|---|
Strengths | Weaknesses |
Multidisciplinary approach | Low inherent medical oxygen production capacity in comparison with the increase in the number of COVID-19 dedicated beds |
Newer initiatives for strengthening in house oxygen manufacturing | Urban-rural divide in terms of available health facilities |
Strengthening of supply chain by involving railways, Indian air force, navy and road transport | Geographical disparities in the production and requirements. |
Opportunities | Challenges |
Better utilization of private sector. | Few manufacturing dedicated units for medical oxygen production |
Establishment of National Oxygen Grid (based on hub and spoke model) | Limited expertise in oxygen manufacturing and supply |
Periodic need assessment of oxygen requirements on a routine basis | Capacity of district hospitals and medical colleges ill equipped to monitor oxygen supply during critical times |
Diversion of resources and funds dedicated for strengthening of oxygen supply chain | Black marketing due to demand supply gap |
Make in India initiative and support of PM CAREs funds | Public panic and fear mongering |
Judicious use of foreign ties and establishments | Media management and handling of public expectations |
Exponential surge of COVID-19 beyond capacity of health system | |
Sudden increase in demand of oxygen because of vulnerable COVID-19 patients with preexisting diseases, comorbidities, and elderly. | |
Unpredictable nature of the pandemic due to emerging variants of concern. |
The sudden rise of COVID-19 cases overwhelmed the health system regarding oxygen supply, trained workforce, drugs, and hospital beds. State governments revised strategies to deal with the pandemic surge early in 2021, learning from the first wave. Key strategies that were rolled included the development of a three-tier arrangement of dedicated COVID-19 health facilities consisting of the COVID Care Centre, dedicated COVID Health Centre, and Dedicated COVID Hospital. Other tertiary care hospitals under Employee State Insurance Corporation (ESIC), defense, railways, paramilitary forces, and steel ministry were also roped in, along with large temporary treatment facilities established by Defence Research and Development Organisation (DRDO). Due to concerted actions of Central and State Governments, the isolation bed and ICU bed capacity, which was only 10180 and 2168 before the first lockdown (as of March 23, 2020), was enhanced to 1821845 and 122035 (as on July 20, 2021) explaining the increase in the sudden demand of MO for COVID-19 patients).[23,24]
The unmet need for MO necessitated restructuring the in-house production, market, and supply chain. The low inherent oxygen production capacity of India with significant urban-rural and geographical disparities was the major roadblock [Table 1]. This was first documented in the 123rd report on the outbreak of the pandemic and its management by the Parliamentary Standing Committee on Health and Family Welfare. Oxygen demand was most pronounced during the second wave (March–May 2021), with the official data showing a maximum of 4.14 lakh cases on a single day, as reported on May 7, 2021. To address this surge, multisectoral efforts were orchestrated under PMO, MoHFW, and the MHA regulation. The coordinated efforts of the various ministries can be appropriately defined in terms of increased capacity for oxygen manufacturing and its streamlined transport and provision across the country [Figure 2]. The Supreme court, an apex judiciary body of India, took cognizance of the oxygen scarcity in the country, as highlighted by the national and international media, and directed to constitute a National Task Force (NTF) in compliance with its orders (SLP (Civil) No. 11622/2021; 6 May 2021). The court laid down twelve Terms of Reference for the NTF, of which five were about oxygen-related issues. This action further escalated the efforts made by the GoI in this direction. For ease of description, we categorized the critical decisions taken by the GoI to counteract the oxygen crisis into three primary domains, i.e. Manufacturing and storage, transportation, and ancillary support.
Figure 2.
Integrated and Multisectoral approach involving various external stakeholder ministries, under the supervision of the Prime-minister’s Office, Ministry of Home Affairs, and Ministry of Health and Family Welfare, to provide an supply of oxygen during the COVID-19 pandemic
-
Manufacturing and storage
The oxygen availability was enhanced to up to 19940 MT per day (by the end of the second wave of the pandemic) [Table 2] through concerted efforts to increase the manufacturing of MO and strengthen the storage capacity in the following ways:
- Granting new licenses and extending the validity of existing permits: Petroleum and Explosives Safety Organization strengthened the manufacturing and supply chain by granting new rights and extending the validity of current permits for manufacturing and transportation of oxygen and other medical gases.[25] Cognizant of the increased oxygen demand in the second wave, the Ministry of Commerce and Industry allowed relaxations for a period of three months in the rules for renewal of licenses under Gas Cylinder Rules, 2016. Further, liquid nitrogen/argon tankers were permitted to transport liquid oxygen after purging and degassing.[26]
- Establish mini oxygen plants at the point of usage: National Council Secretariat (NCS), GoI obligated all establishments with more than 50 beds to establish a mini oxygen plant, providing oxygen support to at least one-third of all the beds. In response to these recommendations by NCS, the Director of Public Health (DPH) mandated every hospital, including private hospitals, to set up a pressure swing adsorption (PSA) plant on their premises. The Indian Medical Council strongly opposed this in certain states due to the financial and space constraint for creating infrastructure.[27] In response, many forms, including New Delhi, Bihar, and Tamil Nadu, offered incentives to the private sector for setting up oxygen production plants and setting up oxygen storage facilities under the oxygen production promotion policy.
- Prohibiting oxygen supply for industrial purposes: Union Home Secretary prohibited oxygen supply for industrial purposes, except those stated by MoHFW.[28,29] Both public and private steel plants were engaged in increasing the production of LMO. With concerted efforts, the daily LMO production, which was about 5700 MTs per day in August 2020, increased to 9690 MTs as of May 13, 2021.[30] Alternative sources of MO production were explored by converting industrial nitrogen plants into oxygen plants by replacing carbon molecular sieve with zeolite molecular sieve.[31]
- Strengthening of storage capacity: The number of oxygen tankers (n = 1040; Capacity of 12480 MT in March 2020) increased with the conversion of nitrogen and argon tankers and additional imports to 1681 (23056 MT) by May 2021, with a 92% and 108% increase in tanks and storage capacity.[32] To further increase LMO storage capacity in the states, under the Emergency COVID Response Package-II (ECRP-II), 938 LMO tanks and 1359 manifold gas pipeline systems were established across the Country. GoI also imported 20 cryogenic tankers of 10 MT and 20 MT capacity and allocated them to States.[33] About 402517 cylinders were disturbed to all states/Union Territories (UTs) through multiple orders.[32] In addition, 1.5 lakh SPO2-based oxygen control systems cylinders were procured by DRDO under PM CARES fund, and 23247 cylinders were received from foreign aid. About 114000 concentrators [one lakh under Prime Minister’s Citizen Assistance and Relief in Emergency Situations (PM CARES) and fourteen thousand under ECRP] were procured and distributed to states/UTs, and 29397 concentrators were received through foreign aid and were distributed to states/UTs. As the MO demand was unpredictable (challenge as per SWOC analysis; Table 1) and the cost of infrastructure to produce, store, and transport is higher than the cost of the product itself, it was therefore essential to create a buffer storage to reduce delivery times. Hence, Union Health Minister instructed all the states and Union Territories to keep a 48 hours buffer stock in all health facilities providing in-patient care.[34] Ministry of Power kept a close eye on providing uninterrupted power supply through close supervision using a 24 hours oxygen plant control room and an internal control group.[35]
- Make in India initiatives: PSA plants are an established technology to generate oxygen at the local level, and hence 3920 of them were installed in hospitals, especially in far-flung areas, with the help of the DRDO, enabling them to become self-sufficient, thereby reducing the burden on the MO supply grid across the country.[36] The GoI supported states/UTs in the installation of 1225 PSA Plants under PM CAREs, while 393, 2366 PSA plants were established with support from the GoI’s Public Sector Units and other sources and through State and Corporate Social Responsibility (CSR) funds [Table 2].[37-39] The National Medical Commission also mandated all medical colleges to establish PSA plants.
“Indigenous hollow fiber membrane technology-based membrane oxygenator equipment (MOE)” was developed through the Department of Science and Technology funding that enriches oxygen in the air by up to 35% by using pressure (4–7 bar, through oil-free compressor).[40] The in-house designed and manufactured Portable Multi-feed Oxygen Manifold, using a six-way radial header fitted to a single cylinder enabled one oxygen cylinder to cater to the needs of six patients concurrently.[41] Oxygen recycling system designed by the Indian Navy helped to extend the life of the existing MO cylinders two to four times by reusing exhaled O2 and CO2.[42] “Oxygen on Wheels,” the mobile oxygen generation plants, were developed by the Indian Navy.[43] An indigenously designed oxygen concentrator was developed to ensure a high-purity oxygen supply for COVID-19 patients.[44] As the MO was transported in liquid form in cryogenic tanks, quick conversion of liquid MO to gas for ensuring timely availability at the patient’s bedside was a fundamental problem that was catered to by the engineers from the Indian Army.[45]
-
Transport
In March 2020, GoI constituted several empowered groups (EGs), which included representatives of related Ministries, to address various issues related to COVID-19 management. EG2 was tasked, inter alia, to address the problems associated with the supply of medical equipment, including MO. To meet the rapidly increasing demand for MO in the states, a supply plan for oxygen was drawn, wherein it was planned to map the high-burden states to sources of oxygen, with the quantity being specified. This was scheduled within a dynamic, rolling framework, with the directions being to review and revisit the allocations with the states every two to three days. The supply chain was strengthened using the established network of the Indian Railways, Indian Air Force (IAF), and Navy in the following ways:
- Railway’s Oxygen Express: Dedicated Oxygen Express by Indian Railways, using a green corridor for transporting LMO and oxygen cylinders, was created.[46-48] Around 477 Oxygen Expresses delivered more than 35000 MT of LMO with more than 1990 tankers to 39 cities in 15 states during the surge.[49] Also, the carrying capacity of liquid oxygen was increased by retrofitting ISO liquid tanks to carry oxygen.[50]
- Operation “CO-JEET”: IAF stepped into action by airlifting oxygen containers and cylinders to various parts.[51] The C-17 aircraft conducted 400 sorties from within the country, to airlift 252 oxygen tankers of 4904 MT. The IAF aircrafts also conducted 59 international transfers to airlift 72 cryogenic oxygen storage containers of 1233 MT total capacity and 1252 empty oxygen cylinders.[52]
- ‘Samudra Setu II’: Indian Navy, as part of the ongoing Operation ‘Samudra Setu II’, deployed nine ships for shipment of LMO and associated medical equipment from friendly foreign countries in the Persian Gulf and southeast Asia. Indian Navy deployed Oxygen Express to the island territories of Lakshadweep.[53,54]
- The transportation was supported by the IT Ministry to enable effective and instantaneous communication for allocating oxygen supply.[30,55] Oxygen demand aggregation system (ODAS) was developed to ascertain the demand for MO from all health facilities based on the availability of beds and occupancy and aggregated them at the state level. In addition, an oxygen digital tracking system (ODTS) was developed to track the daily allocations of oxygen, their dispatch, and deliveries, including the movement of oxygen tankers. Lastly, a compressive platform “OxyCare” for all oxygen-related equipment was developed, which provided real-time information regarding PSA plants, IoT devices, oxygen cylinders, ventilators, oxygen concentrators, and other MO-related equipment. Further, in Uttarakhand, 30000 radio-frequency identification tags were distributed to hospitals, clinical establishments, and MO suppliers to be fixed on oxygen cylinders for real-time tracking and distribution of oxygen.[8]
-
Ancillary support
- Exemptions: To further support the supply chain of oxygen, the PMO announced the exemption of essential customs duties and health cess on importing oxygen and oxygen-related equipment.[56] Free movement of all MO units across the country was ensured by waiving the permits for vehicles carrying oxygen.[57] The government further obligated major ports to waive all ships carrying oxygen and oxygen-related equipment cargo. National Highway Authority of India exempted toll charges for tankers carrying LMO.[58] In addition to the change in the policy of imports for government purchases, custom duties were exempted for purchasing and importing oxygen concentrators for personal usage.[59]
- Import policies: Procedures concerning the import of oxygen cylinders and cryogenic tankers/containers from global manufacturers were simplified by granting online approvals and omitting physical inspections to prevent delays.[60] Further, exporting all ventilators and artificial respiration and oxygen therapy equipment was prohibited.[61]
- Price capping: Although the ex-factory capping price of MO in cylinders was included in the National Pharmaceutical Pricing Authority (NPPA) list, LMO was excluded for capping its selling price. MoHFW delegated special powers under Disaster Management Act, 2005 to NPPA to immediately regulate the pricing of LMO to curtail black marketing.[62] In addition to LMO, the government also enforced the capping of trade margins on oxygen concentrators, reducing prices by up to 54%.[63]
- Community participation and global alliance: World Bank Group extended its support to India’s efforts in response to preparedness for COVID-19 by providing over USD 3 billion in support. ACT Grants, Swasth Alliance, and Feeding India donated 50000 oxygen concentrators nationally.[64] Global aid comprising oxygen concentrators, cylinders, and generation plants received and expedited to states/UTs in their fight against COVID-19.[65] Community participation in surge management like “Oxygen Langar” was appreciated across the world.
- Financial support: Emergency Credit Line Guarantee Scheme (ECLGS) 4.0 accentuated onsite oxygen generation by providing loans for up to INR 2 crore to health setups for setting up on-site oxygen generation plants, with facilities to avail loan tenure of five years for their ECLGS, and current ceiling of Rs. 500 crore of loan outstanding for eligibility under ECLGS 3.0 was removed.[66]
- Capacity-building activities of the health care workers were planned under the Ministry of Skill Development and Entrepreneurship, Indian Navy, and IIT (Kanpur) to operate and maintain PSA plants. MoHFW also launched a “National Oxygen Stewardship Program” to build the capacity of health care workers in oxygen therapy, with a necessary focus on essential knowledge and skills, rational use, and avoiding wastage or overuse of oxygen in resource constraint settings.[67]
Table 2.
Total Medical Oxygen Generation capacity by the end of the second wave of COVID-19 in India (June 2021)
Source of Medical Oxygen | Approximate per day peak production capacity (MT) |
---|---|
Liquid medical oxygen (LMO) | 9690 |
Air separation units (ASU) | 412 |
Direct supply from steel plants to jumbo facilities | 243 |
Output from existing oxygen storage capacity | 3000 |
1.4 lakh oxygen concentrators | 1872 |
Pressure swing adsorption (PSA) plants | |
PM CARES (n=1225) | 1929 |
Central government PSUs (n=283) | 393 |
Foreign aid (n=54) | 35 |
State/CSR initiatives (n=2358) | 2366 |
Total Capacity | 19940 |
DISCUSSION
Oxygen is included in the list of essential medicines in India and worldwide.[68] Oxygen support became one of the rate-limiting steps for medical care during hospitalization in India. The surge in demand for MO exacerbated the preexisting gaps in medical-oxygen supplies, leading to a substantial shortage. Even though there was a lower incremental demand for oxygen to treat COVID-19, the lower preexisting stores contributed to more significant deficits.[69] Despite the odds, India managed to mitigate the dearth within a short period, which is documented in the present study and can be considered a guiding policy document by other developing countries. The overall oxygen capacity, including all sources, touched nearly 16398 MT by the end of 2021. We observed three significant challenges in mitigating the oxygen surge demand during the COVID-19 pandemic. The first challenge was to increase India’s oxygen manufacturing and storage capacity to meet the sudden rise in demand created due to the increase of COVID-19 patients. The second was the transportation of oxygen to high-burden states. The third challenge was developing long-term solutions by introducing new technologies within the country, which can help us become self-sustainable in oxygen manufacturing and mitigate regional imbalances.
In response to the first and second challenges, we observed that processes were comprehensively integrated through active intersectoral participation. As a result, the increase in the oxygen manufacturing capacity of India to meet the surging demand was initially satisfied by diverting industrial oxygen into MO and restricting industrial oxygen use. Increased production necessitated adequate holding capacity of the LMO. In California, such alternate care plans helped alleviate the surge of patients to hospitals, mainly by providing oxygen to 1900 patients.[12] But, in India, patient care outside the designated health care centers increases the burden on mobile sources of oxygen.[70] Further, there was a significant push to develop technologies for the rational use of oxygen. Several low-cost devices were developed under the “Make in India” initiatives and were introduced to generate in-house uninterrupted MO supply. Plans for rapid deployment of oxygen had significant limitations due to vendor supply, the limited national inventory of portable steel oxygen cylinders, and the inability to meet competing demands from multiple hospital systems.
We observed a geographic shift in demand during the pandemic’s second peak, and the dynamics were opposite compared to the early stages of the pandemic. The northern parts of India began to report more cases than central and southern parts.[71] Not all states manufactured LMO, and many of the oxygen-producing states were situated in the eastern and southern parts. Therefore, there was heavy demand for the limited manufacturing plants in these areas, which had to cater to the local state’s needs and of needy states. However, the shift was timely identified and constantly monitored by EG2. To minimize the time for transportation of oxygen from manufacturing states to high-burden states, dedicated Oxygen Express by Indian Railways played a crucial role. The places that were not accessible to Indian Railways were covered by the coordinated approach of the IAF and Indian Navy. To secure the oxygen supply chain from manufacturer to user, real-time tracking of ODTS proved effective.
While the different measures for increasing medical-oxygen production can be scaled to meet global demands, long-distance oxygen transportation is not economically efficient, so favored sources should be available regionally. Hence, the long-term plan to decrease the dependency on procuring MO and self-generate the same initiated the urge to install the PSA plants was economically challenging. This was initially supported by the PM CAREs and was later sustained by timely financial decisions like ECLGS 4.0, as described earlier. The investment in PSA setup also appeared to be highly cost-effective.[72] The Center for Global Development highlighted the need for a balance in immediate needs with long-term cost-effectiveness due to increased oxygen demands due to COVID-19. The note provided considerations for setting up liquid oxygen tanks, PSA oxygen plants, oxygen cylinders, and oxygen concentrators.[73] Having drawn from China’s experiences, even WHO gave similar interim guidance regarding oxygen sources and distribution for treatment centers.[74]
Our study has a few limitations. Although our search strategy was exhaustive, we might have missed some tangential topics relating to oxygen requirements considering the dynamic nature of the pandemic. We analyzed the SWOC of oxygen supply chain management at a macro level, that is, at the national and state levels, and we may have missed some microlevel details. Our study primarily used data from government sources; there might be underreporting of cases that might have undermined the consequent oxygen demand. Nevertheless, the study gives comprehensible evidence and provides amenable recommendations for improving oxygen policy.
Specific recommendations emerge from this study that may be useful for future medical services in a similar context. The initial surge observed during the pandemic necessitated monitoring oxygen requirements at the central, state, and hospital levels by measuring acute and longer-term oxygen needs. The same system can be applied to other essential medical equipment labeled as Vital and Essential components of the health delivery system, like essential drugs, ICU beds, and ventilators, and it has to be backed up by appropriate fund allocation. It is pertinent to devise the methodology for allocating MO at subnational levels on a scientific, rational, and equitable basis as per actual demand and foreseeable surge and facilitate oxygen audits at different levels of health system of the states and hospitals (government and private). It is essential to sustain the increased capacity in various forms, similar to the oxygen stewardship program, as this has been seen as a significant challenge as per our SWOC analysis. Real-time tracking of tankers has been crucial in the timely delivery of oxygen, and the same can be applied to other vital health commodities. Artificial intelligence and similar innovative solutions should be used for forecasting the demands.[75]
There are critical policy implications of this study. Although health is a state subject, GoI provided technical, logistic, and financial support to strengthen the existing health infrastructure. This pandemic offers the opportunity to refocus efforts on the basics of acute care and improvements in logistics, including LMO, till the last mile. To conclude, a comprehensive pandemic response will need more than just oxygen. It requires ensuring access to the necessary devices to deliver oxygen to patients, ranging from pulse oximeters to ventilators and trained health care workers. However daunting, the investment of time and resources to meet the demands imposed by COVID-19 does offer a silver lining. It will improve health systems and health outcomes in the long term beyond the pandemic. The experiences can guide similar surges in demand that will help markedly decrease preventable deaths as an achievable priority for hospitals in LMICs. Leveraging benefits in this aspect will enhance care for other vulnerable groups of patients with severe pneumonia, newborns, and children. This will help build more equitable, resilient, and sustainable health systems.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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