Increasing equitable access to pulse oximetry: progress and considerations for sustainable scale-up in a changing global health landscape

Summary box.

• Pulse oximetry is now globally recognised as essential for quality integrated management of childhood illness (IMCI) at the primary care level, with strong evidence from the Amélioration l’Identification des détresses Respiratoires chez l’Enfant project demonstrating feasibility, clinical value and improved guideline adherence—reinforced by updated WHO guidance and heightened post-COVID global momentum around oxygen access.

• Many of the enabling conditions for scale-up are in place to facilitate routine use, including evidence generation and policy alignment at global and country levels.

• Policy adoption has outpaced sustainable financing and frontline uptake, as most countries have updated IMCI guidelines and scale-up plans but remain heavily donor-dependent, while health worker time constraints and workload pressures threaten sustained use in high-volume primary care settings.

• Future scale-up depends on deeper integration, efficiency gains and new partnership and financing models, positioning pulse oximetry within integrated, person-centred care packages (including oxygen), improving service delivery efficiency and leveraging coalitions and innovative financing to support country-led, sustainable adoption in a constrained global funding environment.

Introduction

Strengthening integrated management of childhood illness (IMCI) is critical to achieving global targets for child survival, particularly in low-income and middle-income countries (LMICs) where most lives are lost. Hypoxaemia is a key indicator of severe disease in children that requires timely detection and appropriate treatment, including oxygen therapy.¹

In 2017, Unitaid—a global health funding organisation focused on increasing equitable access to innovative health products—recognised that while hypoxaemia is easily detected using pulse oximeters (POs), access to these devices remained limited in low-resource settings where detection relied largely on clinical signs and symptoms. Availability and use of POs were largely restricted to higher levels of care due to evidence gaps on the feasibility, acceptability and cost-effectiveness of routine use of POs at the primary health care (PHC) level, procurement and supply chain inefficiencies and lack of practical tools to support scale-up. In response, Unitaid funded the Amélioration l’Identification des détresses Respiratoires chez l’Enfant (AIRE project) and a related project Tools for Integrated Management of Childhood Illness (TIMCI) to overcome these access barriers through evidence generation, demand creation and market entry of low-cost and easy-to-use handheld POs.

A key feature of Unitaid’s investment approach is its focus on establishing enabling conditions for sustainable scale-up, guided by a scalability framework (figure 1). At the global level, this includes generating critical evidence, supporting development of normative guidance, testing delivery models, securing affordable pricing, securing reliable supply and working with partners for greater alignment. At the country level, efforts are focused on increasing and enabling domestic support, both political and financial, while working with local partners to ensure programmatic and operational readiness and community-driven demand creation.

Figure 1. Unitaid Scalability Framework.

Progress towards establishing enabling global-level and country-level conditions for scale-up and remaining gaps

Drawing on the portfolio research findings and an independent evaluation,² we observed significant progress in establishing the foundations for scale-up of the routine use of PO while identifying critical gaps in sustaining uptake and securing long-term financing at the country level.

Strengthened global evidence base and alignment around feasibility and urgency of pulse oximetry to better manage severe disease in children

The projects contributed to a growing body of research evidence making PO a feasible, acceptable and effective tool for identifying and managing sick children in PHC settings in LMICs.3,7 The work also laid bare the criticality of concurrent improvements in referral and medical oxygen systems to deliver improved health outcomes. Broad consensus is now achieved at the global level around the imperative to integrate routine use of PO at the PHC level, underscored in the 2024 WHO guidelines on the management of pneumonia and diarrhoea, which stated strongly that POs should be available at the PHC level to detect hypoxaemia in children.^{1 8} Global attention to respiratory illness management has grown, propelled in large part by the advent of the COVID-19 pandemic that put access to oxygen and related tools such as POs at the centre of global interests, providing unprecedented levels of funding and demand and in turn transforming the market and product adoption landscape.

Improved national policy environment, but considerable gaps in sustained domestic financing and provider uptake in increasingly resource-constrained settings

Encouragingly, governments in project countries have shown strong interest to expand the use of pulse oximetry for children, catalysed by implementation support, research and advocacy efforts.² Country programmatic and operational readiness has improved, with all portfolio countries updating IMCI and other relevant guidelines and operational plans to include POs. Many countries have also developed costed scale-up and/or procurement plans, leveraging resources from oxygen strengthening initiatives and broader health system strengthening programmes.² However, domestic financing continues to lag behind policy support, with scale-up remaining heavily reliant on donor funding.² Further, considerable challenges remain for sustaining uptake among frontline health workers.⁹ Practically, given that the average consultation is often 5 min or less in LMICs,¹⁰ the additional 1–2 min it takes for a pulse oximetry measurement represents a meaningful increase, particularly in high-volume facilities where time can be one of the most limited resources.

Implications for scaling up routine pulse oximetry in a changing global health landscape

The global health context has shifted dramatically, with the restructuring of foreign aid driving a heightened need for more strategic investments in women’s and children’s health that help health systems realise more value from every dollar invested while supporting a transition toward more sustainable, domestically financed health programmes. Learnings from the AIRE and TIMCI projects indicate that supporting country-led scale-up in an evolving landscape will require strengthening integration, improving service delivery efficiencies and investing in partnerships and sustainable financing models.

Integration

Shifting the focus to person-centred rather than disease-specific approaches is needed to enable greater shifts in programming towards integrated and decentralised service delivery, bringing products and services closer to the patient and streamlining and optimising care. Packages of interventions that span prevention, diagnosis, treatment and management can help ensure comprehensive care for the patient and care continuity, leading to better health outcomes. When clinic visits can respond to multiple needs at one time, it is time- and cost-saving for the patient. In addition to integration at the clinic level, investment in integration across facilities and levels of the health system is equally critical. Evidence-based approaches such as Networks of Care¹¹ represent service delivery innovations that can be scaled up alongside the introduction of lifesaving health products to strengthen referral systems and optimise linkages to improve coordination and quality of care. Integration can also be supported with product innovation, such as rapid diagnostic tests that diagnose multiple conditions with one finger-prick blood sample or multimodal devices that monitor oxygen saturation alongside other parameters. Investments in integrated products and service delivery systems not only strengthen primary healthcare but also advance equity and resilience, which are vital in the current global health climate.

Efficiency

To sustain the scale-up of tools, such as POs, it is essential to focus on using resources efficiently to maximise health outcomes. Identifying, testing and tracking efficiencies in service delivery strengthens continued investment. Donors can support this by funding country-led assessments of programme effectiveness, including plan–do–study–act cycles and other continuous learning initiatives. Findings from AIRE showed that ongoing training, supervision and maintenance costs remain major barriers to sustained PO use,¹² yet more efficient service integration offers opportunities to share these costs across programmes. As services are integrated, careful attention to the workload placed on healthcare providers is critical. Service-delivery innovations such as task-shifting may offer valuable efficiencies, though their suitability will vary by context. Approaches to strengthen risk differentiation for children under five should also be explored to better target resources and improve outcomes without compromising quality of care.¹³ There are also increasing opportunities for digitalisation of health systems to increase efficiency. As demonstrated by AIRE, digital clinical decision-support tools can improve guideline adherence.¹² Broader investments in digitalising the supply chain, through electronic logistics management information systems, warehouse management tools and digital dashboards, have demonstrated improved data visibility, reduced stockouts and increased operational efficiency. To avoid fragmentation and ensure sustainability, strong government leadership is essential so that digital systems align with country priorities.

Partnerships and sustainable financing

In a changing global health landscape, coalition-building and new partnership models will be critical for scalability and sustained adoption of health interventions. Coalitions such as the Global Oxygen Alliance (GO₂AL) are on the frontline of catalysing access to medical oxygen through partnerships, including strengthening financing to expand production, lowering the price of oxygen and providing technical support to governments. Partnership models like this are particularly critical in areas beyond HIV, tuberculosis and malaria, in which pathways to scale for health products are more complex and lack traditional scale-up funders like the Global Fund. Advancing access requires targeted action at national, regional and global levels to build political will, mobilise financing and strengthen engagement with the private sector. Combining grant funding with instruments such as concessional loans and volume guarantees can strengthen local manufacturing and innovation, which is increasingly recognised as central to national sovereignty in health. By reducing reliance on volatile global supply chains and enabling countries to shape solutions that fit their own contexts, investments in local production enhance both resilience and control over essential health products. Building on this momentum, new procurement and financing models are ripe for innovation, and country-led partnerships that align incentives and accelerate access to quality health products and services hold significant promise for long-term sustainability.

Conclusion

The evidence and learning generated from introducing pulse oximetry within IMCI at the PHC level demonstrate that sustained scale-up will depend not only on strong evidence and policy alignment but on countries’ ability to convert current momentum into integrated and resilient service delivery models and reliable, domestically anchored financing. Embedding pulse oximetry within broader child health strategies—supported by community-driven demand generation and new partnership and financing models—will be essential to ensuring equitable and sustained access.

Data availability statement

There are no data in this work.