Table 1.

Barriers and Enablers for Broad Scale Pulse Oximetry Implementation in LMICs

	Barriers	Enablers
Logistic Factors	• Initial cost of pulse oximeters • After-sales maintenance and support (spare parts and battery) • Short operational life-span especially with rough use	• Low cost devices • Preventive and minimal maintenance • Devices that are robust under long-term and rough use • Minimal dependence on spare parts and battery replacement
	• Probes that are faulty, sensitive to dust and climate and easily damaged	• Probes more robust to wear and tear
	• Lack of facilities and other resources for management of hypoxic patient • Particularly, absence of sustainable oxygen; oxygen shortages	• Need-based approach for sustainable provision of oxygen • Explore use of more efficient O2 delivery systems • Ensuring adequate transport facilities and funding to ensure a steady supply of oxygen
	• The effect of altitude on the threshold of hypoxemia is confounded by differences in geography	• More outcome-based approaches to study effects of thresholds of hypoxemia on functional outcomes to help define a universally applicable threshold of hypoxemia with regards to the geographical variations
Human Factors	• Lack of expertise in installation and handling of equipment • Lack of understanding of the importance of waveform in pulse oximetry	• Better implementation of clinical and technical training in the use and maintenance of pulse oximeters utilizing the WHO pulse oximetry training manual
	• Lack of institutional clinical protocols related to newborn and childhood pneumonia • Absence of pulse oximeters in national and regional policies and guidelines	• Communication and cooperation necessary between the national health department and public and private sector hospitals to form simple guidelines and protocols for the use of pulse oximeters in improving the detection of hypoxemia
	• Pulse oximetry perceived to be more relevant for assessment of pulse rate in contrast to oxygen saturation • Supposed accuracy of clinical signs and symptoms in predicting hypoxemia	• More research and cost effective studies should be done in heterogeneous local settings to outline the role of pulse oximetry in reducing childhood mortality due to pneumonia in LMICs
	• False impression of low demand of pulse oximeters in the market	• Advocacy on the effective use of pulse oximetry in detecting hypoxemia and its potential role in decreasing mortality due to childhood pneumonia in LMICs