We cannot afford to lose momentum in medical oxygen, and for many low and middle-income countries (LMICs) the difficulties in accessing oxygen are systemic and long-term.

That’s according to Robert Matiru, Director of the Programme Division at Unitaid.

Speaking in an interview with gasworld, Matiru explained that in the context of the Covid-19 pandemic, the lack of access to medical oxygen is threatening entire health systems in countries around the world.

Even before Covid-19, oxygen supply in LMICs was inadequate, demonstrated by the fact that pneumonia is the world’s biggest infectious killer of adults and children, claiming the lives of 2.5 million people in 2019.

Against this backdrop and the onset of the pandemic, the COVID-19 Oxygen Emergency Taskforce was launched in February 2021 to bring together key partners to address critical oxygen gaps, as part of the global COVID-19 response. The taskforce is co-led by Unitaid and Wellcome, under the Therapeutics Pillar of the Access to COVID-19 Tools Accelerator (ACT-A).

Partners include the WHO (and the broader biomedical consortium the WHO coordinates), Unicef, The Global Fund, the World Bank, UNOPS, Save the Children, Every Breath Counts (coalition), CHAI, PATH, The Bill and Melinda Gates Foundation and Access to Medicines Foundation.

Under this initiative, Unitaid and its partners are working closely to mobilise resources under the ACT-A architecture to fund medical oxygen storage and infrastructure, support countries to access the funds that are already available such as through The Global Fund’s COVID-19 Response Mechanism (C19RM), pay for emergency supplies, and finance the transportation of equipment and other tools needed for safe, resilient medical oxygen systems. Market shaping interventions including advance purchase commitments and guarantees form part of this package of measures.

Matiru believes the Taskforce plays a critical role in bridging those gaps in the supply chain.

“The Taskforce plays a critical role in improving the coordination of the global response and mobilizing resources to address the needs in the most acute way,” he said. “The Taskforce focuses on achieving four key objectives as a part of an emergency response plan: measuring acute and longer-term oxygen needs of LMICs ; connecting countries to financing partners for their assessed oxygen requirements; and supporting the procurement and supply of oxygen, along with related products and services; reinforcing advocacy efforts to highlight the importance of oxygen access in the Covid-19 response.”

“Other areas in the scope of the Taskforce include addressing the need for innovative market-shaping interventions, as well as reinforcing advocacy efforts to highlight the importance of oxygen access in the Covid-19 response.”

“In addition,” Matiru continues, “the Taskforce acts as an essential instrument to involve different partners in a broad, collective response: the private sector, governments, civil society and multi-lateral organisations.”

“For example, the Taskforce is a crucial platform to engage with the gas industry via improved public-private partnerships. In June this year, following an intense engagement with the oxygen industry, two memoranda of understanding (MoUs) have been signed with major oxygen suppliers, Air Liquide and Linde. These stakeholders have come to the table to agree to work comprehensively with development agencies on expanding access to medical oxygen: it’s a major milestone in itself. There has never been this level of engagement between the global health community and the major oxygen suppliers before.”

“These MoUs pave the way for fairer, more consistent pricing in LMICs and expanded supply options in countries which currently are not considered financially viable for these companies to operate in. A key component of the MoUs is a commitment by the companies to work to ensure sufficient supply to meet the demands of the pandemic for at least two years.”

The Taskforce is also working to address supply shortages for other vital commodities, Matiru explains, such as pressure swing absorption (PSA) plants and their component parts. Further still, it is working to connect countries to sources of financing for oxygen requests, including C19RM and the World Bank’s Covid-19 emergency health response.

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Source: gasworld / Unitaid

Unitaid’s role

As an organisation and a co-lead, Unitaid clearly has an important role to play in the Taskforce. With so many stakeholders involved, however, it’s easy for readers to misunderstand – or not grasp at all – the roles of the individual bodies. So what is the role of Unitaid in the Taskforce?

Matiru explains, “An important role of the Task force is to coordinate the response to the most acute needs in the countries that are most at risk. To kick-start new funding contributions, following the launch of the Taskforce, Unitaid and Wellcome invested an initial $20m to support work in nine countries in Africa with PATH and the Clinton Health Access Initiative (CHAI), to address gaps in infrastructure, supply and maintenance.”

“In the last months, these efforts have resulted in the deployment of emergency oxygen equipment in those countries. Technical support has also been funded and provided to over 50 LMICs via Unitaid and other partners to help with needs assessments, surge planning and setting-up national oxygen systems.”

“Unitaid has also deployed additional investments for important, market-shaping interventions in bulk liquid oxygen. Actions are also under development to support PSA plant repairs and market interventions for PSA component parts such as air compressors.”

Unitaid has then, played a key role in both funding and effectively unlocking the vital products or actions of the Taskforce – and it was fundamental in brokering the two flagship, unprecedented oxygen agreements with Air Liquide and Linde, back in June.

Matiru explains further, “In the supply market, there are major challenges such as unaffordable pricing and inequitable access to critical oxygen sourcing options such as liquid oxygen. Unitaid, together with CHAI directly brokered the two global agreements, cited earlier, with Air Liquide and Linde that will be leveraged to put in place short and medium-term solutions for countries that would increase access to liquid oxygen as a complementary source alongside PSAs and concentrators.”

‘We cannot afford to lose momentum’

Matiru admits he is ‘somewhat’ disappointed that we have not seen more major medical oxygen agreements signed since those groundbreaking announcements in June, but says “we continue to hold talks with other companies and are cautiously optimistic that they too will sign such framework agreements, to facilitate fairer access.”

“The MoUs are an important first step in establishing access principles that can be operationalised by a variety of purchasers, including countries. In practical terms, these agreements also pave the way for agencies such as UNICEF, The World Bank, The Global Fund, and Ministries of Health, to work with the companies to procure medical oxygen in a sustainable, fairly-priced way, via long-term agreements.”

There is certainly still work to be done and further steps to be taken, and Matiru is clear that we cannot afford to lose momentum in medical oxygen, with 40 countries still at risk of oxygen shortages at the time of writing. A number of these countries are considered ‘code red’ – countries at serious risk.

“We cannot afford to lose momentum,” he urges. “During the UNGA in September, at a summit convened by President Biden, the resounding message was that Covid-19 is far from over. And as regards oxygen access, that many LMICs are seeing, and will likely continue to see, surges in case numbers – largely driven by the Delta variant and low vaccine rates.”

“We know that medical oxygen, taken with corticosteroids, is a treatment that works and is not a new technology, but many LMICs are struggling to access it, resulting in unnecessary deaths. In this context, equitable access has never been more important – ‘no-one is safe until everyone is’. This is the principle that Unitaid was founded upon and what the ACT-Accelerator is working to achieve. But it cannot do this without funding.”

“Strong commitment to funding is also needed to drive key market interventions. ACT-A’s latest estimate, published in its updated strategy on 28th October, is that the initiative needs a minimum of $1.4bn over the next 12 months to enable this vital work to take place.”

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Source: gasworld / Unitaid

gasworld understands that in addition, what needs to be done urgently is to accelerate the translation of C19RM funding awards into procurement and delivery – and to support countries in their efforts to access available funds.

“It’s vital to have an appropriate mix of oxygen solutions in place that suits the country’s needs best,” Matiru affirms.

A large number of countries have applied to the C19RM, including requests for oxygen. In 2021, over 75 countries and multi country awards have included oxygen, and $499m have been awarded under C19RM. “Each country has its own specifics and we need to continue to work with governments and other stakeholders on the ground to get applications that include oxygen and oxygen access,” Matiru explains.

Calling out the challenges…

With 20 years of experience in international development, Matiru has an accomplished track record in leadership and senior management positions, establishing and implementing strategies that have delivered significant impact and return on investment.

In his current role at Unitaid, he is responsible for planning, developing and implementing a complex portfolio of health product innovation investments valued at $1.3bn. Before joining the organsation almost a decade ago (2012), he served as head of Operations and Vaccine Deployment for the World Health Organization’s H1N1 Pandemic Response and as COO of the Global TB Drug Facility.

Not only is his background in dealing with such crises extensive, his current role and previous experiences mean he’s unafraid to face up to the difficulties, the uncomfortable truths about a given situation. In recent months, he’s been vocal about the need to ‘honestly and transparently call out’ the critical challenges that remain in medical oxygen shortages.

Asked to provide his view on those challenges, he points to the bigger picture and not one or two isolated pinch points. “The problem is complex: tools to diagnose respiratory distress are often not well-embedded in health systems, and sustaining oxygen supplies is an expensive, long-term commitment, and equipment is poorly designed for use in low-resource healthcare settings,” he explains.

“Oxygen concentrators are often not designed to withstand the difficult conditions found in many LMICs; oxygen piping systems needed to deliver oxygen to the bedside are lacking or often not well-maintained; and complex logistics mean oxygen cylinders don’t always reach their destination on-time.”

“Medical oxygen is supplied by six major companies, but in countries there is a lack of market competition, which often results in higher prices and access issues.”

“All of these issues have been compounded by the impact of Covid-19. While oxygen is vital for the effective treatment – alongside corticosteroids – of patients with severe and critical Covid-19, access in LMICs is limited due to the cost, infrastructure and logistical barriers outlined above.”

PSA-based systems have been seen during the pandemic as a key solution to meeting the needs of some countries or regions struggling with the fundamental access to bulk liquid oxygen or those logistical barriers that make it challenging to import and deliver, but there are known to be extensive lead times with the financing and/or delivery of critical PSA equipment.

Matiru cites a key priority in overcoming this as the repair and refurbishment of existing PSA plants, which he describes as a cost-effective solution that can also ease some of the pressure on the purchase of new PSA plants. “We are also investigating whether market interventions may be needed for the different component parts that make up a PSA plant, such as air compressors,” he adds. “When these parts are in short supply, it can increase the lead time for PSA plants overall.”

Given the prominence of the Taskforce, the progress made with various interventions as a result, and his own experience in the field, does Matiru remain hopeful about the short-term progress in medical oxygen for all and the long-term change?

He indicates a cautious optimism but is under no illusions that “we are still far from where we need to be.”

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Source: gasworld / Unitaid

There’s time for one more call to action, as he points to the enormity of the challenge ahead. “Right now, we are measuring and assessing both acute and longer-term needs, developing corresponding strategies to address needs with a range of oxygen solutions, connecting countries to financing partners to support requirements, and creating market conditions to enable rapid and affordable access to oxygen products and equipment.”

“In this way, our work is responding to the current crisis but also reinforcing our global capacity so we’re better prepared to tackle whatever comes next.”

“I do remain hopeful about the lasting impact of the work of the Oxygen Taskforce and other stakeholders driving oxygen access during this pandemic – in this year alone more than half a billion dollars has been raised and awarded for oxygen in LMICs. This is unprecedented.”

“That said, my hope is tempered by the fact that we are still far from where we need to be – moving forward, over the next year, we need more than three times this investment and even greater coordination, transparency and alignment, among the many stakeholders involved, on what can and should be achieved if such resources are mobilised.”

Exclusive: The Covid-19 Oxygen Crisis: How Did We Get Here?

Over recent weeks gasworld has released the various chapters of a 10-point playbook of political, social, scientific and economic constructs that underpinned one of the most devastating public health emergencies in a century.

The exclusive series is titled The Covid-19 Oxygen Crisis: How Did We Get Here? and explores how critical oxygen supply chain shortages were seen in various parts of the world over the last 18 months.

In the extended report from gasworld, described last month as having ‘first mover status’ by the Every Breath Counts coalition, all of the factors behind critical lack of medical oxygen in various parts of the world are considered.

Start reading here today with Chapter 1 and look out for the full report released as a white paper via gasworld’s new White Papers platform, in the next week.