Strategies for Oxygen Ecosystems in Middle-Income Countries: A Review and Case Study from Lebanon

Abstract

The COVID-19 pandemic led to a surge of critically ill patients and a sudden increase in the need for oxygen treatment worldwide. Pre-existing gaps in oxygen systems became apparent, and governments, multilateral agencies, and other partners scrambled to increase the production, supply, and use of oxygen to meet this need. The importance of an oxygen ecosystem that is appropriate for the local context became clear. This review describes strategies for oxygen ecosystems in middle-income countries, with specific experiences from Lebanon, following the authors' extensive assessment of the country's oxygen ecosystem, on behalf of the government and UNICEF. In the assessment, fifteen governmental hospitals were visited and evaluated using the UNICEF Oxygen System Planning Tool, discussions were held with key stakeholders, and documents were reviewed. An optimal oxygen ecosystem needs to take into consideration the production of oxygen and delivery to facilities, the maintenance system within facilities, and the clinical use of oxygen. Lebanon, a lower-middle income country in the Middle East, is contending with an extensive economic crisis affecting the health system. Eighteen recommendations for strengthening the oxygen ecosystem in Lebanon that are relevant for other middle-income countries include the establishment of a National Oxygen Committee, installation of additional oxygen plants, strengthened systems for maintenance and electricity supply, increased production, procurement and supply chain resilience, improved training and human resources, the use of data collection and regular information to guide the ecosystem, and integration of oxygen into the rest of the health system.

Figure 1

Comparison of LOX and PSA with reference to Lebanon. ^∗Authors' estimates using calculations performed in the 2022-2023 assessment conducted by the government and UNICEF.

Figure 2

Oxygen ecosystem: four requirements for health impact. 1a: Establish policies such as national oxygen roadmaps and national oxygen committees to enable context-appropriate planning of the oxygen ecosystem. 1b: Gather information about the need, access, and provision of oxygen to guide policy and planning. 2a: Produce sufficient oxygen for the needs of the population. 2b: Maintain safe, efficient, and sustainable oxygen production and integrate the oxygen ecosystem with the rest of the health system. 3a: Establish reliable oxygen delivery systems within health facilities. 3b: Maintain safe, efficient, continuous, and sustainable oxygen delivery systems in health facilities and integrate with the rest of the facility. 4a: Treat patients with oxygen effectively and appropriately. 4b: Treat oxygen-requiring patients with the other essential care they need. 4c: Ensure the clinical use of oxygen is sustainable and integrated with other care provision.

Algorithm 1

Recommendations for strengthening the oxygen ecosystem in Lebanon.