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Review
. 2025 Mar;13(3):e528-e584.
doi: 10.1016/S2214-109X(24)00496-0. Epub 2025 Feb 17.

Reducing global inequities in medical oxygen access: the Lancet Global Health Commission on medical oxygen security

Hamish R Graham  1 , Carina King  2 , Ahmed Ehsanur Rahman  3 , Freddy Eric Kitutu  4 , Leith Greenslade  5 , Masooma Aqeel  6 , Tim Baker  7 , Lucio Flavio de Magalhães Brito  8 , Harry Campbell  9 , Karen Czischke  10 , Mike English  11 , Adegoke G Falade  12 , Patricia J Garcia  13 , Mireia Gil  14 , Stephen M Graham  15 , Amy Z Gray  15 , Stephen R C Howie  16 , Niranjan Kissoon  17 , Ramanan Laxminarayan  18 , Inês Li Lin  19 , Michael S Lipnick  20 , Dianne B Lowe  21 , David Lowrance  22 , Eric D McCollum  23 , Tisungane Mvalo  24 , Jacquie Oliwa  25 , Stefan Swartling Peterson  26 , Rediet Shimeles Workneh  27 , Heather J Zar  28 , Shams El Arifeen  3 , Freddie Ssengooba  29
Affiliations
Review

Reducing global inequities in medical oxygen access: the Lancet Global Health Commission on medical oxygen security

Hamish R Graham et al. Lancet Glob Health. 2025 Mar.

Erratum in

No abstract available

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Conflict of interest statement

Declaration of interests HRG declares salary support, research grants, and consultancies from the Royal Children's Hospital Foundation, the Australian National Health and Medical Research Council, the Bill & Melinda Gates Foundation, ELMA Philanthropies, the Asian Development Bank, and Cambridge Economic Policy Associates; declares travel support from the Royal Children's Hospital Melbourne; and holds advisory or leadership roles with the Oxygen for Life Initiative and Lifebox Foundation. CK declares research funding from the Bill & Melinda Gates Foundation, the Swedish Research Council, the US National Institutes of Health, and the Save the Children–GSK partnership, and has an advisory role with the Lifebox Foundation. AER declares a grant from Clinton Health Access Initiative for Commission work (including salary support; GR-02385) and a research grant from the UK National Institute for Health and Care Research (NIHR). LG declares salary support from the Bill & Melinda Gates Foundation and leadership roles with TEAMFund, Rice360, and la Caixa Foundation. HC declares grant funding from NIHR and the Baszucki Brain Research Foundation, consulting fees from WHO, and is Co-Editor in Chief of the Journal of Global Health. KC led development of the COPD guidelines for the Latin American Thoracic Society. ME declares research grants from Wellcome and NIHR, and a leadership role with UK Research and Innovation. AGF declares research grants from the Bill & Melinda Gates Foundation, ELMA Philanthropies, a Save the Children–GSK Partnership, the Swedish Research Council, and WHO, and a leadership role with the Oxygen for Life Initiative. AZG declares travel support from the Royal Children's Hospital Melbourne. RL declares travel support from UNICEF. MSL declares research grants from the US Agency for International Development, Moore Foundation, McGovern Foundation, Robert Wood Johnson Foundation, Unitaid, PATH, US Food and Drug Administration, Wellcome Trust, and WHO, and has received payment for presentations from the University of California, Los Angeles and Johns Hopkins University. DL is co-chair of the Global Oxygen Alliance. EDM declares research grants from the US National Institutes of Health, the Bill & Melinda Gates Foundation, the US Agency for International Development, the US Centers for Disease Control and Prevention, Thrasher, Moderna, travel support from WHO, and leadership and advisory roles with the Union, the Lifebox Foundation, and the WHO pneumonia guideline development group. JO declares travel support from UNICEF. SSP declares general salary support from Uppsala University and UNICEF Sweden. HJZ declares research grants from the Bill & Melinda Gates Foundation and the South African Medical Research Council and leadership roles with the Forum of International Respiratory Societies, the Pan African Thoracic Society, and WHO pneumonia guideline development group. MG reports consultancy fees from Cure Kids Foundation, is a co-owner of the non-profit cooperative Azimut 360, declares royalties or licences from a utility model for a trailer for the production of medical oxygen with solar devices, and has received travel and meeting support from Cure Kids Foundation and Azimut 360. SRCH declares salary support from Cure Kids New Zealand. ILL declares consulting fees from the International Centre for Diarrhoeal Disease Research, Bangladesh. SEA declares salary support from the Clinton Health Access Initiative. FS declares salary support from a US Agency for International Development grant. FEK declares grants from Meeting Targets and Maintaining Epidemic Control (awarded to Makerere University School of Public Health; 102533), the Swedish Research Council, Clinton Health Access Initiative (awarded to Makerere University School of Public Health), and DT Global International Development UK (awarded to Makerere University School of Public Health; 21886-001) and holds advisory roles with the Global Oxygen Alliance. TB declares research grants and consultancies from Wellcome Trust, NIHR, UNICEF, the World Bank, the US Agency for International Development, and PATH. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Location of people with acute medical and surgical oxygen needs in 2021, and minimum volume of oxygen required to meet need, by World Bank region Note that this figure excludes oxygen requirements related to COVID-19. Oxygen need is represented by the circles, the sizes of which are proportional to the number of people in that region who need medical oxygen therapy. Minimum volume of oxygen required to meet need was calculated using data for recommended and usual flow rates and duration for various conditions and assumes no inefficiencies in oxygen use and no wastage or inefficiencies in upstream oxygen production, supply, and distribution. HICs=high-income countries. LMICs=low-income and middle-income countries. Nm=normal cubic metres.
Figure 2
Figure 2
Trends in estimated global oxygen need (2010–21) for acute medical and surgical oxygen therapy (A) and long-term oxygen therapy (B) Data are from the Global Burden of Disease. Oxygen need related to COVID-19 is excluded. Error bars represent uncertainty intervals.
Figure 3
Figure 3
Oxygen coverage cascade for people with acute medical and surgical conditions This figure shows the effective oxygen coverage cascade for acute medical (A) and surgical (B) purposes in LMICs; and for acute medical purposes in LMICs in sub-Saharan Africa (C), south Asia (D), east Asia and the Pacific (E), Latin America and the Caribbean (F), the Middle East and north Africa (G), and eastern Europe and central Asia (H). The cascade depicts the number of people who need oxygen therapy (ie, the target population), who attend a health service that should offer oxygen services (ie, service contact coverage), who attend a health service that has oxygen available (ie, input-adjusted coverage), who receive oxygen therapy (ie, intervention coverage), and who receive oxygen therapy that is safe and appropriate (ie, quality-adjusted coverage or patient access). (A) details potential reasons for the oxygen coverage gap at each step of the cascade. Long-term oxygen need is not depicted. LMICs=low-income and middle-income countries.
Figure 4
Figure 4
Annual cost to close the acute medical and surgical oxygen gaps in low-income and middle-income countries The minimum cost of the medical and surgical oxygen need is the cost to fill the oxygen coverage gap, based on recommended treatment. We inflated this cost to reflect actual practice and included inefficiencies in the system, clinical wastage, and additional consumables in our estimates (appendix 1 p 78). Supply chain inefficiencies refer to leakages in oxygen delivery systems and losses during production, distribution, and storage. Clinical wastage is the use of higher flow rates for longer periods than recommended, and treatment of patients without a clinical need for oxygen. Consumables includes the cost of pulse oximetry, nasal cannulas, masks, and staff time.
Figure 5
Figure 5
Meta-estimates of oxygen (A) and pulse oximeter (B) availability in health facilities in low-income and middle-income countries, by ward area and facility level Error bars represent 95% CIs. The n in parentheses details the number of datasets included in the meta-estimate. Level 1 describes primary health-care facilities, level 2 general hospitals, and level 3 tertiary hospitals. The darker shading represents overall estimates for a given department or ward. In (A), no data were available for oxygen availability for maternity care in level 1 facilities.
Figure 6
Figure 6
Median proportion of urban and rural health facilities and public and private health facilities in low-income and middle-income countries that have pulse oximeters and oxygen Data are from the Service Availability and Readiness Assessment and the Service Provision Assessment. Both surveys involve large-scale assessment of facility readiness from a representative sample of facilities and are repeated periodically. Data are not disaggregated by level of facility and over-represent level 1 facilities, thus reflecting the lower availability of pulse oximeters and oxygen in smaller facilities.
Figure 7
Figure 7
Pulse oximetry use in (A) and oxygen provision to patients with hypoxaemia (B) in health facilities in low-income and middle-income countries, by ward area and facility level Error bars represent 95% CIs. Data for general acute care areas do not include operating theatres and intensive care units. No data were available for oxygen provision to patients with hypoxaemia in operating theatre, for pulse oximetry on level 2 maternity wards, or for oxygen provision for hypoxaemia in level 1 maternity care. The n in parentheses details the number of datasets included in the meta-estimate. Level 1 describes primary health-care facilities, level 2 general hospitals, and level 3 tertiary hospitals. The darker shading represents overall estimates for a given department or ward.
Figure 8
Figure 8
Key features of a resilient national medical oxygen system The arrows depict inter-related efforts and the direction of patient and medical oxygen flows required to provide treatment to a patient in hospital.
Figure 9
Figure 9
Inclusion of pulse oximetry and oxygen within key clinical guidelines SpO2=oxygen concentration in peripheral blood. *The treatment guideline or health-care package has incorporated all the medical oxygen service items assessed in each group. †The treatment guideline or health-care package has incorporated one or more of the medical oxygen service items assessed in each group.
Figure 10
Figure 10
Capital and operation costs of different oxygen system components Costs are an estimated total cost of ownership. The breakdown of cost categories (in US$) is based on data from publications, , , and Open Oximetry related to projects in six countries (Nigeria, Papua New Guinea, The Gambia, Kenya, Rwanda, and Ethiopia), and is intended to support budget planning. The balance between categories will vary by setting, and this figure should not be used as a cost-comparison tool. *Based on regional hub-and-spoke models.
Figure 11
Figure 11
Key stakeholders in a national medical oxygen system Adapted from Mirza et al (2023).
Figure 12
Figure 12
Mean pulse oximetry bias by skin pigmentation and ethnicity S indicates the number of studies that provided data for these estimates. Error bars show 95% CIs. SpO2=oxygen concentration in peripheral blood.
Figure 13
Figure 13
Proposed approach and indicators for a national medical oxygen monitoring framework
See this image and copyright information in PMC

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