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. 2025 Nov 12;25(1):1463.
doi: 10.1186/s12913-025-13655-z.

Navigating oxygen management challenges amidst COVID-19 pandemic and beyond in India: a modified Total Interpretive Structural Modeling (m-TISM) approach

Mansi Singh  1 , Sanjay Dhir  2 , Jayendra Kasar  3 , Lisa Smith  4 , Ranjan Choudhury  5 , Navya Tondak  2
Affiliations

Navigating oxygen management challenges amidst COVID-19 pandemic and beyond in India: a modified Total Interpretive Structural Modeling (m-TISM) approach

Mansi Singh et al. BMC Health Serv Res. .

Abstract

Background: Given the unprecedented surge in COVID-19 infections, the heightened demand for medical oxygen prompted numerous national and global initiatives to bridge the gap between supply and demand. This was crucial for ensuring adequate treatment for patients suffering from acute respiratory distress syndrome and requiring oxygen therapy. This research aims to explore the factors influencing medical oxygen management in India during the pandemic and beyond, examining both facilitators and barriers.

Method: Through a thorough review of literature, secondary research, and interviews with key stakeholders, critical factors affecting oxygen management were identified. These factors were then analyzed using a modified total interpretive structural modeling (m-TISM) approach and MICMAC (Matrice d’ Impacts croises multiplication applique an classment) analysis to comprehend their hierarchical relationships and driving forces.

Results: The study identifies fourteen key factors that act as facilitators and barriers to oxygen management during the COVID-19 pandemic. These factors also influence medical oxygen management during the non-pandemic period. The development of an m-TISM model gives us the hierarchical interrelationships between these factors, including oxygen management as one of the factors itself. The findings identify key strategic levers to strengthen the national oxygen management ecosystem and cross-sectoral collaborations.

Conclusion: Unlike previous studies, this study moves beyond just identifying the challenges to offering a hierarchical map of pandemic-era and post-pandemic facilitators and barriers in the oxygen management ecosystem in India. This study provides insights into strengthening the oxygen ecosystem, enabling policymakers and program implementers to make informed decisions and implement pre-emptive measures to address future threats from the virus or similar crises.

Supplementary Information: The online version contains supplementary material available at 10.1186/s12913-025-13655-z.

Keywords: Barriers; COVID-19; Facilitators; MICMAC; Oxygen management; m-TISM.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study adhered to the Declaration of Helsinki. This study received ethics approval from the Western Copernicus Group Institutional Review Board (WCG IRB Tracking Number: 20235125) on 28th November 2023. The IRB was in full compliance with Good Clinical Practices, FDA regulations, HHS regulations, and ICH guidelines. All participants provided informed consent before participating in the study. A detailed consent form, titled " Informed Consent Document”, was approved by the WCG IRB on 28th November 2023 and used during data collection. This includes a clear explanation of the study’s purpose, risks, and confidentiality measures. This document has been uploaded with supplementary documents. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Barriers and facilitators of oxygen management
Fig. 2
Fig. 2
Steps in m-TISM methodology [15]
Fig. 3
Fig. 3
Digraph showing the hierarchical relationship among factors
Fig. 4
Fig. 4
Digraph showing direct and transitive linkages between the factors
Fig. 5
Fig. 5
MICMAC analysis (driving and dependence relationship of factors)
Fig. 6
Fig. 6
m-TISM digraph of barriers and facilitators of oxygen management
See this image and copyright information in PMC

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