This urgent global health priority cannot be resolved until gas companies further commit to and act on expanding and sustaining long-term access to the lifesaving product they produce.

In response to the COVID-19 pandemic, some of the world's leading producers of medical liquid oxygen took steps to expand access to their lifesaving product in low- and middle-income countries (LMICs) experiencing critical oxygen shortages. However, the underlying problem of a lack of access to medical oxygen in LMICs remains largely unaddressed. A new report from the Access to Medicine Foundation examines what gas companies have done to tackle this issue and identifies tangible actions they can take to expand access to medical liquid oxygen over the long term.

Medical oxygen is a crucial treatment for many diseases, such as pneumonia and tuberculosis, and it is essential for daily medical procedures like surgery and childbirth. Yet approximately half of healthcare facilities in LMICs lack reliable access to medical oxygen, despite its inclusion in the World Health Organization's Model List of Essential Medicines.

The report from the Access to Medicine Foundation analyses access efforts from six of the world's largest global gas companies producing medical liquid oxygen: Air Liquide, Air Products, Linde, Messer, Nippon Sanso Holdings Corporation, and SOL Group. Although some companies took steps during the COVID-19 pandemic to increase access to medical oxygen, the report notes that clearer commitments are required to prioritise LMICs in gas companies' business operations.

Standout examples of company action, especially during the COVID-19 pandemic, are identified in the report – as are opportunities to harness this momentum.

Better Access to Medical Oxygen is Urgently Needed

The issue is urgent and on a vast scale. In 2021, it was estimated that 73 million people with low blood oxygen (hypoxemia) attended healthcare facilities in LMICs, and of those, only 22 million were suffering from COVID-19. Many more people, including 32 million children, attending these facilities needed oxygen due to other conditions and routine procedures, e.g., if they underwent anaesthesia during surgery. Yet, all too often, these facilities did not have – and still do not have – adequate supplies of medical oxygen to treat their patients, leading to preventable loss of life. Approximately half of healthcare facilities in LMICs do not have reliable access to medical oxygen, despite medical oxygen being included in the World Health Organization’s Model List of Essential Medicines, i.e., it should be available in every country.

A Key Role for Gas Companies

“With a small number of companies responsible for the world’s supply of medical liquid oxygen, their role in the global health ecosystem needs to be prioritised. Medical gases are a small part of these companies’ business. Yet society needs them to ensure this vital lifeline is available during emergencies and to meet all health systems' daily medical oxygen needs.” – Jayasree K. Iyer, CEO, Access to Medicine Foundation.

In analysing the report’s companies’ initiatives to date, the Foundation has identified some agile responses to increase the supply of medical liquid oxygen* in an attempt to meet demand surges caused by the COVID-19 pandemic. These companies now have the opportunity to pursue long-term access planning further to secure sustainable supply beyond this global health crisis.

Six Priorities

The report identifies six priority areas for action that companies can focus on to provide access to medical liquid oxygen in LMICs, both in emergencies and to provide routine delivery:

- Prioritise, measure and report progress on medical liquid oxygen

- Enable improved affordability for different populations and health systems

- Provide a sustainable supply of medical liquid oxygen

- Develop and maintain long-term partnerships to close access gaps

- Support health systems and the human resources required to operate and maintain medical liquid oxygen systems and administer oxygen therapy

- Plan proactively for future emergencies.

“Some companies in scope have demonstrated their steps to improve access over the long term, but clearer commitments are required. The priority areas for action set out in this report show gas companies what they can do to prioritise and invest in LMICs, be proactive in finding new ways of increasing supply, and engage in long-term sustainable approaches to access.” – Johann Kolstee, Research Programme Manager, Access to Medicine Foundation.

What have Companies done so Far?

Some gas companies responded by airlifting whole medical liquid oxygen tankers and trailers into LMICs via specially chartered aircraft to pivoting more production capacity from industrial liquid oxygen to much-needed medical liquid oxygen. However, these efforts were limited in geographic reach. Across the six major gas companies covered by this analysis, initiatives to increase the supply of medical liquid oxygen during the COVID-19 pandemic have been reported, publicly or directly to the Foundation, in only 39 of the 108 LMICs in scope (about one-third).

Moreover, now that the immediate public health emergency has passed, it is not always clear whether companies will continue to address gaps in access in LMICs over the long term.

Of the companies examined in the report, Air Liquide is currently the only company with a clear access-to-medical oxygen strategy targeting LMICs. Air Products, Linde, Messer, Nippon Sanso Holdings Corporation and SOL Group have shown broad commitments to health but with no specific targets related to medical oxygen or LMICs.

The report identifies some company efforts that could lead to a more sustainable supply of medical liquid oxygen in more LMICs over the long term. Since the start of the COVID-19 pandemic, for example, Air Liquide and Linde have reported providing medical liquid oxygen in regions they did not previously supply. Encouragingly, Air Liquide, Air Products, Messer and Nippon Sanso Holdings Corporation have reported installing or acquiring new liquid oxygen-producing Air Separation Units (ASUs), including in South Africa, China, Egypt, India, Vietnam and Thailand. These ASUs have the potential to significantly boost the supply.

There are several challenges to improving access to medical oxygen in LMICs, including healthcare facility infrastructure and a fragmented supply chain involving complicated logistics and distribution networks. However, gas companies play a critical role in helping to overcome some of these challenges, in particular by pursuing and formalising long-term partnerships with governments and global health stakeholders. Air Liquide and Linde have already formalised partnerships with global health organisations to address access gaps in LMICs. Both companies entered into Memoranda of Understanding (MoUs) with Unitaid and the Clinton Health Access Initiative (CHAI).

With the publication of this report, the Foundation calls for gas companies' commitment to and action on expanding and sustaining long-term access to the lifesaving product they produce, which is critical to resolve this urgent global health priority.

About the Access to Medicine Foundation The Access to Medicine Foundation is an independent non-profit organisation that seeks to transform the healthcare ecosystem by motivating and mobilising companies to expand access to their essential healthcare products in low- and middle-income countries. The Foundation is funded by the Dutch and UK governments, the Bill & Melinda Foundation, the Leona M. and Harry B. Helmsley Charitable Trust, and AXA Investment Managers. 

Sources of data for this report

This first published research report from the Foundation’s Medical Oxygen Programme analyses initiatives undertaken by six global gas companies to increase access to medical liquid oxygen (medical LOX). The analysis is based on publicly available information as well as original data provided by some of these companies in response to a questionnaire set by the Foundation, which focused on long-term access to medical LOX initiatives. The report is further informed by insights from four roundtables co-hosted by the Foundation. These were held under the Chatham House Rule, and all participants remain anonymous. Information was crosschecked directly with gas companies to ensure accuracy, where possible.

*While there are three types of medical oxygen production systems, each with its advantages and disadvantages, this report focuses on medical liquid oxygen (medical LOX), which the Foundation has identified as presenting a promising long-term sustainable supply solution to address the persistent gaps in access to medical oxygen in LMICs.