Solving the Problem of Oxygen Access in Developing Countries - BARRONS
By Abby Schultz
During a visit to a hospital in Kano State, Nigeria, four years ago, Tayo Olaleye recalls seeing a young boy connected to an oxygen concentrator and learning he had been on it for more than a month.
Olaleye, a program manager with the Clinton Health Access Initiative’s essential medicines team in Nigeria, says the organization tested the machine and found it was producing oxygen at a 21% level—“which is basically the air you breathe,” she says. It should have read at least 82%. The hospital also didn’t have any pulse oximeters, which measure blood oxygen, so there was no way for the staff to know if the child’s oxygen levels were improving.
The shortfalls in oxygen supply, equipment, and training that Olaleye witnessed are not unusual in many low- and middle-income countries, where the importance of having ample oxygen supplies and quality equipment has not been well understood, nor financed.
That’s beginning to change through the efforts of the Clinton Health Access Initiative (CHAI), a Boston nonprofit founded in 2002 by former President Bill Clinton, in collaboration with the Murdoch Children’s Research Institute (MCRI) in Melbourne, Australia. MCRI was co-founded in 1986 by Dame Elisabeth Murdoch and David Danks, a pediatrician who specialized in clinical genetics. Murdoch, who died in 2012, was the mother of Rupert Murdoch, the owner of News Corp., which owns Barron’s.
Through a collaboration, CHAI and MCRI are boosting access to oxygen therapy in the hospitals of five countries: Nigeria, Ethiopia, Uganda, Kenya, and India.
Their effort is among six finalists in the MacArthur Foundation’s second 100&Change contest. The current competition’s winning recipient, to be announced in early April, will receive US$100 million—a transformative amount that would allow CHAI and MCRI to scale access to oxygen supplies, systems, and training in these five countries—home to a third of all global cases of low blood oxygen in children.
Sesame Workshop and the International Rescue Committee received the first award in 2017, funds that allowed that collaboration to provide educational and therapeutic resources for the children of refugees fleeing conflict, including Syrian refugees.
The other 100&Change finalists are: Community Solutions, which seeks to end homelessness in the U.S.; National Geographic’s Pristine Seas, which is focused on protecting and restoring the oceans; Project ECHO, which is increasing the capacity of healthcare workers to aid underserved communities; Report for America, which aims to reverse the collapse of local news coverage; and the World Mosquito Program, which works to prevent the transmission of mosquito-borne diseases.
While CHAI and MCRI’s work grew out of a focus on children, it benefits adults in developing countries, too, as hospitals that are able to improve their equipment and staff training expand these benefits beyond the pediatric ward.
“When you are working to improve a hospital’s oxygen system, it’s a whole of hospital effort, even if your focus is children,” says Dr. Hamish Graham, a pediatrician leading MCRI’s efforts to boost access to medical oxygen therapy.
How Covid Has Impacted Oxygen Access
The critical role that oxygen plays in treating Covid-19 has elevated this largely invisible need by all hospitals to have functioning, high-quality oxygen resources. But the pandemic has also exacerbated other challenges, Graham says.
“We already had big deficits in oxygen supply and the capacity to provide oxygen well,” he says. “With Covid adding probably an additional 20% in terms of the number of people needing oxygen, that’s pushed those supplies well beyond limits.”
Also, hospitals in low- and middle-income countries that have received new equipment to treat Covid, often don’t have structures in place to keep their oxygen systems running more than a year or so.
“We’ve been trying to use our work and existing connections to nudge that in a way to make it more sustainable,” Graham says. “The MacArthur opportunity would be a way to do that properly, at scale.”
The other challenge is that the global health community’s rush to plug oxygen system deficits in developing countries resulting from the pandemic is “still an emergency response”—not a lasting one, says Jason Houdek, senior technical adviser for CHAI’s essential medicines team.
“We can ride that momentum, to fix those problems and to close the gap for good, but we need people who will come in and make the long-term commitment beyond the immediate emergency.” Houdek says. “We’re excited about the MacArthur [award], because it could be that.”
The 100&Change Boost
Just being part of a highly vetted, competitive pool of finalists, is raising awareness among philanthropists and funders of CHAI and MCRI’s work, and the pervasive problem of being unable to treat low blood oxygen, or hypoxemia, in many low- and middle-income countries.
That exposure has been aided by the fact all finalists are entered in the Bold Solutions Network, a database of finalists from various competitions managed by MacArthur Foundation affiliate Lever for Change. The network can draw attention to nonprofits from philanthropists and foundations searching for viable nonprofits to fund.
At this point “it’s hard to get people to commit” to donating to the project, given it could receive US$100 million. But, if it doesn’t win, the goal is to raise at least US$50 million by April.
“That’s what we need to get this started in order to do this at the scale where we can start setting up the types of collaboration across public and private sectors that are needed, negotiating the right type of deals, and really reaching the critical mass that will get those systems going,” Houdek says.
Already, pilot projects implemented through CHAI and MCRI’s three-year partnership in 74 hospitals in Nigeria and Ethiopia have enabled twice as many children with hypoxemia to receive oxygen, the groups say. At Murtala Mohammed Specialist Hospital, the institution Olaleye visited in Kano, biomedical engineers trained by CHAI, using lessons learned from working closely with MCRI’s team, have since installed more concentrators and set them up to serve up to four pediatric beds, she says.
While US$100 million won’t fix everything overnight, “in the countries where we have that foundation, and where we have a solid plan to bring things to scale, we believe that level of investment will allow us to work across both public and private sectors to put the right systems in place in a sustainable way,” Houdek says.
Genesis of a Collaboration
CHAI and MCRI began working together in Nigeria in 2016 after they were connected by the Bill & Melinda Gates Foundation, which was funding both organizations separately and recognized that they could benefit from collaborating.
Among the first to identify the importance of having working, high-quality oxygen equipment and staff training at hospitals in countries such as Nigeria and Ethiopia was Dr. Adegoke Falade, professor of pediatric respiratory medicine at the University of Ibadan, in Nigeria—who works with MCRI.
Through his research, Falade found that deaths from pneumonia could be cut in half if children had access to pulse oximeters and medical-grade oxygen.
CHAI, meanwhile, had been working on how to stem severe childhood pneumonia in Nigeria’s more sprawling, rural northwestern states when researchers began to recognize how the disease’s trajectory was exacerbated by the lack of available oxygen equipment and training.
Once the groups learned of one another’s work through the Gates Foundation, they realized they could draw on one another’s strengths, says Dr. Chizoba Fashanu, deputy director of CHAI’s essential medicines and malaria projects in Nigeria.
In Nigeria, CHAI “had deep, strong relationships with the government,” while MCRI, had “deep academic experience,” Fashanu says. “Bringing these two strengths together, really helped us in pushing the needle.”
Graham recalls that initial alignment with CHAI led the Nigerian Ministry of Health to develop a national oxygen strategy, and to write new clinical guidelines around oxygen.
“That gave us opportunities as clinicians and field researchers with the government that we wouldn’t have been able to do without CHAI,” Graham says. “And it gave CHAI access to experienced clinicians working in the space.”
“We do a lot of implementation on the ground with health facilities, with governments on the policy side, and we were intimidated by the oxygen space when we first got into it,” Houdek says. But, through working with Graham’s team, they realized it was a treatable, straightforward problem that could be solved.
While CHAI was initially focused on solving deaths from pneumonia, for children, hypoxemia is an issue in a lot of other severe illnesses common to sub-Saharan Africa, such as malaria and meningitis. Premature births and sepsis are other causes.
Fortunately, oxygen, when made available, is a cost-effective treatment. “Because of the high likelihood of really severe poor outcomes, including death, you reach a lot more patients who you can make a big difference in their outcomes for the investment you make,” Houdek says.
In its proposal, the nonprofits point that hypoxemia contributes to more than one million deaths in low- and middle-income countries annually.
“For the impact they get, they are one of the best types of interventions we can fund as a community,” Houdek says.