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COVID-19 has tested many health care systems to the breaking point—and it is the poorest that have suffered most. A lack of equitable access to vaccines and other essential medical tools is the primary reason that low- and middle-income countries are lagging so far behind.

Nowhere is that disparity more evident than in the case of medical oxygen. The pandemic has raised the alarm on the issue—but the response continues to be too slow to tackle the complexities and needs of patients gasping for breath worldwide.

Images of hospitals across India running out of oxygen during a deadly second wave of coronavirus in April and May drew global attention to the crisis. Six months on, however, the fact that demand surged to an unmanageable level in so many places has prevented a smooth response. Today, although some major companies have stepped up, several other major companies have not. Combined with inadequate investment in funds and limitations on capacity within global institutions, this slow response is hampering the supply of medical oxygen to all those who need it.

According to the Every Breath Counts Coalition, oxygen is in short supply in more than 60 countries—home to nearly half the population of planet. And in 22 of these the shortage has been classified as “code red,” posing a real threat to more than 450 million people should they fall seriously ill with COVID-19.

The fact is that medical oxygen is a basic component of modern medicine. It is taken for granted in European and North American hospitals, yet it is all too often a scarce resource—or even a luxury—in poorer parts of the world. This is despite the fact it is needed for nearly all critically ill patients, including millions of children with pneumonia.

Low- and middle-income countries (LMICs) currently need some 10 million cubic meters of oxygen every day to treat patients suffering breathing problems owing to COVID-19. That is down from the peak earlier this year but is still an unprecedented amount compared with pre-pandemic times. As a result, people continue to scramble for limited supplies, often paying five to 10 times the usual price, while the toll of unnecessary deaths worldwide climbs higher and higher.

In February 2021, the ACT-Accelerator Oxygen Emergency Taskforce was set up to tackle the problem, with the backing of organizations such as Unitaid, the Wellcome Trust, WHO, the Global Fund, Unicef, the Clinton Health Access Initiative, PATH, and others. Over $500 million has been allocated to provide LMICs with oxygen supplies, including pressure swing adsorption (PSA) oxygen generating plants, liquid oxygen, oxygen concentrators, pulse oximeters, and ventilators, and to finance health system improvements for delivering oxygen to patients. Several governments have also stepped up, most notably the U.S., which contributed $3.5 billion in 2021 to the Global Fund’s COVID-19 Response Mechanism (C19RM), of which $500 million has been awarded to LMICs for oxygen. The U.S. also last month pledged $50 million and called on global leaders, development agencies, and civil society among others to collectively increase funding and collaboration towards “solving the oxygen crisis.”

But funding to date still falls short of the $2 billion that is needed in order to make transformative steps in health systems worldwide, so that they become more resilient. And there remain significant gaps in coordination of efforts between the private and public sectors and the ongoing complexity of health systems’ capacity issues locally to fully solve the oxygen gap.

There is also the problem of misinformation about oxygen purity, which keeps some poor countries from relying on PSA plants, to the detriment of patients.

Medical oxygen comes from three sources: air separation plants which produce liquid oxygen at 99% purity; PSA plants, which concentrate oxygen from air at 93% purity; and mobile concentrators, which deliver a purity above 86%. Big urban hospitals situated near air separation units often find it cost-effective to use liquid oxygen, delivered in tankers, while smaller regional hospitals can benefit from PSA plants located on site and concentrators.

Although all three approaches can work effectively, there is a mistaken view among some governments, hospital officials, and the public that oxygen below 99% is somehow not safe for medical use. It is a concern that has sometimes been perpetuated by staff at large medical gas companies, with the result that certain hospitals won’t rely on technologies that produce oxygen below 99% purity, causing further bottlenecks.

There are also worrying geographical disparities to solve. For example, companies tend to have established distribution systems in a limited number of high- and middle-income countries, while many global health agencies have built up infrastructure in certain parts of sub-Saharan Africa.

But the pandemic calls for a comprehensive approach. It is no good for global health agencies to focus only on countries on their priority lists, or for companies to target ones where they happen to have offices.

More than 18 months into the pandemic, apart from that provided by the Global Fund, there is still little data on the types of support that have been offered by governments and global health and development agencies to improve oxygen supply in different countries or the actions taken by companies to improve the situation.

The role of companies is critical since six manufacturers dominate the liquid oxygen market. These firms certainly face significant challenges, as medical oxygen is only a small component of their overall industrial gases business and distribution systems are complex, making it hard to deal with sudden surges in demand.

However, two of the big six companies—France’s Air Liquide and the U.S.-German company Linde Group—have taken the lead in showing what is possible by working closely with global health agencies and governments. Linde has stepped up supplies to Brazil, India, Indonesia, and several African countries, with Zambia now a model of such action via its regional subsidiary Afrox. Air Liquide, meanwhile, has increased production four times and delivered shipments from 400 tons of liquid oxygen in 2020 to over 9,000 tons in 2021, going mostly to emergency use in Africa, India, and Latin and Central America. Air Liquide is also working with, for example, the French, Indian, and Tunisian governments to assist in deployment efforts, enabling the company to take routes by ships, roads, and rivers to reach destinations.

Yet a truly coordinated approach is still hampered by limited long-term funding, differing priorities among global organizations and companies, and the failure of more companies to act. The need for oxygen remains critical. While some well-vaccinated richer countries are now freed from lockdown restrictions, for most of the world’s population the pandemic threat continues and is not going away anytime soon. Greater accountability, faster responses, and more short- and long-term money are needed to close the oxygen access gap once and for all.

(Read more about our work on leveraging better access to medical oxygen here.)

Jayasree K. Iyer is executive director of the Access to Medicine Foundation.