Learnings from the field: our Oxygen-as-a-Service portfolio
We believe Oxygen-as-a-Service models can transform the way oxygen is delivered, and could do so more affordably and sustainably than current models when appropriately applied to low-resource settings.
That’s why we’re funding a portfolio of five Oxygen-as-a-Service pilots testing a mix of oxygen concentrator products and technologies alongside a service package of clinical training and maintenance. In doing so, we hope to collectively understand the viability of different business models in each context.
If you are new to our work, you can read more about the aims and approach of the Oxygen CoLab here, and details of our portfolio hypothesis here. You can also learn how we’re building evidence about the use cases for concentrators here.
As part of our first phase of work, our pilots have been implementing on the ground between 6–9 months delivering oxygen to 62 facilities. We have learnt something new every day about the operational, technological and financial components of these service-based models as well as its potential to save lives across the world.
To mark the beginning of this next phase, we’re delighted to share some key insights from across our portfolio.
Below is a summary of the insights. Click on the headline to read a more thorough examination of each learning.
- Don’t expect approvals to be quick or easy: Even once there is an agreement to install 02aaS at healthcare facilities, getting official contracts signed can take a long time. Different states might have different processes and requirements depending on the level of approval needed. Even when contracts or MOUs do exist, this doesn’t guarantee that facilities can start to implement or pay.
- New technologies bring with them new complexities: When a novel technology is introduced into a country it takes time to do things like understand the importing system, form new relationships with customs brokers, identify shipping agencies and set up new upstream supply chains for new technologies. There may also be customs duty and registration costs for components.
- Smart insights come from strong relationships: When working across multiple sites it’s crucial to try and anticipate how different places will operate. But, in often bureaucratic health systems, there is never full transparency or knowledge of what is happening on the ground. By forming pivotal working relationships with key decision-makers it’s possible to get a better understanding of what may otherwise seem like an impenetrable system.
- Technology is nothing without training: Even if you have all the equipment you need, it is useless without adequate training. Proper support and knowledge ensures that equipment doesn’t end up consigned to a store room (as is common for other donated equipment which clinicians have no idea how to use). This is why many pilots reported that their key focus had moved from the technical equipment itself to knowledge improvement and clinical training.
- Support needs to be consistent and tailored: Training isn’t a one time deal. Pilot teams found consistent and repeated support was needed to make a system-wide change. This approach included introducing informal check-ins, formal workshops, and refresher training. Similarly a one-size-fits-all approach is not going to work. For some pilot teams this meant creating and adapting training materials on a context-by-context basis.
- Be ready to capitalise on the impacts: Despite all of the challenges they faced, many of the pilots were surprised by the impact their work has had in such a short amount of time. Validation of approaches and models came in a matter of months and sometimes weeks, with some pilots seeing much higher demand for concentrators than was expected and others eliminating the need for oxygen cylinders in some wards.
The six key insights in detail
1. Manage your expectations on approvals processes
Our grantees recognised the need to manage their expectations as they began implementing. FREO2 and ICChange have learnt to expect delays in approvals. For example, in Tanzania, FRE02 found that even once there is an agreement to install 02aaS at healthcare facilities, getting official contracts signed can take a long time. Competing priorities in some district councils resulted in long delays signing MOUs. In the Siha district, FREO2 waited over 3 months for one MOU to be signed which significantly restricted their ability to start implementation. In Uganda, ICChange has had to wait over 3 months to get formal ethics approval ahead of starting implementation, which is necessary as sites are unwilling to provide data or survey responses without this and it is key to ensuring buy-in for the pilot at the district level.
In India, Sanrai learnt to expect different processes and requirements across different states. Sign-off processes varied depending on the level of approval needed. In one state, everything happened at district level which made things much quicker. This has provided a useful contrast of how things can work in two very different bureaucratic systems which is key for scaling their approach across states.
Even when contracts or MOUs exist, Access Oxygen in Kenya, Sanrai, and FRE02 learnt this doesn’t guarantee that facilities can or will pay. This is especially the case for smaller public health facilities who may have tight budgets and may rely on centralised (subnational) purchasing decisions which they are less able to influence. It may also be that when a free trial period is offered, it creates a lower perception of the value on offer which may influence a facility’s willingness to pay.
2. Expect to face new complexities in the cost and delivery of new technology
As with any pilot, you should expect challenges and blockers along the way. Many of our pilots are implementing new technologies either to a health facility and sometimes the country, leading to key learnings about cost and delivery. ICChange found there to be more complexity than they first anticipated of bringing a new technology into the country. There is an invisible cost in the time taken to understand the importing system, form new relationships with customs brokers, identify shipping agencies and set up new upstream supply chains for new technologies. The key learning was to account for lead times both upstream and downstream of the supply chain, from production of the O2 Cube, which is a novel technology requiring new parts, to delivery in-country.
For Healthport, the challenge was around the customs duty and registration costs of some components that made it difficult to balance the cost overall. The cost of importing piping and small ancillary parts was way beyond what was initially estimated as there are not large in-country manufacturers for these products.
For Access Oxygen, some facilities reported limitations with 5LPM units and believe they would be able to serve more patients with higher literage with bigger units. They are considering increasing provisions for facilities in the next phase as one facility mentioned that many patients suffer from asthma. Better utilisation of oxygen to tackle asthma, especially for babies, could be catalysed by providing nebulisers alongside masks and cannulas.
FRE02 learnt that they could have a bigger impact by implementing different support and maintenance models such as varying allocation of manpower and implementing remote maintenance services. They are now focusing on maximising the utilisation of available resources, improved ground operations and cost of delivery.
3. Relationships are key to building ecosystem support on every level
The diversity of our portfolio has lent itself to some fascinating insights that come through testing in multiple places. Things always work differently from place to place and no matter the plans and preparation you put in place, the reality is always different because the players are different and in the bureaucratic environments of most health systems, there is never full transparency or even knowledge of what is happening on the ground.
ICChange were surprised at how many people were involved in oxygen from production to final delivery to the patient, from government, technical staff, healthcare workers, entrepreneurs, and public and private enterprises. Healthport were surprised by the ease of penetration of some usually impenetrable sections of the healthcare system by forming pivotal relationships with the key decision-makers, and how this differs from facility to facility becoming a challenge in some.
FRE02 learnt the importance of receiving support at the highest level from the Ministry of Health in Tanzania to secure larger NGO funding for their pilot. They secured strong working relationships with the Minister and Deputy Minister and Dr Ntuli Director of Health within the President’s Office. These influential stakeholders are now strong advocates and contribute greatly to the team’s funding tenders and pitches.
4. Training is proving to be one of the most important aspects of 02aaS
Training is a key part of the offer for all our pilots but quite how important it is for the success of their work has come to light during this phase of the work.
Michael from Access 02 in Kenya had expected some teething issues when facilities started to use new technology leading to more equipment breakdowns initially, especially with humidifier bottles. However on this project they found there to be no such breakdowns with their concentrators which they have attributed to their training offer. What’s more he’s heard that the training has ensured that the equipment doesn’t just sit in a store room as is common for other donated equipment which clinicians have no idea how to use. This has highlighted the importance of our training offer. The lesson is that you can have all the equipment, but without training it will be useless.
“We used to refer patients who need any form of oxygen support. With this project, we no longer have to do this. I cannot stress the importance of the training we have received on use of oxygen concentrators [by Access Oxygen]. My team now has the confidence to use it well and serve our patients when they come to us for care.” In charge, Kariobangi Health Center, Kenya
Amarpreet from Sanrai reflected that oftentimes people focus on the concentrator but what they’ve learnt from an earlier phase, which they’ve now implemented, is that when you’re using high quality oxygen concentrators the equipment itself is the least challenging part of implementing O2aaS…
“If you think back to what our stated goal is around actually making sure that oxygen is being used where its needed for patients, the most important element of this and where our oxygen service program is kind of centered or focused around is in capacity building and diagnostics…if you’re not diagnosing successfully, you’re not actually treating patients.”
FRE02 are showing in numbers how important the knowledge improvement and additional capacity in clinical training plays was in improving clinical practices:
“Through the clinical training we witnessed an increase in average score from 55% to 88% in pre training test and post training test respectively. The impact of taking oxygen therapy and pulse oximetry training to community health workers/dispensaries with the aim of improving diagnosis and ensuring better more informed and timely referrals”
5. Support needs to be consistent and tailored to the context in order to prompt the longer term culture change needed for impact
Along with ideas already coming to the surface for the technology, our pilots are constantly noticing improvements that can be made to the training offer. Sanrai validated the need for consistent training and refreshers, not only to maintain clinician capacity but to maintain a supportive ecosystem.
“You need to literally make sure people are comfortable with this equipment, which takes consistent and repeated trainings and support, which is hard.” reflected Amapreet.
They found that training should include informal check-ins, formal workshops, refresher training in order to change the culture and change the way that people are actually diagnosing the oxygen.
Most of the pilots have created and adapted their own training materials to be tailored to the context and ensure where possible they are in first language. One learning is that there is no ‘standard’ protocol beyond the WHO protocol around oxygen therapy and diagnosis used at lower level facilities, and where this is in place it is not always well understood. For example, Sanrai and Healthport have reflected that, a lot of the Western literature says that if somebody looks blue, treat them with oxygen. If they seem to be breathing fast, look at oxygen as a solution. The problem is, those signs are not clear for a practitioner working with different skin tones and especially on a baby. There is a need to ensure healthcare workers are confident in diagnosing and using pulse oximeters which are supplied by all of the pilots on the Oxygen CoLab.
6. Find the tangible stories of impact
One final takeaway is that our pilots have been surprised by some of the impacts their work has had in such a short amount of time, beyond their expectations, and in a number of areas.
FRE02 and Access 02 in Kenya received significant validation of the value that can be provided in isolated locations, further making the case to them that this is a healthcare level worth expanding in. Their system installation at Mafia Island in Tanzania has eliminated the need for oxygen cylinders in its neonate and paediatric wards. This has resulted in $1,211 savings as a cost of refilling cylinders and transportation to the mainland in the period of September 2022 to June 2023.
Access O2 in Kenya didn’t expect they’d find such high demand for oxygen:
“We have seen a significant scale up in the use of the concentrator. In just three months, one of our beneficiary sites has logged more than 400 hours of use proving that there is a need for this device. “ Michael, Technical Lead, CPHD
Another measure of success is a reduction of referrals which many have noted. Access 02 piloted in 2 facilities in Kenya that have never used oxygen before. Prior to using the service they had weekly referrals to level 5 hospitals which are no longer required. Achocho from the team even received a call from the facility manager to say thank you.
With these lessons in mind, we’re excited to enter into this next phase as we contintue to test assumptions and refine the business model for Oxygen-as-a-Service.
Follow our journey as we continue to work and learn together:
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On LinkedIn you can find us on: https://www.linkedin.com/company/better-futures-colab/ Or email us at oxygen@makingbetterfutures.org
