"Outsourced oxygen to the bedside" in five countries: a qualitative implementation assessment

This qualitative study across five countries evaluates the feasibility and acceptability of outsourcing medical oxygen services to private providers, finding that while the "oxygen to the bedside" model shows promise for improving access, its long-term sustainability depends on tailoring solutions to local facility needs and ensuring affordability.

The Gist

Imagine a hospital as a busy restaurant. In this restaurant, oxygen is the most critical ingredient. Without it, patients (the diners) can't survive. But in many parts of the world, this restaurant often runs out of ingredients, or the ingredients are spoiled, or the chefs don't know how to use them.

This paper is about a new experiment to fix that problem. Instead of the restaurant trying to grow its own vegetables, buy its own gas, and fix its own broken stoves, it hires a specialized delivery service to handle everything.

Here is the story of that experiment, broken down simply.

The Problem: The "Broken Stove" Crisis

In many low-income countries, hospitals often have oxygen machines, but they are like broken stoves:

• They sit there doing nothing because no one knows how to fix them.
• They run out of fuel (oxygen) because the delivery trucks are too far away.
• The power goes out, and the machines stop working.
• The staff is scared to use them because they aren't sure if they will work.

The Solution: "Oxygen-as-a-Service" (The All-In-One Subscription)

The researchers tested a new idea called "Outsourced Oxygen to the Bedside" (O2B). Think of this like a subscription box or a food delivery app for hospitals.

Instead of the hospital buying a machine and hoping it works, they pay a private company to do everything:

1. Deliver the oxygen (like a pizza delivery).
2. Fix the machines if they break (like a handyman).
3. Train the nurses on how to use them (like a cooking class).
4. Monitor the patients to make sure they get enough oxygen.

They tested this "subscription service" in five different countries (India, Nigeria, Tanzania, Kenya, and Uganda) to see if it actually works in the real world.

What They Found: The Good, The Bad, and The "What Ifs"

The researchers interviewed 59 people (doctors, nurses, and managers) and found five main stories:

1. The "Confidence Boost" (Good News!)

When the hospitals got this service, the staff felt much more confident.

• Before: Nurses were afraid to turn on the oxygen because the machine might break or run out.
• After: They knew that if something went wrong, a technician would show up immediately.
• The Result: They started checking patients' oxygen levels more often and treating sick people faster. It was like the staff finally felt safe enough to cook the meal properly.

2. The "All-in-One" Wish List

The hospitals loved the idea of a "package deal." They didn't want to buy oxygen and separately buy masks and separately hire a mechanic.

• The Metaphor: They wanted a "Super-Menu" where one payment covered the food, the plates, the waiter, and the cleanup.
• The Catch: Sometimes the "package" didn't include everything. For example, they got the oxygen, but they still needed to buy their own pulse oximeters (the little clip for the finger) or had to deal with their own broken electricity. They wanted the service to be truly "whole."

3. The "Local Chef" Dilemma

There was a tricky balance between relying on the delivery service and learning to cook yourself.

• Some staff said, "Just fix it for us; we are too busy."
• Others said, "We need to learn how to fix it, or what happens when the delivery guy doesn't show up?"
• The Solution: The paper suggests having a "Captain of the Oxygen Team" inside the hospital—a local champion who knows the system, can train new staff, and knows who to call when things go wrong.

4. The "Can We Afford It?" Question

This was the biggest worry.

• The Feeling: Everyone agreed the service was amazing and they wanted to keep it.
• The Reality: Many hospitals are already struggling with money. Some said, "We are willing to pay, but we don't know how."
• The Risk: If the hospital pays more for this great service, they might have to charge the poor patients more. The researchers worried this could make healthcare unfair for the poorest people.

5. The "Hybrid Engine"

Hospitals realized they didn't want just one type of oxygen source.

• The Metaphor: Imagine a car that only runs on electricity. If the power grid goes down, you are stuck. But if you have a car that can run on electricity and has a backup gas tank, you are safe.
• The Need: Hospitals want a mix of oxygen tanks (cylinders) and oxygen machines (concentrators) so that if one fails, the other takes over. They want the service to be flexible enough to handle emergencies.

The Bottom Line

The experiment showed that hiring a private company to manage oxygen works really well. It makes hospitals safer, staff more confident, and patients healthier.

However, for this to become a permanent solution, two things need to happen:

1. Money: We need to figure out how to pay for it without making healthcare too expensive for the poor.
2. Customization: One size does not fit all. A small rural clinic needs a different "oxygen package" than a big city hospital.

In short: The "Oxygen Subscription" is a brilliant idea that saves lives, but we need to make sure the bill is affordable and the service fits the specific needs of every hospital.

Technical Summary

1. Problem Statement

Medical oxygen is a critical, life-saving intervention, yet approximately 60% of the global population lacks access to quality, affordable oxygen services. The primary challenges in Low- and Middle-Income Countries (LMICs) are not merely the lack of equipment, but systemic failures including:

• Non-functional equipment: High rates of broken concentrators, empty cylinders, and missing regulators.
• Infrastructure deficits: Unreliable power supplies and poor logistics for maintenance and distribution.
• Fragmented procurement: Facilities often struggle to manage the complex supply chain of oxygen sources, consumables, and maintenance independently.
• Operational gaps: Investments during the COVID-19 pandemic focused heavily on procurement rather than operationalization, leading to equipment that sits unused.

The paper investigates "Outsourced Oxygen to the Bedside" (O2B), a subset of "Oxygen-as-a-Service" (O2aaS). This model involves private providers delivering a bundled service package (oxygen source, pulse oximetry, consumables, training, and maintenance) directly to health facilities to ensure availability at the point of care.

2. Methodology

The study employed a qualitative, phenomenological approach to evaluate the implementation of O2B pilots across five diverse health system settings: India, Nigeria, Tanzania, Kenya, and Uganda.

• Data Collection:
  • Participants: 59 semi-structured interviews conducted between November 2024 and January 2025.
  • Subjects: Healthcare workers (HCWs), facility managers, district medical officers, and biomedical staff from 20 health facilities (ranging from primary to secondary care, public and private sectors).
  • Sampling: Purposive sampling was used to ensure maximum variation in facility size, geography, ownership, and pre-existing oxygen access.
• Analytical Framework:
  • Frameworks: The analysis utilized Proctor's Implementation Outcomes Framework (assessing acceptability, feasibility, fidelity, etc.) and the Consolidated Framework for Implementation Research (CFIR) (examining inner/outer settings, processes, and innovation characteristics).
  • Coding: A pragmatic codebook approach combining inductive (emergent) and deductive (framework-based) coding. Inter-coder reliability was established through double-coding of a subset of transcripts.
• Ethics: Ethical approvals were obtained from review boards in all participating countries and the Swedish Ethics Review Authority.

3. Key Contributions

This study provides one of the first multi-country qualitative assessments of the O2B business model, moving beyond simple equipment availability to analyze the service delivery ecosystem.

• Shift in Perspective: It highlights that successful oxygen interventions require a "whole-of-facility" approach, integrating equipment with training, maintenance, and infrastructure support.
• Cultural Impact: It identifies the "oxygen culture" shift—how reliable service changes clinical behavior (e.g., increased use of pulse oximetry and earlier initiation of oxygen therapy).
• Implementation Barriers: It uncovers critical tensions between the desire for comprehensive service packages and the financial realities of LMIC health systems, specifically regarding payment mechanisms and equity.

4. Key Results

The analysis identified five central themes regarding the feasibility and scalability of O2B models:

A. Positive Impact on "Oxygen Culture"

• O2B pilots significantly improved staff confidence and trust in facility readiness.
• Reliable access led to a behavioral shift: HCWs reported increased pulse oximetry usage and a greater willingness to initiate oxygen therapy for hypoxemic patients without waiting for physician orders.
• Exception: In India, the impact was less pronounced as many facilities already had other oxygen interventions in place.

B. Demand for Holistic Service Packages

• Participants universally valued the "bundled" nature of O2B (oxygen + transport + maintenance + training).
• Gaps identified: Facilities requested the inclusion of backup power (generators/solar) and piped oxygen systems, which current O2B models often cannot address.
• Equipment needs: There was a strong desire for pediatric-specific equipment and backup sources (e.g., cylinders to supplement concentrators during power outages or surges).

C. Local Ownership and Sustainability

• The Training Paradox: While staff appreciated external maintenance, they expressed a need for more internal training to handle minor issues and manage equipment during staff turnover.
• Champions: The study suggests the creation of local "oxygen champions" within facilities to bridge the gap between external providers and clinical staff, ensuring continuity of care and awareness.

D. Financial Feasibility and Willingness to Pay

• Willingness: Facility managers expressed a strong willingness to pay for O2B services to avoid the logistical burden of self-procurement.
• Affordability Crisis: Actual ability to pay is uncertain. In government-funded facilities, budgets are often insufficient. In patient-pay models, there is a risk that increased service costs will be passed to patients, exacerbating inequity.
• Value Perception: Some respondents viewed the higher cost as "value for money" due to reliability, while others found it cost-prohibitive compared to traditional procurement.

E. Need for Hybrid and Tailored Models

• A "one-size-fits-all" approach is ineffective. Facilities require hybrid solutions that integrate multiple oxygen sources (concentrators, cylinders, and potentially piped systems) and backup power.
• O2B providers must be flexible enough to integrate with existing vendors and infrastructure rather than replacing them entirely.

5. Significance and Implications

• Scalability: The O2B model shows high potential for scaling, but success depends on tailoring service packages to specific facility needs and local health system structures.
• Equity: Future financing models must address the risk of out-of-pocket costs for patients. Regional or ministry-level agreements may be necessary to achieve economies of scale and lower costs in public facilities.
• Implementation Science: The study underscores that technical solutions (equipment) are insufficient without addressing the "soft" infrastructure: training, maintenance culture, and financial sustainability.
• Policy Recommendation: To move from pilot to routine adoption, stakeholders must develop context-specific economic models that balance service costs with facility revenue capabilities and ensure that "oxygen champions" are embedded to sustain the intervention post-pilot.

Conclusion:
The O2B approach effectively addresses the "last mile" of oxygen delivery by improving reliability and clinical culture. However, for long-term sustainability, models must evolve to include hybrid infrastructure solutions, robust local training, and financing mechanisms that protect vulnerable patients from increased costs.