Increasing access to Oxygen; learnings from one year on the Oxygen CoLab.
As I write this at the end of 2021 and the start of 2022, 800,000 children under the age of 5 are estimated to have died in low-and-middle-income countries (LMICs) from a death that in many countries would have been entirely preventable. The reason for this is not a lack of medical skill, it’s simply a lack of access to something that many of us take for granted, medical oxygen. Oxygen is at the forefront of people’s minds because of the COVID-19 pandemic. Nonetheless, lack of access to Medical Oxygen has long been a problem in LMICs before the pandemic illuminated the large global inequalities around Oxygen access. The ability of many to breathe is even more at risk during this pandemic than ever before.
There are lots of oxygen devices on the market. At the start of the pandemic COVIDaction began work as a newly formed UK Aid-funded initiative that aimed to figure out how to make ventilators more widely available. We quickly learned that more lives could be saved if we focused on less intensive oxygen supplies that are easier to access via devices such as Oxygen concentrators. These Oxygen supplies prevent patients from getting to a critical state (requiring a ventilator) in the first place resulting in a much wider impact.
In many countries access to medical devices that produce oxygen is difficult for two key reasons;
- The technology was not built for these environments. We need new technology that is fail-safe in LMICs. Countries where access to stable electricity is not possible or dusty air wreaks havoc on mechanical parts;
- The capacity of the medical device ecosystem needs strengthening to access and maintain medical device technologies
In 2021 the Oxygen CoLab (one of four themes within COVIDaction) set out to interrogate these challenges, offering grants to solve the issues and learning collectives to share what we discover. This article shares some of the key learnings and trajectories for the next stage of the Oxygen CoLab.
Oxygen concentrators often end up in device graveyards in LMIC hospitals in large quantities. The challenging environments in which devices are deployed presents both an engineering challenge and opportunity to fix the myriad of technical problems. Making better oxygen concentrators for LMICs that don’t break as often seems like a no brainer, which is exactly where the Oxygen CoLab started out. What we discovered is that this engineering challenge would be far from straightforward.
We spoke with 100+ Oxygen experts and realised that it’s not as simple as inventing a new technological solution, because of the concurrent ecosystem deficiencies. Both the technology and ecosystem challenges go hand in hand. As well as product innovation we also needed ecosystem innovation to break the cycle of technologies ending up in device graveyards.
Devices are often donated and when oxygen concentrations eventually break there are often no biomedical or mechanical engineers to fix them. Or there’s no access to spare parts to replace the parts that fail. Or there’s less accountability for the device within a hospital, so no one has the mandate to service it or fix simple issues. Or the warranty for the device is long lost. So when the industry creates better, more robust, high quality and longer lasting devices, eventually those devices may meet the same fate as the devices that preceded them.
The issues highlighted here are not unique to Oxygen concentrators either, they echo more broadly across many other medical devices manufactured in the global north and donated or purchased in the global south.
We set out to explore a dual approach to addressing the problem of creating better technology and embedding it more sustainably into local ecosystems. To address ecosystem challenges we needed business model innovation, which seeks to design both new products and services to support those products.
- Technology. A lot of the activity of the Oxygen CoLab involved innovator workshops through which we accumulated a long list of about 140+ ways one could fix different parts of the tech problems from energy efficiency, to dust, to zeolite membrane storage, you can find details here (under ‘learnings from past meet-ups’).
- Business Model Innovation. Adding business model innovation in the form of ‘Oxygen-as-a-service’ is aimed at addressing the maintenance and servicing part of the problem and create a lower overall total cost of ownership. The aim is to create services that build ecosystem capacity and maintain new and old devices to provide stable Oxygen supplies in efficient and scalable forms.
The behaviour shift involved presents an additional challenge, there is seemingly a race to the bottom on Oxygen Concentrator product prices. Customers in LMICs currently have a choice in purchasing expensive either higher quality devices around ~$2,000 that come with warranties or lower quality devices around ~$700, which tend to break much faster. Given budgets are tight, purchase patterns tend to favour cheaper, more disposable products, which tend to be more expensive in the long run. So how might we change this pattern? Read about the details of our affordability workshop here.
Paying large amounts ($700 to $2,000) for devices up front means a continuous cycle of replacing devices that ultimately end up in a device graveyard for fixable reasons. So instead of a large capital expenditure (CapEx) outlay to purchase devices again and again, the idea of ‘Oxygen-as-a-service’ is to create smaller more regular pay-as-you-go style services that offer a much cheaper more regular operating cost (OpEx) outlay. This makes for more manageable costs and in the long run solves the prevailing maintenance issues, because when the device breaks, service providers can swap it for a new device and fix the broken device for redistribution. Device accountability and maintenance is addressed at an affordable price for the service.
Trajectories for the next stage of the Oxygen CoLab
Step One. In the short term, we aim to address ecosystem capacity through business model innovation to prove a viable product market exists. To do so, the Oxygen CoLab has provided several grants for oxygen-as-a-service projects, which aim to decrease the total cost of ownership for customers. We hope to garner learnings from this work that we can scale and replicate in different countries. The big picture here is that we believe we need an industry wide movement in this space to address behaviour change within procurement and overcome scaling barriers through networked learning on the feasibility of business model to strengthen ecosystems. We’re kicking off learning networks to do just this in 2022. We would also like to give kudos and thanks to the Every Breath Counts calls for their crucial platform and input in enabling this work.
Step Two. In the long-term we are aiming for product innovation that is effectively embedded in the local ecosystems of LMICs. The reason this goal is long term is because it can take up to approximately 3–7 years to get through device approvals and pilots to unlock market entry. We’ve spoken to numerous manufacturers and the additional challenge involved is one of innovation risk. Commercialising new oxygen concentrators could cost anywhere between £2M to £20M so to achieve the break even value (or positive Net Present Value) requires a significant number of unit sales. Large manufacturers have to be sure that there’s a market big enough to sell their devices before taking such a risk. Given there’s no data or visibility on market sizes in LMICs, it’s consequently difficult to trigger product innovation in these markets. By enabling Oxygen-as-a-service business model innovation we seek to unlock a de-risked market opportunity to encourage greater product innovation.
In addition, whilst business models innovation is a faster process, the complimentary product innovation remains critical. We partnered with UNICEF in publishing an Oxygen Concentrator Target Product Profile (TPP), which is central to the desired product innovation needs of LMIC’s. Through working with visionary friends, such as UNICEF and TPP contributors the Oxygen CoLab has accelerated progress towards our combined goals of getting fit-for-purpose Oxygen Concentrators to market.
So what? The current market failure around Oxygen Concentrators is not unique and may apply to many medical devices. In an ideal world, local manufacturers would exist in the regions their devices are sold. Device graveyards are the symptom of an ecosystem and market failure, so strengthening market and ecosystems are necessary to get new and more robust technologies into low-and-middle income countries, which is certainly a challenge, although not impossible. We need both business model innovation and product innovation to address the challenges and seek an alternate market opportunity that increases access to Oxygen right to the last mile.
Watch this space. Sadly, Omicron is not going away any time soon and will continue to evolve and impact upon low-and-middle-income countries. The Oxygen CoLab is preparing for a jam-packed second year in which we will continue to test and then scale the best of what we’ve learnt in year one. We’ve covered a huge amount of ground and would like to sincerely thank all of those that have been on the journey with us as CoLab-bers; from the numerous workshops, to the dragons’ den pitches, to our learning communities. We hope that 2022 will be an even better year for the incredible engagement and achievements of this network.