Why India Must Keep Covid-Era Oxygen Plants Running

On October 8, IndiaSpend asked Manoj Kumar Pingua, additional chief secretary, Health and Family Welfare, Chhattisgarh, about the status of these oxygen plants.

“Two being handled by the state agency, the Chhattisgarh Medical Services Corporation, are functional,” said Pingua. “The third one was established by the Prime Minister’s Citizen Assistance and Relief in Emergency Situations Fund (PM Cares Fund) so the CMHO [Chief Medical & Health Officer] is following it up with them to start the oxygen plant.”

A further communique from the Pingua’s office on the same day said that the third plant had become functional on October 5.

These plants were among the 1,225 pressure swing adsorption (PSA) plants costing Rs 1 crore each installed through the PM Cares fund during and after the second wave of the Covid-19 pandemic in 2021, when India faced an acute shortage of oxygen. Another 2,910 PSA plants were funded by states, corporations, public sector undertakings and overseas agencies, according to a document obtained through a right to information (RTI) request by Venkatesh Nayak, Director, Commonwealth Human Rights Initiative. Some private sector hospitals also installed PSA plants, and donors contributed to establishing similar infrastructure in not-for-profit hospitals.

PSA plants produce oxygen with a concentration of 93% ±3 from ambient air, which World Health Organization (WHO) guidelines published in June 2020 recognise as medical grade.

Three years on, news reports suggest that some PSA plants have become non-functional due to mechanical or other reasons (see here, here and here).

A Health & Family Welfare Ministry insider told IndiaSpend on the condition of anonymity that mock drills are ordered periodically to monitor the 4,135 PSA plants that were installed during the pandemic, and the last such drill conducted by states had returned data for 3,005 PSA plants, of which only 53% were functional.

While the Covid-19 pandemic is over, a study by Gingko Bioworks for the WHO shows that over the next 25 years, there is a 66% probability of a respiratory pandemic that would kill 10 million people or more. A functional PSA plant is a certain source of oxygen and, for remote hospitals, it is the only source when logistics fail or demand rises to unprecedented levels as we saw during the pandemic.

That’s why, Narayan Swaroop Nigam, health secretary in West Bengal, told IndiaSpend, it makes sense to keep the PSA plants operational as well as maintain an active supply chain of liquid medical oxygen. “If one fails, you cannot operationalise the other immediately so it is essential to keep both running.”

So far, however, the Union government is silent on how to resolve this situation.

Who is responsible for the public funds spent on PSA plants?

Since the outcome of mock drills conducted to ascertain the functional status of India’s PSA plants is not put in the public domain, calls have grown for an audit of the PSA plants inventory accumulated with monies spent via PM Cares and Corporate Social Responsibility donations.

“All organisations are mandated to be audited, and that includes PSA plants set up in both public and private sector by central and state governments,” said Preeti Kumar, VP (Health Systems), Public Health Foundation of India (PHFI). “While the auditing agencies differ as per the government and company rules, it is one of the essential processes to ensure the productive use of resources.”

“Civil society has been asking for greater transparency of the PM Cares funds,” said Indranil, professor, Jindal School of Government and Public Policy. “On the one hand, public servants were forced to contribute to PM Cares. Opting out was virtually impossible, though the contributions were called voluntary. On the other hand, the funds continue to be kept outside the purview of RTI despite PILs filed to bring them under the CAG [comptroller and auditor general] audit and RTI. We need further persuasion with the judiciary.”

“During the pandemic, the central government developed multiple portals to track the demand and supply of oxygen, and also to monitor the equipment status (see this, this and this), and proposed to merge these into one portal, but nothing has been done in this regard as yet,” Varun Manhas, Associate Director - Public Health Programs, One Health Trust, India (formerly CDDEP), and oxygen lead of the National Medical Oxygen Grid, an IT platform for monitoring, tracking and supporting data-based decision-making relating to oxygen supply, demand, use, analysis, capacity building and policy building in India, told IndiaSpend. “Also, most other portals developed by state governments are now defunct due to very low or no data entry.”

Were PSA plants really necessary?

During the first wave of Covid-19 in September 2020, the demand for liquid medical oxygen across India reportedly increased from the average pre-pandemic level of 750 metric tonnes per day (mtpd) to 2,700 mtpd, touching a high of 3,095 mtpd on September 29.

In April 2021, as the second wave unfolded, the demand increased to 5,500 mtpd in the third week, and further to 7,100 mtpd and 8,943 mtpd in the following weeks.

As against this, before the pandemic, only 1,000 MT of the total 6,900 MT of oxygen produced in India was medical grade.

Further, the medical oxygen shortages in September 2020 and April-May 2021 were not uniformly spread across the country. Liquid oxygen is used in the manufacturing of steel to increase the combustion temperature and replace or enrich air, and so the supply of liquid medical oxygen (LMO) was better in east India where the steel industry is concentrated.

While the government turned to the country’s steel makers to help increase the supply of LMO, liquid oxygen is flammable so it has to be transported by road or rail, a time-consuming journey heavily dependent on tankers, which were in short supply.

States in the north, west and central parts of the country, namely Delhi, Uttar Pradesh, Maharashtra, Gujarat, Rajasthan, Madhya Pradesh, Telangana and Andhra Pradesh, which are not home to large steel producers, saw the worst LMO outages and resultant deaths.

Keeping in mind the country’s vast geographic spread and the difficulty in transporting medical oxygen, an expert committee was created to identify issues and take appropriate decisions to localise production of medical oxygen in PSA plants, explained Kumar of the PHFI.

It was widely believed that installing PSA plants would decentralise the production of oxygen and help hospitals become self-sufficient in their oxygen needs.

“In the midst of the Covid pandemic when the country was dealing with shortage of oxygen, and in the context of small to mid-size hospitals in rural areas where delivering liquid medical oxygen was challenging, PSA technology provided hope,” said Vishakha Jain, head, Department of Medicine, All India Institute of Medical Sciences, Hyderabad, and co-author of the paper Out of breath in pandemic – Is pressure swing adsorption (PSA) technology a solution for saving lives?

Not everyone fully agrees with that view. According to Indranil, “The investment in PSA plants was made without considering their benefits and effectiveness.

“We understand that the decisions were made rather abruptly, but this is only partly justified,” he said. “Had we better prepared ourselves before the emergency, the investment decisions would have been based on scientifically conducted Health Technology Assessment Studies, which involve a proper understanding of the costs and benefits of a particular investment in relationship with existing technologies.”

Indranil believes that decisions to create public health assets should be based on societal needs rather than on the mere invention of new technologies. He pointed out that this would necessitate a bigger role for public bodies like the Department of Health Research, the Indian Council of Medical Research, and particularly Health Technology Assistance India, which, in turn, would need a considerable increase in their budgets.

Nevertheless, the government’s multi-pronged efforts to allay the oxygen situation included installing PSA plants in government hospitals in every district to generate 4,852 mtpd of oxygen, increasing the production of liquid medical oxygen from 5,700 mtpd in August 2020 to 9,690 mtpd by May 2021, and enhancing its distribution.

Why do pandemic-era oxygen plants need attention now?

By October 2021, the installation of 1,225 PSA plants under PM Cares, covering every district in the country, had been completed and more than 7,000 people had undergone online operations and maintenance training conducted by the Directorate General of Training.

In the ensuing months, news reports suggested that operator shortages, insufficiently trained operators, electricity outages and breakdowns in the mechanical parts were hampering the operations of those PSA plants.

States may have believed that the Union government would meet the cost of operator’s wages and maintenance cost, but this had never been explicitly stated. It has been reported that Maharashtra asked the Union government for funds to meet the operators’ wages, a request that was declined.

“We knew when we accepted the plants that we would have to budget for the operators as well as train them,” Nigam told IndiaSpend.

West Bengal received 49 plants under PM Cares, while 29 plants were installed with the support of CSR donations. Of the former category, four plants were never made operational.

A meeting of the West Bengal state government in July 2023 noted that many of these plants were non-functional. Among the issues disrupting their functionality were the expiry of operator agreements and warranties, phase-wise by March 2023, and the proprietary nature of the items needed to service the plants.

A well placed source in the Union health ministry, who IndiaSpend spoke to, agreed that the expiry of the procurement warranty of the PSA plants supplied under PM Cares caused many to malfunction, and also said that the maintenance cost burden should be shared by the Centre as well as states.

In the absence of any such provision, Nigam told IndiaSpend that through revisions in the state health budget, money had been set aside to pay operators, and savings accruing from relying on less expensive oxygen generated by PSA plants were also channelled towards that expense.

As for training, “We involved suppliers in creating modules to train operators, a task that was implemented by our Department of Technical Education,” said Nigam.

Nigam admitted facing “mechanical issues in operating these plants”. However, he said, “PSA plants are electromechanical equipment; possibly the plants had deficiencies because of the urgency with which they were ordered and supplied. In the midst of the pandemic, timing was an issue. The pandemic was a unique situation requiring quick decision-making.”

Any pandemic will present emergency situations, which is why despite West Bengal being a state with no dearth of liquid medical oxygen because of its extensive steel industry, Nigam emphasised the need to keep PSA plants operational as well as to ensure an active supply chain of liquid medical oxygen.

The way forward

Some hospitals with PSA plants continue to use them.

“A large government hospital in Gautam Budh Nagar is relying on oxygen generated by its three PSA plants, and using cylinders only as backups,” Jayendra Kasar, Senior Programme Officer, PATH, told IndiaSpend.

PATH, a global not-for-profit, supported the installation of more than 1,300 PSA plants in health facilities that shared the high burden of Covid-19 cases during the second wave, across more than 22 states in the country including remote areas like Kargil district in Ladakh and Mizoram and Meghalaya in the North-East.

“Fatima Hospital in Lucknow, and the All India Institute of Medical Sciences, Bibinagar, are also relying on their PSA plants,” said Kasar.

Hospitals that aren’t using their PSA plants are either not doing so because their load doesn’t merit such expensive infrastructure (which research shows are cost-effective when they are of higher capacity and used to their maximum capacity on electricity), or because they find it easier to buy oxygen than to maintain and run a PSA plant, or because their doctors have concerns about the purity of the PSA-plant produced oxygen.

“If the hospital’s case load doesn’t justify relying on a PSA plant, other medical oxygen resources (LMO, oxygen cylinders, oxygen concentrators) may seem to be economically more viable options,” said Kasar. “Health facilities with multiple oxygen sources should have a tool to guide them in selecting the most cost-effective option--whether PSA, LMO, or cylinders--based on the patient load at any given time.”

“Since using PSA plants is vital to keep them functional, we need a directive policy to ensure that states primarily use the PSA plants to meet their oxygen needs and rely on liquid medical oxygen cylinders only for their emergency supplies,” said the central ministry source IndiaSpend spoke to.

That said, Kasar pointed out that “The use of oxygen produced by the PSA plant should be expanded to cover a wider range of medical conditions, including accident emergencies, surgeries, heart failure, asthma, pneumonia, as well as maternal and child emergencies.”

One way to encourage hospitals with excess oxygen producing capacity to use their PSA plants is to develop a business model to help them monetise their PSA plants and generate funds to keep it running, proposed Kasar. “However, this would need a pilot demonstration.”

“PSA plant-generated oxygen can be used for non-medical purposes as well as for various commercial activities,” said Indranil. “A Parliamentary Standing Committee should systematically examine these investments and create a mechanism to make use of them in the long run.”

Hospitals have a responsibility to fulfill to the country

Hospitals that aren’t using their PSA plants because “using pre-filled cylinders is easier” must be told that “this is not preferable in the interest of medicine and the society”, said Bhabatosh Biswas, a Kolkata-based cardiothoracic and vascular surgeon appointed to a 12-member National Task Force for oxygen distribution to states that was created by the Supreme Court in May 2021.

“At the time of the pandemic, it was made mandatory for medical colleges and large hospitals to have and maintain a PSA plant,” Biswas told IndiaSpend. “Thereafter, despite the demand for oxygen having dipped, those installed PSA plants must be kept running so that they can be relied on.”

Essentially, experts agree that hospitals should not be allowed to become complacent about operating their PSA plants. “Hospitals should typically have one or two back-ups for critical aspects such as oxygen, electricity, water and waste disposal,” said J.V. Peter, professor, Critical Care Medicine, Christian Medical College, Vellore, and a member of the aforementioned 12-member National Task Force. “Hospitals should keep the PSA plants running as a back-up for emergencies, or if they are not being used, they should be checked at regular intervals to ensure that they are working.”

Skepticism about the quality of PSA plant produced oxygen is another challenge that needs to be addressed. Medical-use oxygen produced by the air-liquefaction process should contain not less than 99.5% v/v of O2, according to the International Pharmacopoeia. The Indian Pharmacopoeia 2018 describes oxygen as containing not less than 99% v/v of oxygen, and oxygen 93% as a separate category containing between 90% and 96% v/v of oxygen.

“Because liquid oxygen is 100% oxygen whereas the oxygen produced by PSA plants has a concentration of 93% +/-3%, liquid oxygen is preferred in critical areas such as intensive care units and operating theatres, where patients may require high concentration of oxygen,” said Peter.

“But when patients are not so critical, oxygen from PSA plants may be considered at par with liquid medical oxygen,” added Jain.

However, Ramanan Laxminarayan, president of the One Health Trust and leader of the National Medical Oxygen Grid initiative, said: “In general 99.5% purity is needed for very few patients; most patients need pure oxygen mixed with air and in that sense a 93% purity is more than adequate for the vast majority of conditions.”

Kasar proposed “an exchange of knowledge and experiences between anaesthetists and critical care specialists in hospitals using PSA plants, and the wider medical community to encourage and further the use of installed PSA plants”.

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