Pilot implementation of 'outsourced oxygen to the bedside' models in five countries: a mixed methods impact assessment.

Background: Medical oxygen is an essential medicine that is often unavailable for patients when they need it. We explored if 'outsourced oxygen to the bedside' (O2B) pilots, where private providers deliver a package of services, were successful in ensuring reliable oxygen access at the patient bedside. Methods: We conducted a sequential explanatory mixed-methods assessment of O2B pilots in Kenya, Nigeria, India, Tanzania and Uganda from September 2024 to January 2025. A quantitative cross-sectional facility audit described facility contexts, tested equipment functionality and assessed healthcare worker (HCW) oxygen knowledge. Qualitative interviews with HCWs and managers explored experiences of O2B pilots. Results: We studied 28 of the 80 facilities participating in the pilots, 179 HCWs completed the knowledge survey and 59 qualitative interviews were conducted. In the audit, we found O2B provided oxygen equipment more functional and usable than non-O2B equipment: 64.5% vs 40.9%, p<0.001 for cylinders, 95.0% vs 25.7% (p<0.001) for concentrators and 84.0% vs 70.0% (p value=0.172) for pulse oximeters. Overall, 21.8% (39/179) of HCWs had received training from O2B providers, and their oxygen knowledge was slightly higher than those who had not (mean score 15.3/24 vs 13.9/24, p value=0.002). Qualitative interviews highlighted positive changes in oxygen access and the ability to treat patients, but also mixed understandings of the O2B services being provided, and requests for additional services. Conclusion: O2B pilots appear to improve medical oxygen access, with effective maintenance and repair services being a key mechanism. However, tailoring to local needs and remaining gaps in HCW capacity need to be addressed.