Context

Medical oxygen is critical for treating a wide range of health conditions and is recognized as an essential medicine by the WHO. Reflecting its therapeutic significance, in May 2023 the World Health Assembly unanimously adopted a resolution to enhance access to medical oxygen, emphasizing its role in strengthening health systems and achieving health-related SDGs.

Medical oxygen is necessary for treating low levels of oxygen of the blood, known as hypoxemia – which can result from various health conditions such as pneumonia, sepsis, trauma, and complications during childbirth. Hypoxemia is a major cause of mortality, especially among children under five and pregnant women.

Pneumonia accounts for approximately 8.5 million cases of hypoxemia in children under five annually in low- and middle-income countries (LMICs). Alarmingly, fewer than 20% of children hospitalized with severe pneumonia and hypoxemia receive the critical oxygen therapy they require.

Despite its importance, access to medical oxygen remains a challenge, particularly in LMICs, due to long-standing under-investment. Less than half of health facilities in sub-Saharan Africa have access to medical oxygen, and the average per capita consumption of oxygen in sub-Saharan Africa is ten times lower than in the US and EU. This significant gap underscores the challenge of meeting demand for oxygen in limited-resource settings.

Access to medical oxygen is hindered by numerous and complex barriers.  Historically, the oxygen market has been characterized by low levels of innovation, with relatively few products introduced before the COVID-19 pandemic.  Existing technologies have been plagued by operational challenges, including high levels of maintenance, significant power requirements, and logistical issues. These barriers have resulted in quality issues, particularly for unmaintained products, affordability challenges, as well as inconsistent supply and lagging adoption. 

Maintaining the quality of respiratory care equipment is challenging due to the inapplicability of traditional quality assurance methods in many locations and a shortage of skilled professionals. This inconsistency in maintenance compromises oxygen purity, negatively impacting patient care.

Affordability is another major issue, particularly in low-income regions where the high cost of oxygen, especially liquid oxygen (LOX), is driven by significant infrastructure investments, market consolidation, and transportation expenses. These financial burdens restrict healthcare facilities’ ability to provide essential oxygen therapy.

Supply and delivery face significant challenges, especially in remote and low-resource settings. These areas often rely on inefficient oxygen cylinder exchanges due to inconsistent supply and the lack of medical gas piping systems. Additionally, obtaining spare parts can be problematic, leading to the underutilization of available oxygen resources.

The demand and adoption of oxygen-related products are constrained by operational issues such as maintenance and power requirements. While improved technologies exist, they are slow to reach the market, and pathways for adoption remain unclear, resulting in underutilized products and unmet demand.

Innovation in oxygen production and distribution technologies has been limited. Introducing new technologies with lower maintenance requirements could significantly enhance access, but the slow pace of innovation limits their availability.

Addressing these barriers is crucial to ensuring that healthcare facilities worldwide have the oxygen needed to provide quality care.

The COVID-19 pandemic underscored critical disparities in access to medical resources globally, revealing the pronounced discrepancies in oxygen availability between high-income countries and LMICs.

In response, the past four years have seen broad investment in medical oxygen. Since 2020, countries have rapidly introduced respiratory care equipment in large volumes to address the emergency, providing a much-needed response that goes far beyond COVID-19. Simultaneously, recognizing the gap in innovation, private industry, non-profits, and academic institutions have developed new products to address persistent design challenges.

Unitaid recently developed a medical oxygen innovation landscape that outlines a pipeline of emerging technologies and business models.   Among the product areas that the landscape identifies as opportunities to fill critical gaps, are emerging large-scale oxygen production systems and medical gas piping systems. The landscape also recognizes pilot and potential business models capable of solving complex delivery challenges. Continued investment to build on the progress made in recent years is now needed to ensure that COVID-19 era investments and innovations are sustained, reach scale, and unlock broader access to oxygen.

Unitaid, having made considerable investments to improve access to oxygen, recognizes that sustained investment is required to catalyze ongoing product innovation and to evolve business models to provide consistent market access. Evidence suggests that enhancing oxygen production and delivery systems could reduce in-hospital mortality rates from childhood pneumonia by 50%, resulting in a cost-effectiveness proposition comparable to vaccination programs. With this significant potential for investment impact, Unitaid is launching a Call for Proposals focused on the following objectives:

• Facilitate introduction of novel oxygen technologies in LMICs: Assess and expand on recent innovations in large-capacity production and medical gas pipeline systems, which have limited uptake in LMICs, to better evaluate their feasibility and establish the most cost-effective use cases under real-world conditions.
• Expand access to oxygen solutions with new business models: Pilot and evaluate new business models, to sustain pandemic investments and optimize respiratory care equipment, including identifying channels for future uptake.

Call scope

Proposals are solicited for the following intervention.

Improving medical oxygen access in LMICs through innovative technologies and sustainable business models.

Proposals should include at least one of the two areas listed below:

Area 1: Introducing technology innovations in oxygen production and distribution for LMICs

In recent years, numerous promising technologies have emerged in the oxygen product pipeline (See landscape). Without continued investment to build on recent advancements and further innovation in large-capacity production and piping systems, many issues that pre-dated the COVID-19 pandemic may persist. To thoroughly assess the potential for these systems to be scaled in LMIC markets, Unitaid seeks proposals focused on developing a proof of concept for two specific technologies: (1) Solid-state, large-capacity oxygen production solutions that reduce the operational complexities of existing on-site systems; (2) Medical Gas Piping System (MGPS) innovations aiming to simplify and reduce the cost of installing distribution systems in both existing and new health facilities, especially at secondary and tertiary levels.

Proposals should evaluate the performance of these solutions under real-world conditions, determining their feasibility, acceptability, and cost-effectiveness. The goal is to understand whether/how these technologies can scale in LMIC markets to address ongoing access challenges. Proponents should outline how their activities will inform potential use cases and support product introduction.

Proof of concept activities should be conducted in areas with the greatest need for oxygen access. For oxygen production technologies, the focus should be on settings with reliable electricity. Piping solutions should target secondary or tertiary health facilities to better manage referrals from primary healthcare.

Area 2: Implementation and evaluation of business models to sustain oxygen investments

During the COVID-19 pandemic, the global procurement of oxygen-related products reached unprecedented levels, providing significant benefits to LMICs. In these settings, operating and maintaining complex systems like Pressure Swing Adsorption (PSA) plants have historically posed significant challenges for the health system.

These challenges include frequent equipment breakdowns, long waiting times for replacement parts, and eventual discontinued use of the equipment. The influx of respiratory care products during the pandemic provides an opportunity to avoid these issues in the future. To do so, innovative operational approaches are now required to ensure the sustainability of these investments over the medium and long term and provide an avenue for further expansion based on the experience gained.

Unitaid seeks the submission of proposals to pilot the development, implementation, and evaluation of business models aimed at supporting the operation and maintenance of respiratory care technologies. Examples of such models could include, but are not limited to, umbrella management agreements, batched service level agreements, lease-back programs, or other innovative approaches to manage oxygen systems. These are illustrative examples, and we welcome proposals featuring other novel business models as well.

Proponents are encouraged to reflect on the lessons learned from previous efforts and demonstrate how their approach builds on these experiences to enhance effectiveness. Additionally, it is important to show how these new models leverage previous investments. The focus of this area should be on generating evidence to better understand which models may be most appropriate for managing the sustainable use of existing products in different contexts within the health system, and on evaluating the scalability of these models to ensure they can be effectively implemented on a larger scale.

Coordination with national programs, regional bodies, civil society, and global partners is essential, and efforts should be made to secure buy-in and funding for transition to scale, for both of these two areas.

Proponents are invited to apply to one or both areas outlined in this call. No preference will be given to proposals covering both areas, and the budget should accurately reflect the scope of work for the chosen area. It is essential that proposals strictly adhere to the scope of each area. Unitaid’s Oxygen Landscape can serve as a valuable resource for identifying products that fall within or outside the scope.

Proposal requirements

Project Structure

Proponents may choose to focus on one or both areas described above. Depending upon the set of planned activities, proponents are welcome to apply individually or as part of a consortium of partners. Broad collaboration with relevant stakeholders will be vital to achieving the project objectives, including coordination with established partnerships such as the Global Oxygen Alliance (GO₂AL). Proponents should specify the key stakeholders with whom they will engage, why they have been selected, and how this will be achieved.

Unitaid will prioritize proposals from South-based lead implementers with experience in implementation and expertise in the technical and market intervention areas needed for the project. This includes supporting product development and introduction in resource-limited settings. Additionally, Unitaid encourages the inclusion of South-based sub-implementers in project consortia where feasible and relevant. It is important to note that Unitaid’s aim to progressively engage more lead implementing partners from the global South does not exclude proposals led by or including partners from the global North. In all cases, coordination and collaboration across implementers are encouraged. Unitaid seeks proposals that demonstrate regional impact across key LMIC markets and a clear path to global impact.

Technical input and oversight of the initiative should be shared across key partners, and to this end an expert advisory group or steering committee, including representatives from communities and civil society, should be formed to oversee project activities at regional and global levels. The steering committee will need to be the strategic support structure for the grant, providing the lead grantee with thought partnership, a forum for problem-solving, relationship support, and evaluating strategic and/or operational shifts over the course of the project. The structure and design of this oversight body can be best defined during grant development to ensure it is fit-for-purpose.

Theory of Change

Proponents should clearly describe their overall project design with a Theory of Change, showing how it meets the objectives of the initiative and how the proposed activities form part of a coherent whole. Proposals should explicitly state what impact will be achieved within the project’s lifetime, as well as what, and how, lasting impact will be achieved. Applicants should be clear about the underlying assumptions made in their proposed approach and should highlight any major risks or other factors that may affect the delivery of results. The proposals are expected to outline a clear pathway to results and impact.

Country engagement

It is important to include a country engagement model that outlines coordination and cooperation with countries to align with their oxygen roadmaps, monitoring of interventions, and assessment of impact. By actively involving government stakeholders in all phases of planning and implementation, projects will gain valuable insights into local contexts, policy frameworks, and stakeholder priorities. This collaboration will lead to more informed and effective project design, increased buy-in from government partners, and greater sustainability of project outcomes beyond the grant funding period.

Civil society and community engagement

Unitaid considers community engagement crucial for generating demand and improving the lives and health of vulnerable populations. Inclusive approaches and the early and sustained involvement of communities are strongly encouraged. Collaboration with affected communities, grassroots organizations, and Civil Society Organizations is essential at all stages of a project, including ideation. This engagement is a key factor for success, and activities should be clearly budgeted in proposal submissions. When designing, planning, implementing, and evaluating activities and programs, it is important to consider and adequately fund community-led approaches.

Climate change and environmental efforts

Unitaid is committed to climate and environmental action in its investments and expects its partners to make similar commitments. Proposals should clearly indicate: (i) Efforts that will be made to minimize carbon emissions from project activities; (ii) Potential opportunities to contribute to broader climate and/or environmental co-benefits, in synergy with core project objectives. More detailed guidance and definitions are provided in the proposal template.

Proposals should demonstrate value for money and measurable impact. Proposals should also include analysis of pathways to impact, scalability, and sustainability of key interventions.

Areas out of scope for this Call: 

Area 1 of this call is specifically focused on two product areas: solid-state, large-capacity oxygen production solutions and medical gas piping system innovations.

Unitaid recognizes the importance of a broad range of products to meet the needs of patients in LMICs, many of which are critical to the organization’s overall oxygen strategy. While acknowledging that access barriers remain for many of these products and noting that subsequent Unitaid calls may include some of them, the products below are not included in this call scope:

• Product classes that are already in use in LMICs. This includes production methods such as oxygen concentrators, PSA/VSA systems, ASUs, as well as standard piping solutions.
• Other products focused on diagnosis and monitoring, oxygen regulation, oxygen storage, and oxygen delivery, such as ventilators, are not in scope for this call for proposals.

Area 2 of this call is specifically focused on business models to sustain respiratory care equipment that has already been procured.

• Models focused only on procuring new products are not in scope for this area of work.

Impact we are seeking

This call seeks to address long-standing design issues with oxygen production and distribution technologies, as well as improve upon business models that are not fit-for-purpose. By introducing improved products and models, Unitaid aims to ensure equitable access to effective oxygen therapy, aiming to save lives and prevent avoidable deaths. While recognizing the potential for cost savings in health systems and for patients, Unitaid acknowledges that trade-offs between cost and life-saving interventions may be necessary.

Unitaid’s interventions are expected to significantly expand access to medical oxygen in LMICs by increasing production capacity and ensuring reliable supply in health facilities and at patient bedsides. These efforts focus on underserved populations by developing and supporting products tailored to their specific needs. Through these investments, Unitaid aims to foster competition, reduce in-hospital morbidity and mortality, and enhance the affordability of oxygen. Additionally, these initiatives will bolster health systems’ resilience and preparedness for future pandemics.

Specifically, Unitaid seeks to:

• Support the introduction of new technologies with the potential to significantly improve access to oxygen in LMICs through more cost-effective and operationally feasible designs.
• Accelerate the adoption of new business models that can sustain existing respiratory care equipment

These activities will be underpinned by the development of strategic partnerships across governments, international organizations, the private sector, and civil society. Proponents are encouraged to consult the relevant key performance indicators for medical oxygen ecosystems, developed by WHO in 2023, which cover operational performance, oxygen ecosystems, patient impact, and procurement. For further details, the WHO KPI Report can be accessed here.

Ultimately, Unitaid expects that meeting the objectives of this Call for Proposals will result in significant outcomes, including multiple Unitaid programmatic priorities, such as (1) improved maternal and neonatal health outcomes through reliable access to oxygen at the point of care; and (2) improved preparedness for future global health emergencies via products and delivery models that are fit for purpose.

Process for proposal submission

When developing a proposal, please note the following resources:

Answers to frequently asked questions relevant to proposal development (this document is regularly updated), please click here [PDF : 500 Ko].

For Unitaid’s preliminary rationale for working in this area, please click here [PDF: 1.5 Mb].

After assessment of the proposals and endorsement by the Unitaid Board all applicants will be officially notified as to whether they will be invited to develop a full grant agreement for Unitaid funding.

Important dates

Submission and format of proposals

• Proposal form with scanned version of signed Front page template, [DOC: 300 KB]
• Annex 1: Log frame and GANTT chart template, [XLS: 278 KB]
• Annex 2: Budget details template, [XLS: 24 KB]
• Annex 3: Organizational details and CVs of key team members [no template]
• Annex 4: Country engagement support Letters [no template]
• Annex 5: Declaration of relevant interest template, [DOC: 21 KB]
• Annex 6: Applicable ethics, anti-discrimination and environmental policies template, [DOC: 21 KB]
• Annex 7: Declaration regarding tobacco entities template, [DOC: 24 KB]
• Annex 8: Anti-Terrorism Declaration template, [DOC: 30 KB]
• Annex 9: Audited financial statements for the past 3 years [no template]

If you have any questions about the application processes throughout any stage of the application review process, please send your queries to the Grant Application Manager:  proposalsUnitaid@who.int

You will find further guidance in the Unitaid proposal process document [PDF: 530 KB]. Additional guidance can be found in the following documents:

• Guidance on Impact Assessment [PDF: 160 KB]
• Financial Guidelines for Unitaid Grantees [PDF: 1,2 MB]
• Unitaid Results Framework [PDF: 1.3 MB]
• Unitaid Scalability Framework [PDF: 466 KB]