Provider and Patient Perspectives on the Impact of Oxygen Scarcity: A Qualitative Study within the Africa Infrastructure Relief and Support Initiative in Liberia

Access to reliable energy and medical oxygen is fundamental for effective healthcare delivery. However, oxygen scarcity remains a persistent challenge in many LMICs across Africa [1]. Healthcare facilities in these contexts often face inconsistent electricity supply and limited oxygen availability, which negatively affect patient outcomes and strain health systems [2, 3].

Previous studies have emphasized the importance of healthcare workers’ perspectives in improving implementation of solar power and oxygen interventions, particularly in resource-limited settings. For example, Pulsan et al. explored the views of rural health workers in Papua New Guinea after introducing solar power and oxygen concentrators [4]. Following implementation, participants reported improvements in service delivery, patient safety, and staff performance. Reliable lighting enabled safer procedures in labor wards and operating theatres, while powered devices enhanced communication and patient care.

The perspectives of healthcare workers and caregivers, whether positive or negative, are crucial in shaping interventions that are both sustainable and contextually appropriate. The day-to-day experiences of medical personnel with existing infrastructure and resource constraints can highlight potential barriers and facilitators to successful implementation [4, 5, 8, 9]. By understanding healthcare workers’ specific needs, difficulties, and concerns solutions can be tailored to improve the working conditions and patient care protocols in these regions. This ensures that the implemented technologies are not only useful but also sustainable. Prior studies from Australia and Canada have also identified barriers to oxygen delivery, including physical constraints of devices and caregiver stress during treatment [6, 7]. Rawat et al. highlighted similar issues in Ethiopia, where device shortages and inconsistent power supply hindered care [8].

The Africa Infrastructure Relief and Support (AIRS) Project, led by the Society of Critical Care Medicine and the Johns Hopkins Global Alliance of Perioperative Professionals (JH-GAPP), was developed to address these very challenges. AIRS focuses on strengthening oxygen and energy infrastructure in resource-limited hospitals across West Africa through solar-powered oxygen generation and training programs for healthcare personnel. FJ Grant Hospital in Sinoe County, Liberia, serves as one of the early implementation sites for this initiative, making it an ideal setting for examining both the operational realities and stakeholder perceptions surrounding oxygen delivery and energy reliability.

Despite growing literature on technological and logistical aspects of oxygen infrastructure, few studies have captured the lived experiences of providers and patients directly engaged in delivering and receiving oxygen therapy in West Africa, particularly within facilities involved in AIRS implementation. This study therefore aims to fill that gap by examining the firsthand perspectives of nurses, physicians, and patients at FJ Grant Hospital to understand the operational, emotional, and systemic challenges of oxygen scarcity. It contributes to existing literature by contextualizing infrastructure challenges within healthcare workers’ daily realities, providing insights that can inform the continued development and scaling of AIRS and similar solar oxygen implementation strategies across low-resource health systems.

Study Design

The research adopted a qualitative interview design to examine the impact of oxygen and solar implementation in Liberia, focusing on the FJ Grant Hospital in Sinoe County. Qualitative methods were well suited for capturing the experiences and perspectives of key stakeholders involved in the implementation process. By using an interview design, the study aimed to gain in-depth insights into the effectiveness of installing oxygen and solar plants at the FJ Grant Hospital. This approach provided a comprehensive understanding of the current practices at FJ Grant Hospital and the benefits the installation of oxygen and solar plants would provide.

Sampling Strategy

A snowball sampling approach was used to identify participants, beginning with key hospital staff and expanding through professional referrals until thematic saturation was reached. Through this approach, 21 participants were enrolled for interviews. Participants were selected based on their involvement in oxygen therapy delivery or experience as patients receiving oxygen treatment. All participants provided verbal and written consent before participation.

Data Collection

A semi-structured interview guide was used to collect data. Researchers from the Johns Hopkins Global Alliance of Perioperative Professional (JH-GAPP) team conducted in person interviews with support from Liberian colleagues associated with the Ministry of Health and FJ Grant Hospital. Interviews were conducted over a period of three days from May 11 to May 14th of 2025 at the FJ Grant Hospital in Greenville, Liberia.

The interviews lasted approximately 5–20 minutes and were recorded with participant permission. The interview guide was developed after reviewing comparable qualitative studies focused on barriers to oxygen therapy in low- and middle-income country settings and was further refined through monthly consultations with the core JH-GAPP Research Team [9].

Data Analysis

Interview transcripts were uploaded into MAXQDA (Version 24) for coding and thematic analysis. Thematic analysis followed a structured, iterative approach: familiarization with transcripts, generation of codes, identification of themes, review, and refinement. Inter-coder reliability was ensured by three independent researchers who compared coding results and resolved discrepancies by consensus.

Study Area and Population

The study was conducted at FJ Grant Hospital, a 100-bed facility located in rural Liberia. The hospital was established to provide specialized medical services, support the efforts of other health service centers, and provide care to the region with approximately 68 health professionals. The study spanned 3 months, from May 2024 to July 2024.

Ethical Considerations

Ethical clearance was obtained from the FJ Grant Hospital Ethics Committee. Participants were anonymized and identified only by role and code in transcripts. Informed consent was obtained from all participants, including patients and caregivers, prior to interviews. The research team adhered to confidentiality standards and ensured data were securely stored throughout the study.

A qualitative study was conducted to explore the barriers to efficient oxygen therapy at FJ Grant Hospital in Liberia, focusing on significant operational, resource, and infrastructural challenges. In-depth interviews were conducted with healthcare providers, including clinicians, nurses, physician assistants, maintenance staff, and patients served at the hospital. Table 1 categorizes 21 individuals involved in the study, distributed across various roles. Among healthcare workers, there were 3 physicians (14%), 5 nurses (23%), 2 physician assistants (10%), 1 epidemiologist (5%), and 1 clinician (5%). Patients and their families constituted 6 individuals, with 4 patients (19%) and 2 patient family representatives (10%). For detailed distribution, please refer to Table 1.

Six themes emerged from the analysis: current oxygen delivery devices, operational and resource challenges, provider preparedness and response, staff and patient perception of the new solar project, operational and emotional impact, and healthcare and patient outcomes. The different codes that were merged to create the above themes and memos are presented in Table 2.

Current Oxygen Delivery Devices

Participants consistently described dependence on a limited number of oxygen concentrators that frequently malfunctioned due to power outages, resulting in delays and interruptions in patient care. A physician stated,

“We have serious challenges when it comes to oxygen. Currently, we only have a few functional oxygen concentrators; most are out of service. Personally, I believe we only have one or two functional concentrators in the hospital—one in the ER and another in a different department. We have no oxygen cylinders available right now.”

The lack of functional equipment particularly affected vulnerable populations, as noted by an epidemiologist:

“We face significant issues with oxygen supply, particularly affecting maternal and neonatal cases. Neonatal and maternal deaths are often due to a lack of oxygen, with hypoxia being a common cause of neonatal deaths. The infant population is most impacted by this shortage.”

Another nurse added,

“We recently received new tanks for the wards and emergency unit, but the supply remains inconsistent. Sometimes, we have only two or three tanks available, and they require frequent replacement.”

These accounts highlight how inconsistent equipment availability and dependence on external refilling services undermine hospital readiness and continuity of care.

Operational and Resource Challenges

The hospital’s operational challenges are primarily driven by reliance on diesel fueled generators and the inconsistent availability of electricity. A maintenance technician explained,

“When patients need oxygen, it can be very difficult. Sometimes, the power goes out, and we have to scramble to get fuel for the generators to keep the oxygen machines running. It’s very challenging. – it can be life-threatening. Doctors often have to use their own money to ensure patients survive. It’s a tough situation.”

Financial constraints were also recurrent concern, with staff noting that energy costs consumed a disproportionate share of the hospital’s budget, leaving little for medical supplies or staff salaries. The Medical Director reported,

“Energy alone consumes 40% of the hospital budget. We rely on the generators to run the hospital, and the generators require fuel… The last budget for the hospital was $110,000, which would have run the hospital for a year, but of the $110,000 that was budgeted, the hospital received only $10,000 of the allocated budget. We had to manage 10% of the budget we received; as a result, when patients need oxygen, we must ask family members to purchase fuel to power the generators.”

A patient summarized the broader challenge:

“The hospital needs to improve the electricity supply; without light, it is impossible to provide care to patients; electricity is critical. Without it, providers cannot conduct operations, nor can the oxygen machines be used for sick patients seeking care at FJ Grant Hospital.”

Preparedness and Response

Participants consistently emphasized that oxygen scarcity significantly hindered clinical preparedness and staff confidence in managing hypoxia and other critical conditions. Providers described preparedness as not only the availability of oxygen but also access to equipment, training, and coordinated response systems. Many expressed frustration that their ability to act swiftly during emergencies was limited by infrastructure rather than skill or motivation.

A nurse described how recent trainings improved diagnostic confidence:

“Recent training has definitely improved my ability to diagnose and treat hypoxia, which is critical for patient outcomes.”

However, several participants stressed that educational efforts alone could not overcome equipment shortages. The Medical Director noted,

“The preparedness would be at its highest if we had the supplies.”

A physician assistant similarly highlighted the gap between training and practical readiness:

“Having the right tools will make a huge difference in patient care and our satisfaction. We know what to do—but sometimes we just don’t have what we need to do it.”

Participants also pointed out that inconsistent power supply disrupted emergency response and limited the hospital’s ability to sustain oxygen therapy for critical patients. A clinician reflected,

“Sometimes, when the power goes out in the middle of treatment, all you can do is wait for the generator to start again. It’s a helpless feeling.”

These accounts reveal that preparedness, as understood by healthcare staff, extends beyond knowledge or clinical competence; it depends on a functional health system with reliable electricity, adequate oxygen equipment, and institutional support. The findings underscore that consistent training, reliable equipment, and supportive infrastructure are equally essential for improving both provider confidence and patient outcomes during emergencies.

Employee and Patient Perception on the New Project

Anticipation and optimism about the upcoming solar-powered oxygen generation system permeate through the voices of the staff. The Medical Director conveyed the collective excitement:

“I was very, very excited. It is one of the best things that has happened to the hospital in a very long time.”

A maintenance supervisor elaborated on the expected impact:

“Having reliable electricity and an oxygen supply will make a huge difference. We wouldn’t have to manually pump water or worry about power outages affecting the oxygen supply”

Participants also highlighted how reallocating funds from generator fuel to essential medications and equipment could improve service delivery. As a physician assistant explained,

“The money saved from not needing fuel for generators can be used to buy drugs, obtain more lab equipment, and improve other areas of the hospital.”

A patient’s family member added,

“Having light and oxygen will save many lives, more than thousands. It will help many people because currently, people use their phones as flashlights even in the bathroom.”

Acknowledging the AIRS team’s efforts, the Medical Director remarked,

“We are very grateful to the program team (IGPC and Johns Hopkins). Implementing the project in Sinoe County shows that the team cares about people in low-resource settings such as ours. The challenges are huge, and the project will significantly impact the lives of people who cannot afford a single meal and talk less about affording healthcare; many lives will be saved.”

The staff collectively believes that the new solar-powered oxygen system will majorly enhance patient outcomes. A physician assistant stated,

“If the project were operational now, I would say 10 [out of 10] in terms of its importance. The ability to provide continuous oxygen will drastically reduce neonatal and maternal deaths,”

Operational and Emotional Impact

This theme captured the emotional and psychological burden experienced by healthcare workers and families due to recurring resource shortages. Staff reported distress when faced with preventable patient deaths linked to oxygen scarcity. A clinician shared,

“Sometimes we have patients on oxygen, and if the power goes out, we need to ask the patient’s relatives to provide fuel for the generators. If they can’t afford it, it becomes a dire situation.”

Another provider reflected,

“When a patient dies of hypoxia and you are the clinician on duty, it’s a very bad day. The conscience feels heavy knowing that the death could have been prevented.”

Patients and caregivers expressed similar emotional exhaustion, emphasizing how unreliable electricity made care delivery unpredictable and frightening. These accounts underscore the mental strain placed on both healthcare staff and families, highlighting the human cost of infrastructural inadequacies.

Healthcare Impact and Patient Outcomes

Participants associated oxygen scarcity and power interruptions with poor patient outcomes, particularly among neonates and mothers. A neonatal clinician noted,

“Sometimes one, two, or three in a month [babies die due to lack of oxygen].”

The Medical Director confirmed,

“Yes, we have had cases where patients die due to lack of oxygen. Sometimes, when there is no oxygen in the cylinders, and the patient’s family members cannot afford to buy fuel for the concentrators, healthcare providers must collect money to purchase fuel to keep the patient on oxygen.”

This study, conducted at FJ Grant Hospital in Liberia, offers critical insights into the multifaceted challenges associated with oxygen therapy in a resource-limited setting. It contributes to the existing literature by not only identifying infrastructural barriers but also illuminating the lived experiences of healthcare workers and patients, providing a more nuanced understanding of how these challenges manifest in daily clinical practice. The findings underscore the profound impact that oxygen scarcity, exacerbated by inconsistent energy supply, has on both healthcare delivery and patient outcomes.

Our results reaffirm several known barriers to effective oxygen therapy in low- and middle-income countries. Unreliable and expensive oxygen concentrators and cylinders, combined with dependence on diesel generators, hinder the consistent delivery of oxygen therapy and place a substantial financial strain on hospitals. Moreover, oxygen cylinders must be imported from distant centers, increasing both cost and supply delays. At FJ Grant Hospital, energy expenses account for nearly 40% of the hospital’s annual budget, diverting resources from other essential needs such as medications, staffing, and equipment maintenance. These constraints disproportionately affect the most vulnerable patients, particularly those in operating rooms, emergency wards, and neonatal units. This reliance on unstable resources, coupled with limited institutional funding, leaves the healthcare system in a continual state of crisis management.

A distinctive contribution of this study is its exploration of the emotional and operational toll that oxygen scarcity imposes on healthcare providers. While prior research has largely focused on the technical aspects of oxygen delivery in low-resource settings, this study reveals the psychological strain experienced by healthcare workers who routinely face preventable deaths due to resource shortages. These narratives offer unique, empirical evidence—rather than theoretical reflection—on the emotional distress, moral injury, and burnout linked to system failures. Such experiences undermine job satisfaction and staff retention, further weakening already strained health systems. Understanding this human dimension adds a layer of evidence to the broader scientific discussion on workforce sustainability and can inform future interventions aimed at improving morale and reducing provider burnout.

The enthusiasm surrounding the upcoming solar-powered oxygen system reflects a major shift in both institutional capacity and provider outlook. Participants viewed this initiative as a technical, financial, and emotional turning point that could enhance service quality while reducing the hospital’s dependence on costly fuel sources. This optimism aligns with findings from Papua New Guinea and The Gambia, where solar-oxygen projects have improved reliability, efficiency, and staff satisfaction [4,9]. However, Liberia’s post-conflict infrastructure and dependence on diesel power make its context distinct, underscoring the importance of locally adapted implementation models.

This study also highlights the need to pair infrastructural advancements with sustained workforce training. Participants described uneven preparedness levels across departments, emphasizing that education alone cannot translate into improved patient outcomes without sufficient equipment and supervision. This finding mirrors evidence from Ethiopia and Uganda, where oxygen program success depended on simultaneous investments in technical maintenance and capacity building [2,8].

Despite its contributions, this study has several limitations. As a single-site qualitative study, the findings are context-specific and may not be generalizable to other hospitals in Liberia or similar low-resource settings. The use of snowball sampling may have introduced selection bias, favoring participants more actively involved in oxygen delivery. Additionally, demographic data such as age, training level, and tenure were not collected, which limited the ability to stratify responses or correlate perceptions with professional background. Nonetheless, the study provides valuable, first-hand evidence that captures how systemic and infrastructural challenges are experienced at multiple levels of care.

The results of this study have several policy implications. First, there is an urgent need for government and international organizations to invest in sustainable healthcare infrastructure solutions (such as solar power and on-site oxygen production) to ensure reliable and cost-effective energy sources for hospitals in low-resource settings. Such initiatives, as envisioned under the Africa Infrastructure Relief and Support (AIRS) Project, could simultaneously strengthen energy resilience and reduce operational costs. Solar-powered oxygen systems, as suggested by participants, may significantly lessen financial strain on hospitals and improve continuity of care for critically ill patients. Future research should evaluate the long-term outcomes of these interventions—particularly their effects on patient mortality, operational efficiency, and healthcare worker satisfaction—to inform scalable policy decisions. The challenges faced by FJ Grant Hospital are not unique; they represent broader systemic weaknesses that can be addressed through coordinated national and regional partnerships aimed at improving oxygen access and energy infrastructure across low-income countries.

In conclusion, this study sheds light on the critical challenges and potential solutions for improving oxygen therapy in resource-limited settings. The implementation of a solar-powered oxygen system with AIRS represents a promising avenue for addressing the infrastructural and operational barriers faced by hospitals like FJ Grant. However, the emotional toll on healthcare workers and the need for comprehensive health system reforms must also be addressed to ensure that these technological advancements translate into meaningful improvements in patient outcomes and healthcare delivery. Future research should continue to explore these themes to develop sustainable and effective solutions for oxygen therapy in low-income settings.