A sharp and deafening noise exhales from an oxygen production centre in the Saris neighbourhood, Nefas Silk District. Two sets of enormous machines operate at full capacity; they are so overpowering that sounds nearby are muffled.

It was a scene in sharp contrast to what the area was like about two months ago when it was filled with the desperate pleas from loved ones of at-home patients, begging to get oxygen cylinders refilled. Back then, the team at Gast Solar Plc's plant was overwhelmed by the sheer enormity of oxygen demand from hospitals as well as individual patients.

“Everyone was desperate, asking for oxygen,” said Solomon Be`ededmariam, general manager of Gast.

Solomon has not seen such a huge demand in over a decade when the plant has been in operation, although he observed it growing steadily even before the pandemic hit last year.

The plant is one of three dozen active oxygen production facilities across the country, assets that now determine the life and death of so many since the outbreak of COVID-19 in March 2020. Gast Solar has thus been compelled to work 24-hour shifts to quadruple its production to 160 litres of oxygen an hour. Around 1,200 cylinders need to be refilled a day at this plant, which uses the cryogenic distillation process, extracting oxygen from air by liquefying at shallow temperatures. It meets, however, one-third of the country's current supply.

Chora is the oldest and by far the largest oxygen plant in Addis Abeba. In late March this year, the city lost this medical oxygen supplier while an average of around 2,500 people tested positive for the virus daily and almost half of this number were under intensive care units. A machine broke down at Chora in the midst of the worst days of the pandemic so far. It was a terrifying moment for the operators and those on the frontlines fighting COVID-19, including Solomon, as a critical shortage of life-saving oxygen hit the city.

Frie Admasu recalled this moment of desperation when her mother was sick, contracting the virus.

"I almost lost her," she said.

Frie had to wait for over two days until she found oxygen at the COVID-19 field hospital at Bole Bulbula, where she had stayed for 10 days.

"Imagine the feeling," she recalled. "Your mother is struggling to breathe due to severe pneumonia from COVID-19, while you cannot get oxygen for her nor cover the cost for the same service at a private hospital."

Running around to more than five hospitals and the COVID-19 centre at Millennium Hall, it was only through the help of a friend working at the Bole Bulbula centre that Frie finally succeeded in finding help for her mother. Treatment centres across the city were overwhelmed by the inflow of patients, and the situation was so desperate that the Millennium Hall, converted to one of the biggest COVID-19 treatment centres in Addis Abeba last year and hosting more than 140 patients, had to limit the flow of oxygen allocated to patients.

What ensued at the time was chaos as an already-existing supply gap was worsened by the insurmountable demand caused by a sharply increased number of COVID-19 patients under critical conditions.

Before the pandemic hit, the demand and supply for oxygen were not followed up in a coordinated manner, according to Amanuel Lulu (MD), in charge of oxygen supplies at the national COVID-19 taskforce case management team. It was difficult to identify the demand back then.

"Even at this time last year, we weren't discussing oxygen," said Mikiyas Teferi (MD), head of the national task force.

Things seem to have improved since, indeed, with government-backed efforts to increase supply, seemingly taking the load off hospitals and treatment centres.

There has always been a walloping gap between oxygen cylinders production at the few plants and the demand by hospitals and centres. Of the 315 health centres surveyed by the Clinton Initiative in 2016, only two percent were found capable of providing oxygen. In hospitals, the figure was found to be two-thirds. Several studies conducted on the availability of oxygen and oxygen delivery equipment have corroborated the findings from the Clinton Health Initiative. They mostly highlight the dearth of oxygen supply that has been a contributor to child and maternal mortality.

Oxygen supplies are essential in combating newborn fatalities as a third of babies with pneumonia need oxygen for proper treatment.

This was among the primary driving factors that led to the design and implementation of a “national scale-up of oxygen management” roadmap. Adopted five years ago in collaboration with the Ministry of Health, the road map targeted six key areas, including rolling out an oxygen supply and logistics chain; establishing a mechanism for the maintenance of oxygen equipment; capacity building of health care workers in oxygen provision; and increasing sustainable funding for oxygen procurement.

Of all the plans set out in the roadmap, perhaps the most ambitious was building oxygen plants in 13 public health centres by 2020, which seems to have been achieved, although the production capacity of these centres still needs to grow. What is available now is a far cry from the one billion cubic metres of oxygen production a month the authorities had hoped they would reach by last year, thus showing a long way to go in addressing oxygen supply gaps.

The health centres have not made the noticeable progress over the past five years they were hoped to, according to Habtamu Seyoum, senior programme manager at the Clinton Health Initiative.

Under the stewardship of Lia Tadesse (MD), the Ministry of Health is trying to take a series of measures targeting to fix the broken distribution system. The Ministry pushed four plants supplying oxygen for industrial purposes to supply the medical oxygen demand fully.

With a combined capacity to fill 1,500 cylinders a day, these four plants have helped take the pressure off the current supply chain near to crumble on the weight of ballooning demand.