IMPORTANCE Pneumonia is the leading cause of childhood mortality worldwide. Severe pneumonia associated with hypoxemia requires oxygen therapy; however, access remains unreliable in low-and middle-income countries. Solar-powered oxygen delivery (solar-powered O 2 ) has been shown to be a safe and effective technology for delivering medical oxygen. Examining the costeffectiveness of this innovation is critical for guiding implementation in low-resource settings. OBJECTIVETo determine the cost-effectiveness of solar-powered O 2 for treating children in low-resource settings with severe pneumonia who require oxygen therapy. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation study of solar-powered O 2 was conducted from January 12, 2020, to February 27, 2021, in compliance with the World Health Organization Choosing Interventions That Are Cost-Effective (WHO-CHOICE) guidelines. Using existing literature, plausible ranges for component costs of solar-powered O 2 were determined in order to calculate the expected total cost of implementation. The costs of implementing solarpowered O 2 at a single health facility in low-and middle-income countries was analyzed for pediatric patients younger than 5 years who required supplemental oxygen. EXPOSURES Treatment with solar-powered O 2 . MAIN OUTCOMES AND MEASURES The incremental cost-effectiveness ratio (ICER) of solarpowered O 2 was calculated as the additional cost per disability-adjusted life-year (DALY) saved. Sensitivity of the ICER to uncertainties of input parameters was assessed through univariate and probabilistic sensitivity analyses. RESULTS The ICER of solar-powered O 2 was estimated to be $20 (US dollars) per DALY saved (95% CI, $2.83-$206) relative to the null case (no oxygen). Costs of solar-powered O 2 were alternatively quantified as $26 per patient treated and $542 per life saved. Univariate sensitivity analysis found that the ICER was most sensitive to the volume of pediatric pneumonia admissions and the case fatality rate. The ICER was insensitive to component costs of solar-powered O 2 systems. In secondary analyses, solar-powered O 2 was cost-effective relative to grid-powered concentrators (ICER $140 per DALY saved) and cost-saving relative to fuel generator-powered concentrators (cost saving of $7120). CONCLUSIONS AND RELEVANCE The results of this economic evaluation suggest that solarpowered O 2 is a cost-effective solution for treating hypoxemia in young children in low-and middleincome countries, relative to no oxygen. Future implementation should prioritize sites with high rates (continued) Key Points Question Is solar-powered oxygen delivery (solar-powered O 2 ) a costeffective intervention for use in children younger than 5 years with hypoxemia in low-resource settings? Findings This economic evaluation compared the costs and health outcomes of solar-powered O 2 with (1) null case with no oxygen, (2) gridpowered oxygen concentrators, and (3) fuel generator-powered concentrators. Use of solar-powered O 2 was costeffective relative to the nul...

Background: Child mortality due to pneumonia is a major global health problem and is associated with hypoxemia. Access to safe and continuous oxygen therapy can reduce mortality; however, low-income countries may lack the necessary resources for oxygen delivery. We have previously demonstrated proof-of-concept that solar-powered oxygen (SPO 2 ) delivery can reliably provide medical oxygen remote settings with minimal access to electricity. This study aims to demonstrate the efficacy of SPO 2 in children hospitalized with acute hypoxemic respiratory illness across Uganda.Methods: Objectives: Demonstrate efficacy of SPO 2 in children hospitalized with acute hypoxemic respiratory illness. Study design: Multi-center, stepped-wedge cluster-randomized trial. Setting: Twenty health facilities across Uganda, a low-income, high-burden country for pediatric pneumonia. Site selection: Facilities with pediatric inpatient services lacking consistent O 2 supply on pediatric wards. Participants: Children aged < 5 years hospitalized with hypoxemia (saturation < 92%) warranting hospital admission based on clinical judgement. Randomization methods: Random installation order generated a priori with allocation concealment. Study procedure: Patients receive standard of care within pediatric wards with or without SPO 2 system installed. Outcome measures: Primary: 48-h mortality. Secondary: safety, efficacy, SPO 2 system functionality, operating costs, nursing knowledge, skills, and retention for oxygen administration. Statistical analysis of primary outcome: Linear mixed effects logistic regression model with 48-h mortality (dependent variable) as a function of SPO 2 treatment (before versus after installation), while adjusting for confounding effects of calendar time (fixed effect) and site (random effect). Sample size: 2400 patients across 20 health facilities, predicted to provide 80% power to detect a 35% reduction in mortality after introduction of SPO 2 , based on a computer simulation of > 5000 trials. Discussion: Overall, our study aims to demonstrate mortality benefit of SPO 2 relative to standard (unreliable) oxygen delivery. The innovative trial design (stepped-wedge, cluster-randomized) is supported by a computer simulation. Capacity building for nursing care and oxygen therapy is a non-scientific objective of the study. If successful, SPO 2 could be scaled across a variety of resource-constrained remote or rural settings in sub-Saharan Africa and beyond.Trial registration: Clinicaltrials.gov, NCT03851783. Registered on 22 February 2019.

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