Background Surgical care is essential for achieving global health equity, yet low- and middle-income countries (LMICs) face major gaps in access and planning, partly due to limited evidence on the costs and resource requirements of surgical interventions. Understanding these costs is vital for designing efficient and equitable health systems. Methods We conducted a systematic literature review (covering MEDLINE, EMBASE, Global Health, EconLit and grey literature) to identify studies reporting the costs of surgeries in LMICs from January 2000 to June 2023. Minor and major surgical procedures were considered, focusing on therapeutic procedures (excluding diagnostic interventions). Studies that clearly identified, quantified and costed hospital resources and services deployed in the provision of surgical care, and included at least two of the surgical production factors (ie, consumables, diagnostics, personnel, infrastructure and overhead) in the costing were included. Costs were standardised to 2023 International dollars (I$) for comparability. Results A total of 74 studies from 29 countries met the inclusion criteria, with 210 cost estimates across 65 procedure groups. Costs varied widely: from I$1.54 for a caesarean section in Tanzania to I$618 098 for paediatric cataract surgery in Zambia. Full costing studies reported higher estimates than partial costing studies. Most studies (60%) originated from upper-middle-income countries, with limited data (10%) from low-income settings. Conclusion This review provides a reference list of surgical procedure costs across LMICs, highlighting considerable cost variation by procedure, specialty and country. The findings underscore the need for better-quality, standardised cost data—especially from low-income countries—to inform national surgical plans, universal health coverage benefit packages and reimbursement policies.
Healthcare quality is commonly assessed using clinical outcomes and service-based metrics that begin after illness has occurred. While such measures are important, they often overlook healthcare’s fundamental purpose: to preserve health, prevent disease and minimise reliance on medical intervention. Drawing from global definitions of healthcare and quality—and philosophical insights from Sunzi’s Art of War—this paper proposes a new framework that shifts evaluation from reactive treatment to proactive health preservation. A two-dimensional model is introduced, plotting age-standardised healthy life expectancy on the vertical (Y) axis against purchasing power parity adjusted per capita healthcare expenditure on the horizontal (X) axis. To enable standardised comparison across countries, both indicators are converted into z-scores, allowing the positioning of healthcare systems within a normalised, intuitive visual space. The ideal health system occupies the upper-left corner of this graph, where long, healthy lives are achieved with minimal spending. By examining relative positions on this graph, the model enables strategic policy discussions about value-based trade-offs between health outcomes and spending. The model also highlights a structural tension between the goals of healthcare and the incentives of capitalist systems, where prevention may paradoxically reduce profitability. By redefining quality in terms of sustained wellbeing rather than service provision, the framework offers a timely, intuitive tool for evaluating system performance. It invites policymakers, researchers and the public to reconsider what constitutes progress in health systems—emphasising that the best healthcare may not be the one that delivers the most care, but the one that is least needed.
Introduction Kangaroo mother care (KMC) is a proven, low-cost intervention to reduce neonatal mortality, yet its coverage remains limited in most low- and middle-income countries (LMICs), including India. In this study, we examined the impact of scaling up KMC in India on distribution of health and financial outcomes using an extended cost-effectiveness analysis (ECEA) framework. Methods Building on primary data from a randomised controlled trial (RCT), we modelled the health and financial outcomes of scaling up KMC to 95% coverage nationally. We estimated lives saved, disability-adjusted life-years (DALYs) averted, out-of-pocket expenditure (OOPE) averted and cases of catastrophic healthcare expenditure prevented. Estimates were disaggregated by socioeconomic quintiles and geography. We used deterministic and probabilistic sensitivity analyses to assess the robustness of our findings. Results Scaling up KMC in India could save around 26 000 neonatal lives annually, avert approximately 1.6 million DALYs, reduce OOPE by around US$13 million and prevent an estimated 57 000 households from experiencing catastrophic health expenditures. Three-fourths of the benefits would be concentrated in the lowest two socioeconomic quintiles. Six high-burden states, including Uttar Pradesh, Bihar and Madhya Pradesh, accounted for 90% of the health and financial gains. The incremental cost-effectiveness ratio ranged from 0.08 to 0.17 times gross domestic product per capita for India across different quintiles. Probabilistic sensitivity analysis showed scaling up KMC would be cost-effective in 97.8% of simulations. Conclusion Our findings suggest that scaling up KMC is cost-effective and can reduce health inequities, particularly benefiting the lowest socioeconomic groups and high-burden states. Incorporating geographical disaggregation and using primary RCT data into ECEA enhance its utility for informing evidence-based, equity-focused health policies in LMICs.
INTRODUCTION:Armed conflict disrupts health systems, but whether it compounds pre-existing geographical barriers to hospital care has not been quantified. We aimed to estimate population-weighted travel time to public hospital care across Myanmar's 330 townships; test whether conflict following the February 2021 coup concentrated in populations with the worst baseline access, and whether attacks on health facilities followed the same pattern; and measure the cumulative person-year burden of simultaneous poor access and intense conflict. METHODS:We conducted a longitudinal ecological analysis of 330 townships over 16 quarters from 2021 to 2024. Travel time from each populated square kilometre to the nearest of 68 general hospitals, representing the surgical-care tier, was estimated using the pre-coup facility registry, OpenStreetMap road data and WorldPop 2020 population estimates. Townships were classified by population-weighted median travel time. Quarterly conflict intensity was calculated from 35 647 Armed Conflict Location and Event Data Project battle and explosion or remote-violence events; 655 Safeguarding Health in Conflict Coalition-reported facility attacks were analysed separately. The concentration index assessed whether conflict events, fatalities and facility attacks were disproportionately concentrated among populations with worse baseline access. Double-burden exposure (poor or very poor access combined with high or extreme conflict) was accumulated in person-years. Because access was held at pre-coup baseline, estimates should be read as optimistic bounds. RESULTS:Before the coup, 5.8 million people (12%) lived over 2 hours from a general hospital. Double-burden exposure grew from 0.4 million (Q1 2021) to 3.1 million (Q1 2024). Conflict was significantly concentrated in worse-access populations: concentration index 0.126 (95% CI 0.053 to 0.199) for events, 0.169 (95% CI 0.078 to 0.263) for fatalities. Facility attacks showed no significant concentration (0.049, 95% CI -0.041 to 0.145), as remote townships lack targetable facilities. An estimated 8.4 million person-years of double-burden exposure accumulated over 2021-2024, rising roughly eightfold quarterly, from about 100 000 (Q1 2021) to 780 000 (Q1 2024). CONCLUSION:Conflict in Myanmar has compounded pre-existing geographical inequality in hospital access, with populations furthest from surgical care bearing a disproportionate burden. The concentration curve framework used is transferable to other conflict-affected settings.
Cluster randomised trials (CRTs) remain key for evaluating the community-wide impact of interventions against infectious diseases such as malaria. Randomising by cluster prevents contamination and enables both the direct and indirect effects of the intervention to be estimated. Although these trials are extremely informative, they can be logistically demanding and costly to carry out, which means it is important that these trials are well powered. Here, we present a framework for planning CRTs that measure malaria prevalence as the outcome using an established mathematical model of malaria transmission. In this way, we explicitly consider the epidemiology of the individual trial clusters. The framework can be used alongside a baseline prevalence survey to help inform the sample size calculations for the trial. We use a case study to illustrate the framework, where we simulate a CRT in which a next-generation pyrethroid-pyrrole insecticide-treated net (ITN) is compared against a standard pyrethroid-only ITN. We show how the malaria endemicity of the trial location and timing of the follow-up surveys can affect the results obtained. We also highlight how other active interventions against malaria can reduce study power by increasing the amount of between-cluster heterogeneity in malaria prevalence.
Background The 2022 global mpox epidemic declined before modified Vaccinia Ankara–Bavarian Nordic (MVA-BN) vaccines were widely deployed, contributing to the perception that transmission was self-limiting within a small high-risk population. This may have delayed global vaccine allocation and weakened responses to the resurgence that has disproportionately affected Africa since 2024. The reasons for the 2022 decline remain uncertain, and prior studies have reported widely divergent estimates of vaccination impact. We systematically reviewed and meta-analysed the evolving transmissibility of mpox clades and the effects of interventions.Methods We searched GenBank, PubMed and Embase through 18 May 2025, for mpox virus sequences, reproduction number (R) estimates and modelling studies evaluating intervention effectiveness. Two reviewers independently assessed eligibility, extracted data and evaluated risk of bias using a validated tool. Random-effects meta-analyses were performed.Results Fifty-two studies reporting R estimates and 40 studies evaluating intervention effectiveness met eligibility criteria. For clade I mpox, pooled R increased from 0.71 (95% CI 0.26 to 1.17) during 1970–2017 to 1.23 (1.12–1.33) for subclades Ib/Ia after 2023 (p=0.0303). For clade II mpox, pooled R was 1.11 (0.90–1.32) during 2017–2021 and increased to 2.66 (2.31–3.00) for subclade IIb in 2022–2023 (p<0.0001). During the 2022 subclade IIb outbreak, empirical modelling studies estimated that behaviour change and vaccination together were associated with a substantial reduction in mpox cases (55%, 95% CI 37 to 73; I²=81.2%), although effect sizes varied across settings according to the extent of behaviour change and the timing and coverage of vaccine rollout.Conclusions Behaviour change and vaccination likely played important roles in the decline of the 2022 mpox epidemic in many studied settings. Given the stepwise increase in human-to-human transmissibility associated with the emergence of new subclades, effective mpox epidemic control requires proactive, rapid and equitable vaccine rollout supported by culturally tailored risk communication.PROSPERO registration number CRD420250653072.
Introduction The Lancet Commission on High Quality Health Systems called for quality measures grounded in user experience. Studies of how stakeholders interpret and prioritise these frameworks are rare for injury care in low- and middle-income countries (LMICs).Objectives The objective was to identify how patients, healthcare providers and policymakers in four LMICs prioritise quality of care after injury using Institute of Medicine (IoM) quality domains (safety, effectiveness, patient-centredness, timeliness and equity).Methods We conducted a Photovoice study across eight urban and rural sites in Ghana, Pakistan, Rwanda and South Africa. Focus group discussions (n=39) convened patients/community members, healthcare providers and policymakers (n=116), supplemented by policymaker interviews (n=6). Participants photographed aspects of injury care, developed captions and used deliberative dialogue to rank these against the IoM domains.Results Stakeholders prioritised timeliness, safety and effectiveness, with rankings varying by local system capability. In settings with significant trauma system gaps (Ghana, Pakistan), timeliness ranked highest: immediate survival, getting to care quickly across transport, referral and facility processes. Safety was also emphasised: avoiding additional harm from unsafe and unreliable environments and resources. In settings with more established access to basic emergency care (Rwanda, South Africa), priorities shifted towards effectiveness, understood in terms of clinical, functional and psychosocial recovery. Across all contexts, equity (fair access and financial protection) was interpreted as foundational rather than as a discrete domain, shaping delays, access, treatment continuity and catastrophic costs. Overall, quality was considered cumulative and relational: early failures in care pathways amplified avoidable downstream complications including disability and impoverishment.Conclusions Stakeholders shared systems understandings of injury care quality, with priorities varying by local capabilities. Timeliness and safety were seen as necessary for survival, enabling effectiveness in clinical and recovery outcomes, while equity operated across care pathways. The findings support aligning emergency quality indicators and improvement strategies with context-specific stakeholder priorities.
Introduction Unintended pregnancy and sexually transmitted infections (STIs) are major public health issues in developing countries. While long-acting reversible contraception (LARC) effectively prevents unintended pregnancy, there is limited evidence from large multinational studies on its association with condom use and STI-related outcomes. This study aimed to investigate the association between LARC use, condom use and STIs among women in developing countries.Methods This serial cross-sectional study extracted data from Demographic and Health Surveys (DHS), a series of nationally representative household surveys conducted in developing countries. The analysis included women aged 15 to 49 years, with data on contraceptive methods and demographics. Generalised linear mixed effect models (GLMMs) were used to estimate adjusted prevalence ratios (aPRs) for condom use and self-reported STI-related outcomes, comparing LARC users with both non-LARC users and oral contraceptive users. Subgroup analyses were conducted at the individual level and at the country level.Results Data from 2 171 884 women across 31 countries were analysed. Overall, the prevalence of self-reported STI-related outcomes was 7.4%, 3.9% of participants used LARC, and 7.5% of participants reported consistent condom use. LARC users were significantly less likely to use condoms compared with non-LARC users (aPR=0.40, 95% CI 0.30 to 0.53) and compared with oral contraceptive users (aPR=0.61, 95% CI 0.48 to 0.78). LARC use was associated with a higher prevalence of STI-related outcomes compared with non-LARC users (aPR=1.19, 95% CI 1.10 to 1.28) and compared with oral contraceptives users (aPR=1.14, 95% CI 1.05 to 1.24). Associations were stronger in low-Human Development Index (HDI) countries, especially among younger women (15–19 years), but were not significant in high-HDI countries. Country-level heterogeneity was observed.Conclusions LARC use is associated with reduced condom use and higher self-reported STI prevalence, particularly among younger women and in lower HDI developing countries. These findings support integrating STI prevention into LARC services and promoting dual-method use to prevent both unintended pregnancies and STIs.
Leadership and mentorship play an important role in supporting the career development of health professionals. In many African countries, supervision activities focus on technical and operational aspects rather than catalysing career and leadership development. Thus, mentorship and coaching interventions need to be implemented in African healthcare institutions as components of health systems strengthening strategies. Due to its holistic nature, cancer care involves interprofessional collaborations to develop and provide a problem-solving mindset. It is therefore an area that would benefit from leadership and mentorship, mainly in a limited-resources context. The identified benefits from leadership development in cancer care in Africa led to the creation of the African Cancer Leaders Institute (ACLI) of the African Organization for Research and Training in Cancer (AORTIC), consisting of mentors and trainees from Africa and the USA. ACLI trainees are selected through a competitive application process. During the ACLI biennial meetings, coinciding with the AORTIC conference, trainees, including early-stage/mid-career investigators, oncologists, nurses, advocates and other health professionals, meet to learn about best practices in cancer research, grant writing, scientific reporting, mentor relationships, academic pressures and professional-personal life balance. This paper describes the goals of the ACLI, its mission and achievements, the vision behind creating such important programmes and the benefits of its participants in leadership, coaching and mentorship in improving cancer care in Africa.
Background In eastern and southern Africa, HIV and depression lead to substantial morbidity and mortality. Each condition affects the other: people living with HIV (PLHIV) have higher depression rates, while depression increases HIV acquisition and hinders treatment. The combined impact of HIV-depression interactions on HIV and mental health remains poorly understood.Methods We adapted the EMOD-HIV simulation model to incorporate depression incidence, recovery and relapse. We modelled a bidirectional scenario between HIV and depression: HIV increased depression incidence; depression increased HIV incidence and reduced HIV care outcomes. In a counterfactual scenario, all HIV-depression interactions were removed. We estimated how interactions impacted depression episodes, HIV acquisitions, HIV-related deaths and HIV treatment benefits in a high-prevalence region of Western Kenya, 1985–2035.Results Without interactions, the model projected 1.23 million (95% CI 1.21M to 1.24M) HIV acquisitions, 658 000 (95% CI 650 000 to 666 000) HIV deaths and 12.88 million (95% CI 12.87M to 12.89M) depression episodes. HIV-depression interactions increased depression episodes by 9.76% (95% CI 9.67% to 9.87%), HIV acquisitions by 12.3% (95% CI 12.0% to 12.6%) and HIV deaths by 12.5% (95% CI 12.2% to 12.9%). These interactions also diminished HIV treatment benefits, with 7.72% (95% CI 7.39% to 8.07%) fewer HIV acquisitions and 3.88% (95% CI 3.71% to 4.05%) fewer deaths averted per person-year on treatment. In secondary analyses, increased depression incidence among PLHIV had the greatest effect on HIV outcomes, contributing 7.26% of acquisitions and 7.55% of deaths.Conclusion HIV-depression interactions have worsened both epidemics. Depression’s effects on HIV incidence have been especially deleterious, while its effect on HIV care engagement is increasingly important.
INTRODUCTION:Surgical care is essential to achieving universal health coverage (UHC) and addressing 30% of the global disease burden, including non-communicable diseases (NCDs), maternal health and injuries. However, low and middle-income countries (LMICs) face significant challenges providing equitable access to surgical services, with 5 billion people lacking access and US$20 trillion in associated global economic losses, emphasising the need for sustainable domestic financing strategies. METHODS:A multifaceted approach combined quantitative analysis of domestic health spending trends (2000-2021) using the WHO Global Health Expenditure Database with illustrative case studies examining fiscal mechanisms. The quantitative analysis assessed government health expenditure (GHE), current health expenditure (CHE) and resource allocation. Illustrative case studies examined fiscal mechanisms, including taxes, subsidies, levies and public health insurance, drawn from published literature and policy reports in selected LMICs. A surgical expenditure surrogate (SES), defined as the proportion of health expenditure allocated to NCDs, reproductive, maternal, neonatal, child and adolescent health and trauma and injuries, was used as a proxy to estimate spending on surgical care. RESULTS:In 2021, global CHE totalled US$9.84 trillion, with GHE contributing a global median of 53.66%. LMICs allocated only 34.88% of CHE to domestic resources, relying heavily on external funding and out-of-pocket payments. Using the SES as a proxy for surgical spending, spending on communicable diseases (CDs) outpaced SES in LMICs (median SES: 40.17% vs CD: 49.38% of CHE). Mechanisms like taxes, subsidies and public health insurance show potential to expand fiscal space but face challenges such as inequities, sustainability concerns and limited allocation to surgical care. CONCLUSION:Strengthening domestic financing through targeted fiscal policies and improved resource allocation can enhance access to surgical care and health system independence in LMICs. National surgical plans and better reporting metrics are critical to integrating surgical care into UHC strategies.
BACKGROUND:Orthopaedic injuries are a major contributor to morbidity and mortality in low-income settings, driven by rising urbanisation and inadequate road safety measures. This study evaluates the cost-effectiveness of treatment for four common orthopaedic injuries in Malawi: femoral shaft fractures, patellar fractures, humeral shaft fractures and paediatric supracondylar humeral fractures (PSCHF). METHODS:We developed a dynamic state-transition model to simulate fatal and non-fatal outcomes from a healthcare perspective from 2021 to 2031, informed by cost, epidemiological and population estimates. We estimated incremental cost-effectiveness ratios (ICER) for conservative and surgical management versus no treatment and each other, conducting one-way and probabilistic sensitivity analyses. We then modelled the population impact of scaling up the most cost-effective intervention under two scenarios. FINDINGS:For femoral shaft fractures, surgical, conservative and no treatment resulted in disability-adjusted life years (DALYs) of 0.10, 0.21 and 0.23, with ICERs of approximately US$3000 and US$60 000 for surgical and conservative treatment. For patellar fractures, DALYs were 0.20, 0.22 and 0.32, with similar cost-effectiveness (ICERs of US$1400). For humeral shaft fractures, DALYs were 0.041, 0.056 and 0.11, with ICERs of US$3000 and US$1400. For PSCHF, DALYs were 0.04, 0.086 and 0.14, with ICERs of US$1600 and US$2600. Comparison of surgical and conservative strategies shows surgery was cost-saving for femoral shaft fractures, similar for patellar fractures, less efficient for humeral shaft fractures and more cost-effective for PSCHF. At Malawi's willingness-to-pay threshold of US$65 per DALY averted, the probability of cost-effectiveness was low. Under the ambitious scale-up scenario, approximately 1800 DALYs (a 10% reduction relative to the baseline) were averted at an incremental cost of US$5 million. CONCLUSION:In Malawi, surgery is more cost-effective for femoral shaft and PSCHF fractures, whereas conservative care is more cost-effective for humeral shaft fractures. For patella fractures with an intact extensor mechanism, both treatments are similarly cost-effective. Targeted scale-up could yield substantial health gains, underscoring the importance of context-specific data for prioritising orthopaedic services in low-resource settings.
Background Despite its broad conceptual scope, the Donabedian model (input–process–outcome) remains one of the most widely used frameworks for evaluating quality of care globally. Numerous tools have been developed to operationalise this model, yet no synthesis has focused specifically on those applied in low-resource settings or examined their validity and applicability in real-world settings. Objective This study sought to review the landscape of tools used to assess each component of quality of care—according to Donabedian’s model—in low- and middle-income countries (LMICs), and to evaluate their reported validity and applicability in routine health system settings. Method A rapid review was conducted from June to November 2023. The following databases were searched using English and/or French keywords with no time limitation: Google Scholar and PubMed. Results A total of 1451 articles were retrieved from PubMed (n=1164) and Google Scholar (n=287), with an additional 74 articles identified through Google. After title, abstract and full-text screening, 85 studies met the inclusion criteria. The review identified a wide range of tools used to assess quality of care in LMICs, characterised by considerable variation in the aspects of quality of care covered, the types of tools and the assessment techniques applied. These tools were categorised as institutional—such as Services Availability and Readiness Assessment, Demographic and Health Surveys (DHS) and Patient Satisfaction with Nursing Care Quality Questionnaire—or investigator-developed, often tailored to particular contexts. While most tools focused on input and process components, outcome measures—especially objective health outcomes—were under-represented. Gaps were also noted in the reporting of tool validation and cost-effectiveness, with few tools integrated into routine health system practices. Conclusions This review highlights the need for context-appropriate, validated and cost-effective tools for assessing quality of care in LMICs. Tools should be user-friendly and embedded within routine monitoring systems to better support continuous quality improvement.
Like many others, Malawi's healthcare system faces significant health workforce shortages largely due to budget constraints that limit training, recruitment and retention of staff. A crucial question is how to best allocate a limited incremental budget to expand different healthcare workers (HCW) cadres so that the potential health gains are maximised, which is more important now than ever considering recent withdrawal and reduction in donor funding. This research aims to provide a practical answer to this question. We designed a range of budget allocation scenarios for HCW expansion across cadres and used the 'all diseases-whole healthcare system' Thanzi La Onse (TLO) model to estimate the resulting population health outcomes. We find that, indeed, how to allocate the incremental budget among cadres is an important determinant of the potential health impact. Concentrating all of the budget on expanding a single cadre-such as clinical, pharmacy or nursing and midwifery-is not the most effective use of the resources, even when that cadre currently faces the greatest staffing shortages. Similarly, allocating the budget in a manner that mirrors the current distribution of spending and results in a uniform expansion across cadres does not generate the greatest possible gains. Instead, an allocation that uplifts staffing for multiple cadres, accounting for the additional time and costs required to meet the future healthcare needs, yields the greatest benefits. We conclude that, in the context of complex interplay between demography, epidemiology, treatment scope and effectiveness and health resource constraints, human resources for health (HRH) bottlenecks in achieving health gains are multifactorial and a needs-based balanced mix of cadres and skills is required for future HRH expansion. As such, health system models such as the TLO that capture this interplay can make potential contributions to strengthening HRH planning.
BACKGROUND:People recently treated for tuberculosis (TB) (TB survivors) face substantial risk of recurrence. The optimal implementation and expected impact of active case-finding are uncertain. METHODS:We developed an individual-level stochastic simulation model of TB recurrence among recently treated people in India, informed by empirical data on the cumulative incidence and timing of TB recurrence, the extent and durations of symptoms and bacteriological positivity and screening-related costs. We modelled post-treatment symptom screening at quarterly or semiannual intervals, with or without universal near-point-of-care bacteriological testing at the first screening encounter. We estimated months of symptomatic TB and of potentially infectious (bacteriologically positive, regardless of symptom status) TB averted over a 2-year period after treatment, along with corresponding screening programme costs, estimated as medians and 95% uncertainty ranges across simulations. RESULTS:Symptomatic TB recurred within 2 years post-treatment in 10% (8%-12%) of recent TB survivors and undiagnosed prevalence peaked in month 2 (1-3). Symptom screening 6, 12 and 18 months post-treatment (as per Indian guidelines) averted 16% (8%-32%) of symptomatic and 8% (5%-17%) of infectious time. An 'early' screening schedule (3, 6 and 9 months post-treatment) increased case detection and health impact (26% (15%-43%) of symptomatic and 16% (9%-27%) of infectious time averted). Adding 'universal bacteriologic testing' at the 3-month encounter doubled the impact on transmission potential (34% (21%-55%) of symptomatic and 37% (22%-62%) of infectious time averted). In this context, 'early' symptom screening cost $190 ($100-$350) per case detected, and adding universal bacteriological testing cost an additional $520 ($240-$1070) per case incrementally detected by the screening programme. CONCLUSIONS:Screening for recurrent TB in high-risk settings such as India could reduce morbidity and time spent with potentially infectious TB. Concentrating screening within the first year has greatest yield. Symptom-based screening is most affordable, but testing for asymptomatic recurrence could further reduce transmission potential.
Objectives This study aimed to identify research priorities for maternal and infant nutrition in the context of climate change in Sindh, Pakistan, using an eco-social framework to examine structural, environmental and gendered inequalities.Setting The study was conducted from March to May 2024 in Sindh province of Pakistan. Survey respondents were drawn from across Sindh province, while the priority-setting workshop and a focus group discussion were conducted with both male and female participants in Karachi and Matiari District, respectively.Participants In total, 127 participants were engaged, including community members, doctors, female health workers, nurses, nutritionists, climate experts, advocates and researchers from across Sindh province of Pakistan.Results Among survey respondents, 89% expressed extreme or very high concern about the impact of climate change on maternal and infant nutritional health. Across the survey and workshop, ‘lack of awareness of proper nutrition’ emerged as the top nutritional priority, while ‘dehydration, weakness and exhaustion’ ranked highest among maternal health concerns. Infant health priorities differed slightly: survey respondents prioritised ‘heat exposure and low birth weight’, whereas workshop participants highlighted ‘heat waves and infant hospital admissions’. Participants also identified climate-resilient nutritional interventions and addressing the nutritional needs of pregnant women as critical research priorities. Focus group findings from Matiari District highlighted structural drivers of vulnerability, including flood-related displacement, disrupted agriculture, gendered labour burdens and limited social protection.Conclusion Awareness and concerns about the increasing impacts of climate change and associated extreme weather events, including floods, extreme heat and changing weather patterns affecting food production, are increasing. However, understanding how these intersect with the everyday realities of affected people, places and communities remains significant for developing meaningful and equitable responses.
