OBJECTIVE:Improving healthcare service user-reported quality of care is one of the three core objectives of the Malawian government's health sector strategic plan. As such, a robust understanding of service user-reported quality is crucial to inform the development of patient-centred services. This study aimed to explore how service users in Malawi evaluate the quality of the healthcare they receive across services and facilities and to investigate the association between individual and health service characteristics and reported quality of care. DESIGN:A national multifacility cross-sectional study using service user exit interview data in which all central hospitals were sampled and remaining facilities were selected via random stratified sampling. Participants were recruited via random selection based on daily patient load within sampled facilities. Descriptive statistics of service user-reported quality of care were estimated in addition to multinomial logistic regression analyses used to determine the association between patient and healthcare characteristics and perceived care quality. SETTINGS:30 health facilities across 15 districts in Malawi. PARTICIPANTS:4181 respondents surveyed after completing their visit and exiting healthcare facilities between January and May 2024. PRIMARY OUTCOME MEASURES:Overall service user-reported quality of care for the facility visit as a categorical variable. This was derived from the Likert scale survey statement assessing 'overall' quality of the participant's visit, with three responses: 'very good', 'good', 'neutral-very bad'. RESULTS:Quality of care was reported as being high with 58% of respondents rating care as 'good' and 35% as 'very good', with some variation by 'dimension' of care (eg, treatment availability). Positive or negative perceptions of care quality were associated with age, sex, education level, illness severity, previously seeking care, referral, facility type, non-governmental facility ownership, service area, access to medication and payment of fees. CONCLUSIONS:Most healthcare service users in Malawi report receiving high-quality care, although a minority report the quality to be inadequate. Action to address gaps in service delivery, such as improving the availability of required medicines, could address the poor perceptions of quality held by the minority of interviewed service users.

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.

Abstract Background Accurately measuring vaccination coverage is crucial for programmatic and policy decision making, however accurate measurement of coverage can be challenging. We aimed to understand the extent of, and reasons for, inaccurate vaccination card records in a rural, low-income setting in Jigawa state, Nigeria. Methods We conducted an explanatory sequential mixed-methods study in Kiyawa Local Government Area, Jigawa State, from September 2022 to July 2023, using data from the INSPIRING Jigawa trial (ISRCTN39213655). Quantitative data was gathered from surveyed women aged 16–49 in sampled compounds, who presented their child’s vaccine card. Vaccine documentation was defined as inaccurate when the vaccine card is discordant with caregiver report. Adjusted logistic regression identified factors associated with inaccuracies. We conducted in-depth interviews with healthcare workers and focus groups with community members, analyzing transcripts using conventional content analysis, and triangulated findings with quantitative results. Results Records for 4258 children under five-years, from 3232 women, were examined. Of these children, 441 (10.4%) had vaccine cards that were deemed inaccurate by their caregivers. Inaccuracies were primarily attributed to cards being filled despite the child not receiving the vaccine, misplacement or loss of vaccine cards, vaccine stock-out when cards had already been filled, and vaccine card stock-out when the vaccine had been administered. Our adjusted logistic regression results show the following variables were associated with reporting inaccurate vaccine cards (under or over-reporting): any education compared to none (adjusted odds ratio (aOR): 1.33, 95%CI: 1.03, 1.75), having co-wives compared to no co-wife (aOR: 0.78, 95%CI: 0.62, 0.98), and child’s age: 12–24 months compared to < 12 months (aOR: 2.70, 95%CI: 1.94, 3.75) and 25 months and above compared to < 12 months (aOR: 2.30, 95%CI: 1.69, 3.12). Our qualitative findings highlighted maternal lack of knowledge of vaccination schedule and forgetfulness about the vaccination schedule as common reasons for vaccine card inaccuracy. Conclusion We identified health system failures and caregiver barriers leading to inaccurate reports in vaccine cards. It is essential to sensitize caregivers and healthcare providers on the importance of accurately documenting vaccines and validating immunization recording systems. Clinical trial number Not applicable.

OBJECTIVES:HIV care in Malawi has been primarily funded through overseas development assistance for health, leading to the establishment of vertically-funded supply chains of key HIV medicines and diagnostics. Cuts in this funding could undermine healthcare services and the success of these supply chains. DESIGN:Using the Thanzi La Onse model, we estimate the potential impact of reduced availability of HIV related consumables that could result from reduced external funding. METHODS:We consider a shift in HIV consumable availability from the high levels achieved currently (≥93% for adult ART and ≥85% for HIV tests in relevant facility levels) to levels comparable to those observed within government-funded integrated supply chains in other areas of health (44-76% and 44-73%, respectively). We assume that if key medicines/diagnostics are not available, a patient's care is delayed or interrupted. We measure the consequences in terms of disability-adjusted life years (DALYs) and AIDS deaths over the period 2025-2040. RESULTS:A reduction in HIV consumable availability could cause a substantial increase in HIV/AIDS-related DALYs, with projected increases exceeding 144% compared with the status quo. Mortality rises sharply within the first 4-5 years of the simulation, as continuity of care is disrupted for the large cohort of people currently on ART, demonstrating the rapid and severe consequences of reduced access to essential HIV consumables. CONCLUSIONS:This study highlights the risks to HIV programs in Malawi from reduced external funding, emphasising the need for governments to sustain current levels of HIV medicines and diagnostics beyond donor funding.

OBJECTIVE:Oxygen is a cornerstone treatment for pneumonia with hypoxaemia. WHO guidelines recommend oxygen therapy for children with a peripheral arterial haemoglobin oxygen saturation (SpO2) <90%. Children in low- and middle-income countries with an SpO2 of 90-93% are at increased risk of mortality and may benefit from oxygen therapy. We aimed to determine the feasibility of a randomised controlled trial comparing standard of care (no oxygen), low-flow nasal cannula (LFNC) and high-flow nasal cannula (HFNC) among children with pneumonia and an SpO2 of 90-93%. DESIGN:Pilot, open-label, three-armed randomised control trial (NCT06176664). SETTING:Salima District Hospital, Malawi. PATIENTS:Children 1-59 months old with WHO-defined pneumonia and an SpO2 of 90-93%. INTERVENTIONS:Standard care (no oxygen), LFNC or HFNC. MAIN OUTCOME MEASURES:The primary outcome was feasibility defined as an average of ≤2 protocol deviations per participant. Secondary outcomes included consent refusal, participant attrition and treatment failure within 14 days. Treatment failure was defined as an SpO2 <90% for standard care participants or <94% in the LFNC and HFNC arms despite maximum therapy as described, any new severe respiratory distress (grunting, very severe chest indrawing) or any new WHO-defined emergency sign. RESULTS:Of the 29 eligible patients, 21 (72%) were enrolled and randomised. There was an average of 0.8 (16/21) deviations per participant. Seven (43.8%) protocol violations were related to study intervention protocols and nine (56.3%) to medication availability and routine care. No participants withdrew from the study. Three of 21 participants (14.3%) had treatment failure. All participants were successfully followed to obtain the 14-day outcome. CONCLUSIONS:A three-armed, open-label randomised control trial is feasible to compare standard of care, LFNC and HFNC oxygen for children with pneumonia and an SpO2 of 90-93% in Malawi. TRIAL REGISTRATION NUMBER:NCT06176664.

Background Preventive chemotherapy targeting school-aged children has substantially reduced schistosomiasis morbidity, however, a key strategic tension remains between sustaining morbidity control and pursuing transmission elimination, particularly in settings characterised by heterogeneous transmission dynamics and persistent adult infection reservoirs. We developed a health system-integrated transmission and economic evaluation framework to identify optimal age-targeting and district-level prioritisation, providing a basis for determining when elimination-focused approaches offer advantages over morbidity reduction alone. Methods The Thanzi la Onse individual-based model was used to evaluate alternative age-targeted mass drug administration (MDA) strategies for Schistosoma haematobium and Schistosoma mansoni across all 32 districts of Malawi from 2024-2050. Strategies included treatment of school-aged children (MDA-SAC), pre-school and school-aged children (MDA-PSAC+SAC), and community-wide treatment (all ages). Health outcomes included person-years with any infection (PY), disability-adjusted life years (DALYs), probability of elimination (defined as reaching <2% prevalence of infection in all ages). The cost-effectiveness was evaluated using incremental cost-effectiveness ratios (ICERs), net health benefit (NHB), and by quantifying the maximum costs available for implementation, using a cost-effectiveness threshld for Malawi of 88 USD per DALY averted. Findings In the absence of MDA, the majority of the infection burden over 2024-2050 would be concentrated in adults aged 15 years and older (219.6 million person-years [PY], 95% CI 215.4-223.4), compared with 72.8 million PY (95% CI 71.5-74.3) among school-aged children (SAC) and 25.5 million PY (95% CI 25.1-26.2) among preschool-aged children. Annual MDA-SAC would avert approximately 18.0 million DALYs (95% CI 17.6-18.4) between 2025 and 2050 and would be highly cost-effective nationally (ICER 4.76 USD/DALY, 95% CI 4.47-4.95). Across districts, ICERs were highly variable; 25 of 32 districts were cost-effective in ≥90% of runs and 29 of 32 in ≥50% of runs. Expanding treatment to include preschool-aged children (MDA PSAC+SAC) would produce modest additional gains (additional 44,500 DALYs averted) but with substantially higher costs (national ICER 606 USD/DALY, 95% CI 472-695), being dominated in 22 districts and cost-effective only in the high-burden Likoma district. Community-wide MDA would achieve elimination for both species in all districts by 2030 and avert a further 98,000 DALYs; nationally it would be cost-saving relative to PSAC+SAC although outcomes were heterogeneous, with this strategy being cost-saving in 11 high-prevalence districts (2023 prevalence range 13.7 - 41.5%) but dominated (in >80% of model runs) in 16 others. Threshold analyses of maximum implementation costs indicated substantial cost margins in high-burden districts, with cost-effectiveness maintained up to approximately 25-38 USD per treatment. Interpretation The choice of schistosomiasis strategies should depend on whether programmes prioritise short-term morbidity reduction or long-term elimination, as well as the local disease burden and the prevailing cost of service delivery. Integrating district-level transmission dynamics with opportunity-cost-based economic evaluation reveals when broader coverage is justified and provides a framework for designing fiscally grounded elimination pathways in heterogeneous endemic settings. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was supported by funding received from the Global Institute for Disease Elimination (GLIDE) as part of the Thanzi Labwino (Better Health) research project. The Thanzi la Mawa project is funded by Wellcome (223120/Z/21/Z). TM, RMW, BS and TBH acknowledge funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/X020258/1) along with funding through Community Jameel. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Background:In 2012, World Health Organization (WHO) recommended outpatient oral amoxicillin for children aged 2-59 months with chest indrawing pneumonia without general danger signs, based on randomised trials. We assessed mortality and case management for such children routinely managed at primary healthcare centres (PHCs) in Lagos, Nigeria. Methods:This prospective observational cohort study (September 2021-September 2023) was conducted in Ikorodu Local Government Area (LGA), nested within the Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) Lagos study across 16 PHCs. PHC healthcare workers (HCWs) trained in Integrated Management of Childhood Illness (IMCI) provided routine care, while INSPIRING staff independently assessed eligibility using IMCI criteria. The primary outcome was the 14-day case fatality rate (CFR) among children with chest indrawing pneumonia without general danger signs; secondary outcomes included antibiotic use, treatment adherence, and referral practices. Results:PHC HCW identified 24 chest indrawing cases, while INSPIRING staff diagnosed 247 cases, including 19 of the 24 identified by PHC HCWs. Among those followed up (n = 16), the CFR was 6.3% (n/N = 1/16; 95% confidence interval (CI) = 0.2-30.2) for PHC HCW identified cases; with the same death identified by INSPIRING staff (n/N = 1/197; CFR = 0.5%). The single event in each cohort, and high loss to follow-up, imply that these CFR estimates are statistically fragile and should be interpreted as indicative only. Only 4% (n/N = 1/24) of children received routine care aligned with IMCI protocols. Of those prescribed antibiotics, 50% (n/N = 4/8) completed the full course, and just 1 of the 6 of referred children was admitted to hospital. Conclusions:PHC HCWs rarely diagnosed chest indrawing pneumonia, and one-third of the patients were lost to follow up leading to a smaller than expected sample and therefore an imprecise CFR. Improving HCW capacity to identify and manage pneumonia, alongside strengthening IMCI implementation, is critical to reducing preventable child deaths in this setting.

Background: In the last two decades, neonatal mortality has significantly reduced globally. However, it still contributes to almost half of the deaths of children under five years of age. Improving access to quality health care during pregnancy, childbirth and postpartum is urgently needed in Low- and Middle-Income Countries (LMICS) to ensure that the sustainable development goal (SDG) targets for neonatal and infant mortality are met. Healthcare delivery in low resource settings is characterised as fragmented, with poorly staffed health facilities working in silos with limited opportunity for cross learning and collaboration. Neotree, a digital health intervention, has been developed and implemented in Zimbabwe and Malawi to improve neonatal survival by optimising and standardising the quality of newborn care in health facilities linked in a network of care. Understanding the key factors that affect the success of Neotree implementation and its effectiveness in a network of health facilities will inform the development of a scale-up plan which is context specific and robust. Objective: We aim to understand how Neotree is implemented and used in a network of health facilities in Kasungu district for the care of newborns, the intervention mechanisms of action and the contextual factors that affect both implementation and intervention effectiveness. Method: We designed a mixed methods process evaluation as part of a wider effectiveness and economic evaluation of Neotree across a network of 11 health facilities, in Kasungu district, Malawi. The evaluation is guided by the RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework, the realist approach, and other implementation science frameworks. Methods include periodic analysis of routine newborn data (collected via Neotree), qualitative interviews and focus group discussions with stakeholders, direct observations of newborn care, health facility and healthcare provider surveys and review of documents related to the implementation plans, processes and reports. Data will be collected over multiple rounds between December 2024 and December 2027. Result: This research project was initiated in December 2024. As of December 2026, all 11 health facilities were enrolled into the intervention. Routine clinical data are being captured using Neotree and data collection for the mixed methods process evaluation is underway. this study will identify barriers and facilitators of successful implementation of a learning digital health system tool, Neotree in a low resource setting. It will enable us to explain the mechanism by which Neotree could contribute to quality of healthcare and better health outcome for the newborns. Furthermore, the result of the study will guide future scaleup of Neotree in Malawi and other similar settings.

BACKGROUND:Hypoxaemic lower respiratory infections (LRIs) are a leading cause of childhood mortality, with the highest burden in low-income and middle-income countries (LMICs). Hypoxaemia-low peripheral capillary oxyhaemoglobin saturation (SpO2)-is a marker of severity, and WHO recommends hospitalisation and oxygen administration for patients with SpO2 <90%. We aimed to update estimates from a 2015 systematic review and meta-analysis examining the association between hypoxaemia and mortality among children with LRIs in LMICs by incorporating studies published over the subsequent decade and evaluating mortality risk across multiple SpO2 thresholds. METHODS:We conducted a systematic review with meta-analysis by searching PubMed, Embase, LILACS, Global Index Medicus, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2015, and June 18, 2025, with combined terms related to pneumonia, children, mortality, and LMICs. We also included selected earlier studies through citation checking. Eligible studies reported associations between hypoxaemia and mortality in children younger than 5 years with LRIs in LMICs. We excluded case reports and case series with fewer than five deaths, studies focused exclusively on the neonatal period, and those limited to children with specific comorbidities or to postoperative patients, for consistency with the original review. Two reviewers independently screened studies, extracted data, and assessed quality. Eligible studies were combined with those from the original review and analysed using random-effects models to estimate odds ratios (ORs) by hypoxaemia threshold subgroup. The protocol was registered on PROSPERO (CRD42023433946). FINDINGS:We identified 7734 records; 26 new studies met inclusion criteria and were combined with 18 from the original review. The 44 studies were published between 1993 and 2024 and were primarily from Africa (25 [57%] of 44) or Asia (19 [43%]); some studies spanned multiple locations. Data from 33 studies including 155 633 participants were included in the primary meta-analysis. Hypoxaemia of any threshold was associated with higher odds of LRI mortality (OR 4·36 [95% CI 3·52-5·39]) compared with no hypoxaemia. For SpO2 <90% versus 90-100%, OR for death was 4·75 (95% CI 3·42-6·58). For SpO2 90-94% versus 95-100%, mortality risk was more than twice as high (OR 2·27 [95% CI 1·22-4·25]). Heterogeneity was substantial (I2 64-85% across analyses), and eight (24%) of 33 studies in the primary meta-analysis had a high overall risk of bias; however, a sensitivity analysis restricted to studies with low or moderate risk of bias yielded similar results. INTERPRETATION:SpO2 <90% strongly predicts mortality in children with LRIs in LMICs. Children with SpO2 90-94% also have elevated risk, suggesting that paediatric LRI and pneumonia treatment algorithms should consider management at this hypoxaemia threshold. FUNDING:None.

Exclusive breastfeeding (EBF) and appropriate complementary feeding (CF) are important for child survival and development. While global guidelines provide clear definitions for these practices, interpretations within communities can differ, influencing infant feeding behaviours. This study explored how EBF and CF are understood, and how these understandings shape infant feeding and nutrition within a community setting in Jigawa State, northern Nigeria. We conducted a qualitative study using life-history interviews and household observations within an ethnographic process evaluation in Kiyawa LGA, Jigawa State, Nigeria, between July 2020 and November 2022. The data formed part of the INSPIRING Jigawa cluster randomized controlled trial process evaluation. From 90 women recruited for the ethnography, we purposively selected 36 women aged 16–49 years who had breastfed in the preceding two years. Data was analysed from midline interviews and notes from monthly facility and household observations. Interviews were conducted in Hausa, transcribed, translated into English, and analysed using reflexive thematic analysis. We found that while most mothers could state the correct definition of EBF as feeding only breastmilk for the first six months, their interpretation allowed for the early introduction of water, and other water solutions without perceiving this as a breach of EBF. Complementary feeding was similarly defined based on infant cues and cultural beliefs, with many mothers introducing family foods before six months in response to perceived signs of hunger or under the influence of older family members. These locally adapted definitions reflected deep-rooted cultural norms and caregiving traditions. While communities in Jigawa are aware of global definitions for EBF, these are not commonly adopted or practiced. Interventions aiming to improve infant feeding practices must consider culturally embedded beliefs around the provision of water earlier than recommended, and engage influential family and community members to align local practices with recommended guidelines.

Abstract Background Malawi’s healthcare system faces strain due to an insufficient number of healthcare workers (HCWs). The number of HCWs currently employed falls below the Malawian government’s own facility-based staffing standards, which are known as the establishment target . While vacancy rates from this target have been estimated, the health consequences of this workforce gap on the population have not. Methods This study quantifies the health-cost of unfilled establishment HCW positions using the Thanzi La Onse (TLO) model, an “all diseases – whole healthcare system” individual-based model, which self-consistently accounts for the dynamics between health system constraints and population health. We constructed two staffing scenarios: one ( Current) in which the currently employed staff are represented, and another ( Target) where all positions planned under the establishment target are filled. Using the TLO model, we then estimate the health impact of filling all establishment positions as the difference in the Disability-Adjusted Life Years (DALYs) incurred between the two scenarios. Results Our results indicate that fulfilling Target positions could reduce the health losses by 13.6% (43.1 million DALYs averted, 95% CI: 40.8–48.6) over the projection period. The largest proportional reductions are for DALYs caused by HIV/AIDS (41%), tuberculosis (26%), and malaria (24%) compared to the Current provision. Conclusions The analysis shows the potential health benefits associated with increasing the fulfilment of establishment positions in Malawi and offers key quantifications for policymakers as they strive to achieve Universal Health Coverage. Author Summary Malawi’s current healthcare workforce is significantly smaller in number than the establishment targets set out by the Ministry of Health. Our research uses an individual-based epidemiological and healthcare system model, Thanzi La Onse , to examine the consequences of filling all the target healthcare worker positions. We find that the healthcare system could reduce the overall disease burden by an extra 43.1 million DALYs (13.6% reduction) between 2023 and 2040, with the greatest reductions in the burden of AIDS, tuberculosis, and malaria. This modelling approach accounts for other barriers to healthcare delivery, such as healthcare-seeking habits, consumables and equipment supply, diagnostic accuracy, and treatment efficacy. Our findings, therefore, show that in Malawi’s healthcare system, every unfilled healthcare worker post represents an important lost opportunity for population health gains.

Abstract Low- and middle-income countries face critical shortages of healthcare workers (HCWs) and funding for human resources for health (HRH), while patients often receive less care time than expected. Understanding how the existing workforce capacity is used is therefore essential for improving health system performance in resource-constrained settings. We examined HCW time-use patterns in Malawi using data from a time-and-motion study conducted between January and May 2024, which recorded activities across multiple cadres, days, and representative health facilities in the healthcare system. Across cadres, median daily working time, including breaks, was 7.35 hours (IQR 4.40-8.35), approximately 1.65 hours below the typical contracted schedule. HCWs spent most time on direct patient care: 2.82 hours per day (IQR 1.89-3.97), accounting for 48% of total working time (IQR 30%-67%). Administrative tasks accounted for 0.30 hours (IQR 0.00-1.23; 5.21%, IQR 0%-18%) and break time remained consistent with the contracted expectations at 1.25 hours (IQR 0.00-2.12; 18%, IQR 0%-28%). Unallocated time, defined as time neither work-related nor recorded as breaks, was 0.72 hours (IQR 0.02-1.92; 12%, IQR 0%-29%), mainly attributed to the absence of patients based on available information. Median patient load was 21 per staff member per day in outpatient care (IQR 12-35), 12 in inpatient care (IQR 7-18), and 14 in emergency care (IQR 10-23), with median time per patient of 3 (IQR 1.0-6.5), 6 (IQR 2.5-14), and 10 (IQR 5-20) minutes, respectively. These measures, particularly time per patient, vary by cadre, facility type, facility ownership, region, and service area. The findings present a first system-wide picture of HCW time use in a low-income setting and can inform health systems planning. The gap between contracted and actual working time and unallocated time suggests scope to improve workforce utilisation, while high patient loads highlight the need for sustained HRH investment and workforce expansion. Key Messages In low- and middle-income countries with persistent health workforce and human resources for health (HRH) funding constraints, it is essential to understand how healthcare worker (HCW) time is utilised in practice to identify opportunities to improve service delivery and overall health system performance. Based on a time-and-motion study in Malawi health system, we observed that HCWs worked a median of 7.35 hours per day (including breaks), below the typical contracted schedule. Although most working time was devoted to direct patient care, the patient-facing time was limited relative to high patient loads, with short service time per patient, particularly in outpatient settings. The time-use patterns also varied across HCW cadres, facility types, regions, facility ownership, and service areas. Workforce planning should address both utilisation and capacity: reducing avoidable unallocated time may improve efficiency, but high patient loads and short service time per patient indicate that sustained HRH investment and workforce expansion remain essential.

Modelling approaches that consider system-wide delivery platforms rather than single diseases can be instrumental in economic evaluation and forward-looking policy formulation. This study develops a costing approach tailored to the Thanzi La Onse (TLO) model of Malawi’s healthcare system, with general applicability to other health system models. We developed a mixed-method costing approach to estimate the total cost of healthcare delivery (excluding high-level administrative costs) in Malawi using the TLO model, from a healthcare provider perspective. Through iterative adjustments of key parameters, we aligned model-based estimates as closely as possible with real-world expenditure and budget data. Costs were projected for 2023–2030 under alternative scenarios of health system capacity. A comparison with expenditure and budget data suggests our costing method is broadly reliable for the conditions captured by the model, though some mismatches remain owing to data limitations and definitional inconsistencies. Under current system capacity, total healthcare delivery costs for 2023–2030 were estimated at 2.83 billion US dollars [95

Pulse oximeters may be inaccurate in children who are critically ill and/or have darker skin pigmentation. To date no studies have published accuracy metrics that align with proposed regulatory standards. Our objective is to determine if the Nellcor Oximax pulse oximeter has differential accuracy when used in critically ill children with fair, medium, and dark skin tones. This is a prospective single-center study of critically ill children aged 1 month to 17 years hospitalized in an intensive care unit at Texas Children’s Hospital (Houston, USA) undergoing arterial blood gas analysis. We exclude children with conditions known to affect the accuracy of pulse oximeters. We will report the mean bias between the oxygen saturation from the Nellcor pulse oximeter with wrap probe and arterial co-oximetry, stratified by the child’s skin tone. Skin tone is classified by the Individual Typology Angle measured by a skin colorimeter and Monk Skin Tone scale. The Institutional Review Board of Baylor College of Medicine approved this study (H-53514). Results will be shared in peer reviewed journals, conferences, and lay summaries for the public and other stakeholders.

Global health initiatives have expanded access to HIV, tuberculosis, and malaria services in low-income countries, yet these programmes often operate within fragile health systems where shortages of healthcare workers and essential medicines limit their effectiveness and sustainability. Evaluating investments in health system capacity remains challenging because their benefits are difficult to attribute. Here, using a dynamic microsimulation model of Malawi’s health system, we show that health system strengthening investments alone could avert 11.4% of disability-adjusted life years between 2025 and 2035, delivering a return of $26.1 per dollar invested. Combining system strengthening with HIV, tuberculosis, and malaria programme expansion produces three times greater health impact than disease-focused investment alone, delivering a return of $11.7 per dollar invested compared with $5.4 for disease-focused expansion alone. These findings support a shift toward integrated global health financing strategies that combine health system strengthening with disease-targeted programmes. A modelling study of Malawi’s health system shows that combining health system strengthening with disease-targeted programmes delivers twice the return on investment and three times the health impact of disease-focused investment alone.

Background Acute malnutrition remains a major public health challenge among children under five in Malawi due to undetected and untreated cases. While several policies and programmes are in place, they face significant resource input and implementation constraints. In this study, we evaluate the potential health impact and cost-effectiveness of three interventions designed to address constraints along the care pathway in childhood acute malnutrition management. These include improving early recognition of symptoms by caregivers, increasing attendance at routine growth monitoring visits through community outreach, and scaling up the availability of therapeutic food supplements. Methods and Findings We use a newly developed model representing the natural history and management of acute malnutrition, implemented within the Thanzi La Onse (TLO) dynamic individual-based simulation framework, which captures the public health system in Malawi. Each of the three interventions is assessed both individually and in combination, translated into seven scenarios which we evaluate in comparison to the status quo. The optimal strategy combines two interventions, improved caregiver awareness of early symptoms with increased availability of therapeutic food supplements. Over five years, this strategy is predicted to avert 840,470 (95% CI: 682,057–998,883) DALYs with total incremental costs of $34 million. This corresponds to an annual health expenditure increase of $0.32 per capita. At a cost-effectiveness threshold of $76 per DALY averted, the strategy results in an incremental net health benefit of 394,252 (95% CI: 235,839–552,665) DALYs averted. Conclusions The cost-effective strategy for addressing constraints in childhood acute malnutrition management is simultaneously improving caregiver recognition of early symptoms and expanding therapeutic food supplement availability. Out of the seven scenarios evaluated, this integrated approach was found to be the optimal strategy within the Malawian public health system, yielding substantial health at modest costs. These findings provide critical evidence to inform national policy and guide investment prioritisation for the management of childhood acute malnutrition. ### Competing Interest Statement SM reports grants from National Institutes of Health (NIH), grants from Global Institute for Disease Elimination, outside the submitted work. TC has received funding in the last 5 years to his institution (UCL) from the Wellcome Trust, UK Medical Research Council, US National Institutes for Health, the Save the Children UK ? GSK partnership, and The Global Fund to Fight AIDS, Tuberculosis and Malaria. TC also reports being the chair of a Trial Steering Committee for a trial in Nepal on adolescent mental health. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Thanzi La Onse project received ethical approval from the College of Medicine Malawi Research Ethics Committee (COMREC, P.10/19/2820) in Malawi. Only publicly available anonymised secondary data is used in the Thanzi La Onse modelling framework therefore, individual informed consent was not required. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The Thanzi La Onse modelling framework is open source and available for review and usage at https://github.com/UCL/TLOmodel. In particular, the outputs analysed in this study can be reproduced from the tag accessible at https://github.com/UCL/TLOmodel/releases/tag/Janouskova\_etal2026\_wasting\_intervs\_v0.1, using the scenario files from src/scripts/wasting\_analyses/scenarios/100K. The scripts used to generate the plots in the manuscript and the appendix (heatmaps\_cons\_wast.py, calib\_analysis\_wasting.py, run\_interventions\_analysis\_wasting.py) can be found in the src/scripts/wasting_analyses directory. [https://github.com/UCL/TLOmodel/releases/tag/Janouskova\_etal2026\_wasting\_intervs\_v0.1][1] [1]: https://github.com/UCL/TLOmodel/releases/tag/Janouskova_etal2026_wasting_intervs_v0.1

Background acute lower respiratory infections (ALRIs) are the leading global cause of post-neonatal death in children younger than 5 years. The impact, cost, and cost-effectiveness of routine pulse oximetry and oxygen on ALRI outcomes at scale remain unquantified. Methods We evaluate the impact and cost-effectiveness of scaling up pulse oximetry and oxygen on childhood ALRI outcomes in Malawi using a new and detailed individual-based model, together with a comprehensive costing assessment for 2024 that includes both capital and operational expenditures. We model 15 scenarios ranging from no pulse oximetry or oxygen (null scenario) to high coverage (90% pulse oximetry usage and 80% oxygen availability) across the health system. Cost-effectiveness results are presented in incremental cost-effectiveness ratios (ICERs) and incremental net health benefits (INHBs) using a Malawi-specific cost-effectiveness threshold of US$80 per disability-adjusted life-year (DALY) averted. Findings The cost-effective strategy is the full scale-up of pulse oximetry to 90% usage rate and oxygen to 80% availability. This combination results in 72% (95% CI 72-72) of hypoxaemic ALRI cases accessing oxygen, averting 71 000 (68 100-74 000) DALYs per year of implementation and 28% (27-29) of potential ALRI deaths, at an ICER of US$35 (33-36) per DALY averted and $924 (887-963) per death averted. The INHB is 40 200 (37 300-43 100) net DALYs averted. Interpretation Pulse oximetry and oxygen are complementary cost-effective interventions in Malawi, where health expenditure is low, and should be scaled up in parallel. Copyright (c) 2025 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.