BMJ Global Health

Sub-Saharan Africa has fewer medical workers per capita than any region of the world, and that shortage has been highlighted consistently as a critical constraint to improving health outcomes in the region. This paper draws on newly available, systematic, comparable data from ten countries in the region to explore the dimensions of this shortage. We find wide variation in human resources performance metrics, both within and across countries. Many facilities are barely staffed, and effective staffing levels fall further when adjusted for absenteeism. However, caseloads--while also varying widely within and across countries--are also low in many settings, suggesting that even within countries, deployment rather than shortages, together with barriers to demand, may be the principal challenges. Beyond raw numbers, we observe significant proportions of health workers with very low levels of clinical knowledge on standard maternal and child health conditions. This work demonstrates that countries may need to invest broadly in health workforce deployment, improvements in capacity and performance of the health workforce, and on addressing demand constraints, rather than focusing narrowly on increases in staffing numbers. Key messagesO_LIThis study analyzed health worker surveys from ten countries in Sub-Saharan Africa for a deeper understanding of human resource challenges. C_LIO_LIAverage staffing across facilities is far below the stated staffing norms for each country. C_LIO_LIHalf of health centers and health posts have one or fewer clinical staff assigned to them. C_LIO_LIStaffing is even lower when adjusted for absence, which is highest in small facilities and public facilities. C_LIO_LIMassive within-country variation in caseload suggests that staffing problems may be solved in part by reallocation of clinical staff. C_LIO_LIHealth workers lack basic clinical competencies, caseloads are imbalanced, and there is substantial absence of workers from health facilities. C_LI

Tuberculosis (TB) is the leading global cause of death from a single infectious agent, with more than 10 million new cases annually. As a part of its efforts to control TB, the World Health Organisation (WHO) adopted the End TB Strategy in 2014 to reduce TB incidence by 90% between 2015 and 2035, with intermediate targets every five years. We examined TB incidence data from 2000 to 2018 for 40 high burden countries (HBCs) from the WHO published statistics, contextualized and assessed their trends over time, and projected the incidence to 2035 for each country. Two recurrent patterns accounted for 26 of the 40 HBCs: linear decrease (n = 14) or a peak in the 2000s followed by decline (n = 12). As uncontrolled HIV is the greatest risk factor for TB, trends in HIV infected and uninfected people were analysed separately for 15 Sub-Saharan African HBCs with high HIV prevalence. The projections of current trends were compared against the reductions required to meet the WHO End TB targets. Of the 25 countries without a high burden of HIV, only 5 are on track to meet the End TB targets: Ethiopia, Laos, Myanmar, Russia, and South Korea. Of the 15 high HIV burden countries, 6 are on track: Eswatini, Kenya, Lesotho, South Africa, Tanzania, and Zimbabwe. Three high HIV burden countries, Botswana, Namibia, and Zambia will miss the End TB targets due to the diminishing returns of indirectly decreasing TB incidence by controlling the HIV epidemic. Overall, we predict 62 million excess cases of TB between 2020 and 2035 in the 29 HBCs projected to miss the WHO End TB targets. In high HIV burden countries, new programs aimed directly at TB will be required to maintain momentum. Moreover, our projections are based on data prior to the COVID-19 pandemic; the disruption of the pandemic is overwhelmingly likely to interrupt vital TB services and increase TB incidence. We anticipate that these findings will help orientate countries to their progress towards the End TB goals and inform the level of investment required to meet these important targets for a TB-free world. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed and Google Scholar with the terms "End TB assessment," "End TB Strategy," or "WHO End TB" between June 2019 and September 2020 to identify studies in English reporting on progress towards meeting the End TB targets. We only identified two studies that carried out a quantitative assessment of current estimates against the End TB targets. One study limited its analyses to current estimates, rather than using statistical methods to produce projections based on current trends, while the other study and the WHO Global TB Report 2019 presented projections to 2020 only. No report provided a per-country estimate of the progress toward the End TB targets through 2035. Added value of this studyThis study presents projections of TB incidence from 2020 to 2035 for 40 high TB burden countries. We benchmark the progress of each country against the reductions necessary to meet the WHO End TB targets. We provide per country (rather than per WHO region) breakdowns of these numbers and place the results into broader global health and socio-political contexts. Additionally, we separately model incidence trends in HIV infected and uninfected populations to account for different trajectories in the two populations. Implications of all the available evidenceOnly 11 of the 40 countries assessed are on track to meet the 2035 End TB targets, leading to a total of 62 million excess cases of TB compared with if the targets were met. This is consistent with previous reports such as the WHO Global TB Report 2019, which found that only 11 of 30 high burden countries were on track to meet targets for 2020. We additionally demonstrate that TB specific programs should be developed in most high HIV burden countries, as reductions in TB in HIV uninfected people are declining much more slowly than in HIV infected people.

ObjectiveThe purpose of this analysis was to describe national critical care capacity shortages for 52 African countries and to outline needs for each country to adequately respond to the COVID-19 pandemic. MethodsA modified SECIR compartment model was used to estimate the number of severe COVID-19 cases at the peak of the outbreak. Projections of the number of hospital beds, ICU beds, and ventilators needed at outbreak peak were generated for four scenarios - if 30, 50, 70, or 100% of patients with severe COVID-19 symptoms seek health services--assuming that all people with severe infections would require hospitalization, that 4.72% would require ICU admission, and that 2.3% would require mechanical ventilation. FindingsAcross the 52 countries included in this analysis, the average number of severe COVID-19 cases projected at outbreak peak was 138 per 100,000 (SD: 9.6). Comparing current national capacities to estimated needs at outbreak peak, we found that 31of 50 countries (62%) do not have a sufficient number of hospital beds per 100,000 people if 100% of patients with severe infections seek out health services and assuming that all hospital beds are empty and available for use by patients with COVID-19. If only 30% of patients seek out health services then 10 of 50 countries (20%) do not have sufficient hospital bed capacity. The average number of ICU beds needed at outbreak peak across the 52 included countries ranged from 2 per 100,000 people (SD: 0.1) when 30% of people with severe COVID-19 infections access health services to 6.5 per 100,000 (SD: 0.5) assuming 100% of people seek out health services. Even if only 30% of severely infected patients seek health services at outbreak peak, then 34 of 48 countries (71%) do not have a sufficient number of ICU beds per 100,000 people to handle projected need. Only four countries (Cabo Verde, Egypt, Gabon, and South Africa) have a sufficient number of ventilators to meet projected national needs if 100% of severely infected individuals seek health services assuming all ventilators are functioning and available for COVID-19 patients, while 35 other countries require two or more additional ventilators per 100,000 people. ConclusionThe majority of countries lack sufficient ICU bed and ventilator capacity to care for the projected number of patients with severe COVID-19 infections at outbreak peak even if only 30% of severely infected patients seek health services. This analysis reveals there is an urgent need to allocate resources and increase critical care capacity in these countries.

Sub-Saharan Africa (SSA) continues to bear a disproportionate global disease burden while also facing significant disparities in research productivity and impact. As such, strengthening the research capacity in SSA is an urgent priority, necessitating a multifaceted assessment of the current landscape, the role of international collaboration, and the alignment of research efforts with health needs. In this study, we conducted a macro-level bibliometric analysis to assess research capacity, thematic alignment, and structural autonomy in SSA. We found that SSA accounted for approximately 15% of the global population and 21% of the global disease burden, yet it received only 2.7% of global citations in 2021. Despite increasing the research output over time, academic impact and leadership remain limited. Higher international collaboration rates were positively associated with a higher research impact, but also with a markedly greater proportion of publications without SSA researchers in key authorship positions, indicating persistent structural dependency. Researcher autonomy in SSA was substantially lower than in other regions, though slight improvements were observed during the COVID-19 period. Meanwhile, the Burden-Adjusted Research Intensity analysis showed a disproportionate concentration of research on HIV/AIDS, tuberculosis, and malaria, a focus that was sustained--and even intensified--in SSA during the pandemic, while many other high-burden diseases, including neglected tropical diseases, remained severely under-researched. In conclusion, this study provides quantitative evidence of persistent academic dependency and misaligned research priorities in SSA, with our analyses revealing how structural inequities in international collaborations and externally driven research agendas limit local research leadership and potentially hinder effective responses to regional health needs. Achieving a more just global research ecosystem demands active decolonization efforts centered on empowering Global South ownership, necessitating the fostering of genuinely equitable partnerships, reforming of funding mechanisms to prioritize locally led research, and sustained investment in developing the local research and leadership capacity. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LISub-Saharan Africa (SSA) bears a disproportionate share of the global disease burden but has historically lagged in research output and scientific capacity. C_LIO_LIStructural and systemic barriers have long hindered the development of robust research ecosystems in SSA. C_LI What this study addsO_LISSA faces a critical mismatch between its high disease burden and its limited capacity to generate scientific research needed to address local health challenges. C_LIO_LIHigher international collaboration in SSA is correlated with both greater citation impact and diminished local leadership. C_LIO_LIThere are persistent inequities in research in SSA in relation to the COVID-19 pandemic. C_LI How this study might affect research, practice or policyO_LIOur results underscore the need to focus on structural equity, in addition to the quantity and quality, in global health research. C_LIO_LITo decolonize knowledge production, international partnerships must prioritize local leadership, long-term investment, and alignment with regional health needs. RSI and BARI offer practical tools to monitor these goals and guide policy reform. C_LIO_LIEquitable research ecosystems will require both capacity building in SSA and behavioral shifts in high-income country funders and institutions. C_LI

Though much has been written about the importance of decolonising global health, there is a lack of consensus around how it should be defined, conceptualised and actioned, and who has responsibility to do so. In accordance with PRISMA guidelines, we undertook a scoping review of the decolonising global health literature to explore the meaning of decolonising global health, to identify examples of best practice, and to find out how those writing about the issue see the future of the movement. We searched databases for peer-reviewed and grey literature with titles and abstracts, and then full texts double-screened by authors to identify papers for inclusion. Our search strategy focussed on opinions and discourse using terms broadly linked to decolonising global health. Papers published in either the peer reviewed and grey literature were eligible for inclusion. Data, including conclusions and recommendations, were extracted and results presented as a narrative synthesis of included papers to provide a contemporary account of the decolonising global health agenda. Included papers (n=129) were predominantly commentary or opinion pieces (n=95). Authors of the included papers were affiliated with institutions predominantly from high income countries including the USA (n=53) and UK (n=30). Included papers presented a broad range of definitions for decolonising global health, describe the historical, colonial influence on global health, explore power imbalances in current global health structures, and make a number of suggestions as to how to address these imbalances. Despite the clear imperative in the literature to take action, there is no clear consensus on where to start. Drawing from the findings of our review, we conclude with a set of recommended approaches and next steps for decolonising global health, focussing on epistemic injustice, partnership working, the structure of global health, and individual duty.

IntroductionMultidimensional poverty (deprivations in education, health, and living standards) affects people with and without HIV. We compared poverty levels by HIV status in Eastern and Southern Africa and identified indicators driving deprivations. MethodWe analysed the 2020-22 Population HIV Impact Assessment data from Eswatini, Lesotho, Malawi, Mozambique, Tanzania, Uganda, and Zimbabwe using the Alkire-Foster method, calculating the multidimensional poverty index (MPI), headcount ratio, and poverty intensity, using the Stata 14.2 mpi command. We classified individuals deprived in 20{middle dot}0%-33{middle dot}3% of indicators as vulnerable to poverty, [&ge;]33{middle dot}3% as poor, and [&ge;]50{middle dot}0% as severely poor. We estimated the number of people in each poverty category, and decomposed poverty by indicators. Analyses were survey-weighted, disaggregated by sex, residence, and age (15-24 years), and differences by HIV status tested using the Rao-Scott chi-square test (p <0{middle dot}05). ResultsPeople living with HIV (PLHIV) comprised 7{middle dot}1% (11{middle dot}8 million) of the study population (164{middle dot}9 million). PLHIV were more likely to be vulnerable to poverty, poor, or severely poor than people without HIV. In Eswatini, with the lowest poverty level, PLHIV had higher MPIs (0{middle dot}248 95% CI [0{middle dot}239-0{middle dot}257]) than people without HIV (0{middle dot}220 [0{middle dot}215-0{middle dot}226]). 53{middle dot}7% [51{middle dot}8%-55{middle dot}5%], 99,000, PLHIV were poor compared to 47{middle dot}5% [46{middle dot}4%- 48{middle dot}6%], 266,000, of people without HIV. In Mozambique, with the highest poverty level, the MPIs were similar for people living with and without HIV, but poverty remained higher among PLHIV (70{middle dot}2% [67{middle dot}8%- 72{middle dot}5%], 1{middle dot}5 million, versus 69{middle dot}6% [68{middle dot}6%-70{middle dot}5%], 10{middle dot}5 million). The intensity of poverty did not differ across the countries. Education/employment and living standards accounted most for deprivations. InterpretationNearly three-quarters of PLHIV in Eastern and Southern Africa experienced multidimensional poverty. Integrating HIV and poverty-reduction efforts, prioritising education, employment, clean energy, water, sanitation, housing, and assets is required. Including HIV indicators in poverty surveys, and research to accelerate joint progress are required. FundingThis study received no external funding Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed, Google Scholar, reports by UNAIDS, UNDP, World Bank, and other grey literature, using subject headings and keyword terms ("HIV and poverty", "Differences in poverty between people living with HIV and people not living with HIV", "Multidimensional poverty and HIV", "HIV and sanitation", and "Differences between PLHIV and general population in assets") for English-language publications from January 1, 2005, to September 31, 2025. We reviewed 52 articles published in English (Supplement A1). The studies showed that people living with HIV (PLHIV) face socioeconomic disadvantage, including material deprivation, reduced employment, and limited household assets. The studies find as association between poverty among PLHIV with poorer immunologic and virologic response to antiretroviral therapy, lower adherence, and greater comorbidity. They further show inadequate access to safe drinking water, sanitation, and hygiene, increasing diarrhoeal disease and reducing treatment absorption among PLHIV. Other studies find that people living with HIV are deprived in cooking fuels, leading to upper respiratory infections. Most studies used single indicators of poverty or were restricted to individual settings or countries. Added value of this studyThis study, to our knowledge, provides the first multi-country assessment of multidimensional poverty by HIV status in Eastern and Southern Africa. We find across countries, that people living with HIV (PLHIV) were more likely to be vulnerable to poverty, poor, or severely poor than people without HIV. Multidimensional poverty among PLHIV was driven by deprivations in education and employment, and deprivations in living standards such as electricity, clean cooking energy, safe drinking water, sanitation, housing, and household assets. Implications of all the available evidenceDespite major gains in HIV treatment and prevention and in national poverty reduction efforts, PLHIV continue to face socioeconomic and infrastructural disadvantage. These deprivations increase PLHIVs risk to comorbidities and undermine HIV prevention and treatment services, slowing progress toward the Sustainable Development Goals. Integrating HIV responses with poverty reduction and social protection strategies is essential. Incorporating HIV indicators into national poverty monitoring systems and prioritising investment in education, employment, and essential services can accelerate joint progress towards ending AIDS and reducing poverty, in a context of declining external funding.

Transboundary health partnerships are shaped by global inequities. Voices from "global South" research partners are critical to understand and redress power asymmetries in research partnerships. We undertook research with Liverpool School of Tropical Medicine (LSTM) partners to inform LSTMs equitable partnership strategy and co-develop principles for equitable partnerships. We applied mixed methods and participatory approaches. An online survey (n=21) was conducted with transboundary partners on fairness of opportunity, fair process, and fair sharing of benefits in partnership with LSTM-Liverpool. We triangulated the survey with key informant interviews (n=12). Qualitative narratives were coded and analysed using the thematic framework approach. These findings were presented in a participatory workshop with transboundary partners to co-develop principles for equitable partnership, which were then refined and validated. Transboundary partners identified being involved in agenda setting from the outset, shaping the design of research projects and theories of change as mechanisms to support fair opportunity however, funding mechanisms that shape power structures was reported as limiting fair opportunities. Fair process was supported by multi-directional, long-term collaborations with opportunities for capacity strengthening. Participants raised concerns about funder requirements and outdated language in contracting process that hindered equity. Fair benefit sharing was facilitated by early discussions on authorship to promote equity and policy influence. Funding also influenced the ability to travel and network, important for benefit sharing and fair opportunity. High paywalls limit sharing of research findings and access to research findings for many "global-South" partners. The co-developed principles are part of ongoing reflections and dialogue to improve and undo harmful power structures that perpetuate coloniality within global health. While this process was conducted with LSTM-Liverpool partners, the principles to strengthen equity are applicable to other institutions engaged in transboundary research partnerships and relevant for funders.

BackgroundUndernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost prohibitive. The RATIONS study demonstrated that nutritional support provided to household contacts of persons with TB can reduce TB incidence. However, the long-term cost-effectiveness of this intervention is unclear. MethodsWe assessed the cost-effectiveness of a RATIONS-style intervention (daily 750 kcal dietary supplementation and multi-micronutrient tablet). Using a Markov state transition model we simulated TB incidence, treatment, and TB-attributable mortality among household contacts receiving the RATIONS intervention, as compared to no nutritional support. We calculated health outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from government and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. FindingsOver two years, household contacts receiving the RATIONS intervention would experience 39% (95% uncertainty interval (UI): 23-52) fewer TB cases and 59% (95% UI: 44-69) fewer TB deaths. The intervention was estimated to avert 13,775 (95% UI: 9036-20,199) TB DALYs over the lifetime of the study cohort comprising 100,000 household contacts and was cost-effective from both government (incremental cost-effectiveness ratio: $229 per DALY averted [95% UI: 133-387]) and societal perspectives ($184 per DALY averted [95% UI: 83-344]). The results were most sensitive to the cost of the nutritional supplement. InterpretationPrompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India. SummaryUndernutrition is the leading cause of tuberculosis in India. Using a Markov state-transition model, we found that food baskets for household contacts of persons with tuberculosis would be cost-effective in reducing tuberculosis incidence and mortality in India. Research in contextEvidence before this study: Undernutrition is the leading risk factor for TB worldwide. Recently, the RATIONS study demonstrated a roughly 40% reduction in incident TB among household contacts who received in-kind macronutrient and micronutrient supplementation. Added value of this study: Although the RATIONS study demonstrated a dramatic reduction in incident TB, it is unclear if nutritional interventions to prevent TB are cost-effective. Previously, only one cost-effectiveness analysis of nutritional interventions for household contacts has been published. Due to lack of published data, that study had to make assumptions regarding the impact of nutritional interventions on TB incidence and mortality. In this study, we conducted an economic evaluation of a RATIONS-style intervention to reduce incident TB and mortality in India using observed data. Implications of all the available evidence: In-kind nutritional supplementation for household contacts of individuals with TB disease would be cost-effective in reducing incident TB and TB mortality, particularly if TB programs leverage economies of scale to bring down the cost of the nutritional intervention.

BackgroundClimate change is increasingly recognised as a significant barrier to malaria elimination, especially in low-and middle-income countries (LMICs), where vulnerability to vector-and waterborne diseases is heightened. Climate variability increasingly influences malaria transmission dynamics, yet its impact on malaria control efforts remains underexplored. This study explored healthcare workers and community-based volunteers (CBVs) perspectives on climate change and the perceived contribution of climate variability to malaria transmission in Zambia. MethodsA cross-sectional qualitative study was conducted between August and October 2023 across twenty purposefully selected districts representing high-and low-burden malaria settings. Nine key informant interviews and fourteen focus group discussions were conducted with malaria program officers, clinicians, environmental health officers and CBVs. Data were transcribed verbatim, imported into ATLAS.ti version 23, and analysed thematically. ResultsParticipants consistently reported that flooding, drought, deforestation, and shifting rainfall patterns were increasing mosquito breeding sites and altering malaria transmission seasons. Climate-related disruptions, poor road access during floods and competing health priorities, including cholera outbreaks and COVID-19, were perceived to hinder effective malaria prevention and case management. While participants acknowledged the need for a more integrated response, they largely emphasised reinforcing existing malaria control strategies, such as indoor residual spraying (IRS) and insecticide-treated nets (ITNs), with limited reference to broader climate adaptation measures or national climate policies, highlighting gaps in policy dissemination and implementation. Participants also noted contextual barriers, including vector resistance and diagnostic inaccuracies. Notably, the emerging role of malaria vaccination was not mentioned, indicating a potential knowledge gap in climate-adaptive malaria strategies. ConclusionsFrontline perspectives highlight substantial climate-related challenges to sustaining malaria control in Zambia and gaps in climate-health knowledge among HCWs and CBVs. Strengthening climate-resilient systems, improving policy dissemination and integrating climate adaptation into malaria programming and training are critical to sustaining progress towards elimination. Author SummaryDespite clear evidence that climate change is reshaping malaria transmission in sub-Saharan Africa, little is known about how frontline health workers perceive and respond to these shifts. This study provides the first multi-district qualitative examination of healthcare worker and community volunteer perspectives on climate-malaria interactions in Zambia. Our findings reveal critical knowledge gaps, limited awareness of existing climate-health policies, and an over-reliance on traditional malaria interventions that fail to integrate climate-resilient strategies. These insights underscore a pressing need for targeted training, strengthened policy dissemination, and multisectoral collaboration to build climate-ready malaria programmes. By illuminating the disconnect between climate science and frontline practice, this study highlights a fundamental barrier to sustaining malaria elimination in a rapidly changing climate.

BackgroundReducing mortality of children <5 years in Sierra Leone is a priority. Despite an enabling policy environment, health indicators have remained poor. Evidence on barriers to care is limited. ObjectivesThis study describes barriers to care, health-seeking behaviour, and health outcomes of children <5 years. MethodsFrom October 2016 to January 2017, we conducted a sequential mixed-methods study in urban and rural areas of Tonkolili District comprising: household survey targeting carers of children <5 years; and in-depth interviews (IDIs) targeting community leaders and healthcare workers (HCWs). We chose 30 clusters in urban and 30 clusters in rural areas. Topics that were identified during the survey were examined further through IDIs. ResultsWe surveyed 643 carers of 1092 children <5 years and conducted 72 IDIs. Of children <5 years, 62% had experienced febrile illness in the 2 weeks prior, and mortality was higher rurally (1.55/10,000/day vs urban 0.26/10,000/day). Barriers, including costs and physical inaccessibility of healthcare facilities, delayed or prevented 90% (287/318; 95%CI: 80-96) rural and 48% (155/325; 95%CI: 37-58) urban carers from accessing care for a febrile child. Mistrust of HCWs was frequent, primarily due to their requests for payment. HCWs described lack of pay and holistic support precluding provision of quality care. ConclusionsChildren <5 faced important barriers to healthcare, particularly in rural areas, contributing to high preventable mortality near to the emergency threshold. Access to healthcare was important to carers, however available services were costly and unreachable. Equally, HCWs experienced structural barriers to provide quality care. Key messagesO_LIChild <5years mortality near to the humanitarian emergency threshold and substantially high among rural children. C_LIO_LIInequity in healthcare access and inequality in health between urban and rural areas. C_LIO_LIBarriers, including costs of healthcare and physical inaccessibility of healthcare facilities, delayed or prevented 90% of rural and 48% of urban carers from accessing care for a febrile child. C_LIO_LIJust 8% of rural children <5 years used Long-Lasting Insecticide-Treated bednets. C_LIO_LIMistrust of healthcare workers was widely expressed primarily due to payment demanded for "free" healthcare. Healthcare workers described lack of pay and poor conditions precluding provision of quality care. C_LI

IntroductionMalaria remains a leading cause of under-five mortality in Nigeria, with Abia State exemplifying hyperendemic transmission. The 2024 introduction of the R21/Matrix-M and RTS,S/AS01 vaccines offers promise, but evidence on caregiver awareness and acceptance in the non-pilot South-East region to inform equitable rollout is scarce. MethodsWe conducted a mixed-methods study from June to August 2025 among 618 caregivers of under-fives caregivers engaged with the routine immunization programme in Abia State. Quantitative cross-sectional surveys assessed awareness (knowledge of malaria vaccines) and acceptance (willingness on Likert scales), and inferential analysis was carried out using logistic regression. Qualitative in-depth interviews (n=28) and focus group discussions (n=6, 50 participants) explored perceptions using thematic analysis. Triangulation integrated findings. ResultsAwareness was low (38.2%; 95% CI: 34.5-42.0) and highest among urban educated caregivers (52.3%). However, acceptance was high (88.7%), driven by child protection (67.4%) and provider trust (59.8%). Barriers included fears of side effects (51.4%) and misinformation (18.7%). Significantly, education (AOR=3.28) and urban residence (AOR=1.78) predicted awareness, and income (AOR=2.05) and awareness status (AOR=6.92) influenced acceptance. Qualitative themes corroborated quantitative findings: "fragmented information" explained rural gaps, and "maternal instinct" amplified willingness to accept. ConclusionBased on our findings, caregivers demonstrated strong acceptance of malaria vaccines despite critically low awareness, a disparity fuelled by information gaps and sociodemographic inequities such as low education and rural residence that threaten vaccine rollout and malaria elimination goals. Based on our findings, this pioneering mixed-methods study recommends that specific channels that leverage PHC providers and community leaders for information dissemination should be utilised, given the high levels of trust, to ensure malaria vaccine uptake and accelerate progress in reducing under-five deaths. KEY MESSAGES What is already known on this topicO_LIMalaria vaccines (RTS,S/AS01 and R21/Matrix-M) were introduced in Nigeria in late 2024, with prior studies in northern regions reporting low caregiver awareness and high acceptance rates. However, evidence remains scarce in non-pilot South-East states like Abia, where hyperendemic transmission and urban-rural disparities necessitate localised data to guide equitable rollout and integration into routine immunisation. C_LI What this study addsO_LIThis pioneering mixed-methods study in Abia State of Nigeria reveals critically low malaria vaccine awareness (38.2%) among 618 routine immunisation-engaged caregivers, contrasted by robust acceptance (88.7%), with education, urban residence, income, and awareness status as key predictors, corroborated by qualitative themes of "fragmented information" barriers and "maternal instinct" facilitators. C_LIO_LIIt provides the first post-approval, pre-expansion insights from Abia State, rejecting the null hypothesis of no sociodemographic associations and highlighting resilience in acceptance despite informational gaps. C_LI How this study might affect research, practice or policyO_LIPolicymakers should integrate these findings into Nigerias National Malaria Strategic Plan 2024-2028 with South-East-contextualised, Igbo-language awareness campaigns through church networks and media to bridge the 38.2% awareness gap and align with African Union vaccination targets. C_LIO_LIProgramme managers can leverage high provider trust (59.8%) through community health worker-led dialogues and mobile clinics to dispel side-effect myths, targeting low-education rural caregivers and potentially elevating acceptance beyond 88.7% for improved under-five malaria prevention. C_LI GRAHICAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=144 HEIGHT=200 SRC="FIGDIR/small/25340288v1_ufig1.gif" ALT="Figure 1"> View larger version (28K): org.highwire.dtl.DTLVardef@1786b98org.highwire.dtl.DTLVardef@dff0eaorg.highwire.dtl.DTLVardef@41c977org.highwire.dtl.DTLVardef@111ae04_HPS_FORMAT_FIGEXP M_FIG C_FIG

Spatially detailed estimates of childhood vaccination coverage are crucial to guide program design, targeting interventions, and evaluating progress within countries. In settings where substantial geographic inequities persist, high-resolution vaccination coverage and corresponding zero-dose maps can be helpful for understanding local patterns and informing strategies to reach underserved or missed populations. In this study, we produce annual 1x1 km and district level estimates of coverage for the first and third doses of diphtheria-tetanus-pertussis vaccine (DTP1 and DTP3) and the first dose of measles-containing vaccine (MCV1), as well as zero-dose prevalence, across Nigeria from 2000 to 2024. Our analyses draw on data from five Demographic and Health Surveys and two Multiple Indicator Cluster Surveys conducted between 2003 and 2024, alongside a suite of geospatial covariates. We fitted and evaluated Bayesian geostatistical models using the INLA-SPDE framework applied to cluster-level survey data. The resulting estimates highlight a persistent north-south divide in coverage, with consistently lower rates in the northern regions across the study period. Minimal gains were observed prior to 2015, followed by marked improvements that peaked in 2019 and declined slightly thereafter, with Jigawa and Yobe showing more sustained progress. We estimate that more than two million zero-dose children reside in Nigeria each year, with the highest burdens concentrated in the northeast, northwest, and parts of the south. These high-resolution outputs provide critical evidence to support subnational prioritization, strengthen routine immunization, and accelerate progress toward equitable vaccination coverage and disease elimination in Nigeria. What is already known on this topicO_LIVaccination is one of the most successful public health interventions, saving millions of lives each year and making a major contribution to child survival. C_LIO_LIHowever, substantial gaps in vaccination coverage remain, particularly among children living in low- and middle-income countries (LMICs). C_LIO_LIZero-dose and under-vaccinated children remain vulnerable to vaccine-preventable diseases and reaching them is crucial to prevent disease transmission and outbreaks. C_LIO_LIReliable, current and spatially detailed evidence on coverage and the sizes and geographical distribution of zero-dose children is often unavailable in many LMICs, making the design of targeted interventions more challenging. C_LI What this study addsO_LIWe employed Bayesian geostatistical modelling approaches to produce annual vaccination coverage and zero-dose estimates for Nigeria at 1x1 km resolution, the district and other administrative levels, covering the period from 2000 to 2024 (including predictions for 2025). C_LIO_LIOur results showed substantial heterogeneities and a persistent north-south divide in coverage. These also revealed that more than two million zero-dose children reside in Nigeria each year, with the highest burdens concentrated in the northeast, northwest, and parts of the south. C_LI How this study might affect research, practice or policyO_LIOur outputs can be triangulated with subnational administrative data for data quality assessments and other complementary datasets, such as travel time to the nearest health facility, to produce additional operationally relevant outputs. C_LIO_LIUsing these outputs, program managers and policy makers can plan and implement targeted interventions to reach zero-dose and under-immunized children, hence accelerating progress towards Immunization Agenda 2030 goals in Nigeria. C_LI

The COVID-19 pandemic has brought about significant disruptions to health care delivery worldwide, including in Rwanda. Countries experienced variable disruptions both at the national and the subnational level. Here we report results from mixed methods implementation research on lessons learned from Rwanda to mitigate inequity in the delivery of health care interventions during health shocks as in the COVID-19 pandemic. To estimate the coverage of primary health care interventions known to reduce under-5 mortality during the initial period of COVID-19 in Rwanda, we analyzed existing data from the health management information system. Using the available administrative health management information system data in Rwanda during 2019 and 2020, we calculated i) cumulative and ii) monthly disruption ratios of number of cases of facility-based delivery, number of four or more antenatal care visits, and number of diarrheal cases treated at health facility and community levels in 2019 and in 2020. We conducted key informant interviews between February to April 2021 with policymakers, donors, implementing partners, and direct health services providers to identify barriers and facilitators of subnational variability in the delivery of primary health care interventions, as well as implementation strategies, across Rwandas districts. We report district-level results of cumulative and monthly disruptions for three interventions. We found minimal disruption across most districts in Rwanda in the first phase of the COVID-19 pandemic (March to December 2020) and, furthermore, we found minimal subnational variability across districts. Implementation strategies such as community health worker interventions, community engagement and education, provision of transport, and command posts, were important in ensuring minimal disruption across most districts. Rwandas focus on equity likely helped to strengthen facilitating contextual factors including a culture of accountability and a strong pre-existing community health system and structure, which contributed to the low level of disruption and minimal subnational variability in the interventions studied. Rwandas experience offers potentially transferable knowledge for policymakers and decision-makers in other regions and countries to minimize disruptions at the subnational and national levels to essential health services during future health shocks. Key messagesO_LIIn the first phase of the COVID-19 pandemic, we found minimal disruption across most districts in Rwanda, similar to previous findings of minimal disruption for the country as a whole and, furthermore, we found minimal subnational variability in disruption across districts. C_LIO_LIWe found that implementation strategies such as community health worker interventions, community engagement and education, provision of transport, and command posts (the National Joint Task Force composed of multidisciplinary teams and supported by subnational task force from all 30 districts to ensure all the coordination around COVID-19 runs smoothly and supports health care delivery) were important factors in delivering minimal disruption across most districts in Rwanda during the first period of COVID-19. C_LIO_LIRwandas focus on equity likely helped to strengthen facilitating contextual factors including a culture of accountability and a strong pre-existing community health system and structure, which contributed to the low level of disruption and minimal subnational variability in the interventions we considered. C_LIO_LIThe capacity to conduct both national and subnational analysis of disruption and understand strategies which were applied is valuable for providing meaningful lessons learned for communities in other regions and countries. C_LI

BackgroundProduct Development Partnerships (PDPs) are non-profit organizations that bridge the gap between the need for new treatments for poverty-related diseases and the resources available to develop them, leveraging a mix of public, philanthropic, multilateral, and private sector funding. This paper describes how two financial metrics were used to estimate the return on investments of drugs developed by the PDP Medicines for Malaria Venture (MMV) as a case study. MethodsThe internal rate of return (IRR) and benefit-cost ratio (BCR) were used to estimate the economic return on investment for the PDP. IRR was based on total investments from 2000 to 2023 and health gains derived from PDP-supported drugs, measured as monetized disability-adjusted life years (DALYs) minus the delivery cost of the products. BCR was calculated by dividing the present value of monetized DALYs by the present value of cost, indicating the overall efficiency and impact of the investments received by MMV. FindingsTotal investment received was $2{middle dot}3 billion over the study period, and the antimalarial drugs developed and launched with the support of MMV averted an estimated 1{middle dot}6 million deaths and 87 million DALYs for a cost of delivery estimated at $785 million. The IRR for the base scenario was 52{middle dot}13% (CI: 52{middle dot}11% - 52{middle dot}16%) and the BCR 12{middle dot}99 (CI: 12{middle dot}92 - 13{middle dot}06). InterpretationThe substantial IRR and BCR generated by investment in antimalarial drug development suggest that the PDP model has a potentially pivotal role to play in global health. FundingNo funding to declare.

We conducted a randomized, controlled trial (RCT) to investigate our hypothesis that the interactive chatbot, Vitalk, is more effective in improving mental wellbeing and resilience outcomes of health workers in Malawi than the passive use of Internet resources. For our 2-arm, 8-week, parallel RCT (ISRCTN Registry: trial ID ISRCTN16378480), we recruited participants from 8 professional cadres from public and private healthcare facilities. The treatment arm used Vitalk; the control arm received links to Internet resources. The research team was blinded to the assignment. Of 1,584 participants randomly assigned to the treatment and control arms, 215 participants in the treatment and 296 in the control group completed baseline and endline anxiety assessments. Six assessments provided outcome measures for: anxiety (GAD-7); depression (PHQ-9); burnout (OLBI); loneliness (ULCA); resilience (RS-14); and resilience-building activities. We analyzed effectiveness using mixed-effects linear models, effect size estimates, and reliable change in risk levels. Results support our hypothesis. Difference-in-differences estimators showed that Vitalk reduced: depression (-0.68 [95% CI -1.15 to -0.21]); anxiety (-0.44 [95% CI -0.88 to 0.01]); and burnout (-0.58 [95% CI -1.32 to 0.15]). Changes in resilience (1.47 [95% CI 0.05 to 2.88]) and resilience-building activities (1.22 [95% CI 0.56 to 1.87]) were significantly greater in the treatment group. Our RCT produced a medium effect size for the treatment and a small effect size for the control group. This is the first RCT of a mental health app for healthcare workers during the COVID-19 pandemic in Southern Africa combining multiple mental wellbeing outcomes and measuring resilience and resilience-building activities. A substantial number of participants could have benefited from mental health support (1 in 8 reported anxiety and depression; 3 in 4 suffered burnout; and 1 in 4 had low resilience). Such help is not readily available in Malawi. Vitalk has the potential to fill this gap.

RationaleTuberculosis (TB) remains a global health crisis, disproportionately affecting low- and middle-income countries. Strategic resource allocation is essential to achieving the WHO End TB targets. Existing TB costing tools have limitations in conducting global analyses, prompting the development of a novel model tailored to address these gaps. MethodsWe developed a new, open-source TB costing model that simulates detailed TB care cascades comprising steps of screening, diagnosis, treatment, and prevention for those eligible - according to WHO guidelines for 20 distinct population groups. These include 10 groups each from patient-initiated and provider-initiated pathways, capturing variations in pulmonary status, age, HIV/ART status, and drug sensitivity. The model captures the cost of a large-scale vaccine. We demonstrate the models functionality through a case study that informed the Global Funds Investment Case for its 8th replenishment (2027-2029). ResultsIn the case study, the model was first used to estimate the cost of implementing the TB Global Plan 2023 - 2030. This scenario incorporated intervention targets, normative standards of care, and the availability of new TB tools. An optimization routine applied to 29 high-burden countries estimated maximal TB impact under constrained funding scenarios. The results were also used to assess the potential impact and contribution of innovation within the Global Funds 8th replenishment. DiscussionThis new TB costing model offers improved representation of TB care complexity across diverse populations, with enhanced transparency, flexibility, and policy relevance. Its application in global TB strategy analysis highlights its value in informing investment cases and prioritizing interventions for maximal impact under resource constraints.

IntroductionTuberculosis (TB) is the leading cause of death due to infectious disease worldwide. Social protection interventions can benefit TB-affected households. We conducted a systematic review and meta-analysis to quantify the effectiveness of social protection on TB treatment and socioeconomic outcomes. MethodsWe identified articles published from January 2012 to July 2024 by searching PubMed (includes MEDLINE), Embase, and Web of Science. We included studies that described at least one social protection intervention and reported on either TB treatment or socioeconomic outcomes for people with TB or TB-affected households. Random-effects meta-analysis was used for our primary outcome of interest, TB treatment success (treatment completion or cure). We performed a meta-regression to evaluate the association of study characteristics with odds of TB treatment success. Risk of bias was assessed using the Newcastle Ottawa Scale and the Cochrane Risk of Bias tool. This review was registered prospectively in the PROSPERO database (registration number CRD42022382181). FindingsOur search generated 47,245 articles. Of the 50 which were eligible for inclusion, 36 reported TB treatment outcomes, 8 reported on socioeconomic, and two studies reported both TB treatment and socioeconomic outcomes. Random-effects meta-analysis of 24 articles found that people with TB who received social protection interventions during treatment had 2.23 times the odds of TB treatment success (95% CI 1.82, 2.74, I2 93.8%). ConclusionSocial protection interventions significantly improve odds of TB treatment success. Outcomes and definitions used in our study have the potential to guide further research and implementation of social protection for TB-affected populations. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSSeveral studies have found that social and financial interventions designed to mitigate socioeconomic risk and promote resiliency, termed social protection interventions, have the potential to improve treatment outcomes for tuberculosis (TB), including treatment completion and cure. Additionally, several studies have demonstrated that social protection interventions can improve socioeconomic outcomes among TB-affected households such as averting catastrophic costs and negative financial coping strategies. What this study addsThis is the first systematic review and meta-analysis that comprehensively evaluates the impact of TB specific and TB sensitive social protection interventions on both TB treatment and socioeconomic outcomes, thereby generating evidence on the ability of these interventions to curb the well-known cycle of TB disease and poverty. Through the use of an extensive list of search terms, expanded and systematic inclusion of outcomes of interest, and a focused definition of social protection interventions, our systematic review included the adequate number of high-quality studies needed to conduct a meta-analysis. Additionally, our systematic review evaluated implementation outcomes described in eligible studies which provides the basis for feasibility of these strategies in programmatic settings. How this study might affect research, practice or policyOur study provides evidence that social protection interventions, when used in conjunction with standard biomedical treatment, have the potential to significantly improve TB treatment outcomes. This study fills an essential gap in existing synthesized evidence of the impact of social protection interventions on TB, socioeconomic, and implementation outcomes. Our findings also highlight the need for standardized definitions of social protection, as well as uniform reporting procedures, to better help evaluate the impact of social protection interventions for TB-affected individuals and households. Addressing these gaps provides scientific basis for meeting the commitments articulated in the 2023 United Nations General Assembly high level meeting for TB which calls for social protection for all individuals with TB.

There is increasing recognition that without stronger health systems, efforts to improve global health and Universal Health Coverage cannot be achieved. Over the last three decades, initiatives to strengthen health systems in low-income countries have attracted huge investments in the context of achieving the Millennium Development Goals, the Sustainable Development Goals, as well as Universal Health Coverage. Yet, health system inadequacies persist, especially at the subnational level. Our paper presents a political economy analysis featuring a three-district case study in Uganda, where district-based health systems strengthening initiatives were implemented. The study sought to understand why health systems at the subnational level are failing to improve despite marked investments. This problem-based political economy analysis draws from a document review and key informant interviews [N=49] at the central and district levels with government actors, development partners and civil society in three purposively selected districts. Available financial data extraction and analysis were used to complement qualitative data. We found that challenges in strengthening district health systems were numerous. Themes related to financing and planning broadly interacted to curtail progress on strengthening subnational level health systems. Specific challenges included inadequate financing, mismatch of resources and targets, convoluted financial flows, as well as unwieldy bureaucratic processes. Sticky issues related to planning process-included variations in planning cycles, conflicting interests among actors, insufficient community engagement, limited decision space, and distorted accounting mechanisms. In conclusion, the political economy analysis lens was a useful tool that enabled understanding the dynamics of decision-making and resource allocation within district health systems as well as the performance in terms of implementation of the district work plans with existing resources. Whereas it is clear that the District health teams play a big role in service program implementation, the context in which they work needs to be improved in terms of sufficient resources, setting realistic targets, widening the decision space and capacity necessary to engage with other various stakeholders and effectively harmonize the implementation of the programs. Despite playing a crucial role of compensating for local shortfalls in resources, donor resources and engagements should not happen at the cost of the subnational voice in priority setting and decision-making. Key messagesO_LIThe challenges for Health Systems Strengthening at the district level are embedded in the structural reality as well as agency interests, power-relations, and actions. C_LIO_LIInsufficient resources, delayed disbursement, and extreme conditional funding undercut the effectiveness of health system planning, management, performance, and accountability. C_LIO_LIDistorted accountability mechanisms and conflicting incentives among subnational level actors limit district health stakeholders decision space, displace local priorities, and contribute to community engagement strategies are not robust. C_LIO_LISubnational level actors are alienated from the central and donor driven priorities and decision-making and further constrained by bureaucracies. Hence, their decision space needs amplification. C_LIO_LIImplementing partners should harmonize accounting and reporting mechanisms and align them to the government systems. C_LIO_LIBureaucracy related to resource allocation, financial flows, and decision-making between central and district teams hinders timely implementation of services. C_LI

IntroductionImproved housing has been shown to reduce the risk of malaria infections compared to traditional houses; however, it is unclear if the effects differ in different malaria transmission settings. This study evaluated the effects of improved housing on malaria transmission among different endemic areas. Methods and AnalysisElectronic databases, clinical trial registries and grey literature were searched for randomised controlled trials, cohort studies, case-control studies, and cross-sectional surveys on housing done between 1987 and 2022. Forest plots were done, and the quality of evidence was assessed using the Grading of Recommendations, Assessments, Development and Evaluation Framework. FindingsTwenty-two studies were included; twelve were cross-sectional, four were case-control, four were cohort studies and two were RCTs. RCTs indicated that modern houses did not protect against malaria compared to traditional houses. Cohort studies showed an adjusted risk ratio of 0.68 (95% CI 0.48 - 0.96) and Cross-sectional studies indicated an adjusted odds ratio (aOR) of 0.47 (95% CI 0.31 - 0.72). By endemic transmission regions, the adjusted odds ratio in the high endemic was 0.43 (95% CI 0.29 - 0.63); in the moderate transmission regions, aOR = 0.91 (95% CI 0.91 - 1.07) and in the low transmission settings, aOR = 0.42 (95% CI 0.26 - 0.66). ConclusionThe evidence from observational studies suggests that the risk reduction associated with modern housing is comparable or higher in low malaria transmission settings compared to high transmission settings. Evidence from RCTs in high-transmission settings shows that house improvements may induce risky behaviours such as staying outside for longer hours. Key MessagesO_LIIt is known that improved housing reduces the risk of malaria compared to traditional housing; however, the effects of improved housing in different endemic settings are unclear. C_LIO_LITo the best of our knowledge, this is the first time a systematic review and meta-analysis has stratified the effect measures of improved housing on malaria transmission in different transmission settings. C_LIO_LIOur study found no literature from high-quality research designs such as RCTs and Cohort studies on improved housing in low and moderate transmission settings. We call on researchers and funders to conduct and support high-quality research designs in low and moderate-transmission areas, especially in Africa, as more countries are reducing their malaria burdens due to increased interventions. This will help to achieve and sustain malaria elimination. C_LIO_LIPiecemeal improvements, such as closing eaves, screening and iron roofing, are not necessarily associated with a reduced risk of malaria. They may induce risky behaviours due to poor ventilation and higher indoor temperatures resulting in residents staying longer outside thus exposing themselves to infective mosquito bites. C_LI

BackgroundFormerly incarcerated individuals experience high tuberculosis (TB) incidence rates but are generally not considered among risk groups eligible for TB prevention. We investigated the potential health impact and cost-effectiveness of Mycobacterium tuberculosis (Mtb) infection screening and TB preventive treatment (TPT) for formerly incarcerated individuals in Brazil. MethodsUsing published evidence for Brazil, we constructed a Markov state transition model simulating TB-related health outcomes and costs among formerly incarcerated individuals. The analysis compared TB infection screening and TPT to no screening, considering a combination of Mtb infection tests and TPT regimens. We quantified health effects as reductions in TB cases, TB deaths and disability-adjusted life years (DALYs). We assessed costs from a TB programme perspective. We report intervention cost-effectiveness as the incremental costs per DALY averted, and tested how results changed across subgroups of the target population. FindingsAll TPT interventions were cost-effective in comparison to no screening, with a strategy including a tuberculin skin test and a 3-month isoniazid and rifapentine regimen costing $242 per DALY averted. It was estimated to avert 31 (95% uncertainty interval: 14-56) lifetime TB cases and 4.1 (1.4-8.5) lifetime TB deaths per 1,000 individuals receiving the intervention. Younger age, longer incarceration, and more recent prison release were each associated with significantly greater health benefits and more favorable cost-effectiveness ratios; however, the intervention was cost-effective for all subgroups examined. InterpretationMtb infection screening and TPT appear cost-effective for formerly incarcerated individuals. FundingNIH. Evidence in contextO_ST_ABSEvidence before this studyC_ST_ABSIn many settings, incarcerated individuals have been shown to face higher risks of Mycobacterium tuberculosis (Mtb) infection than the general population. Individuals exiting prison have been found to experience elevated tuberculosis incidence rates over several years, and studies have also reported evidence of elevated tuberculosis incidence in surrounding communities. While several studies have investigated the health impact and cost-effectiveness of interventions to detect and prevent TB disease within prisons, few studies have examined the health impact and cost-effectiveness of interventions to treat Mtb infection among formerly incarcerated individuals. Added value of this studyUsing a Markov model, we simulated lifetime results among a cohort of formerly incarcerated individuals in Brazil offered screening and treatment for Mtb infection. To our knowledge, this is the first study to investigate the health impact and cost-effectiveness of screening and treatment among this cohort. The results contribute to the ongoing efforts to effectively reduce the TB burden and reach the WHOs End TB goals in 2030. Implications of all the available evidenceScreening and treatment of Mtb infection among formerly incarcerated individuals would produce substantial health benefits and be highly cost-effective in the setting examined in this study.