BMJ Global Health

Background: Cambodia is a high-TB burden country where over a third of TB cases have gone undetected. The Community Mobilisation Initiatives to End TB (COMMIT) programme, implemented across four provinces and 27 operational districts (ODs) in Cambodia from October 2019 to September 2024, aimed to improve TB case finding, diagnosis, treatment, and prevention through community-driven approaches. This study evaluated the implementation, programme outcomes, and sustainability of COMMIT to inform future TB initiatives. Methods: This mixed-methods explanatory sequential study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Quantitative data were collected from the programme database and the national TB Management Information System (TB-MIS). In-depth interviews, guided by the Theoretical Domains Framework (TDF), explored contextual factors influencing programme implementation and complement quantitative findings. Quantitative data were analysed descriptively to estimate screening coverage, diagnostic yield, and construct care cascades. Qualitative data were transcribed and translated into English, coded, consolidated into a matrix structured using RE-AIM and TDF components, and analysed thematically. Results: COMMIT screened 695,970 people for TB. Key populations were reached, though sex and age disparities in screening participation reflected underlying social and structural barriers. Approximately 98% of those screened underwent diagnostic testing. Treatment initiation (>99%) and completion (>97%) rates were high. COMMIT operationalised contact investigation and evaluation for TB preventive treatment (TPT), screening over 90% of notified contacts. More than 20,000 people were TPT-eligible, of whom 68.7% enrolled in and 86.2% completed TPT. These programme outcomes were supported by strong community engagement, expansion of rapid molecular diagnostics, and programme adaptability during COVID-19. COMMIT was scaled from 10 to 27 ODs, during which it strengthened community capacity by training healthcare workers and expanding peer support groups. Stakeholders emphasised the need to reinforce local ownership and public-private sector collaboration, strengthen integrated services, and de-implement low-value practices such as symptom-based screening. Conclusions: COMMIT improved TB case detection, treatment support, and prevention in Cambodia through community-led strategies and sustained capacity building. Maintaining the programme impact will require continued investment in community systems, de-implementation of low-value practices, and the adoption of efficient, person-centred approaches that address evolving community needs.

Summary- In a cross-sectional study, we calculated direct and indirect costs incurred by people prior to starting tuberculosis (TB) treatment in primary healthcare facilities in KwaZulu-Natal, South Africa. We related the total costs to patient income to explore the economic impact of TB care-seeking and contribute to the literature by exploring differences between those with and without TB symptoms. Background- Patient costs during tuberculosis (TB) treatment in South Africa are high. There are fewer data about the costs incurred prior to starting treatment. We measured pre-TB treatment costs for people in rural KwaZulu-Natal, South Africa. Design/methods- In the context of a TB case-contact study, we interviewed people starting TB treatment at primary healthcare facilities in rural South Africa. We estimated total direct and indirect costs incurred by respondents and their households in the three months prior to starting TB treatment. We estimated other coping costs, such as selling productive assets, as well as the value of any loans taken. Results- Among 98 participants (52 female, median age 36 years), 86/98 (88%) reported one or more symptoms from the WHO 4-symptom TB screening tool prior to starting treatment. The median total pre-treatment cost for TB affected households was USD 10.78 (IQR: [4.13 -- 20.23]). Total, pre-treatment costs for those with TB symptoms were USD 10.78 (IQR: [4.83 -- 20.23]) compared to USD 8.91 (IQR: [1.27 -- 22.19]) for those without TB symptoms. Conclusions- Whilst TB testing and care is free in South African public health facilities, patients still face costs that are burdensome. Our results indicate people affected by TB, including patients and their families, also face an economic burden. Our study highlights the need for further consideration of social protection policies to reduce the economic effects of asymptomatic TB.

Rational use of medicines (RUM) is a global health priority, yet significant challenges persist in low- and middle-income countries (LMICs), particularly around medicine access, affordability, and quality. While RUM studies often focus on prescribing practices, systemic barriers such as supply chain inefficiencies and pricing receive less attention. This study assessed three key health system components of RUM (availability, affordability, and quality of essential medicines) at two public primary health facilities in Ghana and examined patient care practices against WHO RUM standards. A quantitative, cross-sectional study was conducted at Kekele Polyclinic and Rawlings Circle Polyclinic in Accra. Retrospective data were extracted from prescription sheets, medicine tally cards, and ledgers to evaluate WHO Level II core drug use indicators. Fifteen essential medicines were selected based on the Ghana Essential Medicines List, Standard Treatment Guidelines, and municipal disease burden data. Exit interviews with 107 patients assessed dispensing and counselling practices, and structured observation covered storage conditions and pharmaceutical handling. Availability of key medicines fell significantly short of WHO targets, with Rawlings Circle meeting only 40% and Kekele 73.3% of the 100% benchmark. Treatment of malaria and pneumonia cost patients up to three times the national daily minimum wage, indicating poor affordability. The average number of medicines prescribed per encounter (3.2) exceeded the WHO recommended standard ([≤]2). Storage and handling infrastructure was inadequate, with both facilities falling short of recommended conservation standards. Gaps in medicine availability, affordability, and infrastructure undermine rational medicine use in primary healthcare. Strengthening procurement systems, enforcing storage protocols, and implementing financial protection mechanisms are essential for equitable and safe medicine use within Ghanas health system.

Objective: To identify facility-level characteristics - including care level, ownership type, and funding model - associated with poor HIV treatment outcomes, and quantify their independent contributions after adjustment for patient-level clinical factors. Design: Retrospective cross-sectional analysis using multivariable logistic regression with HC3 cluster-robust standard errors to account for facility-level clustering. Setting: HIV care facilities in the Nigerian national HIV programme, spanning primary health centres, secondary health facilities, and tertiary hospitals. Participants: 27,288 HIV-positive patients enrolled on ART, from a publicly available de-identified Quality of Care dataset. Main outcome measures: Composite poor outcome (poor ART adherence, treatment interruption, or mortality); individual outcomes including poor adherence rate, mortality, ART interruption, and diagnosis-to-ART delay exceeding 90 days. Results: Primary health centres had 15.4% composite poor outcome versus 10.2% at tertiary hospitals. After adjustment for patient age, sex, WHO stage, and CD4 count, primary health centre patients had 95% higher odds of poor outcome (OR=1.95; 95%CI 1.45-2.61; p<0.001). NGO-funded facilities had 24% higher odds (OR=1.24; 95%CI 1.10-1.39; p<0.001) and federally funded facilities 25% higher odds (OR=1.25; 95%CI 1.06-1.48; p=0.008). Female sex was independently protective (OR=0.87; 95%CI 0.79-0.96; p=0.003). Diagnosis-to-ART delays exceeded 90 days in 47.3% of patients, with significant variation by facility level (chi-squared=49.4, p<0.001). Conclusions: Facility level and funding model independently predict HIV treatment outcomes after patient-level adjustment. Primary health centres and NGO/federally funded facilities may require targeted quality improvement support. These findings have direct implications for PEPFAR, the Global Fund, and national HIV programme managers.

While significant progress has been made in perinatal outcomes over recent decades in low- and middle-income countries (LMICs), maternal and newborn quality improvement initiatives often fail to account for the spatial conditions in which they are implemented. Health systems are increasingly deploying evidence-based care models into built environments that are not optimally structured to meet the needs of its patient population. As the principal users, patients and health care workers can offer pragmatic insights about improving these structural designs. Our objective was to gather insights from patients, providers, and companions about how the physical design of their health facilities influenced their experience receiving or delivering perinatal care. We conducted a prospective observational study using a human-centred design (HCD) approach to analyse perceptions of the quality of perinatal care across two low resource settings: Ethiopia and Bangladesh. Using engagement and assessment tools, we conducted interviews, focus groups, facility walk-throughs, co-design workshops, and infrastructural assessments with patients, companions, providers, and Ministry of Health representatives. Descriptive statistics and thematic analysis were used to identify key learnings and develop recommendations. Across both countries, participants identified the need for facility layouts that better support privacy, mobility during labour, alternative birth positions, companion involvement, cultural and religious practices, sanitation, and provider visibility. Based on these insights, we developed six recommendations to better align health facility infrastructure with maternal and newborn care delivery needs. Our findings suggest that investments in health facility infrastructure may improve care experiences and help enable respectful, safe, and evidence-based maternal and newborn care. Alongside targeted spatial improvements, government authorities responsible for health facility planning should incorporate participatory design processes to ensure infrastructure reflects the needs of patients, companions, and providers and supports high-quality care delivery.

Background Tanzanias Direct Health Facility Financing (DHFF) reform was introduced to strengthen primary health care through decentralized financing, autonomy, and accountability, but persistent weaknesses in monitoring and evaluation (M&E) data management and use continue to constrain implementation effectiveness, particularly in rural settings. Methods A convergent mixed-methods design was used to examine how M&E data management and use influence DHFF implementation effectiveness in an urban council (Kinondoni Municipal Council, KMC) and a rural council (Morogoro District Council, MDC), while also assessing the role of stakeholder perceptions of the DHFF M&E framework and contextual variation. Quantitative data were analyzed using descriptive statistics, relative importance indices, regression and ANOVA, while qualitative data from key informant interviews and focus group discussions were thematically analyzed and triangulated with quantitative results. Results Of 233 respondents analysed, 51.1% were from Morogoro District Council, 48.9% from Kinondoni Municipal Council, 51.2% worked in rural settings, 42.9% were from health centres, and 38.2% from dispensaries, providing an analytically useful spread across managerial and frontline contexts relevant to DHFF implementation. Descriptive statistics showed generally favourable perceptions across the five major constructs, with mean scores ranging from 3.09 for M&E capacity to 3.73 for urban-rural M&E practice context, while DHFF implementation effectiveness scored 3.71 overall. Data quality checks showed acceptable factor loadings above 0.4, reliability coefficients above 0.7, bivariate correlations of 0.34-0.76, and VIF values of 1.31-2.95, indicating that the dataset was screened, cleaned and analytically fit for regression and ANOVA modelling. In the aggregated model, the explanatory variables jointly accounted for about 52% of the variation in DHFF implementation effectiveness, with M&E data management and use, stakeholder perceptions of the DHFF M&E framework, and urban-rural context emerging as the most influential predictors. Qualitative testimonies clarified these patterns: one council respondent explained, "We have DHIS2... GoTHOMIS... FFARS... also PlanRep," while another facility respondent observed, "We only add up numbers for the monthly report--we dont really analyze what they mean," illustrating the contrast between data availability and meaningful local use. Conclusions DHFF implementation effectiveness in Tanzania depends substantially on robust M&E data management and use, supportive stakeholder perceptions of the M&E framework, and context-sensitive strategies that address persistent urban-rural inequities. Strengthening technical capacity, digital infrastructure, participatory governance and feedback systems is essential for sustaining DHFF gains and improving equitable service delivery.

Background India accounts for nearly one-fourth of the global tuberculosis (TB) burden. The country's progress towards elimination of TB is hindered by considerable heterogeneity in behavioural, social, and health system determinants, which influence transmission dynamics and care access. Evidence from the recent national TB prevalence survey showed that almost half of individuals with active disease were asymptomatic, underscoring the limitations of symptom -based case finding. Achieving the End TB targets will therefore require strategies that simultaneously address the substantial pool of individuals with undiagnosed, asymptomatic disease and those symptomatic individuals who do not seek care. Methods We developed a transmission model of TB that explicitly incorporates individuals with asymptomatic disease, and those who do not seek care. Model calibration was performed within a Bayesian framework using epidemiological and programmatic data for India. The calibrated model was then used to project the potential impact of intervention on TB incidence and mortality. Results Under the baseline scenario, the estimated TB incidence and mortality rates for 2024 were 180 (163-203) and 24 (18-31) per 100,000 population, respectively. Across all intervention scenarios targeting improved diagnosis, active case finding, nutrition support and their combination the reduction in incidence rate by 2030 ranged from 13% to 60% compared with 2025, while the corresponding decline in mortality rate ranged from 16% to 66%. Conclusion While individual interventions yield measurable reductions in TB incidence and mortality, but greater impact is achieved when implemented in combination reflecting the need for a comprehensive, multi-component response towards TB elimination.

Background Antimicrobial stewardship (AMS) and infection prevention and control (IPC) are complementary strategies to improve patient safety and address antimicrobial resistance (AMR). In low- and middle-income countries (LMICs), they are often implemented separately, reducing effectiveness. Evidence on integrating AMS and IPC in routine hospital practice remains limited. Objective To evaluate the feasibility of an integrated AMS-IPC improvement approach and describe changes in implementation in Vietnamese hospitals. Methods We conducted a multisite quality improvement initiative in four hospitals within the national AMR surveillance network in Viet Nam (March-September 2025). We used US-CDC tools to guide the implementation, including the Global Antibiotic Stewardship Evaluation Tool (G-ASET) and the Infection Control Assessment and Response (ICAR) tool. Baseline assessments were followed by feedback, multidisciplinary action planning, and targeted capacity building. Follow-up occurred 2-5 months later. Changes were analysed descriptively using quantitative scores and qualitative synthesis, and reported following the SQUIRE 2.0 guidelines. Results All hospitals had established IPC programmes at baseline, while AMS maturity varied. G-ASET scores improved across all sites, with greater gains in hospitals starting from lower baselines. Key improvements included leadership and governance, education and training, stewardship actions, and monitoring and reporting. IPC practices aligned with AMS priorities also improved, particularly transmission-based precautions, environmental cleaning, and cross-team coordination. Infrastructure-dependent areas, such as water safety, showed limited short-term progress. Conclusions An integrated AMS-IPC approach using repeated assessment and feedback is feasible and associated with meaningful improvements. This model offers a scalable strategy for strengthening hospital responses to AMR in LMICs and informs national programmes.

Background: Despite rising enthusiasm for active case-finding for TB, there have been concerns about conducting simultaneous HIV screenings due to perceived stigma, although the evidence to support this concern is scarce. We assessed the acceptability of integrated HIV-TB community screening and characterised participants' motivations and prior testing history. Methods: The SLIM study was a non-interventional cross-sectional study conducted in Puducherry (February 2023 to January 2024). In two community health camp-style screening events (one urban and one peri-urban), adults 18 years and older were offered TB screening via portable chest X-ray with AI-assisted interpretation (qXR, Qure.ai), plus sputum testing (Truenat), alongside point-of-care HIV testing. Structured questionnaires captured sociodemographics, prior testing history, and motivations for participation. Acceptability was pre-specified as >50% uptake. Results: Of 273 eligible adults approached, 264 (96.7%) accepted integrated screening, nearly double our pre-specified threshold. Participants were predominantly low-income with limited formal employment. The dominant motivation was a desire to know one's health status (HIV: 74.8%; TB: 73.7%), followed by convenience (16 to 17%). Prior HIV and TB testing was rare (7 to 13% and 15 to 18%, respectively). Participation was uniformly high across demographic groups; however, the screened population skewed older and female (mean age 58 (standard deviation: 12.6) years; 67% female). Men under 45 comprised only 3.7% of participants, substantially below their 24.7% share in the Puducherry population per the most recent census. Conclusions: Integrated HIV-TB screening achieved near-universal uptake in a socioeconomically vulnerable population with little prior testing exposure, contradicting concerns that community HIV screening would be poorly accepted in India. Integrated community-based screening should be scaled up as a cornerstone of TB elimination in high-burden settings. Crucially, because TB incidence in India peaks in the 15 to 45 age group and disproportionately affects men, targeted strategies to bring younger men and women into community screenings are essential.

Background In the Democratic Republic of the Congo (DRC), health care financing relies heavily on out-of-pocket payments, limiting access to essential services. In a context of declining external funding and ongoing efforts toward Universal Health Coverage (UHC), understanding households willingness to pay (WTP) for health care is critical for designing sustainable financing strategies. This study aimed to assess WTP for primary health care services and identify its associated factors in Eastern Kasai Province. Methods A cross-sectional study based on the contingent valuation method was conducted from 10 to 30 July 2025 among 633 randomly selected households using a multistage probabilistic sampling approach. Data were collected through semi-structured interviews using KoboToolBox. WTP was assessed using a stated preference approach. Logistic regression analyses using R 4.5.0 were performed to identify factors associated with WTP at a significance level of p < 0.05. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were reported. Results Overall, 70% of household heads reported willingness to pay for their own health care, and 73% for other household members. WTP decreased significantly as the cost of services increased, dropping from 95.5% for free care to 6.3% at the highest cost levels (above CDF 230,000). Poor perceived quality of care was a consistent reason for refusal, alongside financial constraints such as low income and indebtedness. Multivariable analysis showed that having a professional activity (OR = 1.9; 95% CI: 1.2-3.0; p = 0.006), residence in rural areas (OR = 2.1; 95% CI: 1.3-3.7; p = 0.008), and higher household income (OR = 2.2; 95% CI: 1.2-4.0; p = 0.011) were significantly associated with WTP. Despite relatively low absolute health care costs, the majority of households perceived them as high. Conclusion Willingness to pay for health care services in Eastern Kasai is moderate but highly sensitive to cost and strongly influenced by socioeconomic conditions and perceived quality of care. These findings underscore the need to strengthen financial protection mechanisms, particularly prepayment and risk-pooling systems, while improving service quality to enhance health care utilization and progress toward UHC in the DRC.

Background Vector control is essential to malaria control and elimination. National Malaria Programmes (NMPs) must make complicated decisions about vector control in the face of evolving epidemiology, biological threats like insecticide resistance, a growing vector control toolbox, and an increasingly constrained funding landscape. The WHO recently published a manual on subnational tailoring of malaria strategies, but limited efforts have been made to understand how NMPs prioritize data and factors that impact decision-making in practice. This study explores vector control decision-making processes, enablers, and barriers across 12 African malaria programmes. Methods We conducted semi-structured interviews with 13 NMP managers or designated representatives from 12 African countries. Interviews were conducted virtually via Zoom or in-person, audio-recorded, transcribed, and thematically analyzed using content analysis. Participants described the interventions in use, decision-making factors, stratification approaches, perspectives on new tools, and operational challenges. Results Insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS) are the core interventions in all countries, with limited but growing use of larval source management, mainly larviciding. Vector control tool selection is driven by WHO guidance, resistance profiles and patterns, epidemiological trends, operational feasibility, and donor funding priorities. Sub-national stratification is widely applied; however, limited analytic and modeling capacity hinder consistent application. Gaps in entomological data result in incomplete data availability to guide stratification. New vector control tools were perceived as promising options, albeit constrained by cost, limited evidence, regulatory delays, and community acceptability. Funding emerged as the dominant driver of decisions, shaping intervention choices regardless of country preference. Participants emphasized substantial gaps in vector control protection related to residual transmission, outdoor biting, insecticide resistance, and unprotected populations living in temporary structures or associated with high-risk occupations. Conclusions Vector control decision-making among NMPs is shaped by an interplay of scientific evidence, operational realities, and external funding dynamics. Strengthening entomological surveillance, enhancing SNT analytic and model output interpretation capacity, securing sustainable financing, and improving community engagement are critical to advancing tailored deployment of tools. Decision-support frameworks that reflect the complexities facing NMPs may further enhance evidence-based, context-specific vector control planning.

Background: The traditional wealth index, based on principal component analysis (PCA), used in the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), suffers from urban bias, distorting estimates of health inequality. We compared the traditional index (PEAR1) with an alternative two-component polychoric PCA index (POLY2) using annual expenditure from 12 LSMS surveys as the gold standard to determine which provides more accurate SEP measures for equitable policy targeting. Methods: We compared the traditional wealth index (PEAR1) with a two-component polychoric PCA approach (POLY2) using 12 LSMS (Living Standards Measurement Study) surveys (2015-2022) from 12 African countries. Annual household consumption expenditure was the gold standard. We assessed agreement using weighted Cohen's kappa and validated against education (proportion of households with secondary or higher education) using the concentration index (CIX) and slope index of inequality (SII). Results: The POLY2 index showed higher agreement with expenditure quintiles (average national weighted kappa = 43.3%) than the PEAR1 index (35.1%), with notable improvements in urban (43.5% vs. 27.5%) and rural (35.3% vs. 22.4%) areas. POLY2 also attenuated extreme household distributions observed in PEAR1. Education validation showed that POLY2 produced intermediate inequality gradients between the flatter expenditure-based gradient and the steeper PEAR1-based gradient. Conclusion: The POLY2 wealth index is superior to the traditional index, reducing urban-rural bias and providing more accurate socioeconomic classifications. Its adoption in large-scale surveys such as DHS and MICS is recommended to improve equitable monitoring of health inequalities in low- and middle-income countries.

Background Malawis healthcare system faces strain due to an insufficient number of healthcare workers (HCWs). The number of HCWs currently employed falls below the Malawian governments 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.

Strengthening the resilience and inclusivity of primary health care (PHC) systems during crises is critical to achieving equitable access to health care in low-income countries. The COVID-19 pandemic exposed significant weaknesses in PHC systems, highlighting gaps in inclusivity and resilience, particularly for persons with disabilities (PWDs). Although studies have examined PWDs, few have applied systems thinking approaches such as Group Model Building (GMB). This study aimed to develop a resilient and inclusive PHC system to improve access to services and vaccine uptake among PWDs during pandemics. A mixed-methods design incorporating GMB was employed in three phases. First, quantitative and qualitative data were collected to identify barriers and facilitators to PHC access and vaccine uptake. Second, a stakeholder GMB workshop was conducted in Monze to map system dynamics and develop causal loop diagrams. Third, validation and refinement meetings were held, including a final workshop in Lusaka. Findings identified key endogenous system drivers influencing vaccine uptake and access to PHC services and consumables, including financing mechanisms, human resources, outreach services, transport, staff commitment, and availability of accessible information such as Braille materials. These interact through reinforcing and balancing feedback mechanisms. In addition, critical contextual (exogenous) drivers such as political will, health insurance, community gatekeepers, and road networks shape system performance and influence access and service delivery. Strengthening both endogenous system drivers and contextual factors through inclusive strategies, coordinated financing, and supportive governance is essential for building resilient PHC systems that improve equitable access and vaccine uptake among PWDs during health crises. These findings contribute to Universal Health Coverage and equity by showing that strengthening both health systems drivers and contextual drivers is essential to ensure inclusive, accessible, and fair delivery of PHC services for all populations, including persons with disabilities.

Essential medicines are one of the cornerstones of financial protection and health equity. The REMEDIAR Program is an initiative of the Argentine Ministry of Health aimed at ensuring free access to essential medicines for the uninsured at the point of care in primary healthcare centers (PHC). This study analyzes the financing, procurement, and distribution of this program over two decades (2002 to 2024). It evaluates how the program's capacity to navigate economic and political challenges ensured an uninterrupted supply of essential drugs at the primary healthcare level in a federal country where health services are devolved to provinces. We adopted a mixed-methods approach to examine the duality between international concessional loans and domestic treasury funding. Findings reveal that while international financing enhanced predictability and efficiency, reducing procurement timelines from 458 to 235 days, it also constrained domestic planning through external conditionalities. Conversely, while national centralized procurement achieved superior price efficiency and lower dispersion, it faced rigidities in adapting to local needs. Territorial distribution analysis confirms that REMEDIAR reduced access barriers for vulnerable households without formal insurance. However, the program entered a stabilization phase, failing to consolidate robust coordination with subnational policies, becoming entrenched in its own operational logic. The study concludes that program effectiveness depends not only on resource volume but on management quality. To guarantee long-term sustainability, transition to national financing requires profound institutional redesign. This must integrate operational capacities with federal coordination and domestic regulations, ensuring that the primary healthcare supply chain remains resilient to macroeconomic volatility and political shifts, aligned with sub-national strategies.

South Sudan faces among the highest maternal and newborn mortality rates globally, with approximately 87% of deliveries occurring at home without skilled birth attendance. In 2024, the International Rescue Committee launched a Community-Based Maternal and Newborn Care (CBMNC) program in Aweil East County, Northern Bahr El Ghazal, deploying trained Boma Health Workers (BHWs) to deliver essential maternal and newborn health services at the household level. This study explored the acceptability of the CBMNC model among diverse stakeholders. This qualitative descriptive study was grounded in the Theoretical Framework of Acceptability (TFA). Data were collected between May and July 2025 through 17 focus group discussions (FGDs), 14 in-depth interviews (IDIs), and 10 key informant interviews (KIIs) with 185 participants, including program recipients, male partners, mothers and mothers-in-law, Boma and Hospital Health Committee (BHC/HHC) members, BHWs, supervisors, and health system stakeholders at state and national levels. Framework analysis, combining deductive coding based on the seven TFA constructs with inductive thematic analysis, was used. CBMNC was well accepted by recipients and their families, despite provider and health system concerns about sustainability. Trust in community-selected BHWs made home-based care valuable, especially given limited facility access. Intervention coherence relied on pictorial aids, repeated visits, and peer learning to address low literacy. Participants perceived commodity interventions like misoprostol and chlorhexidine as impactful, while behavioral counseling was less recognized. Clients faced minimal burden, but providers experienced significant challenges and inadequate compensation. Health stakeholders were cautiously optimistic but questioned lay provider capacity and long-term viability in a fragile environment. CBMNC can achieve high community acceptability when delivered through trusted, community-selected health workers using contextually appropriate strategies. However, community acceptability alone is insufficient for sustainable scale-up. Addressing provider compensation, workload, and structural integration into national health systems is essential to ensure that gains in acceptability translate into sustained service delivery.

Tuberculosis (TB) remains a major global health challenge, particularly in low- and middle-income countries such as Mozambique. To address this burden, promising new preventive TB vaccines targeting adolescents and adults are currently in phase III efficacy trials. This study aimed to assess stakeholders perspectives on priority high-risk groups, the challenges in reaching them, and potential strategies for delivering a TB vaccine. We conducted a qualitative study using semi-structured interviews with members of the National TB Program, the National Immunization Program, and the National Immunization Technical Advisory Group. Data were collected between March and July 2024. Our findings suggest that a TB vaccine program in Mozambique should prioritize individuals with comorbidities, especially those living with HIV or diabetes, and close contacts of TB patients, followed by healthcare workers, miners, and incarcerated populations. Although uptake is expected to vary across groups, relatively high coverage was anticipated among people living with HIV, TB contacts, and older adults, as well as healthcare workers, incarcerated individuals, formal miners, and in-school adolescents. To improve uptake, campaign-based strategies using mobile brigades were considered promising approaches to expand coverage. Stakeholder perspectives highlight the importance of prioritizing high-risk groups and adopting context-specific delivery strategies to support the effective introduction of a TB vaccine in Mozambique. Clinical trial numbernot applicable.

Tobacco control treaties were written for billboards and television, not for the people now selling lifestyles to young Africans. As mobile internet saturates East African cities, social media influencers have become an unmeasured channel, especially when it comes to tobacco promotion. We assessed the prevalence of tobacco use, its association with influencer exposure, and how urban youth interpret that exposure in two capitals with different tobacco laws. We conducted a comparative mixed-methods study among youth aged 18-29 years in Kampala, Uganda, and Nairobi, Kenya (January-August 2025), combining (i) a cross-sectional survey using systematic sampling at youth-dense venues (n=772), (ii) four online focus group discussions (FGDs; n=40), and (iii) content analysis of 30 tobacco-related posts from high-reach influencers (greater than 50,000 followers). We used chi-square tests and multivariable logistic regression, thematic analysis (Braun and Clarke), and descriptive engagement metrics. Ever tobacco use among urban youth in East Africa was 29.3% (226/772), similar in Kampala (30.7%) and Nairobi (28.0%; p=0.409). After adjustment, exposure to influencers promoting tobacco independently predicted ever use (adjusted odds ratio [aOR] 1.90, 95% confidence interval [CI] 1.29-2.82; p=0.001), alongside male sex (aOR 2.35) and age 26-29 years (aOR 1.99). Tertiary education (aOR 0.45) and never seeing tobacco content (aOR 0.26) were protective. Posts framed tobacco as aspirational lifestyle; 77% of sampled comments were positive and 47.5% expressed interest in trying the product. Influencer exposure behaved as a modifiable risk factor of a magnitude comparable to established demographic drivers. Tobacco control in the region must move from print-era advertising bans to platform governance, mandatory disclosure of paid promotion, and youth-led counter-marketing.

Background: Strong management capacity is essential for effective primary healthcare (PHC) service delivery and health system strengthening [1]. The AURUM Management Development Programme (MDP) was implemented to strengthen district and PHC leadership in the Western Cape province of South Africa. This study explored the contextual barriers and enabling conditions influencing the scalability of the programme within district health systems. Methods: This study employed a qualitative exploratory design to investigate barriers and enablers associated with scaling the MDP. In-depth interviews were conducted with purposively selected district health managers from three Western Cape districts. Interviews were audio-recorded, transcribed verbatim, and analysed thematically using NVivo 14. The study explored perceptions regarding programme adaptability, district readiness, implementation challenges, and enabling conditions for sustainability and scale-up. Results: Twenty participants (7 males and 13 females) from the Cape Winelands, Garden Route, and Cape Town Metro district health offices were interviewed. The MDP was viewed as relevant, practical, and adaptable to district health system contexts. District readiness for implementation emerged as an important determinant of perceived programme success. High readiness was characterised by clear team roles, strong management structures, decentralised decision-making, digital tool utilisation, ongoing mentorship systems, and prior exposure to PHC reforms such as the Ideal Clinic Realisation and Maintenance (ICRM) programme. Lower readiness was associated with staff shortages, operational pressures, limited leadership support, and partially functional health systems. Key enabling factors included integration with existing training structures, visible improvements in service delivery, mentorship support, and active engagement from district leadership. Conclusion: The MDP demonstrates potential for scalability within South Africas public health system. However, successful scale-up depends on district-level readiness, supportive leadership structures, integration into existing training and management systems, and sustained mentorship and implementation support.

Introduction: Adolescent girls and young women (AGYW) in southern Africa are disproportionately affected by HIV. Despite increasing availability of HIV pre-exposure prophylaxis (PrEP), uptake and sustained use remain low. Existing service delivery models may not adequately meet the needs of AGYW, particularly in remote settings. We conducted a discrete choice experiment (DCE) to assess preferences for PrEP service delivery among AGYW living in Lesotho, a country with one of the highest HIV incidence rates globally. Methods: The DCE was conducted among AGYW (16-24 years) in two districts in Lesotho. Participants completed a series of binary choice tasks comparing hypothetical PrEP service delivery scenarios defined by six attributes: service location, provider type, provider characteristics, provider confidentiality, PrEP product type, and the combination of additional prevention services offered. Preferences were analysed using mixed logit and latent class models. Results: A total of 537 AGYW (median age 19 years, IQR 17-22) were included. Provider confidentiality was the strongest driver of choice, with non-confidential providers significantly less preferred ({beta} = -0.58; 95% CI -0.69 to -0.46). Compared with nurses, services delivered by ComBaCaL CHWs were preferred (0.17; 0.01 to 0.33), while those provided by doctors were less preferred (-0.15; -0.30 to 0.00). Younger female providers were preferred over older female providers (0.20; 0.04 to 0.36). Compared with the daily oral pill, both the 2-monthly injectable (-0.24; -0.39 to -0.08) and the vaginal ring (-1.02; -1.20 to -0.82) were less preferred. Differences in preferences were observed across age groups and districts. Latent class analysis identified two preference profiles, indicating variation in preferences for delivery and product characteristics. Conclusions: Preferences for PrEP delivery among AGYW in Lesotho were strongly influenced by provider confidentiality. Among some AGYW, there was openness to decentralised delivery, particularly through CHWs and community-based models, which may reduce access barriers in remote settings. Product preferences were varied, and not all options were acceptable. Differences by age group and district indicate that no single delivery model will meet all needs. Building on the current standard of care, offering acceptable options in accessible and confidential ways may support PrEP uptake.