BMJ Global Health

BACKGROUND: Undernutrition is the leading risk factor for tuberculosis (TB), yet evidence on programmatic nutritional support during treatment is limited. Benin and Togo are neighboring West African counties. Benin provides in-kind food support to all people with drug-susceptible TB; neighbouring Togo does not. This created the opportunity for a natural experiment. METHODS: We conducted a prospective cohort study at 13 sites in Benin and Togo (September 2023-June 2024). We compared recipients of nutritional support with non-recipients, using Beninese non-recipients as an internal comparison. Primary outcomes were [≥]5% weight gain at month 2, change in 6-minute walk test (6MWT) distance, and pill-count adherence. We used multivariable regression adjusted for pre-specified covariates. RESULTS: Of 769 participants, 450 received nutritional support and 319 did not. Recipients had higher odds of [≥]5% weight gain at month 2 (adjusted odds ratio [aOR] 1.57, 95% CI 1.13-2.19) and [≥]10% at month 6 (aOR 1.92, 1.35-2.74), greater 6MWT improvement (adjusted {beta} 40.6 m, 26.5-54.6), and higher adherence (aOR 3.43, 1.81-6.51). Mortality was lower among recipients (aOR 0.32, 0.11-0.93). Sputum conversion and treatment success did not differ. Beninese non-recipients resembled Togolese participants across outcomes. CONCLUSION: Programmatic nutritional support was associated with improved weight gain, functional recovery, adherence, and lower mortality during TB treatment, supporting its integration into national TB programmes.

Background Respiratory infections remain the leading infectious cause of death among children and adolescents, yet the share of these deaths that could be averted with currently feasible care is not routinely quantified. Existing amenable-mortality frameworks rely on cause lists and population-level mortality benchmarks and do not exploit information on how many episodes occur. We propose an episode-fatality-ratio (EFR) frontier approach and apply it to lower respiratory infections (LRI), whooping cough (pertussis) and upper respiratory infections (URI) in 204 countries, 1990-2023. Methods For each cause, country and year we computed EFR = deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. The frontier was defined as the 10th-percentile country EFR within each GBD super-region, cause and year; avoidable deaths = max(0, deaths - episodes x frontier EFR). Primary estimates are deterministic; 95% uncertainty intervals (UIs) come from 2,000 Monte Carlo draws. Sensitivity analyses varied the frontier percentile, applied an aspirational global frontier, constructed pertussis counterfactuals, and recomputed all estimates within the single under-5 age band. Results In 2023, 333,803 childhood deaths from lower respiratory infections (95% UI 289,123-417,460; 46.9% of LRI deaths) were avoidable. Summing the three causes deterministically gives 391,034 avoidable deaths (46.5% of 840,444); the combined figure is a deterministic sum, and a UI is available for the LRI component only. The pertussis (43,958; 39.0%) and URI (13,273; 81.0%) estimates are secondary: their deterministic point values fall below their own Monte Carlo intervals and the underlying death estimates carry very wide uncertainty (global pertussis UI 12,545-321,874). Avoidable deaths fell from 1,050,468 (44.9%) in 1990, but between 2019 and 2023 the avoidable share for LRI+URI barely moved (48.7% to 47.7%) while absolute avoidable deaths fell 14.5%, a pattern consistent with stalled convergence to the frontier. Sub-Saharan Africa plus South Asia held 73.1% of avoidable deaths in 2023 versus 41.8% in 1990; ten countries accounted for 59.1%. Conclusion Nearly half of childhood respiratory-infection deaths remain avoidable relative to within-region best practice, and the residual burden is increasingly concentrated in low-income settings. In the pertussis counterfactual, most countries kept pace with their regional frontier, so further gains require advancing the frontier itself through quality-of-care improvements.

Despite significant progress in reducing vaccine-preventable diseases, Cameroons Expanded Programme on Immunisation operates within structures shaped by colonial history. Overreliance on external donor funding, centralised governance, and limited recognition of local knowledge raise concerns about equity, local ownership, and programme sustainability, particularly as the country plans for donor transition and self-financing. This study, aligned with the decolonising global health movement, examines how colonial legacies shape stakeholders experiences within the EPI and proposes practical steps towards a more locally owned immunisation programme. A qualitative case study was conducted in the Southwest Region of Cameroon from June to July 2025, comprising fifteen online semi-structured interviews in English with selected stakeholders (regional and district EPI managers, civil society members, and community leaders). Interviews were audio-recorded, transcribed verbatim, and analysed thematically using Clarke and Brauns six-step framework in NVivo version 11. Participants identified subtle colonial influences, including centralised decision-making, donor-driven priorities, pay disparities favouring international actors over local staff, and the marginalisation of local and traditional knowledge. The COVID-19 response was frequently cited as an example of inequity, with Western biomedical approaches prioritised over locally led solutions. Major structural issues included heavy reliance on external funding, outdated colonial-era training curricula, centralised governance, and a lack of local vaccine manufacturing capacity. Despite these issues, participants recognised the significant technical and financial support from international organisations. They proposed concrete pathways for decolonisation, including decentralised governance, participatory programme design, regulation and integration of traditional medicine, community engagement, domestic resource mobilisation, leveraging Cameroons emerging universal health coverage to reduce donor dependence, and investing in local vaccine production. Conclusion: Colonial legacies continue to influence Cameroons EPI, undermining local ownership and self-determination, even when external support is effective. Achieving decolonisation requires multifaceted efforts to strengthen domestic financing and governance, empower local stakeholders, and legitimise local knowledge alongside biomedical approaches. Policymakers should embed local ownership, governance reforms, and local capacity building in transition strategies while donor funding persists, ensuring immunisation gains are sustained beyond external support. These insights provide a context-specific roadmap for developing a sustainable, equitable, and locally driven immunisation programme in Cameroon and other countries facing similar donor transitions.

Introduction: In early 2025, North and South Kivu Provinces in the Democratic Republic of the Congo (DRC) underwent a major geopolitical shift marked by the concurrent abrupt withdrawal of humanitarian support and large-scale military takeover by the M23 armed group. This study sought to quantify mortality before and after the humanitarian and security collapse. Methods: We conducted a retrospective, two-stage cluster household survey comparing mortality in the pre- and post-crisis periods. Difference-in-differences were analyzed using survey-weighted Poisson regression with a log-link and person-time offset to estimate adjusted incident rate ratios for crude, under-five, and sex-specific mortality. We interviewed community leaders and health facility staff as key informants to provide qualitative data. Results: The adjusted risk of death was 2.02 times higher in the post-crisis than the pre-crisis period (95% CI 1.07, 3.80; p=0.03). Crude mortality rose from a pre-crisis adjusted marginal mean of 0.38 (95% CI 0.22, 0.53) to 0.74 (95% CI 0.56, 0.92) deaths/10,000/day. The increase in mortality was consistent across DRC-Government and M23 controlled areas. Results indicate that 165,391 (95%CI: 63,557, 267,225) excess deaths occurred in the post-crisis period, equating to 245,397 annual excess deaths. Conclusion: The crisis in DRC is driven by the convergence of humanitarian funding withdrawals and escalating conflict. Averting further preventable deaths requires large-scale restoration of humanitarian assistance. The resources needed to do so represent a small fraction of global economic capacity.

Reducing inequality in health-service coverage is central to universal health coverage, but the evidence base on how to design successful equity-oriented policies is inadequate to inform decision makers and tends to rely on case studies. Further, conventional measures of inequality capture a single timepoint, one service at a time; this obscures how inequity evolves as coverage increases. We reframe equity as a trajectory and ask how it evolves as total coverage rises, comparing systematically across countries and health areas. Using 132 Demographic and Health Surveys from 22 low- and middle-income countries (1990-2023), we estimated coverage at the subnational (admin1) level by wealth quintile for six representative maternal and child health indicators. For each country-indicator pair, we fit a natural cubic spline of the wealthiest-poorest gap against total regional coverage, extracted features describing each curve, and grouped them using hierarchical clustering. This yielded three archetypes: large rollout gaps (mean peak ~58%), modest but persistent inequality (~30%), and minimal inequality that sometimes reversed to favor the poor (~17%). Most trajectories traced an inverted U pattern, widening early, then closing only near 100% regional coverage. How a service is delivered, more than where, drove its path: institutional delivery was the most inequitable (15 of 20 countries with large gaps), whereas one-touch and campaign-delivered services such as bed nets and vaccines rarely produced large gaps and were sometimes pro-poor. Despite this, some countries achieved equity across nearly all services, indicating that proactive governance may be able to overcome structural challenges to achieve equitable outcomes. For policy, these archetypes let programs anticipate which groups will be left behind and when, replace assumed scenarios with empirical ones in impact models, and target investment early to ensure that new services achieve more equitable coverage.

The World Health Organization declared the 2026 outbreak of Ebola disease caused by Bundibugyo virus in the Democratic Republic of the Congo and Uganda a Public Health Emergency of International Concern. Public engagement on video-sharing platforms such as YouTube offers insight into public perceptions during such crises, particularly in the affected region, yet these reactions remain largely uncharacterised. We analysed public discourse and sentiment surrounding the outbreak, focusing on thematic trends in YouTube comments, using a qualitative synthesis that combined thematic content analysis with topic modelling. Videos were identified through the YouTube Data application programming interface, which returned 50 videos each for the search terms "Ebola" and "Ebola virus disease." After removing duplicates and excluding videos published before the 17 May 2026 emergency declaration, the 10 most-viewed videos were retained. From 4,457 extracted comments, 4,087 were analysed using Latent Dirichlet Allocation topic modelling, complemented by a lexicon-based sentiment analysis. Five themes emerged: geopolitical and cultural context; public figures, conspiracy theories, and misinformation; disease spread and transmission; public health measures and preparedness; and religious and spiritual interpretation. Discourse was strongly shaped by border concerns, mistrust of institutions, global aid politics, and comparisons with COVID-19, and sentiment was split near-evenly between fear and trust. Effective health communication during this outbreak must therefore address not only the scientific and medical dimensions of the emergency but also its geopolitical, cultural, and religious dimensions, while countering misinformation and building public trust.

Background: Neonatal mortality remains disproportionately high in sub-Saharan Africa (SSA), accounting for nearly half of all deaths in children under five. Although antenatal care, skilled birth attendance, and postnatal care are individually associated with improved newborn survival, few studies have examined whether their integrated receipt as a continuum of care (CoC) confers additional protection against neonatal death, particularly after accounting for sociodemographic confounding and heterogeneity across country contexts. Methods: A pooled cross-sectional analysis was conducted using DHS-8 Births Recode files from five countries: Nigeria (2024), Mali (2023-2024), Congo DRC (2023-2024), Kenya (2022), and Lesotho (2023-2024). The analytical sample comprised 37,351 births within the 36-month postnatal care reference window. Complete CoC was defined as receipt of adequate antenatal care ([≥]4 visits with first-trimester initiation), skilled birth attendance, and postnatal care within 48 hours for the mother or newborn. Neonatal mortality was defined as death within 27 days of birth. Survey-weighted logistic and log-Poisson regression models estimated adjusted odds ratios (aOR) and adjusted prevalence ratios (aPR). G-computation quantified the population attributable fraction (PAF). Country-specific heterogeneity was examined through random-effects meta-analysis (DerSimonian-Laird method) and a two-level multilevel logistic regression model. Results: The overall neonatal mortality rate was 29.3 per 1,000 live births (95% CI: 27.6-31.0). Complete CoC prevalence was 19.2% (95% CI: 18.5-19.9%), ranging from 7.8% in Congo DRC to 47.8% in Lesotho. In unadjusted analysis, complete CoC was associated with a 24% reduction in neonatal death odds (cOR: 0.764, 95% CI: 0.583-1.000, p = 0.050). After adjustment for wealth, education, residence, parity, maternal age, child sex, and country, the association was substantially attenuated and non-significant (aOR: 0.961, 95% CI: 0.717-1.289; aPR: 0.962, 95% CI: 0.722-1.282). The PAF under universal complete CoC was 3.2%. The pooled meta-analytic estimate was aOR 0.718 (95% CI: 0.447-1.152), with moderate heterogeneity (I{superscript 2} = 38.9%; {tau}{superscript 2} = 0.089). Country-specific estimates ranged from aOR 0.455 (95% CI: 0.256-0.810) in Kenya to 1.447 (95% CI: 0.496-4.220) in Lesotho. Conclusion: Complete continuity of maternal healthcare was not independently associated with reduced neonatal mortality after full adjustment, suggesting that the unadjusted benefit was attributable to sociodemographic selection rather than a direct causal pathway. These findings underscore the insufficiency of service utilisation metrics in isolation and highlight the need to address the structural and contextual determinants that simultaneously constrain both care access and neonatal survival. Country-level heterogeneity in the CoC-mortality relationship points to the importance of tailored, context-specific interventions.

Background Climate change and extreme weather events (EWEs) threaten health systems, disrupt continuity of HIV and TB services, amplify communicable disease burdens, and exacerbate health inequities in South Africa. Yet few empirical studies have quantified district-level vulnerability, where HIV and TB service delivery and climate adaptation are operationalised. Methods We developed a district-level composite HIV/TB Vulnerability Index, integrating indicators of HIV & tuberculosis burden (sensitivity), health system capacity, and socio-economic vulnerability. We also developed a Hazard Index which when combined with the HIV/TB vulnerability Index, identifies districts where underlying vulnerability coincides with higher likelihood of EWEs. Indicators were drawn from national surveys, routine health information systems, and international hazard datasets, normalised using a min-max scaling, and aggregated with equal weighting. Sensitivity analysis were conducted to assess the robustness of the composite indices. Findings The most vulnerable districts were located in the Northern Cape, Eastern Cape and KwaZulu Natal provinces where high HIV/TB burden and socio-economic sensitivity coincided with limited health system adaptive capacity. In contrast, the least vulnerable districts, were concentrated in Gauteng and Western Cape, reflecting stronger health system capacity and more favourable socio-economic conditions. Hazard exposure exhibited a clear spatial division with western districts experiencing greater heat stress and eastern districts facing higher flood and heavy-rainfall hazards. When hazard exposure was combined with the HIV/TB vulnerability Index, districts with both high vulnerability and hazard scores clustered predominantly along the east coast (Ugu, uMkhanyakude, and Harry Gwala in KwaZulu-Natal, and O.R. Tambo and Alfred Nzo in the Eastern Cape). Interpretation South Africa's district-level vulnerability to climate and weather hazards is driven by the convergence of high HIV/TB burden, constrained health system capacity, and socio-economic disadvantage. Where this vulnerability intersects with increased hazard risk, it creates a compound susceptibility that needs attention. Our findings provide evidence for geographically targeted adaptation, prioritising continuity of HIV/TB services, health system resilience, and hazard-specific preparedness.

Background Lower respiratory infections (LRI) remain the leading infectious cause of death in children, and survival once ill is a direct tracer of health-system quality. Whether countries are converging toward the best survival performance achieved within their own region has never been tested at national level. We measured each country's distance to an empirical episode-fatality-ratio (EFR) frontier in 204 countries from 1990 to 2023. Methods For each country and year we computed EFR = LRI deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. Deaths span the full 1990-2023 series; episodes are observed for 1990, 2019 and 2023, with intermediate years linearly interpolated. The frontier was the 10th-percentile country EFR within each GBD super-region and year (sensitivity: 5th and 25th percentiles); the gap = EFR_country/EFR_frontier. We classified 33-year gap trajectories into catch-up phenotypes, ranked COVID-window (2019-2023) movers, cross-tabulated gap against avoidable deaths to build a priority list, and benchmarked upper respiratory infections (URI) at three time points as a near-zero-fatality contrast. Findings The median country's gap was 1.86 in 1990, 1.80 in 2019 and 1.86 in 2023; the share of countries more than twice their regional frontier was 44.6% in 1990 and 46.6% in 2023. Of 137 eligible countries, 67 narrowed and 69 widened their gap, with one unchanged. Nineteen countries achieved sustained catch-up, concentrated in North Africa and the Middle East (7) and Latin America (5), with China closing from 2.43 to 0.50, below its regional frontier; 28 countries regressed, led by Central Asia (Uzbekistan x3.5) and including the United States (x2.0). Over the COVID-19 window the median gap peaked at 2.00 in 2021 (+10.8% versus 2019, from unrounded medians) before returning to 1.86. Combining gap with avoidable deaths identifies two distinct policy problems: high-burden, moderate-gap giants (Nigeria 67,490 avoidable deaths, gap 2.4; India 54,109, gap 1.6) and extreme-gap outliers (Uzbekistan, gap 28.6). The Sub-Saharan Africa frontier fell further behind the High-income frontier (ratio 4.2 in 1990, 9.5 in 2023); the median Sub-Saharan African country sits 11.0 times the global 10th-percentile frontier but only 1.78 times its own regional frontier, so within-region benchmarking understates the region's true distance. URI gaps likewise did not converge (median 4.15 to 4.60). Interpretation Convergence toward the survival frontier is not the default national trajectory: over three decades the typical country made no net progress toward the best decile of its own region, and pandemic-era divergence was only partly reversed. National gap trajectories separate system-wide quality shortfalls from extreme outliers warranting audit, and expose a measurement trap in which regions whose frontiers stagnate appear closer to best practice than they are.

Introduction: School feeding programs (SFPs) can contribute to address undernutrition in low- and middle-income country settings while can simultaneously improve education outcomes and deliver social and economic benefits. However, evidence on their comprehensive value for money (VfM) remains limited. This study models the multi-sectoral impacts of SFPs across education, health, social protection, and the local agricultural economy in five sub-Saharan African countries, providing benefit-cost ratio (BCR) and VfM estimates to inform policy decisions. Methods: The analysis used secondary data from national reports, program budgets, and national household surveys. SFP impacts on education were assessed through changes in years of schooling and linked to lifetime income gains. Health impacts were quantified as averted anemia cases, converted into disability-adjusted life years (DALYs) and monetized using gross domestic product (GDP) per capita. Social protection benefits were measured as the in-kind value of school meals relative to household food expenditures, while local economic impacts were assessed through monetary transfers to smallholder farmers (SHFs) from local food procurement. BCRs were calculated considering education and health impacts, with additional VfM and expanded BCR estimates considering broader benefits and transfers. Results: Across countries, SFPs were associated with a cumulative gain of 0.6 to 2.3 years of schooling per beneficiary. Moreover, reductions in anemia cases are expected to avert between 4 to 51 DALYs per 1,000 beneficiaries. The BCR for education and health ranged between 3 and 31. Meals provided covered up to 28% of annual household food expenditures for low-income families. Local food procurement generated economic transfers between USD 7 and USD 15 per beneficiary per year to SHFs. Conclusion: SFPs demonstrate high VfM, offering significant educational, health, and economic benefits. Policymakers in sub-Saharan Africa should prioritize the expansion and scaling of SFPs to enhance educational attainment, improve health, and foster economic resilience, contributing to sustainable development.

Introduction Safe and timely blood availability remains a major global health challenge, especially in low- and middle-income countries. Digital tools may accelerate donor contact, but digital reachability alone does not ensure that people will notice, trust and act on urgent requests to support blood donation efforts. We examined factors associated with anticipated engagement in digitally coordinated urgent blood-donor mobilisation among digitally reachable adults in Ghana. Methods We conducted a cross-sectional online survey from September 2025 to January 2026 across Ghana's 16 regions. Participants were recruited via Facebook advertising and snowball sampling. Factors associated with urgent blood-donor mobilisability were assessed under four criteria: high future-donation willingness; high willingness to install a trusted donation app; high willingness to respond to a trusted urgent-request; and high practical flexibility to leave current activities. Descriptive analyses and multivariable logistic regression examined prevalence and associated factors. Results Among 1,067 participants, 577 (54.1%) met all four criteria. Future-donation willingness (91.8%), trusted-app installation willingness (83.2%) and trusted-request response willingness (82.7%) were common, whereas practical flexibility was lower (66.6%). In the adjusted model, high formal health-system trust (adjusted OR (AOR) 3.95, 95% CI 2.08-7.50), high digital-response readiness (AOR 2.26, 1.66-3.08), previous donation (AOR 1.47, 1.08-2.01), high donation knowledge (AOR 1.42, 1.03-1.97) and willingness to donate to strangers were positively associated with high mobilisability. Women (AOR 0.60, 0.43-0.83), participants reporting a work-schedule barrier (AOR 0.43, 0.29-0.66) and those travelling over 30 min to the nearest healthcare facility at night (AOR 0.66, 0.45-0.96) had lower adjusted odds. Conclusions Digital reachability and stated donation willingness may overestimate the population pool available for emergency donation. Digital blood-donor solutions should consider verifiable health-system requests, account for response readiness and current availability, and connect willing individuals with accessible collection options and transport support where needed.

Background. Nigeria carries one of the world's largest burdens of neonatal death and remains far from the Sustainable Development Goal target. Whether health financing and macroeconomic instability are associated with newborn survival has rarely been examined for neonatal mortality specifically. Methods. We conducted an ecological time-series analysis of national annual data, covering 1990-2024 for macroeconomic models (n = 35) and 2000-2023 for health-financing models (n = 24), the periods for which published data exist; no values were imputed. Neonatal mortality came from the UN Inter-agency Group for Child Mortality Estimation 2025 round with 90% uncertainty intervals, and other series from the World Development Indicators. The primary model regressed log neonatal mortality on government health expenditure per capita (purchasing power parity), out-of-pocket share and currency instability, with a linear trend, a post-break trend spline and Newey-West standard errors; first differences without trend terms were the main sensitivity analysis. The break was located by segmented regression; currency instability was tested under four constructions. Results. The decline broke around 2010, the trend moving from -0.74 to +0.14 deaths per 1,000 annually (F = 145.4, p < 0.001). The subsequent rise fell within estimation uncertainty (2012: 37.6, 90% interval 33.9-41.5; 2022: 39.3, 33.4-46.4), supporting stagnation rather than reversal; Demographic and Health Surveys concur, reporting 42 per 1,000 for the five years preceding the 1990 survey and 41 preceding the 2024 survey. Government health expenditure per capita was inversely associated with neonatal mortality (-0.040, 95% CI -0.051 to -0.029, p < 0.001; first differences -0.016, p = 0.033) and was the only expenditure measure surviving both specifications; share-of-GDP measures did not (p = 0.196 and 0.889) and correlated positively in raw terms. Currency instability showed no association under any construction (p = 0.65-0.83). Public expenditure per capita moved non-monotonically, peaking in 2005, falling by 2010 and recovering by 2023 to a level still below the 2005 peak. Conclusions. Neonatal mortality in Nigeria is ecologically associated with public health expenditure per capita, but not with commonly used share-based measures, nor with currency instability. Rising public spending accompanied stalled progress, directing attention toward how health resources are converted into services. Annual modelled mortality estimates could not support year-to-year inference, a limitation relevant to comparable studies

Background Deconfliction is a central pillar of humanitarian risk mitigation in contemporary armed conflicts. Intended as a notification system through which parties to a conflict can mitigate against harm to humanitarian personnel and infrastructure, its effectiveness is dependent on respect for humanitarian protections. Since October 2023, repeated Israeli attacks on deconflicted sites and routes in Gaza, alongside increasing restrictions on humanitarian movement as notification-based coordination was replaced by a permission-based system, have raised fundamental questions about the utility and function of deconfliction. This study examines how deconfliction shaped humanitarian access, healthcare delivery, and Palestinian health infrastructure from the perspective of international healthcare workers in Gaza since 2023. Methods We conducted semi-structured interviews with 18 international healthcare providers who worked in Gaza between January 2024 and December 2025. Participants completed 31 deployments across 16 healthcare facilities. Interviews were analyzed using inductive thematic analysis. Results Two major themes emerged. First, participants described deconfliction as an unstable and ineffective means of ensuring humanitarian protection or access. They reported delays, denials, sudden revocations of movement permissions, and strikes on deconflicted sites. These conditions disrupted clinical care, delayed transfers and evacuations, limited facility access, and exposed both patients and providers to ongoing risk. Second, participants described deconfliction as a mechanism of control that shifted responsibility for protection from parties to a conflict to humanitarian actors and redirected resources and personnel away from Palestinian hospitals toward NGO (Non-Governmental Organization) facilities, eroding Palestinian healthcare autonomy. Conclusion Rather than a neutral protection mechanism, deconfliction operated as a conditional authorization regime through which Israel regulated humanitarian movement, medical supply chains, and healthcare delivery. This mechanism rendered protection contingent on compliance, allowing Israel to reframe attacks as humanitarian operational failures rather than violations of international law by military actors. Deconfliction also facilitated the substitution of Palestinian healthcare with internationally managed structures that were dependent on Israeli approval. By undermining local health system autonomy, deconfliction was instrumentalized within a broader Israeli strategy to deliberately inflict conditions to bring about the physical destruction of life in Gaza. These findings raise urgent questions about humanitarian actors obligations when operating within non-neutral systems and underscore the need to prioritize direct support for local healthcare institutions.

Background In 2016, the World Health Organization revised its antenatal care (ANC) recommendation from four to eight visits. For low- and middle-income countries like Uganda, where achieving even four visits remains a challenge, this transition has significant cost implications for both the health system and households. This study estimated the incremental costs of adopting the eight-visit model from a societal perspective. Methods The study was conducted in six government health facilities in southwestern Uganda. A micro-costing approach estimated health facility costs (personnel, equipment, consumables, and overhead). Costs incurred at patients end (transport, ultrasound, medical expenses, and time) were collected from 785 women using a questionnaire, with all costs in 2025 USD. Results For an average of 4.3 visits, total cost per woman was $100.1: facility costs $43.7 (43.7%), and patient costs $56.4 (56.3%). Transitioning to eight visits would increase total cost by $57.8 (57.8%), of which $36.4 (63.0%) would fall on households, equivalent to 68.8% of average monthly household income. Total costs would rise by 55.4% ($115.5 to $179.5) at Health Center IVs and 64.3% ($102.3 to $168.1) at Health Center IIIs, with facility costs up 43.4% and 62.9% and patient costs up 61.2% and 65.7%, respectively. Conclusion Transitioning to eight ANC visits would impose a large financial burden on households, with the incremental patient cost equivalent to more than two-thirds of average monthly household income. Equitable implementation requires improving availability of medicines and diagnostics, subsidizing transport, exploring telemedicine or community-based models, and improving efficiency at lower-tier health centers.

Background Timely access to essential health technologies depends on aligning evidence-informed adoption with financing, procurement, delivery, monitoring, and learning. We examined how decision pathways shaped selected health technologies progression from prioritisation to implementation in South African public sector, and their implications for access, equity, sustainability, and learning. Methods We conducted a qualitative, retrospective, multi-case health policy analysis of twenty essential health technologies purposively selected to capture variation in technology type, disease area, delivery platform, adoption trajectory, and implementation outcome. Document review, process mapping, and key informant interviews were used to reconstruct decision pathways. Analysis was guided by the Policy Cycle Framework, Health Policy Triangle, and Health Technology Assessment (HTA) process domains. Results Decision pathways varied by technology and delivery platform but followed a common sequence from prioritisation and appraisal to policy endorsement, implementation, and limited reassessment. Medicines and vaccines were generally embedded within established national decision structures. Diagnostics required coordination across laboratory, programme, procurement, and service-delivery systems, while medical-device decisions were more decentralised. Upstream appraisal focused on safety, effectiveness, and public health needs; affordability, infrastructure, equity and sustainability were addressed inconsistently. System learning was evident when routine data, pharmacovigilance, programme review, and guideline revision informed post-adoption adaptation. Weak feedback loops limited reassessment of implementation barriers, equity effects, and sustainability, contributing to delays despite policy endorsement. Conclusion South Africa has formal structures for evidence-informed technology adoption. HTA would be strengthened by treating appraisal as part of lifecycle governance, with earlier alignment between adoption decisions, financing, procurement, implementation readiness, monitoring, and reassessment.

Background: Prematurity is the leading cause of child deaths worldwide, with the highest neonatal mortality in sub Saharan Africa. Respiratory distress syndrome (RDS) is the leading mortality pathway in preterm neonates, but continuous positive airway pressure (CPAP) has high impact. This analysis reports CPAP coverage and quality of care for preterm neonates admitted to 66 neonatal units in Kenya, Malawi, Nigeria and Tanzania. Methods: Analyses used individually linked neonatal inpatient data and cross-sectional health systems data. All admitted neonates were eligible for inclusion (January 2021 through December 2024). Service readiness for CPAP delivery and mean CPAP coverage were described for CPAP eligible newborns (weighing <1500g and symptomatic newborns >1500g). Quality of care cascades were constructed to illustrate key indicators. Survival among CPAP eligible neonates was analysed using regression models, stratified by clinical severity scores. Results: 375,255 newborn admissions were analysed in 66 neonatal units. Functional CPAP availability varied with median 16% of days (IQR: 4 to 47%) classified as high demand (>1.5 eligible newborns per CPAP). Of 64,761 CPAP eligible neonates, 22,006 (34%, 95% CI 33 to 34%) received CPAP. All countries showed improvement in CPAP coverage, with Tanzanian hospitals recording 63% increase in mean coverage (p-value=0.001) over time. Quality of care cascades showed treatment was initiated <24 hours after birth and continued for >1 day for 42% (95% CI 41 to 43%) of eligible neonates receiving CPAP. Only 10% of neonates <1500g started CPAP within the first hour of life. Among newborns on CPAP, 55% also received KMC (from 48% in Tanzania to 88% in Nigeria). Among newborns with high clinical severity, those treated with CPAP had a higher probability of survival (32%, 95% CI 29 to 36%) than those who were not (23%, 95% CI 21 to 26%). Odds of survival were higher for CPAP eligible newborns whose mothers received antenatal corticosteroids (aOR 1.07, p=0.001). Lower aOR of survival was associated with hypoglycaemia (aOR 0.71, p<0.001), respiratory distress (aOR 0.91, p<0.001), and outborn newborns (aOR 0.72, p<0.001). Conclusion: CPAP coverage and quality are critical for premature neonates. Clinical cascades highlight quality gaps, particularly in timely prophylactic CPAP initiation and appropriate duration. Improving comprehensive care quality for newborns on CPAP, including provision of co-interventions and maternal antenatal corticosteroids, can improve survival for preterm neonates.

Antimicrobial resistance is a growing threat to health systems, but stewardship programs must compete for funding with many urgent health priorities in low- and middle-income countries. Evidence that quantifies not only effectiveness but also economic value is therefore essential for policy and budget decisions. We evaluated targeted antimicrobial stewardship programs in four tertiary hospitals in Nepal and Laos using interrupted time-series analyses of antibiotic use, combined with micro-costing to estimate benefit-cost ratios. Stewardship was associated with immediate reductions in antibiotic use across the three Nepal hospitals, whereas effects in Laos were more heterogeneous. Economic returns were positive across sites, with the largest returns observed in the private hospital in Nepal. Here, we show that pragmatic, ward-focused stewardship can reduce antibiotic use and generate measurable economic value in resource-constrained hospital settings, supporting its prioritization as a scalable investment for antimicrobial resistance control.

All primary healthcare centers owned by the Ugandan government in the Western Region of Uganda were submitted to a questionnaire concerning current availability of POCT from the Essential diagnostic List 2 part 1a and 1b, and the African laboratory inventory done by African Society of Laboratory Medicine and AfricaCDC. The data from the questionnaire was then linked to open source geodata provided by TomTom, and population data to calculate and visualize the accessibility of captured POCT. Findings: Availability of POCT Malaria is almost 100%, HIV 68-90%, and >30% for a majority of the POCT in the EDL-2 panel. 90% of the population in Western Region live within 1 hour by car from most of the essential POCT. Figures in the complementary web-based application visualize the accessibility of POCT for Western Uganda. Diagnostic deserts are visualized. Interpretation: Access to POCT at primary health care facilities in western Uganda has expanded substantially over the past decades. The geo-mapping tool presented here could inform policy decisions on strengthening diagnostic capacity at the national, regional, and provincial level. Funding: Swedish Research Council and Infravis All supplementary materials and a preprint of this submission are available on our OSF repository https://osf.io/j7puk/.

Background: A central concern in global health priority-setting is whether the supply of scientific knowledge aligns with health needs and demands. This alignment is usually assessed by comparing research effort with disease burden, overlooking other type of "social demand" of disease, in particular whether diseases are socially visible and generate public attention. We develop an analytical framework that treats public attention and epidemiological burden as complementary dimensions of health demand and examines their alignment with knowledge supply. Methods: We combine data on publications indexed in OpenAlex, disability-adjusted life years from the Global Burden of Disease, and Wikipedia pageviews for 2016 to 2023, as indicators of research effort, disease burden, and public attention, respectively. We map 19 disease groups and 138 specific diseases across these three dimensions. Ternary plots are used to position diseases according to their relative balance across dimensions and to identify diseases that are over- or under-represented in research effort relative to epidemiological burden and public attention. We compare Global North-South patterns using German, Persian, Swahili, and Vietnamese language areas to assess how these relationships vary across territories. Results: The three dimensions show limited alignment. At the disease group level, cardiovascular diseases account for the largest share of disease burden, mental disorders attract the largest share of public attention, and neoplasms concentrate the largest share of research effort. Public attention and disease burden are weakly correlated at both group and specific disease levels, indicating that Wikipedia pageviews and DALYs capture distinct dimensions of health demand. Ternary plots reveal different forms of misalignment, with some diseases showing plots dominated by burden, others by research effort, and others by public attention. Territorial analyses add a further layer by showing that diseases follow disparate patterns of supply-demand (mis)alignment across different linguistic territories. Conclusions: Public attention provides a complementary dimension for mapping global health needs and demands. Our approach identifies where scientific knowledge supply fails to match epidemiological and/or public attention, supporting more nuanced global health analysis that may be useful for priority-setting.

Prehospital emergency care in many African cities is constrained not by ambulance scarcity but by fragmentation: multiple uncoordinated provider types operating parallel dispatch systems, with no shared data and no capacity to measure system performance. Despite the World Health Assembly's 2023 resolution on integrated emergency care (WHA 76.2) and Ethiopia's Health Sector Transformation Plan II (HSTP-II), prehospital coordination has remained a critical missing link. In response, Ethiopia developed the Hospital Emergency Assistance and Response Tracking System (HEARTS) under the Ethiopian Ambulance Alliance Network (EAAN), a governed, multi-provider federation established through consultation with the Network for Perioperative and Critical Care (N4PCc), Federal Ministry of Health, the Addis Ababa city administration fire and disaster response team, a humanitarian NGO provider, and dedicated private ambulance providers. HEARTS provides real-time fleet tracking, unified call processing, community access via a dedicated mobile application, and performance dashboards disaggregated by sub-city and provider type. This paper reports the first phase of the Prehospital Care Outcome Study (PRECOS-1), a programmatic research platform established to generate longitudinal evidence on prehospital coordination in Ethiopia and to inform replication across Africa. During the first operational phase in Addis Ababa (December 2025 to June 2026), HEARTS coordinated 1,403 trips across four provider types and 59 response units. The majority of trips were high- or critical-acuity (63.3%), with maternal and obstetric presentations forming the largest clinical category (44.3%). Median response time was 14.5 minutes (IQR 5.8 to 27.0; 90th percentile 75.0 minutes), the first unified prehospital performance baseline for this city. These findings demonstrate that a coordination-first approach to prehospital system strengthening is feasible in a fragmented low- and middle-income country setting, generate the measurement infrastructure for future improvement studies (PRECOS-2 onward), and offer a replicable model for African cities pursuing integrated emergency care.