BMJ Global Health

Estimates of the marginal cost per disability-adjusted life year (DALY) averted from government health expenditure (GHE) provide an empirical basis for allocating scarce health resources to maximise population health. Existing cross-country estimates have informed priority setting in several countries and international policy discussions but are based on data that are now more than a decade old. Since then, patterns of health expenditure, disease burden, and global health financing have changed substantially. This paper provides updated estimates of the marginal cost per DALY averted for 92 low- and middle-income countries (LMIC) by applying previously estimated elasticities of the effect of GHE on health outcomes from Ochalek et al. (2018) to recent data on mortality, morbidity, population structure, and GHE. Two policy options for improving health in LMIC are assessed: (1) the implications of countries allocating 15% of general government expenditure to health consistent with the Abuja Declaration; and (2) reallocating development assistance for health (DAH) to maximise health across countries. Scenario analyses use the estimated elasticities to reflect diminishing marginal returns to health expenditure when calculating the health gains associated with additional resources. Updated estimates of the marginal costs per DALY averted range from approximately $78 to $15,789 across countries. In most countries (72%), estimates are higher than in the previous analysis, largely reflecting increases in GHE. Increasing domestic expenditure to achieve the Abuja Declaration objective would avert 234 million DALYs but require $563 billion across countries. Reallocating $39.1 billion in existing DAH could avert 133.6 million DALYs. Updated estimates provide an empirical basis for informing both domestic priority setting and the allocation of international health financing. Aligning donor funding with country-specific opportunity costs could substantially increase the global health gains achieved with limited resources.

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

BackgroundTuberculosis (TB) continues to cause substantial morbidity and mortality, with adults and adolescents carrying the largest burden of disease. Multiple promising novel vaccine candidates are in clinical trials, and their eventual impact will depend on effective implementation strategies. Information on TB vaccine preparedness efforts that could inform coordination remains fragmented. MethodsWe developed the first living and interactive online repository (https://tbvaxrepository.org/) collating completed, ongoing, and planned adult and adolescent TB vaccine preparedness initiatives. Data were obtained through a prior scoping review, direct stakeholder engagement, international conferences, and open calls via social media and partner networks between March 2023-November 2024. Projects were categorized using the World Health Organizations (WHO) framework for TB vaccine preparedness across three thematic areas: availability, accessibility, and acceptability. FindingsBy December 2024, the repository included 90 projects from 119 countries. Most projects focused on health- (47%) and economic modelling (21%), demand and acceptability studies (19%) or implementation feasibility (14%). Most of the projects were situated in India (n=36), South Africa (n=34), China (n=19), Indonesia, (n=17), Kenya (n=17), Brazil (n=14), and Pakistan (n=14). Few initiatives targeted key populations such as people living with HIV, pregnant or lactating individuals, or socially marginalized and occupational high-risk groups. Research on communication strategies for facilitating uptake as part of rollout were absent. ConclusionsThe repository reveals both progress and gaps in global TB vaccine preparedness across WHOs three thematic areas, with particular attention to geographic coverage, and the inclusion of key populations. As novel vaccines for adults and adolescents approach potential licensure, coordinated and inclusive preparedness efforts will be critical to ensure equitable and effective rollout. This repository offers a transparent platform to strengthen collaboration, reduce duplication, and guide strategic planning in a historically underfunded field.

BackgroundRegulatory inconsistency across African countries contributes to duplicative scientific assessments, prolonged approval timelines, and delayed access to essential medical products. To inform the operationalisation of the African Medicines Agency (AMA), the African Medicines Regulatory Harmonisation (AMRH) programme implemented Africas first continental pilot study for the scientific evaluation and listing of human medicinal products. This study evaluates the pilots procedural performance and examines how continental scientific opinions were translated into national regulatory decisions through reliance mechanisms. Methods and FindingsA mixed-methods programme evaluation was conducted using regulatory datasets generated during the pilot study. Quantitative data included assessment timelines, GMP inspection outcomes and national post-listing regulatory actions. Qualitative thematic analysis was applied to governance documents and National Regulatory Authority (NRA) feedback to identify legal, institutional and procedural determinants influencing uptake. Of 64 expressions of interest, 24 products progressed to full evaluation and 12 received positive continental scientific opinions. Ten met the predefined performance target of [≤]210 working days. Twenty-four GMP inspections identified no critical deficiencies and aligned with global regulatory benchmarks. National uptake demonstrated active reliance: full reliance (continental opinion as primary basis for national approval) for 7 products (58%); sequential reliance (continental assessment supplemented with targeted national queries) for 3 products (25%); and supplemented national review (separate national assessment undertaken) for 2 products (17%). Products with broader market strategies achieved registration in up to 23 African countries within a median of 77 working days post-listing. Variability in uptake reflected national legal authority, administrative requirements, and applicant submission strategies ConclusionsThe pilot study demonstrates the feasibility of a continent-wide regulatory assessment mechanism capable of producing trusted scientific outputs and enabling reliance-based national decision-making in Africa. While reliance was widely applied, heterogeneity in national procedures and administrative sequencing affected time to national registration. Findings provide empirical evidence to inform the AMA scale-up, highlighting the need for harmonised reliance pathways, streamlined administrative processes, and coordinated digital regulatory infrastructure. Author SummaryWhy Was This Study Done? Access to essential, safe, and effective medicines in Africa is often delayed because regulatory systems across countries work independently and have different capacities. To strengthen regulatory efficiency, African institutions have established the African Medicines Agency (AMA) which will carry out continent-wide scientific assessments that countries can rely on when making their own regulatory decisions. However, since no evidence previously existed to show whether such a continental process could work in practice, there was a need to carry out such a study. What Did the Researchers Do and Find? Africas first pilot study of a continent-wide regulatory assessment process for human medicines was evaluated. Of 24 eligible applications, 12 products were listed following a positive scientific opinion issued after scientific assessment and manufacturing quality evaluation. Sixteen national regulatory authorities used the continental assessments directly when granting marketing authorisations, reducing duplication and accelerating decision-making. Countries varied in how quickly and extensively they adopted the continental recommendations, depending on national laws, administrative procedures and capacity. What Do These Findings Mean? A continental assessment system is feasible in Africa that can provide the basis for reliance-based national decisions. To make this approach fully effective under the African Medicines Agency, countries will need clearer reliance legislations and pathways, streamlined administrative processes, and systems that connect continental, regional and national regulatory procedures.

Malaria imposes societal costs beyond health, including substantial effects on education, yet economic evaluations often overlook these broader impacts. We conducted a cross-sectoral benefit-cost analysis of malaria chemoprevention in school-aged children (SAC) across ten high-burden sub-Saharan African countries. Using recent trial data, we estimated impacts on malaria morbidity, mortality, school absenteeism, and literacy. The intervention was projected to cost $422 million and generate $5.7 billion in societal net benefits, yielding a benefit-cost ratio (BCR) of 14.3. Country-level BCRs ranged from 3.71 to 39.5, with the highest returns in Nigeria. Results were sensitive to drug choice, discount rate, and valuation of education benefits. When using school quality metrics (estimated via Learning-Adjusted Years of Schooling (LAYS)), BCRs increased up to 100-fold compared to estimates based on school quantity alone. Probabilistic sensitivity analysis yielded a mean simulated BCR of 11.00 (95% CI: 10.89-11.11), with a >95% probability of being cost-beneficial at a BCR threshold of 3. This study advances the evidence base for malaria chemoprevention in SAC, highlighting its dual health and educational benefits. These findings offer policymakers and funders strong evidence to prioritize malaria chemoprevention in SAC as a high-value investment in both health and human capital in malaria-endemic regions.

IntroductionRadical cure of Plasmodium vivax malaria remains a major challenge in endemic countries. New treatment options add opportunities but also increase complexity of policy decisions. Malaria treatment policies are often shaped by World Health Organisation (WHO) guidance, limiting scope for local adaptation. The Options Assessment Toolkit (OAT) was developed to support national policy making for the radical cure of vivax malaria. This study evaluates its co-development, uptake and practical influence. MethodsWe conducted a qualitative study with stakeholders in Afghanistan, the Solomon Islands, and Vietnam (co-developers) and Nepal (new user context). In-depth interviews were conducted with representatives from the National Malaria Programs between January and March 2025. Thematic analysis was conducted using NVivo 12, guided by pre-defined research questions, and reported according to COREQ criteria. ResultsParticipants described a strong ownership resulting from the inclusive co-development process. However, none of the co-developing countries used the OAT for formal policy decision-making. Instead, it primarily supported structured deliberation, planning, and contextual appraisal of emerging treatment options. A key finding was the conflation between decision-support and implementation feasibility: the toolkits perceived value was often judged according to whether recommended strategies could be operationalised within existing system constraints. Instrumental uptake was shaped by institutional structures, system readiness, variation in national analytic capacity, and reliance on WHO endorsement. ConclusionsThe findings suggest that ownership alone is insufficient for institutional uptake. Decision-support tools exert influence primarily by reshaping deliberation, but require embedding within formal policy, regulatory, and financing processes for sustained impact.

IntroductionReliable estimates of resource requirements for essential health interventions are critical for universal health coverage (UHC) planning. Existing benchmarks provide limited operational guidance for national decision-making. MethodsWe developed an ingredient-based costing model aligned with the WHO Universal Health Coverage Compendium (UHCC), which specifies delivery platforms, actions and technologies for 544 interventions. We estimated resource needs and costs associated with delivery of all UHCC-defined interventions at 80% coverage across 122 low- and middle-income countries, applying a multimorbidity adjustment to reduce potential double counting and using authoritative epidemiological, demographic and cost data. ResultsModeled delivery of Core UHCC interventions is estimated at USD 2.0 trillion annually (5.7% of aggregate gross domestic product) or USD$249, 294 and 363 per capita in low-, lower-middle- and upper-middle-income countries, respectively. Cost estimates closely aligned with WHO projections for achieving Sustainable Development Goal 3, but were 1.7-2.7x higher than Disease Control Priorities Network internal cost estimates. ConclusionThe UHCC aligned cost model provides transparent resource need and cost data under normative service delivery assumptions, and offers a practical starting point for country-level contextualization for health service packages planning.

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.

BackgroundKenyas facility autonomy reforms are intended to improve health system equity, efficiency, and responsiveness to community needs by shifting decision-making to the frontline. This study evaluates the implementation process and experience of facility autonomy reforms in Kenya post devolution of health services. MethodsWe conducted a concurrent mixed methods study of counties (n=6) in Kenya, selected based on their implementation of facility financial autonomy reforms as of June 2023. For the quantitative aspect, we assessed 141 randomly selected public health facilities across all levels of service provision. We then did a descriptive analysis to measure the level and perceptions of autonomy. For the qualitative aspect, we reviewed documents and interviewed purposively selected stakeholders (n=71) involved with autonomy reforms at national, county, and facility levels, cutting across health, finance, legal, political and community actors. We analyzed the transcripts thematically using NVivo 12. ResultsThe emergence of the FIF reforms in Kenya was driven by the convergence of political, technical, and public needs. While counties have developed their own facility autonomy laws to fit local contexts, some provisions are not fully aligned with the national legislation. Some aspects of both the county specific and national laws are not implemented. These include allocation of matching funds from the exchequer and reimbursing facilities for expenses incurred from providing care to indigents and for unpaid bills. The implementation of autonomy also varies, with some aspects partially or not implemented. Autonomy reforms have contributed to improved decision-making, staff satisfaction, availability of essential medicines, and facility maintenance. However, challenges have emerged, including the failure of counties to provide matching funds, which disproportionately affects lower-level facilities that do not generate revenue. Additionally, the absence of waiver repayment mechanisms has led to inequities, and the risk of increased service costs threatens financial accessibility for marginalized populations. ConclusionFacility autonomy reforms support people-centered decision-making and aligns with PHC principles. While these reforms hold promise for improving service delivery and access, their success depends on complementary measures such as sustainable funding mechanisms and stronger protections for vulnerable populations.

BackgroundThe COVID-19 pandemic disrupted childhood immunization programmes in many countries worldwide. However, evidence on its impact in low and middle-income countries remains limited. This study examined the impact of the COVID-19 pandemic on childhood immunization coverage across 514 districts in Indonesia and identified district-level associated factors. MethodsWe conducted a nationwide longitudinal analysis of the Expanded Programme on Immunization to compare immunization coverage before and after the pandemic. The outcome variable was the annual childhood immunization coverage (proportion of children aged 0-12 months who have received all recommended doses of childhood immunization as per the national immunization schedule). The explanatory variables include COVID-19 burden and vaccination rates, health system and human development indicators. Mixed-effect logistic regression was done to assess association between the explanatory and outcome variables. ResultsAt the national level, the coverage was 83.2% in pre-pandemic, 75.0% in the first year of pandemic, and 88.6%, in the second. In the first year, 69.3% of districts experienced significant decline, with a lower national coverage ratio of 0.92 (95% confidence interval 0.89-0.94). In the second year, 36.2% districts were still affected. The multivariable analysis showed that a significant decline in coverage during the first pandemic year was associated with high COVID-19 incidence (adjusted odds ratio 2.19, 95%CI 1.01-4.73 for the highest vs. lowest group), low midwife adequacy (5.84, 2.40-14.16 for the lowest vs. the highest group, 2.61, 1.26-5.40 for low-middle vs. the highest group), and a high proportion of health facility-based births (2.98, 1.49-5.98 for middle-high vs. the lowest group). ConclusionsThe COVID-19 pandemic negatively and unevenly impacted childhood immunization in Indonesia, with greatest impacts in districts facing a higher COVID-19 burden and weaker health system capacity. These findings underscore the need for targeted efforts to strengthen the local health system for future health crises. Summary boxO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIAccording to the WHO Pulse Survey, routine immunizations were the most disrupted essential health services during the COVID-19 pandemic, reported by 70% of countries. Southeast Asia experienced the steepest drop in childhood immunization coverage compared to the other regions. C_LIO_LIIndonesia had the highest number of COVID-19 cases and related mortality in Southeast Asia. However, the magnitude and heterogeneity of the impact of COVID-19 pandemic on childhood immunization coverage across all 514 districts in Indonesia has not been evaluated. C_LI What this study addsO_LIThis study affirmed that the COVID-19 pandemic greatly impacted childhood immunization coverage, disproportionately impacting district with vulnerable health systems capacity. C_LI How this study might affect research, practice, or policyO_LIThis study highlights the critical need of addressing health inequity to strengthen health system resilience for future global health crises. C_LIO_LIIn the context of a decentralised health system such as in Indonesia, coordination and prioritisation of available resources and public health intervention will be critical to ensure optimal health outcomes for children living in districts with weak health systems. C_LI

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.

Despite robust policy frameworks, Ugandas digital health landscape is characterised by fragmentation--often termed "Pilotitis"--where stand-alone applications impede the integrated delivery of health, nutrition, and food security services. As part of the IGNITE project, this study mapped existing digital health systems (DHSs), identified systemic gaps, and explored opportunities and resource requirements for sustainable integration of existing Health, Nutrition and Food security data systems. The IGNITE project adopted a mixed-methods design; however, this paper reports findings from the first phase--a national cross-sectional survey conducted in Uganda. The survey mapped digital health, nutrition, and food security systems, identifying gaps, resource needs, and potential actions. Stakeholders from government, NGOs, academia, UN agencies, and frontline health workers were included using purposive and snowball sampling. Data were collected online and through field support. Of 134 respondents, 110 with [≥]70% survey completion was included in the analysis. While 93% of respondents utilise digital tools (predominantly DHIS2 and mobile apps), only 20% reported full automated integration with national platforms. Critical barriers to interoperability included a lack of technical expertise (90%), insufficient DHIS2 training (82%), different data formats (77%), and infrastructure constraints (75%). Respondents identified workforce development (56%) and DHIS2 use and adoption (29%) as primary opportunities. Immediate priorities include staff training and provision of mobile hardware, while long-term strategies focus on standardised data formats (78%) and formalised governance frameworks for Integrated platforms (64%) and automated data exchange (56%). Uganda possesses a vibrant but disconnected digital ecosystem. Transitioning from isolated "data islands" to a cohesive system requires addressing the massive technical capacity gap and establishing mandated interoperability guidelines. The findings provide a data-driven roadmap for the Ministry of Health and partners to optimise digital health adoption, ensuring that nutrition and food security interventions are supported by a unified, evidence-informed digital architecture

Background: Extreme weather events (EWEs) are increasing in frequency and intensity due to climate change. EWEs negatively affect both physical and mental health, with vulnerable populations disproportionately impacted. Limited data on the specific effects of EWEs on mental health in Africa highlights the need for more research to guide policy and practice. The WEMA study aims to explore the impact of EWEs, in particular storms, cyclones, flooding, and heavy rainfall on common mental disorders (CMDs) in Burkina Faso, Kenya, Mozambique, and South Africa. Methods: This study will employ a transdisciplinary research approach integrating qualitative and quantitative methods to generate contextually grounded and policy-relevant evidence on the mental health impacts of EWEs in sub-Saharan Africa (SSA). We begin with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guided rapid literature review to synthesise existing evidence on the relationship between EWEs and mental health. Secondary analysis of health and demographic surveillance system (HDSS) data across multiple African sites will assess the temporal association between temperature, precipitation, and mental health-related morbidity and mortality, using time series regression with distributed lag non-linear models. In parallel, cross-sectional surveys will estimate the prevalence of CMDs among adults exposed and unexposed to flooding. Logistic regression, accounting for confounders, will be used to estimate odd ratios of the impact of flooding on CMDs. An embedded qualitative study will involve thematic analysis of digital stories produced by community-based co-researchers through participatory workshops, capturing lived experiences of EWEs. Findings from both components will be synthesised and disseminated through knowledge exchange meetings to bridge scientific and experiential insights and inform locally relevant interventions. Discussion: The pool of evidence generated through this transdisciplinary study will be widely shared to draw attention to the impact of EWEs on mental health and to inform relevant policy and practice. Through this work, we aim to advance locally relevant climate adaptation strategies to help reduce health inequalities and support the psychosocial well-being of affected communities.

BackgroundPrevious Ugandan studies estimated travel time to childbirth services using generic speeds, incomplete facility databases, and nearest-facility assumptions, without accounting for referrals. We estimated travel times to facilities women actually used, incorporating referral pathways and context-specific speeds, and assessed urban-wealth inequities in access and bypassing in rural midwestern Uganda. MethodsWe assembled spatial data on facilities, socioeconomic status, urbanisation, roads, land cover, and geotraced speeds from car journeys in Kasese and Bundibugyo. From records, we extracted residential addresses and referral pathways for 357 women delivering in all 42 public childbirth facilities during November-December 2024. Using a least-cost path algorithm, we estimated travel times to nearest and utilised facilities under slowest, average, and fastest scenarios; incorporated referrals; examined wealth and urban-rural inequalities; and estimated proportions of women of childbearing age (WoCBA) living within 15, 30, 60, and 120 minutes of the nearest childbirth facility. ResultsTravel speeds ranged from 8.1 to 49.4 km/h. Mean travel time to the nearest facility was 24 minutes, rising to 56 minutes under the slowest scenario. Under the slowest scenario, 99.3% of WoCBA lived within 2 hours of the nearest facility, but only 52.1% within 30 minutes. Travel times were longer for rural and poorer women. Overall, 65.1% used their nearest facility, and referrals added a mean of 21 minutes. ConclusionsTravel times were longest for poorer rural women, with bypassing and referrals increasing journey time. Investigating bypassing and reducing unnecessary referrals is needed. Utilised-facility travel with referrals better reflects access than nearest-facility models.

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.

BackgroundThe global burden of gastrointestinal (GI) cancers is projected to rise by 2050, with incidence and mortality in Africa nearly double global estimates. Surgery remains the cornerstone of treatment but imposes substantial financial burdens. In Uganda, where no national health insurance scheme exists, patients are especially vulnerable. We therefore investigated the magnitude of catastrophic health expenditure (CHE) among GI cancer patients undergoing surgery in public hospitals. MethodsA prospective study was conducted over 10 months in the GI surgery wards of a tertiary hospital, with ethics approval. Adults with GI cancer scheduled for surgery were consecutively recruited. Sociodemographic, clinical, and household expenditure data were collected at baseline and discharge. Out-of-pocket (OOP) costs, annual household expenditure, non-food expenditure, and capacity to pay were derived. CHE was assessed using Wagstaff/van Doorslaer and Xu thresholds and determinants of CHE assessed. Results164 participants were recruited, 54.3% were male and 75.0% aged above 50 years. The median out-of-pocket (OOP) expenditure for GI cancer surgery was USD 663, nearly twice the median annual household income. At the 10% threshold, the prevalence of CHE was 64%. Sources of financing for OOP varied by socioeconomic status (SES): households in the highest SES relied primarily on savings, whereas those in the lowest SES depended on asset sales and loans. School fees payment was disrupted, particularly among middle- and low-SES households. Factors independently associated with higher CHE included female sex, formal employment, curative intent of surgery, and low household SES. ConclusionOver half of patients experienced financial toxicity, often selling assets and compromising long-term security. The burden was greatest among poorer households, women, and those undergoing curative surgery. Findings highlight the urgent need for national health insurance in Uganda. Although recall bias may have influenced reporting, critical gaps in financial protection for cancer surgery patients are evident. Summary BoxO_ST_ABSWhat is already known about this topicC_ST_ABSO_LIGastrointestinal cancers are rising in incidence across Africa yet treatment of GI cancers is costly due to the multimodal treatment approaches. GI cancer treatment and surgery lead to catastrophic health expenditures even in high income countries. C_LI What this study addsO_LIThis study evaluates surgery as a key management modality for gastrointestinal cancers and quantifies the catastrophic health expenditure associated with it, found to be 64%. C_LIO_LIIt identifies risk factors for CHE in this context, emphasizing the vulnerability of households undergoing surgical cancer care. C_LIO_LIIt highlights differences in sources of health care financing across socioeconomic strata, revealing inequities in how households mobilize funds. C_LIO_LIIt highlights basic needs that are negatively affected by the shortage of resources such as education, and reveals a high likelihood of future financial hardship due to the impact of crowding out effect on income generating activities. C_LI How might this impact on clinical practice?O_LISurgery remains one of the most cost-effective and potentially curative modalities for gastrointestinal cancers, these findings stress the urgent need for financial risk protection strategies in Uganda. C_LIO_LINational cancer plans should prioritise procurement of specialised surgical equipment and safe guard vulnerable individuals especially females and financially deprived who stand to benefit from curative surgery. C_LI

Sexually transmitted infections (STIs) remain a major global public health concern, with a disproportionate burden in low- and middle-income countries affected by conflict and displacement. In Nigeria, STI prevention and treatment sit within a crowded sexual and reproductive health (SRH) policy landscape shaped by vertically financed HIV programmes, expanding self-care agendas and one of the largest internally displaced populations in Africa. This qualitative study examines how structural, institutional and sociocultural forces shape STI service delivery for IDPs and how they reproduce or challenge sexual and reproductive health and rights. We conducted in-depth interviews with federal and state policymakers, United Nations representatives and national and international non-governmental actors involved in SRH and humanitarian programming in Nigeria. Using an interpretive, structurally informed approach, we explored participants accounts of funding architectures, governance priorities, humanitarian protocols, provider practices and gendered norms. Nigeria was considered "policy-rich but implementation-poor", with HIV-centred vertical financing creating a hierarchy of infections that renders non-HIV STIs comparatively invisible, unsubsidised and often effectively privatised in displacement settings. Chronic commodity shortages, workforce depletion in conflict-affected areas, weak surveillance systems and reliance on informal providers were seen as routine features of STI care in IDP camps. Sociocultural dynamics, including toilet infection narratives, gendered gatekeeping of womens healthcare and STI-related stigma, shaped how IDPs interpreted symptoms, when they sought care and which providers they used. At programme and government levels, self-care and task-shifting policies, although framed as expanding choice and autonomy, were implemented through fragile supply chains, limited regulation of informal providers and uneven access to digital platforms. The findings indicate that improving STI care for IDPs in Nigeria will require rebalancing HIV-dominated financing, securing affordable STI commodities, strengthening supervision and data systems and referral pathways so that self-care and humanitarian responses translate into accessible, reliable services.

BackgroundDuring Nigerias largest recorded diphtheria outbreak, hospital capacity in Kano State was rapidly overwhelmed. Medecins Sans Frontieres introduced home-based care (HBC) for patients with mild disease to prioritise facility-based care for severe cases. We assessed whether HBC was non-inferior to facility-based treatment in terms of mortality, sequelae, and household transmission. MethodsWe conducted a retrospective matched cohort study. Mild diphtheria cases treated between January 2023 and May 2024 were matched 1:1 by treatment modality (HBC or diphtheria treatment centre [DTC]) on sex, age group, vaccination status, and residence. Conditional logistic regression estimated the association between treatment modality and mortality, with robustness assessed through propensity score weighting, sensitivity analyses, and E-value computation. FindingsOf 990 sampled patients, 678 (367 HBC, 311 DTC) were enrolled (68{middle dot}5%). After adjustment, treatment modality was not independently associated with mortality (HBC vs. DTC: aOR 0{middle dot}40, 95% CI 0{middle dot}13-1{middle dot}30), with similar estimates across sensitivity analyses (E-value 4{middle dot}40). Clinical complications were the strongest predictor of death (aOR 23{middle dot}1, 95% CI 1{middle dot}73-307). Vaccination was protective (aOR 0{middle dot}28, 95% CI 0{middle dot}08- 0{middle dot}94) and treatment delay of four or more days increased mortality (aOR 4{middle dot}15, 95% CI 1{middle dot}23-14{middle dot}0). HBC was not associated with increased household transmission or long-term sequelae. InterpretationVaccination and early treatment, rather than care setting, were the main determinants of survival. When supported by clinical triage and structured follow-up, decentralised care can be used to manage mild cases during diphtheria epidemics in settings with constrained hospital capacity. FundingMedecins Sans Frontieres, West and Central Africa. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed and Google Scholar for articles published between January 1, 2000, and February 28, 2026, using combinations of the terms "diphtheria", "outbreak", "home-based care", "outpatient", "ambulatory", "community care", and "decentralised care". We found no published studies evaluating any form of decentralised or home-based clinical management for diphtheria. The existing literature on diphtheria case management is confined to facility-based settings: outbreak reports from multiple affected countries describe hospital-based treatment with diphtheria antitoxin (DAT) and antibiotics, and a systematic review pooled epidemiological and clinical data from historical outbreaks. Decentralised care models have been evaluated for other epidemic-prone diseases, including a measles epidemic in the Democratic Republic of the Congo (DRC) where decentralised management reduced mortality among children, and Ebola virus disease outbreaks in DRC where decentralised treatment centres were piloted to improve geographic access, though with limited outcome data. No study has assessed whether patients with diphtheria can be safely managed outside hospital settings. Added value of this studyNo prior evaluation of home-based care for diphtheria has been published. Using a retrospective matched cohort design with 678 patients during the largest diphtheria outbreak in Africa in decades, we found no evidence that home-based care increased mortality, long-term complications, or household transmission compared with facility-based care, and acceptability was high among patients in both groups. The study also provides one of the largest datasets on household transmission of diphtheria in an urban epidemic setting, finding no evidence that home-based care increased secondary transmission, and showing that vaccination status of the index case was the main factor influencing spread within the household. Implications of all the available evidenceProvided that triage is reliable, antibiotics are started promptly, and a functioning referral pathway exists, mild diphtheria can be managed safely at home during large epidemics. This approach preserves limited hospital and DAT resources for patients with moderate or severe disease, shortens treatment delays, and is acceptable to patients. Given ongoing outbreaks across West and Central Africa and persistent DAT supply constraints, decentralised care warrants inclusion in epidemic preparedness.

BackgroundVietnams disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnams epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. MethodsUsing Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnams NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. FindingsThe CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. InterpretationVietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum. FundingThis research received no specific grant from any funding agency.

Background: Malaria remains a major global health threat, with 249 million cases and 609,000 deaths reported in 2022. The Ashanti Region of Ghana bears a disproportionate burden, with severe malaria accounting for 24% of hospital admissions in 2021, above the national average of 19%. Despite intensified control efforts, inpatient mortality patterns remain poorly understood. This study identifies key determinants of severe malaria mortality among hospitalized patients in the Ashanti Region. Methods: We analyzed inpatient surveillance data from the District Health Information Management System 2 (DHIMS2) for severe malaria admissions from 2018 to 2022. Descriptive statistics, bivariate analyses with robust survey estimation (accounting for design effects), and multivariable Firth penalized logistic regression were used to identify mortality predictors. Survey-adjusted logistic regression served as a sensitivity analysis to validate findings. Results: Among 54,544 severe malaria admissions, females comprised 51.1% and children under five 39.4%. The case fatality rate was 0.4% (200 deaths). Mortality was significantly associated with age, occupation, insurance status, facility ownership, admitting department, length of stay, and comorbidities. Males had 1.4 times higher mortality odds than females. Compared to children under five, patients aged 5 to 17 years had 44% lower odds of mortality (aOR = 0.56, 95% CI: 0.33, 0.94). Active NHIS membership had lower mortality odds by 67% (aOR=0.33, 95% CI: 0.25, 0.45) compared to inactive membership. Admissions to faith-based facilities showed lower mortality odds (aOR=0.38, 95% CI: 0.23, 0.65) than government facilities, while medical wards had higher odds (aOR=2.38, 95% CI: 1.48, 3.84) than paediatric wards. Stays of 3 to 5 days were associated with lower mortality odds (aOR=0.67, 95% CI: 0.47, 0.97) compared to stays <3 days. Those with comorbidities had twice the mortality odds versus those without. Sensitivity analysis confirmed consistent direction and significance. Conclusion: Age, comorbidities, insurance coverage, facility type, and admission practices strongly influence severe malaria mortality in Ashanti. Strengthening NHIS enrollment, extending inpatient monitoring beyond three days, and adopting best practices from paediatric and faith based facilities could improve survival. Integrating comorbidity screening and management into malaria protocols is essential to reducing preventable deaths.