BMJ Global Health

BackgroundMost births worldwide (>80%) occur in health care facilities, yet 2.3 million newborns die annually. If the know-do gap between evidence and implementation was closed, an estimated 752,000 newborn deaths could be prevented per year. To bridge this gap, we describe the co-design of the Implementation Toolkit for Small and Sick Newborn Care (Newborn Toolkit), a web platform and linked community of global implementers, facilitated by NEST360 and UNICEF. The Newborn Toolkit enables access to practical, curated resources, including tools for peer learning and adaptation to country contexts. MethodsA systematic three step process was followed. Step 1) Structure: We used an organising framework of WHO and UNICEF ten core components for health systems strengthening. We then reviewed relevant knowledge management platforms to identify elements facilitating user engagement. Step 2) Content: >300 implementers collated publications and tools for ten core components. Step 3) Refining and building community: User data analytics and surveys plus direct feedback from the global communities of practice provided data to improve website and webinar content. ResultsStep 1) Structure: In 2020, the Newborn Toolkit website structure was co-designed based on the ten core components. Step 2) Content: Working groups, organised by core components, collated over 1,100 resources in 15 languages. Step 3) Refining and building community: Cross-country learning was facilitated through 45 webinars with multi-disciplinary speakers from all continents including caregivers, clinicians, non-governmental organisation representatives, engineers, and data scientists. French language translation and engagement was added between 2023-2025. Unique user counts increased with 28,146 in 2023 to 62,561 in 2025 from 198 countries and territories. The most viewed content includes WHO guidelines, neonatal floor plans, the ABC device costing tool, and data tools. ConclusionsGiven the urgency for accelerated progress for newborn survival by 2030, rapid implementation of proven solutions is needed. It is crucial that implementers can access evidence and tools to adapt for their specific context, rather than "reinventing the wheel". Systems change is complex, requiring novel approaches to make it doable, such as standard, simplified action pathways available on the Newborn Toolkit. Gaps to address include evidence availability in multiple languages. KEY FINDINGSO_LIWHAT WAS KNOWN? O_LI2.3 million neonatal deaths are estimated annually and 65 countries are at-risk of missing Sustainable Development Goal 3.2 of reducing the number of neonatal deaths to less than 12 per 1,000 live births by 2030 C_LIO_LIThere exists a know-do gap in global newborn health referring to the inability to translate evidence, what is known to work, into practice to improve health outcomes for WHO-UNICEF level-2 Small and Sick Newborn Care C_LIO_LIFrameworks based on country experiences have been created to guide health systems strengthening such as the WHO/UNICEF core components; however, operationalisation is needed C_LIO_LIEvidence, guidelines, and resources for Small and Sick Newborn Care were available; however, there existed a gap in knowledge management platforms dedicated to enabling evidence-based implementation of health systems strengthening interventions in low-resource settings C_LI C_LIO_LIWHAT WAS DONE THAT IS NEW? O_LIWe co-designed a knowledge management platform for resources including tools, readings, and case studies to bridge the know-do gap for Small and Sick Newborn Care in low-resource settings C_LIO_LIContent and resources on the site were organised according to the ten WHO/UNICEF core components for health systems strengthening plus infection prevention and control C_LIO_LIThis platform was operationalised and scaled by linking to, and engaging with, a global community of practice C_LIO_LIWe applied a continuous learning and feedback integration approach to develop and refine content, enable accessibility including by language, and tailor engagement initiatives to implementer needs informed by website user and webinar data analytics C_LI C_LIO_LIWHAT WAS FOUND? O_LIThe platform hosts over 1,100 tools and readings with resources available in 15 languages C_LIO_LIBetween 2021-2025, this platform had 157,452 unique users, from 198 countries and territories C_LIO_LI45 webinars were hosted between 2022-2025 showcasing implementation case studies and facilitating cross-country learning C_LIO_LIKnowledge management and targeted engagement can enable uptake of information by organising content in practical, digestible, and feasible formats C_LI C_LIO_LIWHAT NEXT? O_LIThe know-do gap in Small and Sick Newborn Care needs to be closed. Providing up-to-date, relevant evidence that adapts to emerging knowledge and local learning, alongside leadership and financial inputs, could facilitate quality care delivery through data-driven decision making C_LIO_LIBridging language barriers, through content translation, is a priority and crucial to enable wider access to up-to-date evidence C_LI C_LI

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.

IntroductionAccess to medical oxygen remains a challenge, with 60% of the worlds population lacking access to quality oxygen services. We explored whether outsourced oxygen to the bedside (O2B), where private providers offer bundles of oxygen services, could be adopted and scaled across diverse health systems, to improve patient access to oxygen. MethodsQualitative interviews were conducted with healthcare workers (HCWs), facility management staff and district medical officers in India, Nigeria, Tanzania, Kenya and Uganda, who had taken part in an O2B pilot. Interviews were conducted between 19th November 2024 and 25th January 2025, and explored the feasibility, fidelity, acceptability, perceived benefits and weaknesses of five O2B models. Analysis used a pragmatic codebook approach, with inductive and deductive coding, informed by implementation science frameworks. ResultsWe conducted 59 interviews, with managers and HCWs from 20 health facilities. We identified five themes relating to the potential for O2B pilots to be adopted within the health system: effect on oxygen culture, feasibility of whole of facility solutions, promotion of local ownership, being willing but unsure about the ability to pay, and the desire for hybrid tailored service models. HCWs and facility staff raised several positive factors within these themes but highlighted that understanding local facility needs and tailoring the services to embed within existing structures were important for sustainability. ConclusionOverall, the O2B service approach shows potential for implementation beyond the pilots, but more understanding of how to optimize service delivery packages to different facility needs, while also prioritizing affordability is needed.

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.

Background Regulatory 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 Africa's first continental pilot study for the scientific evaluation and listing of human medicinal products. This study evaluates the pilot's procedural performance and examines how continental scientific opinions were translated into national regulatory decisions through reliance mechanisms. Methods and Findings A 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. Retrospective 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 Conclusions The 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.

BackgroundEmergency Departments (EDs) are crucial to managing non-communicable diseases (NCDs), a leading cause of death, yet there is limited information about the capacity and accessibility of emergency care in Kenya. MethodsUsing data from Project 47, a national dataset on EDs, we conducted a secondary analysis to assess capacity for NCD care, as guided by the WHO Package for Essential NCD Interventions for Primary Care (WHO PEN). ResultsOf the 186 facilities included in the assessment, 45.7% (n=85) had a designated ED. ED capacity, distribution of facilities, number of patients seeking care, and WHO PEN indicators varied by Regional Economic Bloc (REB). Mount Kenya and Aberdares (MKAREB) and Lake Region (LREB) REBs included the greatest number of facilities and served the largest patient catchment areas nationally (8.5 million and 17.8 million, respectively). Key diagnostic tools and treatments were inconsistently available, with ECGs lacking outside of Nairobi (100% of EDs in Nairobi, 14.8% to 33.3% outside of Nairobi, P=0.1021). Oxygen was consistently available in only 44.8% of facilities in FCDC-Pwani, 59.3% in LREB, and 42.9% in NAKAEB, highlighting significant regional gaps, despite the LREB serving a disproportionately larger patient population. Glucometers, similarly, were universally available (100%) in Nairobi, but only available variably in other regional blocs (51.7% to 93.3%, P=0.001474). ConclusionMajor disparities exist in emergency care capacity and NCD management resources across Kenyan regions, especially in LREB and NAKAEB, where majority of care occurs in the country. Targeted, equitable investment is required to expand essential infrastructure and diagnostics. Decentralizing emergency services beyond Nairobi must be prioritized to improve timely access to care, enhance quality, reduce patient costs, and address the needs of high-burden regions. KEY MESSAGESO_ST_ABSWhat is already knownC_ST_ABSEmergency departments in Kenya provide a key role in treating and managing non-communicable diseases. The most comprehensive data available about emergency department infrastructure, resources, and clinical visits in the country were collected via Project 47, conducted by the Emergency Medicine Kenya Foundation. What this study addsThis secondary analysis of Project 47 data provides information about the capacity and accessibility of emergency care in Kenya, particularly as it pertains to Noncommunicable Diseases, focusing on cardiovascular disease, chronic respiratory disease, diabetes, and cancer, acute and emergency care, and the variability across different regions. How this study might affect research, practice, or policyResources to improve the capacity and accessibility of emergency care in Kenya can be directed to the areas of highest need in order to maximize the impact on patient care. Similar assessments can be conducted in the region to guide emergency care resource allocation.

BackgroundSouth Africas National Tuberculosis (TB) Programme aims to achieve targets set by the World Health Organizations End TB Strategy, including an 80% reduction in TB incidence and a 90% reduction in TB mortality by 2030, compared to 2015 levels. We were tasked to evaluate 1) the impact on TB incidence and mortality of scaling up individual interventions focusing on TB preventive therapy, screening, testing and linkage to treatment as included in the 2023-2028 National Strategic Plan for TB (NSP); 2) the budget required for implementing the NSP; 3) the cost-effectiveness of scaling up individual interventions aligning with NSP targets, and 4) the health impact and cost-effectiveness of additional aggressive screening scenarios to reach the End TB targets. MethodsWe used the Thembisa TB model and public-sector costs to estimate the incremental cost-effectiveness per life year saved (LYS) for individual and combined interventions under various scenarios from 2023 to 2042. The NSP scenario included expansions of TB preventive therapy (TPT), symptom screening at primary health clinics and testing with Xpert, screening of household contacts of people with TB, and community-based screening (door-to-door and digital chest X-ray), as well as targeted universal testing for TB (TUTT) in people living with HIV (PLHIV), household contacts of people with TB and individuals with a history of TB, and reduction of initial loss-to-follow-up (ILTFU), all to levels deemed feasible by NSP stakeholders. We also assessed two hypothetical scenarios that largely maximise screening: Max scenario 1 (TPT for PLHIV, quarterly symptom screening for all adults) and Max scenario 2 (TPT for PLHIV, with eligible adults receiving yearly chest X-rays, TB testing, and TPT for household contacts). ResultsThe NSP achieved a 44% reduction in TB incidence and a 55% reduction in mortality by 2030 relative to 2015, while the aggressive scenarios (Max 1 and Max 2) achieved 57% and 56% reductions in incidence, respectively; and 75% and 71% reductions in mortality, respectively. Among individual NSP interventions, over the period 2023-2043, TPT for PLHIV and Xpert testing for symptomatic individuals seeking TB care were cost-saving. Symptom screening for household contacts ($12/LYS), ILTFU reduction ($13/LYS), TUTT for household contacts ($84/LYS), and TPT for household contacts ($106/LYS) were the most cost-effective interventions. Compared to baseline, the NSP scenario increased cost by 57%, saving 6.6 million life-years at $308/LYS over the period 2023-2042. The Max 1 and Max 2 scenarios increased the cost significantly, by 329% and 1526%, respectively. Max 1 saved 16.5 million life-years at $712/LYS, while Max 2 saved 14.6 million life-years at $3,774/LYS. ConclusionScaling up TB interventions to NSP coverage targets will substantially save lives and reduce TB morbidity. However, the End TB targets will not be met even under additional scenarios considered, including more aggressive prevention and screening. Accelerating progress would require both improving efficiencies of existing strategies and developing new tools including low-cost diagnostics and effective TB vaccines.

As programs for azithromycin mass drug administration to reduce child mortality have begun in some parts of West Africa, it is imperative to understand their financial costs. We combined a micro-costing framework and observations from an implementation-focused sub-study within the AVENIR trials in 80 communities in the Dosso region of Niger to estimate the national health sector costs of a scaled-up programmatic approach for azithromycin biannual distribution to children aged 1-59 months of age living in nonurban areas, using the door-to-door modality. Our outcomes of interest were the annual budget at the regional and national levels for Niger and the cost per dose delivered. We found that the annual national budget required for azithromycin mass drug administration (MDA) achieving 90% average coverage would be $12.5M (95% Uncertainty Interval (UI) $12.2M, $13.0M) translating to $1.59 (95% UI $1.40, $2.30) per dose delivered. Across regions, cost per dose would vary from $1.17 (95% UI $1.03, $1.69) to $3.61 (95% UI $3.20, $5.16), with higher cost per dose expected for more sparsely populated regions. Training costs represented a large fraction (16.4%) of total costs, and integration of training with that for existing health interventions may provide opportunities for efficiency.

BackgroundThe 2013-2016 Ebola virus disease outbreak in West Africa profoundly affected Sierra Leones health financing, health delivery, health governance, and health workforce. The country becomes the first among those most severely affected ten years ago by the West Africa Ebola outbreak, to launch nationwide preventive Ebola vaccination, targeting 20,000 frontline workers who received a single dose of the Ebola Vaccine. MethodsA mixed-method study design that analysed administrative vaccination data, field supervision reports, and electronic records from all 16 districts in Sierra Leone was used. The following indicators were analysed: vaccination coverage and logistical regression. Qualitative information from stakeholder debriefings and community feedback complemented the findings from the quantitative analysis. Quantitative data were analysed using Statistical Package for the Social Sciences (SPSS) version 27. ResultsA total of 17,454 (vaccine coverage= 84.5%) frontline workers and high-risk populations for EVD infection were vaccinated. Healthcare workers accounted for 35% of all vaccinations. Multivariate analysis showed that females had an AOR of 1.507 (95% CI: 1.293-1.756, P < 0.001) and individuals with tertiary education had an AOR of 1.900 (95% CI: 1.371-2.633, P < 0.001), were more likely to be vaccinated. Western and Southern regions achieved the highest coverage due to superior cold-chain readiness and community mobilisation. No serious adverse events following immunisation were reported. ConclusionSierra Leones decade-long journey from outbreak response to preventive vaccination demonstrates the transformative impact of sustained investment, multisectoral coordination, and community trust. High coverage and operational success affirm the feasibility of nationwide Ebola immunisation in resource-limited settings.

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.

BackgroundDelays in tuberculosis (TB) diagnosis and treatment continue to compromise control efforts, particularly in high-burden settings such as Kenya. These delays increase transmission, worsen clinical outcomes, and elevate mortality. The post-COVID-19 period has further strained health-care systems, influencing patient health-seeking behaviour and diagnostic efficiency. Objective: To quantify patient-related and health-system-related delays in TB diagnosis and treatment and to identify key determinants of these delays among adults receiving care at Kenyatta National Hospital (KNH). MethodsA descriptive cross-sectional study involving 128 smear-positive pulmonary TB patients was conducted in 2022. Participants aged [&ge;]15 years were selected through systematic sampling. Data on socio-demographic factors, care-seeking pathways, and diagnostic intervals were collected through structured interviews. Delay durations were categorized using the median as the cut-off point. Descriptive statistics, chisquare tests, and logistic regression were used to determine predictors of patient and system delays. Statistical significance was set at p < 0.05. ResultsWomen constituted 51.2% of participants, with the largest age group being 40-49 years (32.3%). A substantial proportion (29.9%) sought medical care only after 2-3 months of symptoms. Distance to health facilities, socio-economic constraints, and health-worker-related factors were significantly associated with prolonged delay (p < 0.05). Many patients (66.9%) reported fear upon receiving a diagnosis, while 96.1% believed they should access treatment free of charge. Perceived community stigma was high (96.9%), and both patient behaviour and health-system processes were considered contributors to delayed care. ConclusionSignificant patient-level and system-level delays persist at KNH, highlighting critical gaps in early TB detection and timely initiation of treatment. Strengthening diagnostic capacity, decentralizing services, enhancing patient awareness, and improving health-worker responsiveness are essential to accelerate TB case detection and align with national and global TB-control targets.

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 [&ge;]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 Kenya's 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. Methods We 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. Results The 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. Conclusion Facility 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.

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.

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.

IntroductionEnteric fever, caused by Salmonella enterica serovars Typhi and Paratyphi, remains an important cause of febrile illness in low- and middle-income countries (LMIC). However, the exact burden is difficult to estimate due to limitations in diagnosis and surveillance. MethodsSamples from a representative cross-sectional household serosurvey in rural western Cambodia were used to estimate enteric fever seroincidence among children and young adults. Participants were enrolled between April 7 and December 10, 2023, and 529 samples from individuals aged 5-25 years were analysed. Using IgA and IgG responses to hemolysin E antigen and established models of antibody decay after infection, we estimated seroincidence, conveying the rate of new infection in the population. Participants were enrolled between April and December 2023, and 529 samples from individuals aged 5-25 years were analysed. ResultsThe overall enteric fever seroincidence rate was 161.8/1,000 person-years (95%CI: 144.6, 181.0). Among children 5-15 years, it ranged between 149.5 (95%CI: 128.7, 173.7) and 239.0 (95%CI:169.2, 337.6) across districts. Seroincidence was numerically higher among children 5-15 years from households with unimproved drinking water sources or sanitation facilities, and districts with a higher proportion of households with unimproved WASH. ConclusionThese findings potentially support the introduction of the typhoid conjugate vaccine in rural western Cambodia. However, additional data on the relative contribution of S. Typhi versus S. Paratyphi is needed. We also demonstrate seroincidence as an adjunctive valuable surveillance tool in LMICs where facility-based surveillance may be inadequate. Key questionsO_ST_ABSWhat is already known on this topicC_ST_ABSO_LICambodia is estimated to have a high burden of enteric fever with a modelled incidence of 1.1/1,000 person-years among those under 20 years in 2023, but lacks population-level data. C_LIO_LIExisting estimates likely underestimate the burden because facility-based surveillance is affected by limitations on diagnosis sensitivity and healthcare access, and the modelled approach lacks country-specific incidence data. C_LIO_LIValidated antibody kinetics models using Hemolysin E (HlyE) antigen of Salmonella serovars Typhi and Paratyphi enable estimation of enteric fever seroincidence from cross-sectional serosurveys. C_LI What this study addsO_LIThis study provides the first population-based estimates of enteric fever seroincidence in rural western Cambodia using HlyE antibody kinetics. C_LIO_LIChildren 5-15 years showed high enteric fever seroincidence that potentially meets the WHO definition for a high-typhoid-incidence setting. C_LIO_LISeroincidence varied geographically and by age, with higher seroincidence in districts with poor water, sanitation and hygiene (WASH) access, and the patterns suggest variations in S. Typhi and S. Paratyphi attribution. C_LI How this study might affect research, practice or policyO_LIOur findings indicate a substantially higher enteric fever burden in rural western Cambodia than previously reported. C_LIO_LIHigh seroincidence among children supports the consideration of the typhoid conjugate vaccine introduction, while highlighting the need for blood culture data to clarify S. Typhi and S. Paratyphi attribution to guide vaccination strategies better. C_LIO_LIImproving WASH access should also be prioritised to reduce transmission of both S. Typhi and S. Paratyphi. C_LIO_LISeroincidence estimation from cross-sectional serosurveys offers a scalable approach for settings where blood culture surveillance is limited. C_LI

BackgroundAcute respiratory infection (ARI) remains a leading cause of morbidity and mortality among children under five in Nigeria. Although polluting cooking fuels are widely considered a key risk factor, their effects may be shaped by broader socioeconomic and geographic conditions. This study examined both individual and structural determinants of ARI and assessed how these factors intersect to pattern risk. MethodsWe analysed data from 28,728 children under five in the 2024 Nigeria Demographic and Health Survey. Three ARI definitions were applied. Survey-weighted quasibinomial logistic regression estimated associations between ARI and cooking fuel type, child age and sex, household wealth quintile, residence type, geopolitical zone, and parental education. To examine intersectional patterning, we conducted a Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), constructing strata defined by combinations of cooking fuel, wealth, residence, and geopolitical zone. The intraclass correlation coefficient (ICC) quantified between-strata variance. ResultsStrict ARI prevalence was 1.9%, and 8.3% of children had broader respiratory symptoms. In unadjusted analyses, polluting fuel use was associated with higher odds of respiratory symptoms (OR 1.85, 95% CI 1.43-2.39). After adjustment, this association was substantially attenuated, indicating confounding by structural factors. Child age was the most consistent predictor: children aged 24-59 months had about half the odds of strict ARI compared with infants (aOR 0.53, 95% CI 0.41-0.68). Geopolitical zone showed the strongest overall association. MAIHDA revealed that 9% of total ARI variance lay between intersectional strata (ICC = 0.09), and this variance was not explained by child age or sex. The population-attributable fraction for polluting fuel declined from 41.4% to 12.4% after adjustment. ConclusionsARI risk among Nigerian children is shaped more by structural and geographic inequalities than by household fuel use alone. Equity-focused, subnational policies addressing intersecting socioeconomic and regional disadvantage are needed to reduce the ARI burden.

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.

Introduction: Despite global progress in tuberculosis (TB) control, treatment outcomes remain suboptimal, particularly in high-burden settings and among people with HIV or drug-resistant TB. Identifying predictors of unsuccessful treatment is essential to improve TB care and policy. Methods: We evaluated TB treatment outcomes and patient characteristics associated with unsuccessful outcomes in five cohorts of the International epidemiology database to evaluate AIDS (IeDEA); Center for Infectious Disease Research, Zambia; Chiure health center, Mozambique; Martin Preuss Center, Lighthouse clinic, Malawi; Masvingo health center Zimbabwe; and Themba Lethu clinic, Hellen Joseph hospital, South Africa. We included all patients with TB aged 15 years starting TB treatment and assessed their treatment outcomes in association with sociodemographic and clinical characteristics using multivariable mixed-effects models. Unsuccessful outcomes were defined as death, loss to follow-up and treatment failure. Results: Among 1438 people with TB, median age was 39 years, 67% males, 40% with HIV, and 4% with MDR-TB; 1151 (80%) treatment outcomes were successful (606 cured and 545 completed treatment), 221 (15%) unsuccessful (89 deaths, 129 loss to follow-up and 3 treatment failures), and 66 (5%) other (49 unknown and 17 transfer-outs). Unsuccessful outcomes were more probable among people with multidrug-resistant TB (MDR-TB) and among participants without formal education. Risk of death was lower for people with bacteriologically confirmed TB (adjusted odds ratio (aOR) 0.5, 95%-credible interval [CI] 0.25-0.80), those with a secondary or higher education (aOR 0.3, 95%-CI 0.13-0.69) and BMI 318 kg/m{superscript 2} (aOR 0.6, 95%-CI 0.36-0.99). MDR-TB was associated with an increase (aOR 2.4 95%-CI 1.17-4.97) and primary and secondary or higher education with a decrease in loss to follow-up (aOR 0.3, 95%-CI 0.14-0.89 and aOR 0.3, 95%-CI 0.11-0.67, respectively). Conclusions: TB treatment outcomes fell short of the targets set by the World Health Organization of <10% unsuccessful outcomes, indicating a critical need for enhanced management strategies. Tackling loss to follow-up is crucial, especially among MDR-TB patients, including stronger retention activities and improved diagnostic capacities.