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An efficient allocation of limited resources in low-income settings offers the opportunity to improve population-health outcomes given the available health system capacity. Efforts to achieve this are often framed through the lens of "health benefits packages" (HBPs), which seek to establish which services the public healthcare system should include in its provision. Analytic approaches widely used to weigh evidence in support of different interventions and inform the broader HBP deliberative process however have limitations. In this work, we propose the individual-based Thanzi La Onse (TLO) model as a uniquely-tailored tool to assist in the evaluation of Malawi-specific HBPs while addressing these limitations. By mechanistically modelling—and calibrating to extensive, country-specific data—the incidence of disease, health-seeking behaviour, and the capacity of the healthcare system to meet the demand for care under realistic constraints on human resources for health available, we were able to simulate the health gains achievable under a number of plausible HBP strategies for the country. We found that the HBP emerging from a linear constrained optimisation analysis (LCOA) achieved the largest health gain—∼8% reduction in disability adjusted life years (DALYs) between 2023 and 2042 compared to the benchmark scenario—by concentrating resources on high-impact treatments. This HBP however incurred a relative excess in DALYs in the first few years of its implementation. Other feasible approaches to prioritisation were assessed, including service prioritisation based on patient characteristics, rather than service type. Unlike the LCOA-based HBP, this approach achieved consistent health gains relative to the benchmark scenario on a year- to-year basis, and a 5% reduction in DALYs over the whole period, which suggests an approach based upon patient characteristics might prove beneficial in the future. Author summary: All publicly funded healthcare systems face difficult decisions about how limited resources should be allocated to achieve the greatest possible return in health. These decisions are particularly pressing in lower-income countries (LICs) like Malawi, where resources are extremely limited and their inefficient allocation results in larger morbidity and mortality. In this work, we introduce a new analytical tool to inform such decisions based on an "all diseases, whole healthcare system" simulation specifically tailored to Malawi, the Thanzi La Onse (TLO) model. The TLO model is able to forecast the health burden that should be expected from different resource-allocation strategies in Malawi specifically, allowing policy-makers to explore a wide range of policy options in a safe and theoretical fashion. In this analysis, we compare the forecasted health burden from a set of common resource-prioritisation strategies, and draw some general conclusions as to what makes certain strategies more or less effective in reducing the health burden incurred. [ABSTRACT FROM AUTHOR]

Community–facility linkage interventions are gaining popularity as a way to improve community health in low-income settings. Their aim is to create/strengthen a relationship between community members and local healthcare providers. Representatives from both groups can address health issues together, overcome trust problems, potentially leading to participants' empowerment to be responsible for their own health. This can be achieved via different approaches. We conducted a systematic literature review to explore how this type of intervention has been implemented in rural and low or lower-middle-income countries, its various features and how/if it has helped to improve child health in these settings. Publications from three electronic databases (Web of Science, PubMed and Embase) up to 03 February 2022 were screened, with 14 papers meeting the inclusion criteria (rural setting in low/lower-middle-income countries, presence of a community–facility linkage component, outcomes of interest related to under-5 children's health, peer-reviewed articles containing original data written in English). We used Rosato's integrated conceptual framework for community participation to assess the transformative and community-empowering capacities of the interventions, and realist principles to synthesize the outcomes. The results of this analysis highlight which conditions can lead to the success of this type of intervention: active inclusion of hard-to-reach groups, involvement of community members in implementation's decisions, activities tailored to the actual needs of interventions' contexts and usage of mixed methods for a comprehensive evaluation. These lessons informed the design of a community–facility linkage intervention and offer a framework to inform the development of monitoring and evaluation plans for future implementations. [ABSTRACT FROM AUTHOR]

BackgroundIn 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013-2025.MethodsWe used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts.ResultsNine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour.ConclusionThese findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

BackgroundIn 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013-2025.MethodsWe used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts.ResultsNine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour.ConclusionThese findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

Objective To investigate implementation of outpatient pulse oximetry among children with pneumonia, in Malawi. Methods In 2011, 72 health-care providers at 18 rural health centres and 38 community health workers received training in the use of pulse oximetry to measure haemoglobin oxygen saturations. Data collected, between 1 January 2012 and 30 June 2014 by the trained individuals, on children aged 2-59 months with clinically diagnosed pneumonia were analysed. Findings Of the 14 092 children included in the analysis, 13 266 (94.1 %) were successfully checked by oximetry. Among the children with chest indrawing and/or danger signs, those with a measured oxygen saturation below 90% were more than twice as likely to have been referred as those with higher saturations (84.3% [385/457] vs 41.5% [871/2099]; P< 0.001). The availability of oximetry appeared to have increased the referral rate for severely hypoxaemic children without chest indrawing or danger signs from 0% to 27.2% {P< 0.001). In the absence of oximetry, if the relevant World Health Organization (WHO) guidelines published in 2014 had been applied, 390/568 (68.7%) severely hypoxaemic children at study health centres and 52/84 (61.9%) severely hypoxaemic children seen by community health workers would have been considered ineligible for referral. Conclusion Implementation of pulse oximetry by our trainees substantially increased the referrals of Malawian children with severe hypoxaemic pneumonia. When data from oximetry were excluded, retrospective application of the guidelines published by WHO in 2014 failed to identify a considerable proportion of severely hypoxaemic children eligible only via oximetry. Objectif Etudier l'utilisation de l'oxymetrie de pouls chez les enfants atteints de pneumonie en traitement ambulatoire au Malawi. Methodes En 2011,72 prestataires de soins de sante de 18 centres de sante ruraux et 38 agents de sante communautaires ont ete formes a l'utilisation de l'oxymetrie de pouls pour mesurer la saturation en oxygene de l'hemoglobine. Des donnees collectees entre le 1er janvler 2012 et le 30 juin 2014 par les individus formes sur des enfants ages de 2 a 59 mois atteints d'une pneumonle clinlquement diagnostiquee ont ete analysees. Resultats Sur les 14 092 enfants Indus dans l'analyse, 13 266 (94,1%) ont ete examlnes avec succes grace a roxymetrle. Parml les enfants presentant un tlrage sous-costal et/ou des signes de danger, ceux dont la saturation en oxygene mesuree etalt inferleure a 90% avalent plus de deux fois plus de chances d'etre orientes vers un spedaliste que ceux presentant une saturation plus Importante (84,3% [385/457] contre 41,5% [871/2099]; P< 0,001). L'utilisation de l'oxymetrie semble avoir augmente de 0% a 27,2% (P < 0.001) le taux d'orientation vers un spedaliste dans le cas des enfants souffrant d'hypoxemle severe sans tirage sous-costal ni signes de danger. En /absence d'oxymetrle, si les directives en la matlere publlees par /Organisation mondlale de la Sante (OMS) en 2014 avalent ete appllquees, 390/568 (68,7%) enfants souffrant d'hypoxemle severe examlnes dans les centres de sante conslderes et 52/84(61,9%) enfants souffrant d'hypoxemie severe examlnes par des agents de sante communautalres n'auraient pas pu beneficier d'une orientation vers un spedaliste. Conclusion L'utilisation de l'oxymetrie de pouls par les individus formes a considerablement accru l'orientation vers un spedaliste des enfants malawltes atteints de pneumonle severe et ayant developpe une hypoxemle. Lorsque les donnees provenant de l'oxymetrie etaient exclues, l'application retrospective des directives publlees par I'OMS en 2014 ne permettalt pas d'ldentlfier une proportion considerable d'enfants souffrant d'hypoxemle severe qul rempllssalent les conditions requises uniquement au vu de l'oxymetrie. Objetivo Investigar la implementacion investigar ia impiementacion de la oximetria de pulso ambulatoria en ninos con neumonia en Malawi. Metodos En 2011,72 profesionales de la salud de 18 centros de salud en zonas rurales y 38 trabajadores de la salud comunitarios recibieron formacion con respecto al uso de la oximetria de pulso para medir las saturaciones de oxigeno de la hemoglobina. Se analizaron los datos, que las personas formadas recopilaron entre el 1 de enero de 2012 y el 30 de junio de 2014, de ninos de 2 a 59 meses de edad con un diagnostico clinico de neumonia. Resultados De los 14 092 ninos incluidos en el analisis, se realizaron las pruebas con oximetria de manera satisfactoria a 13 266 (94,1%). Entre los ninos con retraccion costal y/o signos de peligro, aquellos con una medida de saturacion de oxigeno por debajo del 90% tenian mas del doble de probabilidades de haber sido derivados que aquellos con saturaciones mas elevadas (84,3% [385/457] frente al 41,5% [871/2 099]; P < 0,001). La disponibilidad de la oximetria parecio haber incrementado la tasa de derivacion para ninos hlpoxemicos graves sin retraccion costal ni signos de peligro del 0% al 27,2% (P < 0,001). A falta de oximetria, si se hubieran aplicado las directrices de la Organizacion Mundial de la Salud (OMS) pertinentes publicadas en 2014, se podria haber considerado que 390/568 (el 68,7%) de los ninos hipoxemlcos graves en los centros sanitarios del estudio y 52/84 (el 61,9%) de los ninos hlpoxemicos graves visitados por los trabajadores de salud comunitarios no eran elegibles para la derivacion. Conclusion La implementacion de la oximetria de pulso por las personas formadas Incremento de forma sustancial las derivaciones de los ninos de Malawi con neumonia hlpoxemlca grave. Cuando se excluyeron los datos procedentes de la oximetria, la aplicacion retrospectiva de las directrices publicadas por la OMS en 2014 no pudo identificar un porcentaje considerable de ninos hipoxemlcos graves que cumplian los requisitos unicamente a traves de la oximetria., Introduction Among children with pneumonia; hypoxaemia is common, predicts mortality and is a marker of severe illness. (1-3) Pulse oximetry--hereafter called oximetry--is the standard tool for non-invasively measuring peripheral arterial [...]

Background The mortality impact of pulse oximetry use during infant and childhood pneumonia management at the primary healthcare level in low-income countries is unknown. We sought to determine mortality outcomes of infants and children diagnosed and referred using clinical guidelines with or without pulse oximetry in Malawi. Methods and findings We conducted a data linkage study of prospective health facility and community case and mortality data. We matched prospectively collected community health worker (CHW) and health centre (HC) outpatient data to prospectively collected hospital and community-based mortality surveillance outcome data, including episodes followed up to and deaths within 30 days of pneumonia diagnosis amongst children 0-59 months old. All data were collected in Lilongwe and Mchinji districts, Malawi, from January 2012 to June 2014. We determined differences in mortality rates using Conclusions Pulse oximetry identified fatal pneumonia episodes at HCs in Malawi that would otherwise have been missed by WHO referral guidelines alone. Our findings suggest that pulse oximetry could be beneficial in supplementing clinical signs to identify children with pneumonia at high risk of mortality in the outpatient setting in health centres for referral to a hospital for appropriate management., Author(s): Tim Colbourn 1,*, Carina King 1,2, James Beard 1, Tambosi Phiri 3, Malizani Mdala 3, Beatiwel Zadutsa 3, Charles Makwenda 3, Anthony Costello 1, Norman Lufesi 4, Charles Mwansambo [...]