Publications
These are the publications that have been generated either in the course of the model’s development or its application.
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Overview of the model
Hallett et al. (2024). Estimates of resource use in the public-sector health-care system and the effect of strengthening health-care services in Malawi during 2015–19: a modelling study (Thanzi La Onse). The Lancet Global Health.
Type Journal article DOI 10.1016/S2214-109X(24)00413-3 Date November 2024 Authors Timothy B Hallett, Tara D Mangal, Asif U Tamuri, Nimalan Arinaminpathy, Valentina Cambiano, Martin Chalkley, Joseph H Collins, Jonathan Cooper, Matthew S Gillman, Mosè Giordano, Matthew M Graham, William Graham, Iwona Hawryluk, Eva Janoušková, Britta L Jewell, Ines Li Lin, Robert Manning Smith, Gerald Manthalu, Emmanuel Mnjowe, Sakshi Mohan, Margherita Molaro, Wingston Ng'ambi, Dominic Nkhoma, Stefan Piatek, Paul Revill, Alison Rodger, Dimitra Salmanidou, Bingling She, Mikaela Smit, Pakwanja D Twea, Tim Colbourn, Joseph Mfutso-Bengo, and Andrew N Phillips. Abstract Background In all health-care systems, decisions need to be made regarding allocation of available resources. Evidence is needed for these decisions, especially in low-income countries. We aimed to estimate how health-care resources provided by the public sector were used in Malawi during 2015–19 and to estimate the effects of strengthening health-care services. Methods For this modelling study, we used the Thanzi La Onse model, an individual-based simulation model. The scope of the model was health care provided by the public sector in Malawi during 2015–19. Health-care services were delivered during health-care system interaction (HSI) events, which we characterised as occurring at a particular facility level and requiring a particular number of appointments. We developed mechanistic models for the causes of death and disability that were estimated to account for approximately 81% of deaths and approximately 72% of disability-adjusted life-years (DALYs) in Malawi during 2015–19, according to the Global Burden of Disease (GBD) estimates; we computed DALYs incurred in the population as the sum of years of life lost and years lived with disability. The disease models could interact with one another and with the underlying properties of each person. Each person in the Thanzi La Onse model had specific properties (eg, sex, district of residence, wealth percentile, smoking status, and BMI, among others), for which we measured distribution and evolution over time using demographic and health survey data. We also estimated the effect of different types of health-care system improvement. Findings We estimated that the public-sector health-care system in Malawi averted 41·2 million DALYs (95% UI 38·6–43·8) during 2015–19, approximately half of the 84·3 million DALYs (81·5–86·9) that the population would otherwise have incurred. DALYs averted were heavily skewed to children aged 0–4 years due to services averting DALYs that would be caused by acute lower respiratory tract infection, HIV or AIDS, malaria, or neonatal disorders. DALYs averted among adults were mostly attributed to HIV or AIDS and tuberculosis. Under a scenario whereby each appointment took the time expected and health-care workers did not work for longer than contracted, the health-care system in Malawi during 2015–19 would have averted only 19·1 million DALYs (95% UI 17·1–22·4), suggesting that approximately 21·3 million DALYS (20·0–23·6) of total effect were derived through overwork of health-care workers. If people becoming ill immediately accessed care, all referrals were successfully completed, diagnostic accuracy of health-care workers was as good as possible, and consumables (ie, medicines) were always available, 28·2% (95% UI 25·7–30·9) more DALYS (ie, 12·2 million DALYs [95% UI 10·9–13·8]) could be averted. Interpretation The health-care system in Malawi provides substantial health gains with scarce resources. Strengthening interventions could potentially increase these gains, so should be a priority for investigation and investment. An individual-based simulation model of health-care service delivery is valuable for health-care system planning and strengthening. Funding The Wellcome Trust, UK Research and Innovation, the UK Medical Research Council, and Community Jameel.
Analyses using the model
Mangal et al. (2025). Modelling health outcomes of a decade of HIV, malaria and tuberculosis initiatives, Malawi. Bull. World Health Organ.
Type Journal article DOI Date May 2025 Authors Tara Danielle Mangal, Margherita Molaro, Dominic Nkhoma, Tim Colbourn, Joseph H Collins, Eva Janoušková, Matthew M Graham, Ines Li Lin, Emmanuel Mnjowe, Tisungane E Mwenyenkulu, Sakshi Mohan, Bingling She, Asif U Tamuri, Pakwanja D Twea, Peter Winskill, Andrew Phillips, Joseph Mfutso-Bengo, and Timothy B Hallett. Abstract Objective: To estimate the outcome of programmes on human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis and malaria in Malawi across multiple health domains. Methods: We used an integrated epidemiological and health system model to estimate the impact of HIV/AIDS, tuberculosis and malaria programmes in Malawi from 2010 to 2019. We incorporated interacting disease dynamics, intervention effects and health system use in the model. We examined four scenarios, comparing actual programme delivery with hypothetical scenarios excluding the health programmes individually and collectively. Findings: From 2010 to 2019, an estimated 1.08 million deaths and 74.89 million disability-adjusted life years were prevented by the HIV/AIDS, tuberculosis and malaria programmes. An additional 15 600 deaths from other causes were also prevented. Life expectancy increased by 13.0 years for males and 16.9 years for females. The programmes accounted for 18.5% (95% uncertainty interval, UI: 18.2 to 18.6) of all health system interactions, including 157.0 million screening and diagnostic tests and 23.2 million treatment appointments. Only 41.5 million additional health worker hours (17.1%; 95% UI: 15.9 to 17.4%) of total health worker time) were needed to achieve these gains. The HIV/AIDS, tuberculosis and malaria programmes required an additional 120.7 million outpatient appointments, which were offset by a net decrease in inpatient care (9.4 million bed-days) that would have been necessary in their absence. Conclusion: HIV/AIDS, tuberculosis and malaria programmes have greatly increased life expectancy and provided direct and spill-over effects on health in Malawi. These investments reduced the burden on inpatient and emergency care, which requires more intensive health worker involvement. Collins et al. (2025). An individual-based modelling study estimating the impact of maternity service delivery on health in Malawi. Nature Communications.
Type Journal article DOI 10.1038/s41467-025-59060-2 Date April 2025 Authors Joseph H. Collins, Helen Allott, Wingston Ng’ambi, Ines Li Lin, Mosè Giordano, Matthew M. Graham, Eva Janoušková, Fannie Kachale, Kondwani Kawaza, Tara D. Mangal, Joseph Mfutso-Bengo, Emmanuel Mnjowe, Sakshi Mohan, Margherita Molaro, Dominic Nkhoma, Paul Revill, Alison Rodger, Bingling She, Asif U. Tamuri, Cally J. Tann, Pakwanja D. Twea, Valentina Cambiano, Timothy B. Hallett, Andrew N. Phillips, and Tim Colbourn. Abstract Maternal and perinatal morbidity and mortality remain high in Malawi, partially due to gaps in the coverage and quality of health services. We developed an individual-based model of maternal and perinatal health and healthcare in Malawi, situated in a ‘whole-health system, all-disease’ framework (Thanzi La Onse). We modelled sixteen scenarios estimating the impact of current and improved coverage and quality of antenatal, intrapartum, and postnatal services from 2023 to 2030. Whilst current service delivery is inferred to avert morbidity and mortality, the largest reductions in the stillbirth, maternal and neonatal mortality rates were observed when the use and quality of all services was maximised concurrently (a 10%, 52% and 57% reduction respectively). When services were considered in isolation, generally, increased coverage without quality improvement did not impact mortality or DALYs. In only three scenarios was a sufficient reduction in neonatal mortality observed to achieve target 3.2 of the United Nation’s Sustainable Development Goals (SDG), and in no scenarios was a reduction in maternal mortality sufficient to achieve SDG target 3.1 observed, reaffirming that system wide investments are essential to achieve these goals. Mohan (2024). The Potential Impact of Investments in Supply Chain Strengthening (Retrospective analysis). European Health Economics Association (EuHEA) conference 2024.
Type Conference paper DOI 10.15124/yao-7b1g-n044 Date November 2024 Authors Sakshi Mohan. Abstract Supply chain strengthening (SCS) is a key component in the overall strategy of countries to move towards universal health coverage. Estimating the health benefit of investments in such health system strengthening (HSS) interventions has been challenging because these benefits are mediated through their impact on the delivery of a wide range of healthcare interventions, creating a problem of attribution. We overcome this challenge by simulating the impact of SCS within the Thanzi La Onse (TLO) model, an individual-based simulation of health care needs and service delivery for Malawi, drawing upon demographic, epidemiological and routine healthcare system data (on facilities, staff and consumables). In this study, we combine the results of a previous inferential analysis on the factors associated with consumable availability at health facilities in Malawi with the TLO model to estimate the potential for health impact of SCS interventions in the country. We do this by first predicting the expected change in consumable availability by making a positive change to these factors using previously fitted multi-level regression models of consumable availability. We then run the TLO model with these improved consumable availability estimates. The difference in the DALYs accrued by the simulated population under the baseline availability of consumables and that under improved consumable availability estimates gives us the potential for health impact of SCS interventions which would influence these factors. Countries regularly need to make decisions on allocating resources across a range of health interventions (including service delivery and HSS). Crucial to guide these decisions is a value-for-money (VfM) assessment comparing these interventions. Our analysis offers the first step in estimating the VfM of a sample of SCS interventions and can guide Malawi in its evaluation of alternative health sector investments. Mangal et al. (2024). Assessing the effect of health system resources on HIV and tuberculosis programmes in Malawi: a modelling study. The Lancet Global Health.
Type Journal article DOI 10.1016/S2214-109X(24)00259-6 Date October 2024 Authors Tara D Mangal, Sakshi Mohan, Timothy Colbourn, Joseph H Collins, Mathew Graham, Andreas Jahn, Eva Janoušková, Ines Li Lin, Robert Manning Smith, Emmanuel Mnjowe, Margherita Molaro, Tisungane E Mwenyenkulu, Dominic Nkhoma, Bingling She, Asif Tamuri, Paul Revill, Andrew N Phillips, Joseph Mfutso-Bengo, and Timothy B Hallett. Abstract Background Malawi is progressing towards UNAIDS and WHO End TB Strategy targets to eliminate HIV/AIDS and tuberculosis. We aimed to assess the prospective effect of achieving these goals on the health and health system of the country and the influence of consumable constraints. Methods In this modelling study, we used the Thanzi la Onse (Health for All) model, which is an individual-based multi-disease simulation model that simulates HIV and tuberculosis transmission, alongside other diseases (eg, malaria, non-communicable diseases, and maternal diseases), and gates access to essential medicines according to empirical estimates of availability. The model integrates dynamic disease modelling with health system engagement behaviour, health system use, and capabilities (ie, personnel and consumables). We used 2018 data on the availability of HIV and tuberculosis consumables (for testing, treatment, and prevention) across all facility levels of the country to model three scenarios of HIV and tuberculosis programme scale-up from Jan 1, 2023, to Dec 31, 2033: a baseline scenario, when coverage remains static using existing consumable constraints; a constrained scenario, in which prioritised interventions are scaled up with fixed consumable constraints; and an unconstrained scenario, in which prioritised interventions are scaled up with maximum availability of all consumables related to HIV and tuberculosis care. Findings With uninterrupted medical supplies, in Malawi, we projected HIV and tuberculosis incidence to decrease to 26 (95% uncertainty interval [UI] 19–35) cases and 55 (23–74) cases per 100 000 person-years by 2033 (from 152 [98–195] cases and 123 [99–160] cases per 100 000 person-years in 2023), respectively, with programme scale-up, averting a total of 12·21 million (95% UI 11·39–14·16) disability-adjusted life-years. However, the effect was compromised by restricted access to key medicines, resulting in approximately 58 700 additional deaths (33 400 [95% UI 22 000–41 000] due to AIDS and 25 300 [19 300–30 400] due to tuberculosis) compared with the unconstrained scenario. Between 2023 and 2033, eliminating HIV treatment stockouts could avert an estimated 12 100 deaths compared with the baseline scenario, and improved access to tuberculosis prevention medications could prevent 5600 deaths in addition to those achieved through programme scale-up alone. With programme scale-up under the constrained scenario, consumable stockouts are projected to require an estimated 14·3 million extra patient-facing hours between 2023 and 2033, mostly from clinical or nursing staff, compared with the unconstrained scenario. In 2033, with enhanced screening, 188 000 (81%) of 232 900 individuals projected to present with active tuberculosis could start tuberculosis treatment within 2 weeks of initial presentation if all required consumables were available, but only 8600 (57%) of 15 100 presenting under the baseline scenario. Interpretation Ignoring frailties in the health-care system, in particular the potential non-availability of consumables, in projections of HIV and tuberculosis programme scale-up might risk overestimating potential health impacts and underestimating required health system resources. Simultaneous health system strengthening alongside programme scale-up is crucial, and should yield greater benefits to population health while mitigating the strain on a heavily constrained health-care system. Funding Wellcome and UK Research and Innovation as part of the Global Challenges Research Fund. Molaro et al. (2024). The potential impact of declining development assistance for healthcare on population health: projections for Malawi. medRxiv.
Type Pre-print DOI 10.1101/2024.10.11.24315287 Date October 2024 Authors Margherita Molaro, Paul Revill, Martin Chalkley, Sakshi Mohan, Tara Mangal, Tim Colbourn, Joseph H. Collins, Matthew M. Graham, William Graham, Eva Janoušková, Gerald Manthalu, Emmanuel Mnjowe, Watipaso Mulwafu, Rachel Murray-Watson, Pakwanja D. Twea, Andrew N. Phillips, Bingling She, Asif U. Tamuri, Dominic Nkhoma, Joseph Mfutso-Bengo, and Timothy B. Hallett. Abstract Development assistance for health (DAH) to Malawi will likely decrease as a fraction of GDP in the next few decades. Given the country’s significant reliance on DAH for the delivery of its healthcare services, estimating the impact that this could have on health projections for the country is particularly urgent. We use the Malawi-specific, individual-based “all diseases – whole health-system” Thanzi La Onse model to estimate the impact this could have on health system capacities, proxied by the availability of human resources for health, and consequently on population health outcomes. We estimate that the projected changes in DAH could result in a 7-15.8% increase in disability-adjusted life years compared to a scenario where health spending as a percentage of GDP remains unchanged. This could cause a reversal of gains achieved to date in many areas of health, although progress against HIV/AIDS appears to be less vulnerable. The burden due to non-communicable diseases, on the other hand, is found to increase irrespective of yearly growth in health expenditure, if assuming current reach and scope of interventions. Finally, we find that greater health expenditure will improve population health outcomes, but at a diminishing rate. Molaro et al. (2024). A new approach to Health Benefits Package design: an application of the Thanzi La Onse model in Malawi. PLOS Computational Biology.
Type Journal article DOI 10.1371/journal.pcbi.1012462 Date September 2024 Authors Margherita Molaro, Sakshi Mohan, Bingling She, Martin Chalkley, Tim Colbourn, Joseph H. Collins, Emilia Connolly, Matthew M. Graham, Eva Janoušková, Ines Li Lin, Gerald Manthalu, Emmanuel Mnjowe, Dominic Nkhoma, Pakwanja D. Twea, Andrew N. Phillips, Paul Revill, Asif U. Tamuri, Joseph Mfutso-Bengo, Tara D. Mangal, and Timothy B. Hallett. Abstract 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. She et al. (2024). Health workforce needs in Malawi: analysis of the Thanzi La Onse integrated epidemiological model of care. Human Resources for Health.
Type Journal article DOI 10.1186/s12960-024-00949-2 Date September 2024 Authors Bingling She, Tara D. Mangal, Margaret L. Prust, Stephanie Heung, Martin Chalkley, Tim Colbourn, Joseph H. Collins, Matthew M. Graham, Britta Jewell, Purava Joshi, Ines Li Lin, Emmanuel Mnjowe, Sakshi Mohan, Margherita Molaro, Andrew N. Phillips, Paul Revill, Robert Manning Smith, Asif U. Tamuri, Pakwanja D. Twea, Gerald Manthalu, Joseph Mfutso-Bengo, and Timothy B. Hallett. Abstract To make the best use of health resources, it is crucial to understand the healthcare needs of a population—including how needs will evolve and respond to changing epidemiological context and patient behaviour—and how this compares to the capabilities to deliver healthcare with the existing workforce. Existing approaches to planning either rely on using observed healthcare demand from a fixed historical period or using models to estimate healthcare needs within a narrow domain (e.g., a specific disease area or health programme). A new data-grounded modelling method is proposed by which healthcare needs and the capabilities of the healthcare workforce can be compared and analysed under a range of scenarios: in particular, when there is much greater propensity for healthcare seeking. Li Lin et al. (2024). The Impact and Cost-Effectiveness of Pulse Oximetry and Oxygen on Acute Lower Respiratory Infection Outcomes in Children Under-5 in Malawi: A Modelling Study. Social Science Research Network.
Type Pre-print DOI 10.2139/ssrn.4947417 Date September 2024 Authors Ines Li Lin, Eric D. McCollum, Eric Thomas Buckley, Valentina Cambiano, Joseph H. Collins, Matthew M. Graham, Eva Janoušková, Carina King, Norman Lufesi, Tara Danielle Mangal, Joseph Matthew Mfutso-Bengo, Sakshi Mohan, Margherita Molaro, Dominic Nkhoma, Humphreys Nsona, Alexander Rothkopf, Bingling She, Lisa Smith, Asif U. Tamuri, Paul Revill, Andrew N. Phillips, Timothy B. Hallett, and Tim Colbourn. Abstract Background: Acute Lower Respiratory Infections (ALRI) are the leading cause of post-neonatal death in children under-5 globally. The impact, costs, and cost-effectiveness of routine pulse oximetry and oxygen on ALRI outcomes at scale remain unquantified. Methods: We evaluate the impact and cost-effectiveness of scaling up pulse oximetry and oxygen on childhood ALRI outcomes in Malawi using a new and detailed individual-based model, together with a comprehensive costing assessment for 2024 that includes both capital and operational expenditures. We model 15 scenarios ranging from no pulse oximetry or oxygen (null scenario) to high coverage (90% pulse oximetry usage, and 80% oxygen availability) across the health system. Cost-effectiveness results are presented in incremental cost-effectiveness ratio (ICER) and incremental net health benefit (INHB) using Malawi-specific cost-effectiveness threshold of \$80 per Disability-Adjusted Life Year (DALY) averted. Findings: The cost-effective strategy is the full scale-up of both pulse oximetry and oxygen to 90% usage rate and 80% availability, respectively. This combination results in 71% of hypoxaemic ALRI cases accessing oxygen, averting 73,100 DALYs in the first year of implementation and 29% of potential ALRI deaths, at an ICER of \$34 per DALY averted and \$894 per death averted. The INHB is 42,200 net DALYs averted. Interpretation: Pulse oximetry and oxygen are complementary cost-effective interventions in Malawi, where health expenditure is low, and should be scaled-up in parallel. Funding: UKRI, Wellcome Trust, DFID, EU, CHAI, Unitaid.Declaration of Interest: Besides funding from the Wellcome Trust and UK Research and Innovation going towards authors’ institutions, some authors took on private projects, outside the submitted work. ILL declares receiving consulting fees from ICDDR-B for her work for the Lancet Commission on Medical Oxygen Security related to this study. TC declares consulting fees donated to his institution from the Global Fund for related work, personal consulting fees from the UN Economic Commission for Africa, and non-paid work chairing a Trial Steering Committee for a trial of adolescent mental health interventions in Nepal. ANP declares receiving consulting fees from the Bill & Melinda Gates Foundation. All other authors declare no competing interests.Ethical Approval: The Thanzi La Onse project received ethical approval from the College of Medicine Malawi Research Ethics Committee (COMREC, P.10/19/2820) in Malawi. Only anonymized secondary data are used in the Thanzi La Onse model including in the ALRI model used in this paper; therefore, individual informed consent was not required. Mohan et al. (2024). Factors associated with medical consumable availability in level 1 facilities in Malawi: a secondary analysis of a facility census. The Lancet Global Health.
Type Journal article DOI 10.1016/S2214-109X(24)00095-0 Date June 2024 Authors Sakshi Mohan, Tara D Mangal, Tim Colbourn, Martin Chalkley, Chikhulupiliro Chimwaza, Joseph H Collins, Matthew M Graham, Eva Janoušková, Britta Jewell, Godfrey Kadewere, Ines Li Lin, Gerald Manthalu, Joseph Mfutso-Bengo, Emmanuel Mnjowe, Margherita Molaro, Dominic Nkhoma, Paul Revill, Bingling She, Robert Manning Smith, Wiktoria Tafesse, Asif U Tamuri, Pakwanja Twea, Andrew N Phillips, and Timothy B Hallett. Abstract Background Medical consumable stock-outs negatively affect health outcomes not only by impeding or delaying the effective delivery of services but also by discouraging patients from seeking care. Consequently, supply chain strengthening is being adopted as a key component of national health strategies. However, evidence on the factors associated with increased consumable availability is limited. Methods In this study, we used the 2018–19 Harmonised Health Facility Assessment data from Malawi to identify the factors associated with the availability of consumables in level 1 facilities, ie, rural hospitals or health centres with a small number of beds and a sparsely equipped operating room for minor procedures. We estimate a multilevel logistic regression model with a binary outcome variable representing consumable availability (of 130 consumables across 940 facilities) and explanatory variables chosen based on current evidence. Further subgroup analyses are carried out to assess the presence of effect modification by level of care, facility ownership, and a categorisation of consumables by public health or disease programme, Malawi's Essential Medicine List classification, whether the consumable is a drug or not, and level of average national availability. Findings Our results suggest that the following characteristics had a positive association with consumable availability—level 1b facilities or community hospitals had 64% (odds ratio [OR] 1·64, 95% CI 1·37–1·97) higher odds of consumable availability than level 1a facilities or health centres, Christian Health Association of Malawi and private-for-profit ownership had 63% (1·63, 1·40–1·89) and 49% (1·49, 1·24–1·80) higher odds respectively than government-owned facilities, the availability of a computer had 46% (1·46, 1·32–1·62) higher odds than in its absence, pharmacists managing drug orders had 85% (1·85, 1·40–2·44) higher odds than a drug store clerk, proximity to the corresponding regional administrative office (facilities greater than 75 km away had 21% lower odds [0·79, 0·63–0·98] than facilities within 10 km of the district health office), and having three drug order fulfilments in the 3 months before the survey had 14% (1·14, 1·02–1·27) higher odds than one fulfilment in 3 months. Further, consumables categorised as vital in Malawi's Essential Medicine List performed considerably better with 235% (OR 3·35, 95% CI 1·60–7·05) higher odds than other essential or non-essential consumables and drugs performed worse with 79% (0·21, 0·08–0·51) lower odds than other medical consumables in terms of availability across facilities. Interpretation Our results provide evidence on the areas of intervention with potential to improve consumable availability. Further exploration of the health and resource consequences of the strategies discussed will be useful in guiding investments into supply chain strengthening. Funding UK Research and Innovation as part of the Global Challenges Research Fund (Thanzi La Onse; reference MR/P028004/1), the Wellcome Trust (Thanzi La Mawa; reference 223120/Z/21/Z), the UK Medical Research Council, the UK Department for International Development, and the EU (reference MR/R015600/1). She et al. (2024). The changes in health service utilisation in Malawi during the COVID-19 pandemic. PLOS ONE.
Type Journal article DOI 10.1371/journal.pone.0290823 Date January 2024 Authors Bingling She, Tara D. Mangal, Anna Y. Adjabeng, Tim Colbourn, Joseph H. Collins, Eva Janoušková, Ines Li Lin, Emmanuel Mnjowe, Sakshi Mohan, Margherita Molaro, Andrew N. Phillips, Paul Revill, Robert Manning Smith, Pakwanja D. Twea, Dominic Nkhoma, Gerald Manthalu, and Timothy B. Hallett. Abstract Introduction The COVID-19 pandemic and the restriction policies implemented by the Government of Malawi may have disrupted routine health service utilisation. We aimed to find evidence for such disruptions and quantify any changes by service type and level of health care. Methods We extracted nationwide routine health service usage data for 2015–2021 from the electronic health information management systems in Malawi. Two datasets were prepared: unadjusted and adjusted; for the latter, unreported monthly data entries for a facility were filled in through systematic rules based on reported mean values of that facility or facility type and considering both reporting rates and comparability with published data. Using statistical descriptive methods, we first described the patterns of service utilisation in pre-pandemic years (2015–2019). We then tested for evidence of departures from this routine pattern, i.e., service volume delivered being below recent average by more than two standard deviations was viewed as a substantial reduction, and calculated the cumulative net differences of service volume during the pandemic period (2020–2021), in aggregate and within each specific facility. Results Evidence of disruptions were found: from April 2020 to December 2021, services delivered of several types were reduced across primary and secondary levels of care–including inpatient care (-20.03% less total interactions in that period compared to the recent average), immunisation (-17.61%), malnutrition treatment (-34.5%), accidents and emergency services (-16.03%), HIV (human immunodeficiency viruses) tests (-27.34%), antiretroviral therapy (ART) initiations for adults (-33.52%), and ART treatment for paediatrics (-41.32%). Reductions of service volume were greatest in the first wave of the pandemic during April-August 2020, and whereas some service types rebounded quickly (e.g., outpatient visits from -17.7% to +3.23%), many others persisted at lower level through 2021 (e.g., under-five malnutrition treatment from -15.24% to -42.23%). The total reduced service volume between April 2020 and December 2021 was 8 066 956 (-10.23%), equating to 444 units per 1000 persons. Conclusion We have found substantial evidence for reductions in health service delivered in Malawi during the COVID-19 pandemic which may have potential health consequences, the effect of which should inform how decisions are taken in the future to maximise the resilience of healthcare system during similar events. Colbourn et al. (2023). Modeling Contraception and Pregnancy in Malawi: A Thanzi La Onse Mathematical Modeling Study. Studies in Family Planning.
Type Journal article DOI 10.1111/sifp.12255 Date 2023 Authors Tim Colbourn, Eva Janoušková, Ines Li Lin, Joseph Collins, Emilia Connolly, Matt Graham, Britta Jewel, Fannie Kachale, Tara Mangal, Gerald Manthalu, Joseph Mfutso-Bengo, Emmanuel Mnjowe, Sakshi Mohan, Margherita Molaro, Wingston Ng'ambi, Dominic Nkhoma, Paul Revill, Bingling She, Robert Manning Smith, Pakwanja Twea, Asif Tamuri, Andrew Phillips, and Timothy B. Hallett. Abstract Malawi has high unmet need for contraception with a costed national plan to increase contraception use. Estimating how such investments might impact future population size in Malawi can help policymakers understand effects and value of policies to increase contraception uptake. We developed a new model of contraception and pregnancy using individual-level data capturing complexities of contraception initiation, switching, discontinuation, and failure by contraception method, accounting for differences by individual characteristics. We modeled contraception scale-up via a population campaign to increase initiation of contraception (Pop) and a postpartum family planning intervention (PPFP). We calibrated the model without new interventions to the UN World Population Prospects 2019 medium variant projection of births for Malawi. Without interventions Malawi's population passes 60 million in 2084; with Pop and PPFP interventions. it peaks below 35 million by 2100. We compare contraception coverage and costs, by method, with and without interventions, from 2023 to 2050. We estimate investments in contraception scale-up correspond to only 0.9 percent of total health expenditure per capita though could result in dramatic reductions of current pressures of very rapid population growth on health services, schools, land, and society, helping Malawi achieve national and global health and development goals. Manning Smith et al. (2022). Estimating the health burden of road traffic injuries in Malawi using an individual-based model. Injury Epidemiology.
Type Journal article DOI 10.1186/s40621-022-00386-6 Date July 2022 Authors Robert Manning Smith, Valentina Cambiano, Tim Colbourn, Joseph H. Collins, Matthew Graham, Britta Jewell, Ines Li Lin, Tara D. Mangal, Gerald Manthalu, Joseph Mfutso-Bengo, Emmanuel Mnjowe, Sakshi Mohan, Wingston Ng’ambi, Andrew N. Phillips, Paul Revill, Bingling She, Mads Sundet, Asif Tamuri, Pakwanja D. Twea, and Timothy B. Hallet. Abstract Road traffic injuries are a significant cause of death and disability globally. However, in some countries the exact health burden caused by road traffic injuries is unknown. In Malawi, there is no central reporting mechanism for road traffic injuries and so the exact extent of the health burden caused by road traffic injuries is hard to determine. A limited number of models predict the incidence of mortality due to road traffic injury in Malawi. These estimates vary greatly, owing to differences in assumptions, and so the health burden caused on the population by road traffic injuries remains unclear. Mangal et al. (2021). Potential impact of intervention strategies on COVID-19 transmission in Malawi: a mathematical modelling study. BMJ Open.
Type Journal article DOI 10.1136/bmjopen-2020-045196 Date July 2021 Authors Tara Mangal, Charlie Whittaker, Dominic Nkhoma, Wingston Ng'ambi, Oliver Watson, Patrick Walker, Azra Ghani, Paul Revill, Timothy Colbourn, Andrew Phillips, Timothy Hallett, and Joseph Mfutso-Bengo. Abstract Background COVID-19 mitigation strategies have been challenging to implement in resource-limited settings due to the potential for widespread disruption to social and economic well-being. Here we predict the clinical severity of COVID-19 in Malawi, quantifying the potential impact of intervention strategies and increases in health system capacity. Methods The infection fatality ratios (IFR) were predicted by adjusting reported IFR for China, accounting for demography, the current prevalence of comorbidities and health system capacity. These estimates were input into an age-structured deterministic model, which simulated the epidemic trajectory with non-pharmaceutical interventions and increases in health system capacity. Findings The predicted population-level IFR in Malawi, adjusted for age and comorbidity prevalence, is lower than that estimated for China (0.26%, 95% uncertainty interval (UI) 0.12%–0.69%, compared with 0.60%, 95% CI 0.4% to 1.3% in China); however, the health system constraints increase the predicted IFR to 0.83%, 95% UI 0.49%–1.39%. The interventions implemented in January 2021 could potentially avert 54 400 deaths (95% UI 26 900–97 300) over the course of the epidemic compared with an unmitigated outbreak. Enhanced shielding of people aged ≥60 years could avert 40 200 further deaths (95% UI 25 300–69 700) and halve intensive care unit admissions at the peak of the outbreak. A novel therapeutic agent which reduces mortality by 0.65 and 0.8 for severe and critical cases, respectively, in combination with increasing hospital capacity, could reduce projected mortality to 2.5 deaths per 1000 population (95% UI 1.9–3.6). Conclusion We find the interventions currently used in Malawi are unlikely to effectively prevent SARS-CoV-2 transmission but will have a significant impact on mortality. Increases in health system capacity and the introduction of novel therapeutics are likely to further reduce the projected numbers of deaths. Hawryluk et al. (2020). The potential impact of including pre-school aged children in the praziquantel mass-drug administration programmes on the S.haematobium infections in Malawi: a modelling study. medRxiv.
Type Pre-print DOI 10.1101/2020.12.09.20246652 Date December 2020 Authors Iwona Hawryluk, Tara Mangal, Andrew Nguluwe, Chikonzero Kambalame, Stanley Banda, Memory Magaleta, Lazarus Juziwelo, and Timothy B. Hallett. Abstract Background Mass drug administration (MDA) of praziquantel is an intervention used in the treatment and prevention of schistosomiasis. In Malawi, MDA happens annually across high-risk districts and covers around 80% of school aged children and 50% of adults. The current formulation of praziquantel is not approved for use in the preventive chemotherapy for children under 5 years old, known as pre-school aged children (PSAC). However, a new formulation for PSAC will be available by 2022. A comprehensive analysis of the potential additional benefits of including PSAC in the MDA will be critical to guide policy-makers. Methods We developed a new individual-based stochastic transmission model of Schistosoma haematobium for the 6 highest prevalence districts of Malawi. The model was used to evaluate the benefits of including PSAC in the MDA campaigns, with respect to the prevalence of high-intensity infections (\textgreater 500 eggs per ml of urine) and reaching the elimination target, meaning the prevalence of high-intensity infections under 5% in all sentinel sites. The impact of different MDA frequencies and coverages is quantified by prevalence of high-intensity infection and number of rounds needed to decrease that prevalence below 1%. Results Including PSAC in the MDA campaigns can reduce the time needed to achieve the elimination target for S. haematobium infections in Malawi by one year. The modelling suggests that in the case of a lower threshold of high-intensity infection, currently set by WHO to 500 eggs per ml of urine, including PSAC in the preventive chemotherapy programmes for 5 years can reduce the number of the high-intensity infection case years for pre-school aged children by up to 9.1 years per 100 children. Conclusions Regularly treating PSAC in the MDA is likely to lead to overall better health of children as well as a decrease in the severe morbidities caused by persistent schistosomiasis infections and bring forward the date of elimination. Moreover, mass administration of praziquantel to PSAC will decrease the prevalence among the SAC, who are at the most risk of infection.
Healthcare seeking behaviour
Murray-Watson et al. (2025). Extreme weather and healthcare access in Malawi: the impact of precipitation on ANC service utilisation. medRxiv.
Type Pre-print DOI 10.1101/2025.04.15.25325855 Date 2025 Authors Rachel E. Murray-Watson, Margherita Molaro, Rebecca J. Murray-Watson, Sakshi Mohan, Bingling She, Tara Mangal, Joseph H. Collins, Sangeeta Bhatia, Eva Janoušková, and Timothy B. Hallett. Abstract Malawi is vulnerable to climate-related shocks, which are projected to worsen. Whilst some dimensions of this vulnerability have been characterised, little is known about healthcare sector resilience. Coupling facility-specific data on antenatal care (ANC) service provision in Malawi with gridded precipitation data, we use regression analyses to characterise the historic relationship between precipitation and healthcare access. We estimate that, between 2012 and 2024, precipitation negatively impacted ANC service utilisation in Malawi, with up to 1 in 20 appointments disrupted annually in some districts. Projecting further to 2060 indicates that, cumulatively, up to 250,000 pregnancies could be affected. Notably, if precipitation patterns from 1941–1953 had persisted into the 21st century, disruptions between 2012 — 2024 would be a hundred times less frequent, highlighting the significant influence of anthropogenic climate change on healthcare access. In a country already facing high maternal and neonatal mortality, such disruptions could further hinder access to care and worsen health outcomes. Ng'ambi et al. (2022). Socio-demographic factors associated with early antenatal care visits among pregnant women in Malawi: 2004–2016. PLOS ONE.
Type Journal article DOI 10.1371/journal.pone.0263650 Date February 2022 Authors Wingston Felix Ng'ambi, Joseph H. Collins, Tim Colbourn, Tara Mangal, Andrew Phillips, Fannie Kachale, Joseph Mfutso-Bengo, Paul Revill, and Timothy B. Hallett. Abstract Introduction In 2016, the WHO published recommendations increasing the number of recommended antenatal care (ANC) visits per pregnancy from four to eight. Prior to the implementation of this policy, coverage of four ANC visits has been suboptimal in many low-income settings. In this study we explore socio-demographic factors associated with early initiation of first ANC contact and attending at least four ANC visits (“ANC4+”) in Malawi using the Malawi Demographic and Health Survey (MDHS) data collected between 2004 and 2016, prior to the implementation of new recommendations. Methods We combined data from the 2004–5, 2010 and 2015–16 MDHS using Stata version 16. Participants included all women surveyed between the ages of 15–49 who had given birth in the five years preceding the survey. We conducted weighted univariate, bivariate and multivariable logistic regression analysis of the effects of each of the predictor variables on the binary endpoint of the woman attending at least four ANC visits and having the first ANC attendance within or before the four months of pregnancy (ANC4+). To determine whether a factor was included in the model, the likelihood ratio test was used with a statistical significance of P\textless 0.05 as the threshold. Results We evaluated data collected in surveys in 2004/5, 2010 and 2015/6 from 26386 women who had given birth in the five years before being surveyed. The median gestational age, in months, at the time of presenting for the first ANC visit was 5 (inter quartile range: 4–6). The proportion of women initiating ANC4+ increased from 21.3% in 2004–5 to 38.8% in 2015–16. From multivariate analysis, there was increasing trend in ANC4+ from women aged 20–24 years (adjusted odds ratio (aOR) = 1.27, 95%CI:1.05–1.53, P = 0.01) to women aged 45–49 years (aOR = 1.91, 95%CI:1.18–3.09, P = 0.008) compared to those aged 15–19 years. Women from richest socio-economic position ((aOR = 1.32, 95%CI:1.12–1.58, P\textless 0.001) were more likely to demonstrate ANC4+ than those from low socio-economic position. Additionally, women who had completed secondary (aOR = 1.24, 95%CI:1.02–1.51, P = 0.03) and tertiary (aOR = 2.64, 95%CI:1.65–4.22, P\textless 0.001) education were more likely to report having ANC4+ than those with no formal education. Conversely increasing parity was associated with a reduction in likelihood of ANC4+ with women who had previously delivered 2–3 (aOR = 0.74, 95%CI:0.63–0.86, P\textless 0.001), 4–5 (aOR = 0.65, 95%CI:0.53–0.80, P\textless 0.001) or greater than 6 (aOR = 0.61, 95%CI: 0.47–0.79, \textless 0.001) children being less likely to demonstrate ANC4+. Conclusion The proportion of women reporting ANC4+ and of key ANC interventions in Malawi have increased significantly since 2004. However, we found that most women did not access the recommended number of ANC visits in Malawi, prior to the 2016 WHO policy change which may mean that women are less likely to undertake the 2016 WHO recommendation of 8 contacts per pregnancy. Additionally, our results highlighted significant variation in coverage according to key socio-demographic variables which should be considered when devising national strategies to ensure that all women access the appropriate frequency of ANC visits during their pregnancy. Ng'ambi et al. (2020). A cross-sectional study on factors associated with health seeking behaviour of Malawians aged 15+ years in 2016. Malawi Medical Journal.
Type Journal article DOI Date 2020 Authors Wingston Ng'ambi, Tara Mangal, Andrew Phillips, Tim Colbourn, Dominic Nkhoma, Joseph Mfutso- Bengo, Paul Revill, and Timothy B. Hallett. Abstract IntroductionHealth seeking behaviour (HSB) refers to actions taken by individuals who are ill in order to find appropriate remedy. Most studies on HSB have only examined one symptom or covered only a specific geographical location within a country. In this study, we used a representative sample of adults to explore the factors associated with HSB in response to 30 symptoms reported by adult Malawians in 2016.MethodsWe used the 2016 Malawi Integrated Household Survey dataset. We fitted a multilevel logistic regression model of likelihood of ‘seeking care at a health facility’ using a forward step-wise selection method, with age, sex and reported symptoms entered as a priori variables. We calculated the odds ratios (ORs) and their associated 95% confidence intervals (95% CI). We set the level of statistical significance at P < 0.05.Results Of 6909 adults included in the survey, 1907 (29%) reported symptoms during the 2 weeks preceding the survey. Of these, 937 (57%) sought care at a health facility. Adults in urban areas were more likely to seek health care at a health facility than those in rural areas (AOR = 1.65, 95% CI: 1.19–2.30, P = 0.003). Females had a higher likelihood of seeking care from health facilities than males (AOR = 1.26, 95% CI: 1.03–1.59, P = 0.029). Being of higher wealth status was associated with a higher likelihood of seeking care from a health facility (AOR = 1.58, 95% CI: 1.16–2.16, P = 0.004). Having fever and eye problems were associated with higher likelihood of seeking care at a health facility, while having headache, stomach ache and respiratory tract infections were associated with lower likelihood of seeking care at a health facility.ConclusionThis study has shown that there is a need to understand and address individual, socioeconomic and geographical barriers to health seeking to increase access and appropriate use of health care and fast-track progress towards Universal Health Coverage among the adult population. Ng'ambi et al. (2020). Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Tropical Medicine & International Health.
Type Journal article DOI 10.1111/tmi.13499 Date 2020 Authors Wingston Ng'ambi, Tara Mangal, Andrew Phillips, Tim Colbourn, Joseph Mfutso-Bengo, Paul Revill, and Timothy B. Hallett. Abstract Objective To characterise health seeking behaviour (HSB) and determine its predictors amongst children in Malawi in 2016. Methods We used the 2016 Malawi Integrated Household Survey data set. The outcome of interest was HSB, defined as seeking care at a health facility amongst people who reported one or more of a list of possible symptoms given on the questionnaire in the past two weeks. We fitted a multivariate logistic regression model of HSB using a forward step-wise selection method, with age, sex and symptoms entered as a priori variables. Results Of 5350 children, 1666 (32%) had symptoms in the past two weeks. Of the 1666, 1008 (61%) sought care at health facility. The children aged 5–14 years were less likely to be taken to health facilities for health care than those aged 0–4 years. Having fever vs. not having fever and having a skin problem vs. not having skin problem were associated with increased likelihood of HSB. Having a headache vs. not having a headache was associated with lower likelihood of accessing care at health facilities (AOR = 0.50, 95% CI: 0.26–0.96, P = 0.04). Children from urban areas were more likely to be taken to health facilities for health care (AOR = 1.81, 95% CI: 1.17–2.85, P = 0.008), as were children from households with a high wealth status (AOR = 1.86, 95% CI: 1.25–2.78, P = 0.02). Conclusion There is a need to understand and address individual, socio-economic and geographical barriers to health seeking to increase access and use of health care and fast-track progress towards Universal Health Coverage.
Healthcare provision
Mangal et al. (2025). System-wide investments enhance HIV, TB and malaria control in Malawi and deliver greater health impact. medRxiv.
Type Pre-print DOI 10.1101/2025.04.29.25326667 Date 2025 Authors Tara D Mangal, Sakshi Mohan, Margherita Molaro, Joseph Collins, Tim Colbourn, Eva Janoušková, Rachel E Murray-Watson, Dominic Nkhoma, Andrew Phillips, Bingling She, Pakwanja D Twea, Simon Walker, Paul Revill, and Timothy B. Hallett. Abstract Global health initiatives have expanded access to treatment for infectious diseases - especially HIV, tuberculosis, and malaria (HTM) - in low- and middle-income countries. However, these \textquotedblleft vertically\textquotedblright -funded programs often operate within fragile health systems, where workforce shortages and supply chain failures constrain their effectiveness and sustainability 1,2. Meanwhile, evaluating the health impact and value-for- money of \textquotedblleft horizontal\textquotedblright investments in systems, such as supply chain strengthening or boosting healthcare workforce, and their synergies with vertical programs (through \textquotedblleft diagonal\textquotedblright investments combining both) - remains challenging because their benefits are mediated through improvements in many aspects of healthcare delivery and are therefore difficult to measure3.Using a dynamic microsimulation model of Malawi\textquoteright s healthcare system, we show that a diagonal investment approach yields a four-fold greater health impact, measured in disability-adjusted life years (DALYs) averted, than the vertical approach. This approach not only improves health outcomes for non-HTM causes of DALYs but also amplifies the effect on DALYs caused by HTM. Additionally, diagonal investments offer greater value for money and a 24.94% higher return on investment (6.67 [5.81 - 6.85] compared with 5.34 [3.44 - 6.24]), even after accounting for their additional costs. Our findings demonstrate that HSS investments generate synergistic effects, amplifying the benefits of GHIs while also strengthening broader healthcare delivery. These results support a shift toward more integrated global health financing strategies. Tafesse and Chalkley (2024). The difference in clinical knowledge between staff employed at faith-based and public facilities in Malawi. Christian Journal for Global Health.
Type Journal article DOI 10.15566/cjgh.v11i1.853 Date February 2024 Authors Wiktoria Tafesse and Martin Chalkley. Abstract A peer-reviewed, scholarly, and multidisciplinary journal on global health policy and practice, promoting evidence-based and thoughtful analysis on effective and innovative approaches to global health from an integrated Christian perspective. The Journal publishes evidence-based research and Christian reflection addressing the biological, social, environmental, psychological, and spiritual determinants of health in a global context. The broad scope of the journal facilitates actionable learning and capacity building in development contexts within a scholarly framework. Topics include: Community and Public Health (Health Promotion/Prevention, Nutrition and Food Security, Environmental Health, Maternal and Child Health, Community Development) Health Care Services (Primary Health Care, Surgical Service, Disaster and Emergency, Rehabilitative services, Mental Health, Palliative Care) Organization (Administration and Finance, Policy and Advocacy, Workforce) Mission and Health (Theology, Outreach, Transformational Development) Conditions of Special Interest (HIV/AIDS, Non-Communicable Disease, Neglected Tropical Diseases) Tafesse and Chalkley (2021). Faith-based provision of sexual and reproductive healthcare in Malawi. Social Science & Medicine.
Type Journal article DOI 10.1016/j.socscimed.2021.113997 Date 2021 Authors Wiktoria Tafesse and Martin Chalkley. Abstract Abstract Faith-based organisations constitute the second largest healthcare providers in Sub-Saharan Africa but their religious values might be in conflict with providing some sexual and reproductive health services. We undertake regression analysis on data detailing client-provider interactions from a facility census in Malawi and examine whether religious ownership of facilities is associated with the degree of adherence to family planning guidelines. We find that faith-based organisations offer fewer services related to the investigation and prevention of sexually transmitted infections (STIs) and the promotion of condom use. The estimates are robust to several sensitivity checks on the impact of client selection. Given the prevalence of faith-based facilities in Sub-Saharan Africa, our results suggest that populations across the region may be at risk from inadequate sexual and reproductive healthcare provision which could exacerbate the incidence of STIs, such as HIV/AIDS, and unplanned pregnancies. Highlights Investigates whether faith-based facilities provide fewer sexual health services. Uses data on client-provider interactions from a facility-level census from Malawi. Faith-based providers are less likely to investigate STIs and promote condoms. Results are robust to matching and are not driven by client selection.
Data collection - protocol and analyses
Nkhoma et al. (2024). Thanzi La Mawa (TLM) datasets: health worker time and motion, patient exit interview and follow-up, and health facility resources, perceptions and quality in Malawi. medRxiv.
Type Pre-print DOI 10.1101/2024.11.14.24317330 Date November 2024 Authors Dominic Nkhoma, Precious Chitsulo, Watipaso Mulwafu, Emmanuel Mnjowe, Wiktoria Tafesse, Sakshi Mohan, Timothy B. Hallet, Joseph H. Collins, Paul Revill, Martin Chalkley, Victor Mwapasa, Joseph Mfutso-Bengo, and Tim Colbourn. Abstract The Thanzi La Mawa (TLM) study aims to enhance understanding of healthcare delivery and resource allocation in Malawi by capturing real-world data across a range of health facilities. To inform the Thanzi La Onse (TLO) model, which is the first comprehensive health system model developed for any country, this study uses a cross-sectional, mixed-methods approach to collect data on healthcare worker productivity, patient experiences, facility resources, and care quality. The TLM dataset includes information from 29 health facilities sampled across Malawi, covering facility audits, patient exit interviews, follow-ups, time and motion studies, and healthcare worker interviews, conducted from January to May 2024. Through these data collection tools, the TLM study gathers insights into critical areas such as time allocation of health workers, healthcare resource availability, patient satisfaction, and overall service quality. This data is crucial for enhancing the TLO model’s capacity to answer complex policy questions related to health resource allocation in Malawi. The study also offers a structured framework that other countries in East, Central, and Southern Africa can adopt to improve their healthcare systems. By documenting methods and protocols, this paper provides valuable guidance for researchers and policymakers interested in healthcare system evaluation and improvement. Given the formal adoption of the TLO model in Malawi, the TLM dataset serves as a foundation for ongoing analyses into quality of care, healthcare workforce efficiency, and patient outcomes. This study seeks to support informed decision-making and future implementation of comprehensive healthcare system models in similar settings.
Theoretical frameworks
Mohan et al. (2024). Theory of Change Framework for Economic Evaluation Using Health System Models. York Research Database.
Type Pre-print DOI https://doi.org/10.15124/yao-w4yt-p922 Date November 2024 Authors Sakshi Mohan, Paul Revill, Martin Chalkley, Tim Colbourn, Tara Mangal, Margherita Molaro, Dominic Nkhoma, Bingling She, Simon Walker, Andrew Phillips, Timothy Hallet, and Mark Sculpher. Abstract All-disease health systems models (HSMs) represent the new frontier of economic evaluation to help guide sector-wide resource allocation, allowing for decision analysis in the context of interacting health system capacity constraints. Although there are frameworks for how health systems and their relationship with health outcomes may be characterised, there is a gap in the literature in providing a comprehensive list of health system components and a template for impact pathways from health system components to health outcomes to consider when designing, using and communicating HSMs for economic evaluation. This paper provides a conceptual framework to serve as a theoretical underpinning for the design and use of HSMs developed for economic evaluation. The framework builds upon previous literature as well as our experience developing the Thanzi La Onse (TLO) Model for Malawi. Rao et al. (2024). Using economic analysis to inform health resource allocation: lessons from Malawi. Discover Health Systems.
Type Journal article DOI 10.1007/s44250-024-00115-4 Date 2024 Authors Megha Rao, Dominic Nkhoma, Sakshi Mohan, Pakwanja Twea, Benson Chilima, Joseph Mfutso-Bengo, Jessica Ochalek, Timothy B. Hallett, Andrew N. Phillips, Finn McGuire, Beth Woods, Simon Walker, Mark Sculpher, and Paul Revill. Abstract Despite making remarkable strides in improving health outcomes, Malawi faces concerns about sustaining the progress achieved due to limited fiscal space and donor dependency. The imperative for efficient health spending becomes evident, necessitating strategic allocation of resources to areas with the greatest impact on mortality and morbidity. Health benefits packages hold promise in supporting efficient resource allocation. However, despite defining these packages over the last two decades, their development and implementation have posed significant challenges for Malawi. In response, the Malawian government, in collaboration with the Thanzi la Onse Programme, has developed a set of tools and frameworks, primarily based on cost-effectiveness analysis, to guide the design of health benefits packages likely to achieve national health objectives. This review provides an overview of these tools and frameworks, accompanied by other related analyses, aiming to better align health financing with health benefits package prioritization. The paper is organized around five key policy questions facing decision-makers: (i) What interventions should the health system deliver? (ii) How should resources be allocated geographically? (iii) How should investments in health system inputs be prioritized? (iv) How should equity considerations be incorporated into resource allocation decisions? and (v) How should evidence generation be prioritized to support resource allocation decisions (guiding research)? The tools and frameworks presented here are intended to be compatible for use in diverse and often complex healthcare systems across Africa, supporting the health resource allocation process as countries pursue Universal Health Coverage.