Dominic Nkhoma

This paper provides an overview of the Thanzi La Mawa (TLM) survey, data collection methods and procedures, data modules and core variables, and quality assurance measures and expected analytical outputs from the TLM survey. The TLM survey is part of the Thanzi la Onse (TLO) model initiative. This is the first comprehensive health system model developed for any country, and aims to enhance understanding of healthcare delivery and resource allocation by capturing real-world data across the levels of healthcare delivery. The study seeks to support informed decision-making and future implementation of comprehensive healthcare system models in similar settings. The study uses a cross-sectional, mixed-methods approach to collect data on healthcare workers use of time, patient experiences, facility resources, and quality of care. The TLM dataset is based on a sample of 30 health facilities across Malawi comprising facility audits, patient interviews, and health worker use of time collected through time and motion studies. Data collection was conducted from January-May 2024. The analyses from this dataset provide insights into health workers’ time allocation to different activities, availability and use of healthcare resources at facilities, 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, especially in East, Central, and Southern Africa that have expressed strong demand for the TLO model, can adopt as part of efforts to improve healthcare systems. By documenting methods and datasets, this paper provides guidance and tools 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.

Non-profit, faith-based providers (FBPs) play a major role in primary care delivery across Sub-Saharan Africa and are increasingly integrated into national health systems, yet evidence on how the quality of faith-based primary care compares to that of public providers remains limited. Using healthcare worker observations, patient exit interviews, and patient follow-up data from Malawi, we compare consul-tation duration, clinical content, and patient-reported outcomes across faith-based and government facilities. Ordinary least squares estimates controlling for facility-, provider-, and shift-level characteristics, as well as patient health conditions, indicate that FBPs conduct significantly longer consultations, by around 1.9 minutes (75% of the sample mean), and perform a greater number of key clinical processes, including physical examinations and diagnostic tests. Patient-reported data corroborate these findings. Patients attending FBPs report receiving more tests and examinations and, at follow-up, are more likely to state that their treatment is working. These findings provide new evidence that publicly supported FBPs de-liver higher-quality primary care on both process measures and patient-reported outcomes, underscoring the importance of accounting for provider ownership when examining variation in access to quality primary care in Sub-Saharan Africa.

Introduction: Malawi’s Ministry of Health (MOH) launched the Health Sector Strategic Plan III (HSSP III) 2023–2030, which features catalytic efficiency and accountability reforms under the “One Plan, One Budget, One Report” framework. This policy analysis examined the context, historical influences, processes, and stakeholders shaping the development and early implementation of the HSSP III. Methods: Between June and December 2023, we conducted a document review guideline (n=21) and in-depth semi-structured interviews with health stakeholders (n=12). We initially analysed the data using inductive content analysis, employing the HSSP III development process, followed by a deductive approach that utilised the Walt and Gilson policy triangle, complemented by other conceptual frameworks, with triangulation and consensus validation. Results: Historically, economic and decision-making inequities in Malawi’s health sector have led to centralised processes, vertical funding, and low staff motivation. In response, HSSP III was aligned with current movements for universal health coverage and donor aid coordination. The plan’s development promoted capacity building, country ownership, and accountability through an inclusive and participatory approach, as well as a performance management-oriented framework. However, incomplete operational plans and misaligned decision-making systems have impeded early implementation. Discussion/Conclusion: The Malawi HSSP III responded to the fragmented health sector through a government-led, sector-aligned approach. Its development leveraged long-term leadership and a consultative learning environment to foster capacity and stakeholder ownership. However, the transformative development process alone was not sufficient. Operationalisation and long-term reform require increased government accountability. These findings provide valuable insights for policy development, implementation, and long-term transformational change in Malawi and similar settings.

Objectives Modelling approaches that consider system-wide delivery platforms rather than single diseases are increasingly recognized as crucial for the economic evaluation of policy and investment choices and can be instrumental in forward-looking policy formulation. This paper develops a costing approach tailored to one such model, the Thanzi La Onse (TLO) model of Malawi’s healthcare system, to estimate healthcare delivery costs under varying health system assumptions. Methods We developed a mixed-method costing approach to estimate the total cost of healthcare delivery in Malawi using the TLO model, from a healthcare provider perspective. Through an iterative adjustment of key costing parameters, we attempted to align our model-based estimates with real-world expenditure and budget data. Costs were estimated over an 8-year period (2023–2030) under alternative scenarios of health system capacity, including supply chain performance and the size of the health workforce. Results A detailed comparison of our cost estimates against expenditure and budget data demonstrates the reliability of our costing method and assumptions, for the conditions and resources captured by the model. Under current health system capacity, the total cost of healthcare delivery in Malawi between 2023 and 2030 was estimated at $1.53 billion [95% confidence interval, $1.51b -$1.54b], which translates to an average annual cost of $309.83 million [$306.17m -$313.56m]. The estimation of costs under alternative scenarios demonstrates the importance of capturing feedback effects to correctly forecast healthcare costs. Conclusion Mixed-method costing used within health system models, such as TLO, is a feasible and robust method for estimating healthcare delivery costs. This approach can provide valuable insights for health sector planning and resource allocation.

Background The COVID-19 epidemic in Malawi involved almost 90,000 recorded cases and 2,638 deaths. In response to early concerns about vulnerable older people in rural areas, we developed ‘Kuteteza’: a COVID-19 mitigation response project. Clinicians, public health professionals, and researchers collaborated with government and district-level staff in two Southern Malawi districts. Interventions included supported ‘shielding’ of older people – minimising social mixing whilst having their daily needs supported. Additional mitigation strategies included provision of masks, handwashing stations, and soap. Government partnerships allowed additional support for vulnerable groups. We present the findings of a realist project evaluation, assessing the feasibility of this approach. Methods We collated anonymised descriptive data on Kuteteza procedures and conducted qualitative structured observations in villages involved in the initiative. We carried out three focus groups involving community members, frontline health staff, and volunteers in each setting. These provided deeper insights into experiences of the pandemic and impacts of the intervention, including suggested opportunities during future outbreaks. Results The project involved 25 villages across two districts, with 1,087 people over the age of 60 voluntarily participating in ‘shielding’. Supplies of food, water, and cooking fuel were mostly arranged within the family. In Kuteteza villages, the handwashing stations and soap were widely used, and there was awareness and some observance of COVID-19 prevention measures. The project, including the provision of supplies, was greatly appreciated by communities, but wider contextual constraints – namely widespread economic insecurity – presented persisting challenges. Suggestions for improvement largely concerned project enhancements and extensions. Conclusions Through effective stakeholder engagement and contribution to national response strategy, the Kuteteza project helped raise COVID-19 awareness and supported populations at a critical time in the pandemic. Kuteteza approaches were welcomed locally and may be incorporated in future epidemic responses. Supported ‘shielding’ should be paired with government-led measures to mitigate economic hardship.

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.

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.

Background The COVID-19 epidemic in Malawi involved almost 90,000 recorded cases and 2,638 deaths. Data suggest that the Malawi epidemic developed largely in urban settings, but the extent of rural spread – exposing older adults in particular – is unclear. This concern led us, to develop the ‘Kuteteza’ partnership project: a community-based Public Health intervention involving the shielding of older adults and additional strategies to mitigate COVID-19 impacts in rural Malawi. We now present the results of a realist project evaluation. Methods Clinicians, Public Health professionals, and researchers collaborated with government and district level staff in two Malawi districts. After engagement with local structures, willing older adults (>60 years) and their communities made arrangements for supported 'shielding'. Masks, handwashing stations, and soap were also provided, and government partnerships allowed additional support for vulnerable groups. Finally, context-responsive community engagement reinforced COVID-19 prevention during peak risk periods. Our realist evaluation included collation of anonymised descriptive data and qualitative structured observations and focus groups – involving community members and volunteers – in each setting. Results The project involved 25 villages. Multi-level stakeholder engagement was pivotal in developing and establishing the work, and strong District Health Office support was integral to implementation. Team members contributed to national meetings, aligning the project with national guidance and stakeholder actions. Established partnerships with relevant ministries resulted in the incorporation of shielding in the Malawi COVID-19 response plan. In Kuteteza villages, handwashing stations and soap were used, and there was awareness of COVID-19 prevention measures. Further experiences and evaluation results are presented, including learning points for future outbreak responses. Conclusions Through effective stakeholder engagement and contribution to national response strategy, the Kuteteza project raised awareness and supported populations at a critical time in the pandemic. These approaches can be incorporated in future epidemic and emergency responses.

Background Decisions need to be made in all healthcare systems about the allocation of available resources with the aim of improving population health. Evidence is needed for these decisions, which can have enormous consequences for population health, especially in lower-income settings. Methods We address this need using an individual-based simulation model of healthcare need and service delivery that we have developed for Malawi, drawing on demographic, epidemiological and routine healthcare system data (on facilities, staff, and consumables). We compare the model’s simulated outputs with available data and estimate the impact that the healthcare system is having currently. We analyse the effects of improvements in healthcare access, clinician performance and consumables availability. Findings Malawi’s healthcare system averted 40 million Disability-Adjusted Life-Years (DALYs) in the five-year period to end-2019, which is half of the total DALYS that the population (total size: 19 million in 2020) would otherwise incur. This impact is strongly focussed on young children (mediated largely by programmes addressing respiratory infections, HIV/AIDS and malaria) and also by the HIV/AIDS and TB programmes (among adults). More services seem to be delivered than would be expected based on the number of staff and expected time needed for services. Nevertheless, the additional services that are provided (through service times being reduced or additional HCW hours worked) account for half the impact of the healthcare system (i.e., ∼20 million DALYS averted). If system improvements gave ill persons immediate access to healthcare, led to optimal referral and diagnosis accuracy, and eliminated consumable stock-outs, the overall impact of the healthcare system could increase by up to ∼30% (12 million more DALYS averted). Conclusions The healthcare system in Malawi generates substantial health gains to the population with very limited resources. Strengthening interventions could potentially increase these gains considerably and so should be a priority for investigation and investment. A detailed individual-based simulation model of healthcare service delivery is a valuable tool for healthcare system planning and for evaluating proposals for healthcare system strengthening.

Health benefits packages (HBPs) are increasingly used in many countries to guide spending priorities on the path towards universal health coverage. Their design is, however, informed by an uncertain evidence base but research funds available to address this are limited. This gives rise to the question of which piece of research relating to the cost-effectiveness of interventions would most contribute to improving resource allocation. We propose to incorporate research prioritisation as an integral part of HBP design. We have, therefore, developed a framework and a freely available companion stand-alone tool, to quantify in terms of net disability-adjusted life-years (DALYs) averted, the value of research for the interventions considered for inclusion in a package. Using the tool, the framework can be implemented using sensitivity analysis results typically reported in cost-effectiveness studies. To illustrate the framework, we applied the tool to the evidence base that informed the Malawi Health Sector Strategic Plan 2017–2022. Out of 21 interventions considered, 8 investment decisions were found to be uncertain and three showed strong potential for research to generate large health gains: ‘male circumcision’, ‘community-management of acute malnutrition in children’ and ‘isoniazid preventive therapy in HIV +individuals’, with a potential to avert up to 65 762, 36 438 and 20 132 net DALYs, respectively. Our work can help set research priorities in resource-constrained settings so that research funds are invested where they have the largest potential to impact on the population health generated via HBPs.