Krishna Udayakumar

Introduction: This study examines artificial intelligence (AI) policies in low- and middle-income countries (LMICs) and their implications for health systems and public health. Methods: We searched and reviewed 59 official AI-related policies from 27 Asian and African LMICs issued up to December 2025. An inductive codebook was developed to analyze policy patterns. Results: Policy development has accelerated since 2020, yet healthcare-specific AI regulation remains rare, with most policy documents emphasizing the general AI governance. Across regions, policies consistently prioritize data, ethics, institutional frameworks, infrastructure, and workforce development, while monitoring, environmental sustainability, and sector-specific regulation receive limited attention. African policies more often address workforce displacement, foreign investment, and environmental sustainability, whereas Asian policies emphasize domestic resource mobilization and skills development. Investment commitments are rarely linked to measurable health system outcomes. Conclusions: Overall, the primary health governance gap lies not in the absence of responsible AI principles, but in their limited translation into sector-specific operational requirements. Cross-sectoral governance should therefore be complemented by health-specific requirements for clinical validation, human oversight, accountability, and post-deployment monitoring.

Background/Objectives: The global rollout of COVID-19 vaccines faced significant implementation challenges: limited adult immunization infrastructure, particularly in low- and middle-income countries; rapidly shifting viral epidemiology driven by emerging variants; and widespread vaccine misinformation that fueled hesitancy. Achieving the high coverage necessary to curb transmission required urgent attention to demand-side barriers, making the identification of effective interventions a critical public health priority. This systematic review synthesized global evidence on communication, behavioral, and health systems interventions to increase COVID-19 vaccine demand and uptake. The review assessed intervention effectiveness across diverse population groups and settings and identified lessons to inform the design of adult vaccination programs and future outbreak response. Methods: Between March 2022 and July 2024, we performed a systematic search in PubMed, Scopus, and Global Index Medicus, for COVID-19 demand and uptake studies published after December 2020, with no language or geographic restrictions. Eligible papers were those that reported intervention studies with quantitative comparative outcomes on vaccination attitudes, appointment rates, uptake, or coverage following an intervention. Study quality was assessed using adapted Critical Appraisal Skills Program (CASP) criteria. Studies were categorized into nine intervention approaches, based on an adapted communication and service-delivery taxonomy. Interventions operated at individual, systems, and structural levels. A narrative synthesis was combined with vote counting of studies with positive findings to understand what intervention approaches were effective. and under what conditions. Results: From over 23,000 records, 57 studies from 27 countries met inclusion and quality criteria. Most studies were conducted in high-income countries. Overall, 70% of studies reported positive findings on at least one vaccination outcome. Educational interventions were the most frequently studied approach and were most effective when delivered through multiple channels by trusted messengers and integrated with complementary strategies, rather than as standalone information provision. Reminder and nudge interventions showed mixed results, performing best when embedded within multicomponent approaches that addressed both logistical and attitudinal barriers. Access-enhancing and service delivery interventions demonstrated the most consistent evidence of effectiveness, with nine of ten studies reporting positive outcomes; successful approaches included on-site vaccination, mobile units, pharmacy and community health worker delivery, and integration into existing healthcare touchpoints. Vaccine mandates demonstrated the strongest and most consistent effects on coverage at scale, though their coercive mechanism raises ethical considerations around autonomy, equity, and public trust. Conclusions: Improving COVID-19 vaccine uptake requires interventions that simultaneously address knowledge gaps, practical barriers to access, and structural determinants of vaccination behavior. The most effective strategies combined educational, behavioral, and service delivery components tailored to the needs and barriers of specific groups. Policymakers should prioritize access-enhancing and systems-strengthening interventions as a foundation, supplement these with targeted communication delivered by trusted messengers, and reserve mandate-based approaches for situations where less restrictive measures have proven insufficient. These findings have relevance beyond COVID-19, offering transferable lessons for adult immunization programs and future outbreak preparedness.

Community health workers are crucial to public health efforts in low– and middle-income countries. Despite their contributions to improving health, they encounter numerous barriers in performing their day-to-day work. Artificial intelligence applications may offer a potential solution to some of these barriers. We examined the implementation of smartphone-based artificial intelligence interventions with community health workers in Uganda, Rwanda, and Nigeria, including how the interventions were developed, how they were used, and successes and challenges of their implementation. This research identified four key considerations for intervention developers, implementing partners, and governments, with respect to implementation of these applications, including: 1) empowering community health workers through professionalization, compensation, and training; 2) understanding the digital ecosystem and aligning with digitization efforts; 3) designing the solution to fit local context, ensuring the development and training of the intervention is applicable to the local environment; and, 4) managing data responsibly with adherence to data privacy and security regulations. This research describes the opportunities for filling gaps in supervisory support, improving diagnosis, and making work more efficient. Providing the community health workforce with digital tools replaces onerous, inefficient paper-based record keeping, enables opportunities for improved supervision, and facilitates decision-making in settings where these workers may be the only point of access to health services and information. Author Summary: Community health workers are often the backbone of the health workforce in low– and middle-income countries. Despite their contributions to community health improvement, they often face barriers and inefficiencies in delivering services. The expansion of smartphone-based artificial intelligence interventions may offer solutions. We examined the implementation of smartphone-based artificial intelligence interventions with community health workers in Uganda, Rwanda, and Nigeria. We found that smartphone-based artificial intelligence applications may help to replace onerous, inefficient paper-based record keeping, enable opportunities for improved supervision, and facilitate decision-making in settings where these individuals may be the only health service providers. This research also identified four key considerations for intervention developers, implementing partners, and governments, with respect to implementation of these applications, including: 1) empowering community health workers through professionalization, compensation, and training; 2) understanding the digital ecosystem and aligning with digitization efforts; 3) designing the solution to fit local context, ensuring the development and training of the intervention is applicable to the local environment; and, 4) managing data responsibly with adherence to data privacy and security regulations.

The COVID-19 Treatment QuickStart Consortium worked with governments in seven low- and middle-income countries (LMICs), Ghana, Laos, Malawi, Nigeria, Rwanda, Uganda and Zambia, to implement COVID-19 test-and-treat programmes at 776 health facilities, including training over 5000 staff and facilitating a donation of 11 300 courses of the oral antiviral nirmatrelvir/ritonavir for treatment. This paper describes the process of implementing COVID-19 test-and-treat programmes in each country, provides aggregate programme monitoring data on numbers tested and treated and analyzes programme enablers and challenges. Between country-level programme initiation (Ghana, May 2023; Laos and Malawi, July 2023; Nigeria, June 2023; Rwanda, March 2023; Uganda, September 2023; Zambia, December 2022) and June 2024, a total of 731 970 SARS-CoV-2 tests were conducted. Of 6724 positive tests, a subset were documented to meet eligibility criteria for nirmatrelvir/ritonavir initiation, and 3041 patients were prescribed nirmatrelvir/ritonavir. The largest number of prescriptions was in Zambia. Programme enablers included decentralisation of services; task-shifting from higher to lower health worker cadres; increased access to point of care antigen tests, including self-tests; and the integration of COVID-19 with other health services. Challenges included COVID-19 de-prioritisation at the time of programme rollout, test commodity stockouts and expiries, and dwindling national surveillance efforts. Learnings from rapid initiation and scale-up of COVID-19 test-and-treat programmes in these seven countries can be used to inform future pandemic preparedness strategies in LMICs.

Sub-Saharan Africa is undergoing rapid demographic and epidemiological transitions, fuelled by urbanisation, lifestyle changes and ageing populations. Consequently, the continent is faced with a ballooning burden of both communicable and non-communicable diseases (NCDs). Cardiovascular diseases are the leading cause of NCD-related mortality in SSA, with heart failure (HF) being the common phenotypic manifestation, afflicting a relatively younger population compared to other world regions. Even though the burden of HF is expected to double by 2030, HF systems of care remain poor in sub-Saharan Africa. Poor outcomes are especially aggravated by systemic barriers including under-resourced and siloed prevention, diagnostic, treatment and research efforts. Integrating HF care delivery through a systems approach and addressing risk factor prevention, screening and treatment across various tiers of care is crucial in abating the increasing burden of HF and NCDs. Further, a more patient-centred system of care that strengthens health financing, policies and system capabilities should be adopted to improve HF care and outcomes in sub-Saharan Africa.

The COVID-19 Treatment QuickStart Consortium[1] worked with governments in 7 low- and middle-income countries, Ghana, Laos, Malawi, Nigeria, Rwanda, Uganda, and Zambia, to implement COVID-19 test-and-treat programs at 776 health facilities, including training over 5,000 staff and facilitating a donation of 11,300 courses of the oral antiviral nirmatrelvir/ritonavir for treatment. This paper describes the process of implementing COVID-19 test-and-treat programs in each country, provides aggregate program monitoring data on numbers tested and treated from program initiation through June 2024, and analyzes program enablers and challenges. Between country-level program initiation (ranging from December 2022 for Zambia to September 2023 for Uganda) and June 2024, a total of 731,970 SARS-CoV-2 tests were conducted. Of 6,724 positive tests, a subset were documented to meet eligibility criteria for nirmatrelvir/ritonavir initiation, and 3,041 patients were prescribed nirmatrelvir/ritonavir. The largest number of prescriptions was in Zambia. Program enablers included decentralization of services, task-shifting from higher to lower health worker cadres, increased access to point of care antigen tests - including self-tests, and the integration of COVID-19 with other health services. Challenges included COVID-19 de-prioritization at the time of program rollout, test commodity stockouts and expiries, and dwindling national surveillance efforts. Learnings from rapid initiation and scale-up of COVID-19 test-and-treat programs in these 7 countries can be used to inform future pandemic preparedness strategies in LMICs.

The African continent demonstrated decisive leadership throughout its response to the COVID-19 pandemic, leveraging lessons learned from previous outbreaks and acting quickly to limit the impact of the SARS-CoV-2 virus. We propose a framework to build on these successes that calls for greater collaboration between African leaders, and greater inclusion of African voices in the global health ecosystem.

The slow progress in malaria control efforts and increasing challenges have prompted a need to accelerate the research and development (R&D), launch and scaling of effective interventions for malaria elimination. This research, including desk research and key informant interviews, identified the following challenges along the end-to-end scale-up pathway of malaria interventions. Underinvestment in malaria R&D persists, and developers from low-resource settings are not commonly included in the R&D process. Unpredictable or unclear regulatory and policy pathways have been a hurdle. The private sector has not been fully engaged, which results in a less competitive market with few manufacturers, and consequently, a low supply of products. Persistent challenges also exist in the scaling of malaria interventions, such as the fragmentation of malaria programmes. Further efforts are needed to: (1) Strengthen coordination among stakeholders and especially the private sector to inform decisions and mobilise resources. (2) Increase engagement of national stakeholders, particularly those in low-income and middle-income countries, in planning for and implementing R&D, launching and scaling proven malaria interventions. (3) Use financial incentives and other market-shaping strategies to encourage R&D for innovative malaria products and improve existing interventions. (4) Streamline and improve transparency of WHO’s prequalification and guidelines processes to provide timely technical advice and strategies for different settings. (5) Increase effort to integrate malaria services into the broader primary healthcare system. (6) Generate evidence to inform policies on improving access to malaria interventions.

Over the next decade, millions of deaths could be prevented by increasing access to vaccines in low-income and middle-income countries (LMICs). The COVID-19 pandemic has demonstrated that the research and development (R&D), launch and scale up timelines of vaccines can be drastically shortened. This study compares such timelines for eighteen vaccines and identifies lessons and implications for accelerating the R&D, launch and scale up process for other vaccine candidates. To replicate the rapid R&D process of the COVID-19 vaccines, future vaccine R&D should capitalise on public–private knowledge sharing partnerships to promote technology innovation, establish regional clinical trial centres and data sharing networks to optimise clinical trial efficiency, and create a funding mechanism to support research into novel vaccine platforms that may prove valuable to quickly developing vaccine candidates in future global health emergencies. To accelerate the launch timeline, future efforts to bring safe and efficacious vaccines to market should include LMICs in the decision-making processes of global procurement and delivery alliances to optimise launch in these countries, strengthen the WHO prequalification and Emergency Use Listing programs to ensure LMICs have a robust and transparent regulatory system to rely on, and invest in LMIC regulatory and manufacturing capacity to ensure these countries are vaccine self-sufficient. Lastly, efforts to accelerate scale up of vaccines should include the creation of regional pooled procurement mechanisms between LMICs to increase purchasing power among these countries and an open line of clear communication with the public regarding pertinent vaccine information to combat misinformation and vaccine hesitancy.