The impact and cost-effectiveness of pulse oximetry and oxygen on acute lower respiratory infection outcomes in children in Malawi:a modelling study

BACKGROUND: acute lower respiratory infections (ALRIs) are the leading global cause of post-neonatal death in children younger than 5 years. The impact, cost, 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 ratios (ICERs) and incremental net health benefits (INHBs) using a Malawi-specific cost-effectiveness threshold of US$80 per disability-adjusted life-year (DALY) averted. FINDINGS: The cost-effective strategy is the full scale-up of pulse oximetry to 90% usage rate and oxygen to 80% availability. This combination results in 72% (95% CI 72-72) of hypoxaemic ALRI cases accessing oxygen, averting 71 000 (68 100-74 000) DALYs per year of implementation and 28% (27-29) of potential ALRI deaths, at an ICER of US$35 (33-36) per DALY averted and $924 (887-963) per death averted. The INHB is 40 200 (37 300-43 100) 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: UK Research and Innovation, Wellcome Trust, Department for International Development, EU, Clinton Health Access Initiative, and Unitaid.