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

Abstract

BackgroundAcute 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. MethodsWe 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. FindingsThe 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. InterpretationPulse oximetry and oxygen are complementary cost-effective interventions in Malawi, where health expenditure is low, and should be scaled-up in parallel. FundingUKRI, Wellcome Trust, DFID, EU, CHAI, Unitaid.

Keywords: acute lower respiratory infections, cost-effectiveness, oxygen, pulse oximetry, Malawi