The Impact and Cost-Effectiveness of Pulse Oximetry and Oxygen on Acute Lower Respiratory Infection Outcomes in Children in Malawi: A Modelling Study

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.

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.

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.

Pulse oximetry and oxygen are complementary cost-effective interventions in Malawi, where health expenditure is low, and should be scaled up in parallel.