System-Wide Investments Enhance HIV, TB and Malaria Control in Malawi and Deliver Greater Health Impact

Tara Danielle Mangal; Sakshi Mohan; Margherita Molaro; Joseph H Collins; Timothy Colbourn; Eva Janouskova; Rachel E. Murray-Watson; Dominic Nkhoma; Andrew N Phillips; Bingling She; Pakwanja  Twea; Simon Mark Walker; Paul Revill; Timothy B Hallett

doi:10.1101/2025.04.29.25326667

System-Wide Investments Enhance HIV, TB and Malaria Control in Malawi and Deliver Greater Health Impact

Tara Danielle Mangal^*, Sakshi Mohan^*, Margherita Molaro, Joseph H Collins, Timothy Colbourn, Eva Janouskova, Rachel E. Murray-Watson, Dominic Nkhoma, Andrew N Phillips, Bingling She, Pakwanja Twea, Simon Mark Walker, Paul Revill, Timothy B Hallett

^*Corresponding author for this work

Centre for Health Economics

Research output: Working paper › Preprint

Abstract

Global health initiatives have expanded access to treatment for infectious diseases - especially HIV, tuberculosis, and malaria (HTM) - in low- and middle-income countries. However, these "vertically"-funded programs often operate within fragile health systems, where workforce shortages and supply chain failures constrain their effectiveness and sustainability. Meanwhile, evaluating the health impact and value-for-money of "horizontal" investments in systems, such as supply chain strengthening or boosting healthcare workforce, and their synergies with vertical programs (through "diagonal" investments combining both) - remains challenging because their benefits are mediated through improvements in many aspects of healthcare delivery and are therefore difficult to measure. Using a dynamic microsimulation model of Malawi's healthcare system, we show that a diagonal investment approach yields a four-fold greater health impact, measured in disability-adjusted life years (DALYs) averted, than the vertical approach. This approach not only improves health outcomes for non-HTM causes of DALYs but also amplifies the effect on DALYs caused by HTM. Additionally, diagonal investments offer greater value for money and a 24.94% higher return on investment (6.67 [5.81 - 6.85] compared with 5.34 [3.44 - 6.24]), even after accounting for their additional costs. Our findings demonstrate that HSS investments generate synergistic effects, amplifying the benefits of GHIs while also strengthening broader healthcare delivery. These results support a shift toward more integrated global health financing strategies.

Original language	English
Publisher	medRxiv
DOIs	https://doi.org/10.1101/2025.04.29.25326667
Publication status	Published - 1 May 2025

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Cite this

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title = "System-Wide Investments Enhance HIV, TB and Malaria Control in Malawi and Deliver Greater Health Impact",

abstract = "Global health initiatives have expanded access to treatment for infectious diseases - especially HIV, tuberculosis, and malaria (HTM) - in low- and middle-income countries. However, these {"}vertically{"}-funded programs often operate within fragile health systems, where workforce shortages and supply chain failures constrain their effectiveness and sustainability. Meanwhile, evaluating the health impact and value-for-money of {"}horizontal{"} investments in systems, such as supply chain strengthening or boosting healthcare workforce, and their synergies with vertical programs (through {"}diagonal{"} investments combining both) - remains challenging because their benefits are mediated through improvements in many aspects of healthcare delivery and are therefore difficult to measure. Using a dynamic microsimulation model of Malawi's healthcare system, we show that a diagonal investment approach yields a four-fold greater health impact, measured in disability-adjusted life years (DALYs) averted, than the vertical approach. This approach not only improves health outcomes for non-HTM causes of DALYs but also amplifies the effect on DALYs caused by HTM. Additionally, diagonal investments offer greater value for money and a 24.94% higher return on investment (6.67 [5.81 - 6.85] compared with 5.34 [3.44 - 6.24]), even after accounting for their additional costs. Our findings demonstrate that HSS investments generate synergistic effects, amplifying the benefits of GHIs while also strengthening broader healthcare delivery. These results support a shift toward more integrated global health financing strategies.",

author = "Mangal, {Tara Danielle} and Sakshi Mohan and Margherita Molaro and Collins, {Joseph H} and Timothy Colbourn and Eva Janouskova and Murray-Watson, {Rachel E.} and Dominic Nkhoma and Phillips, {Andrew N} and Bingling She and Pakwanja Twea and Walker, {Simon Mark} and Paul Revill and Hallett, {Timothy B}",

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T1 - System-Wide Investments Enhance HIV, TB and Malaria Control in Malawi and Deliver Greater Health Impact

AU - Mangal, Tara Danielle

AU - Mohan, Sakshi

AU - Molaro, Margherita

AU - Collins, Joseph H

AU - Colbourn, Timothy

AU - Janouskova, Eva

AU - Murray-Watson, Rachel E.

AU - Nkhoma, Dominic

AU - Phillips, Andrew N

AU - She, Bingling

AU - Twea, Pakwanja

AU - Walker, Simon Mark

AU - Revill, Paul

AU - Hallett, Timothy B

PY - 2025/5/1

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AB - Global health initiatives have expanded access to treatment for infectious diseases - especially HIV, tuberculosis, and malaria (HTM) - in low- and middle-income countries. However, these "vertically"-funded programs often operate within fragile health systems, where workforce shortages and supply chain failures constrain their effectiveness and sustainability. Meanwhile, evaluating the health impact and value-for-money of "horizontal" investments in systems, such as supply chain strengthening or boosting healthcare workforce, and their synergies with vertical programs (through "diagonal" investments combining both) - remains challenging because their benefits are mediated through improvements in many aspects of healthcare delivery and are therefore difficult to measure. Using a dynamic microsimulation model of Malawi's healthcare system, we show that a diagonal investment approach yields a four-fold greater health impact, measured in disability-adjusted life years (DALYs) averted, than the vertical approach. This approach not only improves health outcomes for non-HTM causes of DALYs but also amplifies the effect on DALYs caused by HTM. Additionally, diagonal investments offer greater value for money and a 24.94% higher return on investment (6.67 [5.81 - 6.85] compared with 5.34 [3.44 - 6.24]), even after accounting for their additional costs. Our findings demonstrate that HSS investments generate synergistic effects, amplifying the benefits of GHIs while also strengthening broader healthcare delivery. These results support a shift toward more integrated global health financing strategies.

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