A Healthcare Service Delivery and Epidemiological Model for Investigating Resource Allocation for Health: The Thanzi La Onse Model

Background Decisions need to be made in all healthcare systems about the allocation of available resources with the aim of improving population health. Evidence is needed for these decisions, which can have enormous consequences for population health, especially in lower-income settings. Methods We address this need using an individual-based simulation model of healthcare need and service delivery that we have developed for Malawi, drawing on demographic, epidemiological and routine healthcare system data (on facilities, staff, and consumables). We compare the model’s simulated outputs with available data and estimate the impact that the healthcare system is having currently. We analyse the effects of improvements in healthcare access, clinician performance and consumables availability. Findings Malawi’s healthcare system averted 40 million Disability-Adjusted Life-Years (DALYs) in the five-year period to end-2019, which is half of the total DALYS that the population (total size: 19 million in 2020) would otherwise incur. This impact is strongly focussed on young children (mediated largely by programmes addressing respiratory infections, HIV/AIDS and malaria) and also by the HIV/AIDS and TB programmes (among adults). More services seem to be delivered than would be expected based on the number of staff and expected time needed for services. Nevertheless, the additional services that are provided (through service times being reduced or additional HCW hours worked) account for half the impact of the healthcare system (i.e., ∼20 million DALYS averted). If system improvements gave ill persons immediate access to healthcare, led to optimal referral and diagnosis accuracy, and eliminated consumable stock-outs, the overall impact of the healthcare system could increase by up to ∼30% (12 million more DALYS averted). Conclusions The healthcare system in Malawi generates substantial health gains to the population with very limited resources. Strengthening interventions could potentially increase these gains considerably and so should be a priority for investigation and investment. A detailed individual-based simulation model of healthcare service delivery is a valuable tool for healthcare system planning and for evaluating proposals for healthcare system strengthening. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This project is funded by The Wellcome Trust (223120/Z/21/Z). The initial development of the model was completed with support by the UK Research and Innovation as part of the Global Challenges Research Fund (MR/P028004/1). TBH, TM, BJ, MM and BS acknowledge funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/X020258/1), funded by the UK Medical Research Council (MRC). This UK funded award iscarriedoutintheframeoftheGlobalHealthEDCTP3JointUndertaking. TBH,TM,BJ,MM and BS also acknowledge funding by Community Jameel. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced are available online at https://zenodo.org/records/10144016