Title : Funding the last mile:A multi-component patient transport intervention to reduce surgical attrition in a paediatric hospital in Malawi
Abstract:
Background: Five billion people globally lack access to safe, affordable surgical and anaesthesia care, with this deficit disproportionately concentrated in low-and middle-income countries (LMICs). Children in sub-Saharan Africa bear a substantial share of this burden, with mortality from common paediatric surgical conditions substantially higher than in high-income settings. A critical and often underaddressed determinant of this access gap is the cost and logistics of transport to centralised surgical facilities.In Malawi, median travel time to a central hospital exceeds 2.5 hours, and many households lack the financial resources to reach referral facilities. Patients frequently face sequential transport barriers across multiple tiers of the health system before reaching a specialist facility. Beit-CURE Children's Hospital of Malawi (BCCHM), a specialist paediatric surgical facility in Blantyre, provides free orthopaedic and reconstructive surgery for children with conditions including clubfoot, bowed legs, burn contractures, and cleft lip and palate. Between 2021 and June 2025, institutional records across 17 districts documented a pre-intervention surgical admission rate of 40.1% (1,120 of 2,794 outreach-booked patients), with lower rates consistently observed in more geographically distant districts. These findings, and qualitative feedback consistently identifying transport cost as the primary barrier, motivated the design and implementation of a structured transport intervention in July 2025.
Objectives: This study describes the design, implementation, and first-year outcomes of a multi-component patient transport intervention piloted at BCCHM from July 2025 across five districts. The primary objective was to assess whether a structured, community-integrated transport programme was associated with increased surgical admission rates among outreach-booked paediatric patients in geographically dispersed, low-income districts of Malawi. A secondary objective was to characterise the financial efficiency of transport subsidisation as a strategy for improving paediatric surgical utilisation, and to identify residual barriers to full transport coverage.
Methods: A prospective uncontrolled before-after operational study was conducted across five intervention districts: Mangochi, Balaka, Thyolo, Blantyre, and Rumphi. The pre-intervention comparator comprised institutional admission data from 17 districts collected between 2021 and 2025 (n = 2,794 outreach-booked patients), establishing a baseline turn-up rate of 40.1%. Given that the comparator includes historical data from different districts and time periods, findings are interpreted as operationally indicative rather than causal.The intervention comprised four integrated components: (1) partner-coordinated group transport through collaboration with World Vision International, PODCAM, and District Health Management Teams; (2) institutional vehicle deployment where partner vehicles were unavailable; (3) direct reimbursement for public transport costs targeting sub-district last-mile barriers; and (4) community health worker-led patient tracing and communication using Health Surveillance Assistants, telephone follow-up, and WhatsApp coordination. Community mobilisation included public address campaigns, local radio engagement, and faith-based communication networks. The primary outcome was surgical admission, defined as successful arrival and formal admission to BCCHM for scheduled paediatric surgical care. Ethics approval is in progress with the CURE International IRB and the Malawi National Health Sciences Research Committee (NHSRC).
Results: Across five intervention districts in FY 2025/26, 456 of 686 eligible outreachbooked children were admitted for surgery, representing an overall turn-up rate of 66.5% compared with the pre-intervention baseline of 40.1% — an improvement of 26.4 percentage points. District-level results were: Balaka 72% (vs. 42% baseline, +30 pp); Thyolo 72% (vs. 51%, +21 pp); Blantyre 69% (vs. 70%, stable); Mangochi 62% (vs. 52%, +10 pp); and Rumphi 63% (no comparable baseline). The total transport expenditure was MWK 47,138,861 (USD 22,183), representing an average cost of USD 49 per patient transported, equivalent to 4.1% of BCCHM's average surgery cost of USD 1,200.The intervention generated 181 additional surgeries above the baseline expectation of 275 admissions (40.1% of 686 booked). At an average surgery cost of USD 1,200, this represents USD 217,200 in surgical value unlocked, yielding a return on transport investment of 9.8x. Patient acquisition efficiency improved markedly: the number of outreach bookings required per surgery delivered fell from 2.49 to 1.50, a 39.7% reduction in acquisition cost per surgery. The intervention was funded entirely through reallocation of the existing outreach budget: three of eight planned outreach clinics were deferred, and the released budget was redirected to patient transport in districts where clinics had already taken place. No additional funding was requested or allocated.
Challenges: Three implementation challenges constrained performance. First, sub-district last-mile transport costs in Rumphi — where village-to-collection-point fares can exceed MWK 20,000 — remained outside the intervention's current coverage, contributing to a lower admission rate in that district. Second, a proportion of booked patients had inactive or unregistered contact numbers, limiting the effectiveness of Health Surveillance Assistant tracing. Third, post-operative follow-up attendance declined substantially following surgery, demonstrating that transport barriers extend across the full continuum of care, not only to initial admission.
Conclusions and Policyimplications: A multi-component transport intervention combining civil society partnerships, group transport coordination, direct reimbursement, and community health worker communication was associated with a 26.4 percentage-point improvement in surgical admission rates among outreach-booked paediatric patients in rural Malawi, at a cost of USD 49 per patient and a return on investment of 9.8x. Transport subsidisation represents a high-yield, low-cost strategy for improving paediatric surgical utilisation in geographically dispersed LMIC populations. Residual non-attendance confirms that partial transport coverage leaves the most geographically and financially vulnerable households unreached. The BCCHM model supports three operational recommendations: (i) explicit inclusion of subdistrict last-mile costs within transport budgets; (ii) strengthened patient contact data capture at outreach clinics; and (iii) extension of transport support to postoperative follow-up care. The BCCHM operational model offers a replicable, datasupported framework for improving paediatric surgical access across subSaharan Africa, with direct relevance to national surgical plan development and donor investment priorities.
Keywords: Paediatric surgery | Global surgery | Transport barriers | Malawi | Sub-Saharan Africa | Surgical attrition | LMIC | Health systems | Implementation research | Last-mile access
