Cost-effectiveness of the IMPALA monitoring system for hospitalised children in low-resource settings: a pragmatic before-and-after study

Background Staff shortages, limited training, and inadequate hospital equipment often delay responses to patient deterioration in low-resource settings. The IMPALA continuous monitoring system was developed to support proactive care for critically ill children in such settings. This study evaluated IMPALA cost-effectiveness compared with current practice manual intermittent monitoring from provider and societal perspectives. Methods We conducted an economic evaluation based on a before-and-after cohort of children (0-180 months) admitted to Zomba Central Hospital (ZCH) and St. Luke’s Hospital (SLH), Malawi (2022-2024), where IMPALA was implemented in high-dependency units (HDUs). Targeted maximum likelihood estimation assessed percentage point (pp) differences in mortality, critical illness events (CIEs), disability-adjusted life years (DALYs), and costs (medical, non-medical, indirect). Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness probabilities were calculated for different willingness-to-pay thresholds. Results At ZCH paediatric ward, 1,840 pre- and 6,255 post-IMPALA children were included; 248 and 736 were admitted to the HDU. Ward mortality decreased (3.7%–2.8%), with an adjusted 1.9pp reduction (95%CI: - 3.8;-0.6). At ZCH-HDU, mortality slightly increased (8.1%–9.0%), but IMPALA was associated with an adjusted 9.8pp reduction (95%CI: −26.5;5.0), a 47.1pp decrease in CIEs (95%CI: −52.9;-41.8), and 5.4 DALYs averted (95%CI: −14.2;3.1). At SLH paediatric ward, mortality decreased (4.0%–2.1%), with an adjusted 1.6pp reduction (95%CI: −3.2;-0.2), a 25.5pp decrease in CIEs (95% CI: −30.1;-20.9), and 1.0 DALYs averted (95% CI: −1.9;-0.1). Provider and societal costs decreased in both wards, but not in the HDU. IMPALA was dominant in wards and slightly more costly but more effective in the HDU (ICERs -$22.5–$0.4 per life saved). Cost-effectiveness probabilities ranged from 0.8–1.0 in wards and 0.3–1.0 in the HDU. Conclusion IMPALA was highly cost-effective, reducing mortality by >40%, morbidity by >50%, increasing DALYs averted, shortening hospital stays, and lowering costs, with spillover benefits from HDUs to wards. Key messages What is already known on this topic Continuous monitoring reduces mortality in high-resource settings, but its (cost-)effectiveness in low-resource contexts is uncertain due to staff shortages, unstable power, and limited supplies. What this study adds Tailored for low-resource settings, IMPALA monitoring system saves lives, reduces illness events, and lowers inpatient and societal costs. How this study might affect research, practice or policy Findings support broader implementation of a tailored continuous monitoring system to improve paediatric outcomes in low-resource settings.