Delays, detours, and gaps - a one‑health study on access to rabies post‑exposure prophylaxis in Malawi

Rabies is a neglected, deadly, but preventable zoonotic disease that disproportionally affects rural and resource-limited populations of Africa and Asia. Timely post-exposure prophylaxis (PEP) can prevent rabies in exposed humans, if the treatment is available and people know where to seek it. To explore the constraints to effective bite-case management and rabies PEP provision in Malawi. Interviews and focus group discussions were conducted to explore perspectives of human health care providers, animal health officers, and dog-bite victims to map the pathways, barriers, and bottlenecks that shape rabies-PEP access in Malawi. We found that the PEP access pathway in Malawi is cumbersome, multi-step, and often lengthy, starting with a veterinary risk assessment and referral before PEP-treatment is provided. Training of service providers was poor, protocols were inconsistent and One Health coordination between sectors was limited. Other barriers included the unavailability of vaccines, insufficient funding, shortages of assistant veterinary officers, long distances to health facilities and a lack of community awareness. Simplifying the pathway to PEP for bite victims may reduce rabies deaths in Malawi. This would require clear service pathways and protocols, trained staff, and sufficient resources across settings and sectors. Structured two‑way information sharing between the animal health and public health sectors, grounded in a One Health framework, could reduce delays, improve patient care and follow‑up, and support vaccine forecasting and procurement. This study highlights the PEP access pathway and intersectoral communication systems as actionable entry points for improving equitable and timely access to rabies PEP in Malawi.