The phase 3 trial of the RTS,S/AS01 malaria vaccine candidate showed modest efficacy of the vaccine against Plasmodium falciparum malaria, but was not powered to assess mortality endpoints. Impact projections and cost-effectiveness estimates for longer timeframes than the trial follow-up and across a range of settings are needed to inform policy recommendations. We aimed to assess the public health impact and cost-effectiveness of routine use of the RTS,S/AS01 vaccine in African settings.

As vaccine manufacturers tackle increasingly intractable pathogens, vaccines will be developed that show efficacy, but that are less efficacious than established vaccines. Consequently, regulatory and public health authorities will be faced with difficult decisions about whether such vaccines should be recommended for implementation and, if so, under what circumstances. The RTS,S/AS01 malaria candidate vaccine provides an important example of such a challenge.

In remote areas, an absence of doctors and nurses leads to poor health outcomes for local populations. To increase access to health-care workers, the World Health Organization recommends interventions in four areas – education, regulatory, financial and professional/personal. To support retention, WHO and other organizations have called for bundled programmes that take into account health workers’ expectations. Retention programmes that enhance workers’ competence, responsiveness and productivity have also been recommended.

Successive Governments of India have promised to transform India's unsatisfactory health-care system, culminating in the present government's promise to expand health assurance for all. Despite substantial improvements in some health indicators in the past decade, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavourably with other middle-income countries and India's regional neighbours. Large health disparities between states, between rural and urban populations, and across social classes persist.