DOI: 10.12688/wellcomeopenres.26861.1 ISSN: 2398-502X

Lessons from developing, implementing and sustaining the first stroke unit in Malawi

Tiwonge Phiri, Irene Sheha, Peter Ndalakwaya, Ethel Waya, Gloria Mwangalika, Yohane Gadama, Vella Kaudzu, Brian Ngwira, George Ransley, Smicky Chiula, Thandie Mwalukomo, Chimota Phiri, Stephen B Gordon, David Werring, Tom Solomon, Patrick Kamalo, Mac Mallewa, Jane Mallewa, Terttu Heikinheimo-Connell, Daryll Baker, Simone Browning, Karen Chetcuti, Dama Phiri, Alex Chitani, George Chimatiro, Katie Atkinson, Alex Dzinkambani, Orlando Swayne, Kelvin Mponda, Samson Mndolo, Emmie Malewezi, Talumba Mankhokwe, Zuze Kawale, Isabel Cary, Selina Edwards, Robert Simister, Henry Mwandumba, Tamara Phiri, Laura Benjamin
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Stroke incidence is rising rapidly in low- and middle-income countries (LMICs), particularly in sub-Saharan Africa, yet access to organised stroke care remains extremely limited. Although stroke units are among the most effective and cost-efficient interventions for improving outcomes after stroke, implementation in resource-constrained settings remains challenging. We describe the development of the first dedicated stroke unit in Malawi, established in 2022 at Queen Elizabeth Central Hospital (QECH), Blantyre. The QECH Comprehensive Stroke Service (QSS) was developed through a partnership involving the Malawi Ministry of Health, QECH, Malawi-Liverpool-Wellcome Research Programme (MLW), Kamuzu University of Health Sciences (KUHeS), University College London Hospitals (UCLH), and academic collaborators in Malawi and the UK. This paper focuses on health-system development rather than clinical outcomes. We describe the processes underpinning implementation, including partnership building, workforce development, infrastructure creation, pathway design, governance, and integration of data systems. Existing research infrastructure provided a foundation for service evaluation, registry development, and future interventional studies. Key lessons from the first three years included the importance of strong nursing leadership, task-shifting, phased implementation, multidisciplinary mentorship, and early alignment with Ministry of Health priorities in addressing workforce shortages and limited specialist capacity. Dedicated clinical space and integration with surveillance and research infrastructure supported sustainability, while weak digital systems and service overload remained ongoing challenges. Our experience demonstrates that organised stroke services can be developed in LMIC settings through adaptive clinical–academic partnerships integrated within existing health systems.

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