Universal Health Coverage (UHC) aims to ensure that all individuals have access to essential healthcare services without facing financial hardship. Achieving UHC requires not only the availability of healthcare services but also the delivery of high-quality care, supported by essential technologies such as medical devices. Medical devices enhance healthcare delivery by enabling timely and accurate medical interventions, yet ensuring that these devices contribute to healthcare outcomes requires more than making them available. In many low- and middle-income countries (LMICs), the functionality and integration of medical devices into healthcare delivery remain a persistent challenge. Devices that are not properly maintained, adapted to local contexts, or aligned with clinical needs often end up unused or broken. Therefore, procurement plays a crucial role in ensuring that medical devices are appropriately selected, acquired, and maintained to meet healthcare needs and remain functional over time.

This research explores how government-led procurement can be structured to support the sustained adoption of high-cost medical devices in LMICs, focusing on Malawi as a case study. A qualitative research design was adopted, using semi-structured interviews with key informants directly involved in the public procurement of medical devices in Malawi. These interviews provided insights into procurement practices, decision-making structures, and broader institutional dynamics. To guide the analysis, this research applies the Adaptability, Scalability, and Sustainability (ASaS) model, a decision-oriented framework designed to assess whether health interventions can be adapted, scaled, and sustained over time. The ASaS model is used as an evaluative tool to assess how well Malawi’s procurement practices align with key determinants of sustained adoption and to identify opportunities for improvement.

The findings show that public procurement of high-cost medical devices in Malawi is organised through a multi-layered system operating across national, institutional, and operational levels. Procurement processes are centrally governed to ensure regulatory oversight and financial accountability, with institutions such as the Internal Procurement and Disposal Committee (IPDC), the Public Procurement and Disposal of Assets Authority (PPDA), and the Ministry of Justice overseeing compliance with national priorities under the PPDA Act of 2017. These formal structures define clear steps for procurement, including needs assessments, technical specifications, supplier selection, tendering, contract negotiation, and quality assurance to ensure procured devices meet required standards. However, while procurement structures define formal decision-making processes, procurement practices encompass the broader systemic and institutional conditions that shape how these processes function in practice and influence procurement outcomes.

Procurement practices in Malawi face challenges that affect the sustained adoption of high-cost medical devices. Externally, fragmented procurement between donor-driven and government-led acquisitions leads to the introduction of devices without government oversight, limiting central tracking and complicating procurement and maintenance planning. Funding constraints further restrict the ability to acquire and sustain essential devices. Although regulatory frameworks promote transparency, they often result in a proliferation of device types that are difficult to manage over time. Internally, poor coordination between procurement and planning departments leads to delays and misalignment with facility readiness. In addition, weak monitoring and evaluation systems hinder follow-up on device functionality and prevent evidence-based decision-making. Finally, procurement outcomes are shaped by device-specific factors, including maintenance needs, spare parts availability, and alignment with clinical workflows, which are not consistently addressed in procurement processes, increasing the risk that devices will become underutilised or non-functional.

Based on these findings, the research concludes that supporting the sustained adoption of high-cost medical devices in Malawi requires shifting from cost-driven acquisition models to more strategic procurement processes that incorporate the Total Cost of Ownership (TCO). Procurement decisions should account for long-term costs such as maintenance, spare parts, operation, and supplier service commitments. Additionally, establishing a centralised national inventory and tracking system for medical devices would improve oversight, support more accurate needs assessments, and enhance future procurement planning. Moving toward evidence-based procurement will require the development of monitoring and evaluation systems to track device functionality and usage over time, ensuring that medical devices remain operational and integrated into healthcare delivery.

Beyond procurement processes, institutional design also influences procurement outcomes. A better balance is needed between centralised technical expertise and local facility input to improve the alignment of procurement decisions with clinical needs and usability. Integration of usability assessments at the need identification stage could help ensure that selected medical devices are both clinically essential and aligned with existing workflows. At the same time, navigating the trade-offs between transparency, competition, and standardisation is essential. While open competition remains important for fairness, moving toward a more standardised selection of device types could simplify maintenance, training, and spare parts sourcing, thereby supporting long-term usability and integration into clinical workflows.

In conclusion, this research underscores that the sustained adoption of high-cost medical devices in Malawi requires rethinking both procurement processes and the broader institutional frameworks in which they are embedded. Aligning procurement with healthcare system capacities requires moving beyond cost-driven acquisitions toward approaches that account for long-term usability, maintenance, and operation. Embedding these elements into procurement planning, alongside the development of monitoring and reporting mechanisms, would help ensure that procurement decisions are aligned with real needs and capacities within healthcare facilities. Equally important is addressing institutional design to ensure that procurement processes are supported by governance structures capable of integrating clinical, technical, and operational perspectives. By aligning procurement with the realities of healthcare system capacities and embedding long-term considerations, Malawi can move from acquiring medical devices to ensuring their sustained use. These insights are critical for policymakers and practitioners seeking to strengthen healthcare systems and promote sustainable outcomes from medical device investments.