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.

Emerging and developing economies are currently growing at a significantly faster pace than their developed counterparts. While the real GDP of advanced economies is expected to grow by 1.7 and 1.8 percent in the years 2024 and 2025 respectively, the real GDP of emerging markets and middle income economies is expected to grow by 4.1 percent per annum. This rapid growth poses an opportunity for developed-market multinational corporations to realize market growth by expanding their business into these markets. However, operating in emerging and developing markets also brings novel challenges and constraints, to which entrants must adapt their strategies. For instance, these markets consist of a large low-income group that favors affordable and high quality products. A concept that addresses the constraints of serving low income groups in emerging and developing markets is frugal innovation, a form of resource constraint innovation. Frugal innovations are products that are affordable, focus on core functionalities, and have an optimized performance level, thus catering to the specific needs of Bottom of the Pyramid (BoP) consumers. This research adopts the perspective of Multinational Corporations (MNCs) and explores frugal innovation as a potential solution to the various challenges MNCs face in emerging and developing markets. This study answers the following research question: “How can frugal innovation complement multinational corporations’ strategies to address business and operational challenges faced in emerging and developing markets?” It thereby links strategies, challenges, and frugal innovation in a novel manner. To answer this question, frugal innovation strategies are identified in the literature and challenges and strategies of MNCs in emerging and developing markets are determined through a literature search and semi structured interviews with representatives of various MNCs. Through the literature review on frugal innovation, five frugal innovation strategies are identified: The first strategy MNCs can employ is a Frugal Innovation Orientation (FIO) strategy, thereby solely focusing on an economic value proposition. Furthermore, they can introduce a local R&D center and engage in customer co-creation. The products offered in emerging and developing markets should be cheap, focus on core functionalities and have an optimized performance level. Finally, the products should also match the quality of the brand. The most prevalent challenges faced by MNCs in emerging and developing markets, as identified through literature and interviews, include institutional voids, infrastructure deficiencies, low purchasing power, political instability, workforce challenges, trade regulations, consumer complexity, balancing standardization with adaptation, gaining product acceptance, and NGO push back. To navigate these challenges, MNCs employ various strategies, including localization, tailoring products and pricing to local markets, collaborating with companies and NGOs, identifying core customer values, understanding the local culture and market, focusing on market potential, adopting frugal innovation, and engaging in social initiatives. Upon comparing these challenges with the current strategies and the frugal innovation strategies, the following conclusion is drawn: The frugal innovation strategies potentially only solve the business challenges of consumer complexity, low purchasing power, and gaining product acceptance. However, these challenges are already being resolved by the current strategies of MNCs. Therefore, the frugal innovation strategies are not essential but can complement the current strategies. Some of the frugal and current strategies do overlap meaning that MNCs currently already use some of the identified frugal innovation strategies.

The healthcare sector is facing serious challenges. On the one hand, the population is ageing, resulting in a higher pressure on healthcare resources. On the other hand, less than half of the world’s global population is covered by essential healthcare services due to limiting resources. Frugal health innovations are developed to be affordable, accessible, and make effective use of limited resources. As such, frugal health innovations can help to decrease the resource-dependency in the healthcare sector, contributing to healthcare access to all. Yet, the adoption of frugal health innovations remains limited. Adding to this issue, the adoption is not studied from a theoretical perspective and empirical evidence on the reasons for (non-)adoption remains scarce. Understanding what affects the adoption from a theoretical perspective helps to identify underlying principles at hand, allowing to build a conceptual framework. Such a conceptual framework can guide frugal health innovation development for increased adoption probability and promote future theoretical studies on frugal health innovations. This research aims to understand what factors affect the adoption of frugal health innovations from a theoretical perspective, by asking the research question “What factors affect the adoption of frugal health innovations?”.

To guide the research, the first sub-research question “What theoretical framework is most appropriate to describe adoption of frugal health innovations?” was asked. Answering this question ensured a departing point for the theoretical understanding of frugal health innovation adoption. Secondary data from the literature was retrieved through a literature review, from which it followed that nine theoretical perspectives have been used to study the adoption of non-health-related frugal innovations. By comparing the theoretical perspectives against the context of frugal health innovations, it followed that the Unified Theory of Acceptance and Use of Technology 2 is the most appropriate theoretical perspective to study the adoption of frugal health innovations.

To further guide the research, the second sub-research question “What empirical evidence exists, that can give information on factors affecting the adoption of frugal health innovations?” was asked. Answering this sub-research question allowed to synthesize empirical evidence in the Unified Theory of Acceptance and Use of Technology 2 framework to arrive at a conceptual framework for the adoption of frugal health innovations. Secondary data from the literature was retrieved through a literature study, and the empirical evidence was put in the context of frugal health innovations. From this, it followed that the possibility to experiment with the innovation (Trialability), the innovation- fit with the customers’ lifestyle (Lifestyle Compatibility), the availability of required knowledge to use the innovation (Consumer Literacy), the trust toward the provider of the innovation (Trust), the technical performance of the innovation (Performance Expectancy), the ease-of-use of the innovation (Effort Expectancy), the degree of social pressure to use the innovation (Social Influence), the price of the innovation (Price Value), and the degree of resource- and infrastructural constraints impeding the use of the innovation (Facilitating Conditions) facilitate the intention to adopt frugal health innovations (Behavioural Intention). Interestingly, the synthesis revealed that Price Value, Facilitating Conditions, and Trust also act as a barrier in case they are not properly addressed by the frugal health innovation.

Ultimately, the conceptual framework was empirically validated in the context of frugal health innovations through semi-structured interviews with four frugal health innovation developers. Because developers were surveyed, in contrast to consumers by the studies from the literature review, the adoption, and not consumer-central behavioural intention to adopt, was studied. To increase the possibility of adoption, results suggest that trust between the developer and consumer should be established (Trust), the innovation should align with the preferences of the consumer (Lifestyle Compatibility), the innovation should be designed so that it is easy to use and install (Effort Expectancy), and the innovation should be priced appropriately to ensure affordability whilst maintaining a positive perceived price- quality relationship (Price Value). Further, results suggest that it is imperative to understand the context of the addressed health-related issues, as the performance of the frugal innovation must be superior to traditional health innovations if the latter shows poor performance or side effects, or can be inferior if they are used indicatively where the traditional innovation is used confirmatively (Performance Expectancy). Understanding the context is also of importance to determine whether the use of the frugal health innovation is not impeded by the lack of resources and/or infrastructure, or, appropriately addresses their absence, thereby providing a market opportunity (Facilitating Conditions). Additionally, results suggest that the severity of the health problem (Problem Severity) also affect the adoption, whilst only relevant in case frugal health innovations are sold to governmental organizations. All in all, this exploratory research provides a first conceptual framework to study the adoption of frugal health innovations and opens up the debate on what is required for their adoption. Developers are advised to tailor frugal health innovations according to the principles observed in this research study, as doing so likely enhances the probability of adoption. However, considering the lack of a consumer-perspective in this research study, a logical next step is to further gather empirical findings on frugal health innovation adoption using the developed conceptual framework, to ensure a more robust image of the factors affecting the adoption of frugal health innovations.