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Child mortality disproportionally clusters in low- and middle-income countries (LMICs), with the highest burden in sub-Saharan Africa, where under-five mortality peaks at 69 deaths per 1000 live births compared with the average global mortality rate of 37 per 1000 live births. 1 The leading primary causes of postneonatal deaths in children aged 1–59 months are lower respiratory tract infections, malaria and diarrhoea, which collectively cause one-third of under-five deaths.1 2 Several interventions with demonstrated efficacy to reduce child mortality exist, such as vaccination, early diagnosis of pneumonia and access to medical oxygen. However, their widespread implementation is often hindered by the fragility of health systems in such settings. Integration of effective interventions into care pathways also affects their potential to impact on child outcomes, and this is particularly the case at the lowest levels of care—such as within primary healthcare (PHC) facilities or at the community level, where care is typically delivered by community health workers or village health teams. Missed hypoxaemia remains a major cause of preventable mortality in children. Integrating pulse oximetry (PO) into the Integrated Management of Childhood Illnesses (IMCI) offers a critical opportunity to improve early detection of severe illness, but findings from the Amélioration de l’Identification des Détresses Respiratoires chez l’Enfant (AIRE) project show that successful implementation requires supportive health system reforms.