Aletheia: An Offline-First Clinical Decision Support System for Differential Diagnosis in Low-Resource Healthcare Settings

Access to specialist clinical expertise remains severely limited across sub-Saharan Africa, where physician-to-patient ratios can fall below 1:25,000 in rural settings. Existing AI-assisted diagnostic tools predominantly require reliable internet connectivity and high-specification hardware, rendering them impractical for frontline healthcare workers in district hospitals and health centres. This paper presents Aletheia, an offline-first clinical decision support system designed for low-resource healthcare contexts across sub-Saharan Africa. Aletheia is built upon Qwen2.5-3B-Instruct, fine-tuned using Quantised Low-Rank Adaptation (QLoRA) on a curated dataset of 27,000 clinical reasoning samples spanning 50 disease conditions with elevated prevalence in East Africa. Evaluation demonstrates a Top-1 diagnostic accuracy of 80% (8 of 10 cases; 95% CI: 49.0-94.3%), Top-3 accuracy of 100% (10 of 10 cases; 95% CI: 72.2-100%), BERTScore-F1 of 0.909, and METEOR of 0.467. These diagnostic figures are computed over a deliberately small set of ten representative clinical case categories, one case each, and are therefore indicative rather than statistically robust; the wide confidence intervals should be read alongside them. The system achieves an Expected Calibration Error (ECE) of 0.275 and passes the Africa Deep Tech Challenge 2026 (ADTC 2026) memory budget constraint of 7168 MB, achieving a peak inference RAM of approximately 3630 MB on the standardised benchmark laptop. These results demonstrate the feasibility of deploying large language model-based clinical reasoning at the primary care level in resource-constrained settings without cloud infrastructure.