AbstractThe global health community has recognized the importance of integrating and sustaining health programs and forming equitable partnerships. Corresponding with these objectives, international aid donors are embracing the principle of localization. The Voluntary Medical Male Circumcision (VMMC) in Zimbabwe is a large vertical HIV prevention program primarily funded through development assistance for health. Program stakeholders want to sustainably integrate VMMC into routine health services so that the program will continue to be a cost-effective HIV prevention strategy through 2030. The purpose of this paper is to describe a bottom-up process of sustainably integrating the program into routine health services through an approach that empowers local stakeholders. At the district level, we facilitated changes to accelerate integration and sustainability. To evaluate our intervention, we used a mixed methods design comprising analysis of district-level work plans with qualitative and quantitative indicators, combined with a survey assessing sustainability capacity of the program, administered at midline and endline to district teams. In all five pilot districts we facilitated the transition of VMMC into the government’s district administration, resulting in a locally owned and managed program, while also strengthening individual and team capacity. We observed improvements across all World Health Organization health system building blocks, suggesting that the intervention strengthened the overall health system. The sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. Compared to traditional top-down change initiatives, the participatory approach to integration was an effective way of addressing specific VMMC challenges at the district level whilst maintaining management and oversight at provincial and national levels. Other health programs in low- and middle-income countries seeking to integrate and sustain health services at subnational levels should consider this diagonal, bottom-up model to promote local leadership development and health system strengthening.

Although it is widely recognized that strong program management is essential to achieving better health outcomes, this priority is not recognized in malaria programmatic practices. Increased management precision offers the opportunity to improve the effectiveness of malaria interventions, overcoming operational barriers to intervention coverage and accelerating the path to elimination. Here we propose a combined approach involving quality improvement, quality management, and participative process improvement, which we refer to as Combined Quality and Process Improvement (CQPI), to improve upon malaria program management. We draw on evidence from other areas of public health, as well as pilot implementation studies in Eswatini, Namibia and Zimbabwe to support the proposal. Summaries of the methodological approaches employed in the pilot studies, overview of activities and an outline of lessons learned from the implementation of CQPI are provided. Our findings suggest that a malaria management strategy that prioritizes quality and participative process improvements at the district-level can strengthen teamwork and communication while enabling the empowerment of subnational staff to solve service delivery challenges. Despite the promise of CQPI, however, policy makers and donors are not aware of its potential. Investments are therefore needed to allow CQPI to come to fruition.

Background Focus for improved malaria programme performance is often placed on the technical challenges, while operational issues are neglected. Many of the operational challenges that inhibit malaria programme effectiveness can be addressed by improving communication and coordination, increasing accountability, maintaining motivation, providing adequate training and supervision, and removing bureaucratic silos. Methods A programme of work was piloted in Zimbabwe with one malaria eliminating province, Matabeleland South in 2016-2017, and scaled up to include two other provinces, Matabeleland North and Midlands, in 2017-2018. The intervention included participatory, organization development and quality improvement methods. Results Workshop participants in Matabeleland South reported an improvement in data management. In Matabeleland North, motivation among nurses improved as they gained confidence in case management from training, and overall staff morale improved. There was also an improvement in data quality and data sharing. In Midlands, the poorly performing district was motivated to improve, and both participating districts became more goal-oriented. They also became more focused on monitoring their data regularly. Participants from all provinces reported having gained skills in listening, communicating, facilitating discussions, and making presentations. Participation in the intervention changed the mindset of malaria programme staff, increasing ownership and accountability, and empowering them to identify and solve problems, make decisions, and act within their sphere of influence, elevating challenges when appropriate. Conclusions This pilot demonstrates that a participatory, organization development and quality improvement approach has broad ranging effects, including improving local delivery of interventions, tailoring strategies to target specific populations, finding efficiencies in the system that could not be found using the traditional top-down approach, and improving motivation and communication between different cadres of health workers. Scale-up of this simple model can be achieved and benefits sustained over time if the process is imbedded into the programme with the training of health staff who can serve as management improvement coaches. Methods to improve operational performance that are scalable at the district level are urgently needed: this approach is a possible tactic that can significantly contribute to the achievement of global malaria eradication goals.