Effective management of district-level malaria control and elimination: implementing quality and participative process improvements.

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.

Scaling up malaria elimination management and leadership: a pilot in three provinces in Zimbabwe, 2016-2018.

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.

Correction to: How far is the journey before malaria is knocked out in Zimbabwe: results of the malaria indicator survey 2016.

Following publication of the original article [1], the authors of the article flagged that their article had gone to publishing with an error in the title.

How far is the journey before malaria is knocked out in Zimbabwe: results of the malaria indicator survey 2016 [corrected].

BACKGROUND: Zimbabwe conducts Malaria Indicator Surveys after 3 years and Demographic and Health Surveys to track the impact of malaria interventions. The last one to be conducted was in 2016 and had set an aim aimed to collect data to track malaria indicators as well as to save as the baseline source for the Malaria Strategic Plan (2016-2020). METHODS: Malaria Indicator Survey-2016 utilized the frame of enumeration areas (EAs) from the Zimbabwe Master Sample (ZMS12) created after the 2012 population census for each of the survey districts. The design for the survey was a representative probability sample to produce estimates at national level for the respective domains, which are the forty-four malaria-endemic districts. Survey teams comprised of Ministry of Health personnel who administered the standard questionnaire (adapted to country setting) to respondents within sampled EAs, performed RDT, anaemia test, prepared microscopic slide and collected DBS and data analysis of collected information was analysed. Microscopic slides examined centrally at the National Institute of Health Research. RESULTS: The overall protection coverage by at least one major vector control measure, IRS and/or Nets, was 82.5%. Use of nets among high-risk groups 32.5% For children under five and 24.5% for pregnant women. LLIN utilization quite low taking into consideration the net ownership per household, which was 58% for the general population. Moreover, IPTp coverage has remained almost unchanged since the 2012 MIS, with only a third of pregnant women receiving at least two doses of IPTp. Malaria prevalence appears to be on the decline with 2016 MIS recording 0.2% compared to 0.4% as of 2012 MIS. Plasmodium falciparum remains the predominant parasite species in the country at 98%. CONCLUSION: The results indicated that some progress has been made in malaria control although there is still subsequent low malaria risk perception that comes with the reduced prevalence. It has been shown that there is low use of interventions shown by the low use of LLINs by vulnerable groups like pregnant women and children under five.