To achieve programme objectives, a collaboration was formed between the Zimbabwe Ministry of Health and Child Care (MoHCC), UCSF, UWE, Clinton Health Access Initiative (CHAI) Zimbabwe, and OD consultants from South Africa and Zimbabwe. The pilot was implemented in one malaria eliminating province, Matabeleland South in 2016-2017, scaling up to two other provinces, Matabeleland North and Midlands, in Zimbabwe during 2017-2018.
Early versions of the process improvement intervention were trialed in field work conducted in the Central Highlands of Vietnam during the 2014-15 malaria season, with funding from the US Naval Health Research Center (Case P, University of West of England, personal communication). During the 2016-2017 malaria season, the project worked with Beitbridge and Gwanda districts in Matabeleland South province. Matabeleland South province had reoriented to focus on malaria elimination in 2012 for all of its seven districts. Beitbridge and Gwanda are the two districts with the highest malaria incidence within the province and the two remaining districts for which indoor residual spraying (IRS) was implemented . From 2017-2018, work continued with the two districts in Matabeleland South and expanded to all seven districts in Matabeleland North province (Binga, Bubi, Hwange, Lupane, Nkayi, Tsholotsho, and Umguza) and two districts in Midlands province (Chirumhanzu and Kwekwe). Of the seven districts in Matabeleland North, five had reoriented towards malaria elimination as had both districts of Midlands.
The programme objective was to change the mindset of district-level malaria teams to: 1) increase productivity, coverage, and quality of operations, 2) develop management capacity at the sub-national level, 3) empower frontline workers to take ownership, solve problems, and act on decisions, and 4) optimize limited resources, while integrating for efficiency with other programmes.
The programme model seeks to strengthen all six World Health Organization (WHO) building blocks of a health system (Fig. 1), focusing directly on leadership/governance, service delivery and health information . Empowerment of staff to find innovative solutions to their local problems has indirect effects on health workforce through improved motivation, optimized use of available medical products and technologies, and on financing through seeking local efficiencies in service delivery.
The intervention was based on organization development principles of building knowledge and skills within district-level malaria teams to improve effectiveness and bring about organizational change and better performance [9-13]. A participatory, action-oriented approach was also employed [16,17]. Quality improvement methods such as root cause analysis and prioritization tools were introduced in 2017-2018 and continue in on-going activities.
A systematic process was employed, involving continual diagnosis of challenges, action planning, implementation and evaluation to build capacity for change management. Fig. 2 depicts the project cycle, which varied from 8 months to one year, depending on the timing of the initial workshop for each province.
During the initial workshop, an OD technique was introduced called “system in the room” to replicate the malaria programme in the meeting space. This entailed inviting participation from approximately 30-60 participants, who represented a full spectrum of disciplines and functions related to malaria control at the health facility, district, provincial, and national levels (see Table 1 for workshop participant composition). UCSF/UWE external facilitators led the workshop participants through structured exercises to identify the range of challenges they faced: from the disbursement of funding and a shortage of motorbikes to accessing flood-prone villages and community resistance to IRS. The purpose of constructing this participatory inventory of challenges was to facilitate communication and see varying perspectives on the system from different cadres and levels. These exercises aimed to focus on psychosocial elements behind the challenges each individual faced and was accomplished through asking all participants to develop graphical representations of the challenges obstructing the implementation of the malaria elimination strategy. Small groups then further analysed each individual challenge and proposed solutions to address them. Through these exercises the group identified and prioritized unresolved operational challenges that a smaller, more focused ‘Task Team’ would take forward over the course of the malaria season.
The Task Team was a cross disciplinary and cross-hierarchical subset of 10-15 workshop participants comprising members from different cadres and both district and provincial levels (see Box 1 for roles and functions). Expert coaching and facilitation were provided to each Task Team to develop a work plan, which consisted of proposed solutions and associated metrics for each operational challenge in order for performance to be systematically evaluated. The focus of the selected challenges and proposed solutions was on those that could be implemented at the local level. Moreover, at the initial Task Team meeting, national level metrics were reviewed and taken into account when the Task Team reviewed priorities agreed to during the workshop to ensure that local action plans contributed to national priorities. Facilitation helped to develop greater specificity around the challenges and proposed solutions, identification of metrics, and assignment of timelines and responsibilities to individuals. The assignment of specific individuals and development of metrics ensured accountability with respect to achievement of results. The Task Team met periodically to take service delivery challenges forward, monitor progress towards targets, and incorporate new challenges and solutions as they arose. A follow-up workshop was scheduled at the end of the project cycle (some 8-10 months after the initial workshop). At this event, the wider whole-system group reconvened to evaluate progress on the challenges from the initial workshop and define new priorities to be incorporated into provincial level planning, budgeting, and reporting for the following year.
During the second year of implementation, local facilitators from within the malaria programme and CHAI who participated in the first year of the programme received leadership training with a focus on process improvement methods and organization development in order to sustain the work after external funding was no longer available. Three of the six selected for training completed a postgraduate certificate award in Professional Practice in Change Leadership (PPCL) at Bristol Business School, UWE . An online handbook for facilitators was developed, and efforts were made to integrate the work into national quality improvement programmes and existing infrastructures.
Monitoring and evaluation
Change was measured within the pilot areas by collecting baseline, midline, and end-line quantitative and qualitative data. However, due to data access limitations, comparative data in non-intervention districts was not collected, nor were confounders to impact measured, such as other district, provincial or national level investments that may have driven the changes that were measured.
The measurement framework consisted of: 1) surveys for the initial and follow-up workshops to gauge overall satisfaction with the workshop and gather suggestions for improvements; 2) baseline, midline, and end-line quantitative and qualitative indicators to assess whether any change had occurred for each prioritized operational challenge within the Task Team workplans; and 3) surveys to supplement the workplan data, assess whether teamwork (communication, coordination, motivation) had improved, and if participants had gained any knowledge or skills from the project. An important aspect of the evaluation and measurement process was that members of the Task Team played a significant role in deciding for themselves which indicators and metrics best matched the challenges that had been identified and prioritized by participants. The chosen metrics were often standardized to national level metrics, ensuring that data were already being collected and could be derived from official sources, though in some instances Task Teams found it necessary to generate their own measures. The key point is that there was a strong participatory dimension not only to the performance improvement but also to the evaluation process.
Costs of the programme
Costs for implementing the programme in Zimbabwe were taken from the programme’s perspective to buy in the service.