Sustainability and Integration of the Voluntary Medical Male Circumcision Program in Zimbabwe

Low- and middle-income countries are increasingly under pressure to determine how to integrate their donor-driven health programs into locally-run health programs. Voluntary Medical Male Circumcision (VMMC) is a cost-effective, evidence-based HIV prevention strategy. It has been shown to reduce female to male transmission of HIV by 60%. The World Health Organization and UNAIDS recommend VMMC in 15 countries. These East and Southern African countries have high HIV prevalence rates, where heterosexual sex is the main driver of HIV transmission, and there are low circumcision prevalence rates in some or all populations. External donors such as the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB, and Malaria (GFATM) are seeking to withdraw financial support for the VMMC program, despite its potential contribution to ending the HIV/AIDS epidemic, because they feel that national governments should be able to continue the program at steady-state. According to PEPFAR, mathematical modeling shows that reaching high levels of VMMC coverage can “…dramatically reduce community-level HIV incidence and save billions of dollars in HIV care and treatment costs. The imminent withdrawal of donor funding has stimulated national governments to mobilize domestic resources and take responsibility for the oversight and operations of the program from NGOs. In Zimbabwe, there is political will from the government to take on the VMMC program, as evidenced by the national VMMC Sustainability Transition Implementation Plan. According to this plan, the sustainability of the VMMC program calls for an integrated, decentralized, and locally owned program. The vertical (or stand-alone) program will be integrated into existing health services. The availability of the procedure at primary health centers will depend on training of more service providers. Decentralization will require a transfer of management responsibilities from implementing partners to subnational government stakeholders, a consolidation of roles, and greater community engagement. In the first paper, Managing change to integrate and sustain a vertical, donor-funded program: a case study on Voluntary Medical Male Circumcision in Zimbabwe, I develop a business-school-style teaching case study that uses an example of a health program that is undergoing a transition from a vertical program to a horizontal health program. The VMMC program in Zimbabwe must make changes to its operating model to sustain the program in preparation for the eventual withdrawal of donor funding. It must also transition from a program that is donor and implementing partner led to one that is government owned and operated. This case study illustrates how a health program pivots after a period of disruption (in this case the COVID-19 pandemic); the likelihood of successful change when leadership is shared rather than dependent upon one individual; and how a team can participate in a process to prioritize addressing a problem and mobilize collective action to resolve it. In the second paper, Sustainable integration of a vertical Voluntary Medical Male Circumcision program into routine health services in Zimbabwe: a mixed methods process evaluation of a participatory change intervention, I address whether a systems change intervention called the LEAD Framework furthered the integration and sustainability of the VMMC program. I focus on how the intervention facilitated the transition of VMMC within five pilot districts into a locally-owned and managed program while also strengthening individual and team capacity. District team actions included greater engagement of multisectoral stakeholders, better use of existing resources, and changes to operating models. I observed improvements across all World Health Organization health system building blocks, suggesting that the intervention strengthened the overall health system. A sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. In the third paper, Understanding stakeholder perspectives on integrating and sustaining voluntary medical male circumcision into routine health services in Zimbabwe: a qualitative study, I describe the range of psychological and structural barriers and facilitators faced by a broad array of stakeholders engaged in integrating and sustaining the VMMC program. Notably, staffing and financing barriers, particularly the obstacles posed by staff attrition, limited domestic resources, and the transition from a fee-for-service to a facility-based performance model, will make decentralized service delivery and maintaining high levels of productivity challenging. Respondents also mentioned resistance to changing the program's operations as a significant barrier, especially as donors and partners continued to control the funding, thereby limiting the Ministry of Health and Child Care's (MoHCC) decision-making power. However, stakeholders saw an opportunity for increased responsibility and a greater sense of ownership at the subnational level through the decentralization of governance. As a whole, this dissertation provides a description of how a transition of the VMMC program in Zimbabwe from a vertical program to a horizontal program can be facilitated through a participatory, bottom-up systems change intervention called the LEAD Framework, answering research questions not previously addressed in the literature and suggesting next steps for countries undergoing similar processes.

Advisor: Bertozzi, Stefano