Scaling up Malaria Elimination Management and Leadership: A pilot in three provinces in Zimbabwe, 2016 -2018
Authors: Chung Amanda Marr , Case Peter , Gosling Jonathan , Gosling Roland , Madinga Munashe , Chikodzore Rudo , Hove Macdonald , Viljoen Greyling , Chitapi Precious , Gumbi Matsiliso , Mnguni Peliwe , Murungu Joseph , Dube Busisani , Dhliwayo Patience , Mberikunashe Joseph 
Published: January 2020

Abstract
Background Focus for improved malaria program performance is often placed on the technical challenges, while operational issues are neglected. Many of the operational challenges that inhibit malaria program effectiveness can be addressed by improving communication and coordination, increasing accountability, maintaining motivation, providing adequate training and supervision, and removing bureaucratic silos.Methods In collaboration with the Zimbabwe Ministry of Health and Child Care (MoHCC), University of California San Francisco (UCSF), University of West of England (UWE), Clinton Health Access Initiative (CHAI) Zimbabwe, and organization development consultants from South Africa and Zimbabwe, a program of work was piloted in Zimbabwe starting 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, with the development of a data collection tool, the initiation of data reporting from district to province on a weekly basis, and the establishment of a data focal point in each district. In Matabeleland North, motivation among nurses improved as they gained confidence in case management from training, and overall staff morale was impacted positively. There was also an improvement in data quality and the frequency in which data was shared via weekly bulletins. 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 and learned how to develop indicators to measure the process improvement changes they were making. Participants from all provinces reported having a better appreciation of the value of communication, team work, planning, continuous monitoring of data, and adjustment of work plans and gained skills in listening, communicating, facilitating discussions, and making presentations. Participation in the intervention changed the mindset of malaria program 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 inter alia : 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 program 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: a participatory, organization development and quality improvement approach is a possible tactic that can significantly contribute to the achievement of global malaria eradication goals.