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

Abstract

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.

Fig. 1

Participative Process Improvement Model for District and Provicincial Teams [21]. This figure depicts the annual PPI cycle, starting with an initial workshop consisting of the ‘system in the room’ at the top, where problems are identified and a situational assessment is conducted. Participants include representatives from national and provincial malaria and health leadership, district workers from cadres involved in delivering malaria activities and community representatives including local politicians, traditional healers etc. that should receive them. A prioritized list of problems are then transformed into a work plan with associated metrics by a self-selected multidisciplinary Task Team of 8-10 people. The Task Team implements the work plan, devising solutions to each challenge, gathers data, and analyzes results in a Plan-Do-Study-Act cycle, while also receiving continuous mentoring and coaching. At the same time, local facilitators are trained in how to lead the workshops and Task Team meetings. A follow-up workshop closes the loop, during which progress on problem-solving is fed back to the group, and the cycle begins again with the resolution of some problems and the addition of new problems