Sustainable integration of a vertical voluntary medical male circumcision program into routine health services in Zimbabwe: A mixed methods evaluation of a participatory change intervention

The global health community has recognized the importance of integrating and sustaining health programs and forming equitable partnerships. Corresponding with these objectives, international aid donors are embracing the principle of localization. The Voluntary Medical Male Circumcision (VMMC) in Zimbabwe is a large vertical HIV prevention program primarily funded through development assistance for health. Program stakeholders want to sustainably integrate VMMC into routine health services so that the program will continue to be a cost-effective HIV prevention strategy through 2030. The purpose of this paper is to describe a bottom-up process of sustainably integrating the program into routine health services through an approach that empowers local stakeholders. At the district level, we facilitated changes to accelerate integration and sustainability. To evaluate our intervention, we used a mixed methods design comprising analysis of district-level work plans with qualitative and quantitative indicators, combined with a survey assessing sustainability capacity of the program, administered at midline and endline to district teams. In all five pilot districts we facilitated the transition of VMMC into the governments district administration, resulting in a locally owned and managed program, while also strengthening individual and team capacity. We observed improvements across all World Health Organization health system building blocks, suggesting that the intervention strengthened the overall health system. The sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. Compared to traditional top-down change initiatives, the participatory approach to integration was an effective way of addressing specific VMMC challenges at the district level whilst maintaining management and oversight at provincial and national levels. Other health programs in low- and middle-income countries seeking to integrate and sustain health services at subnational levels should consider this diagonal, bottom-up model to promote local leadership development and health system strengthening.