Our study demonstrates that the CPM is one strategy that can be used to effectively scale up and optimise PMTCT programmes in sub-Saharan Africa where MTCT rates remain unacceptably high. In PMTCT, the efficacy of ARV regimens used determine the reduction of the MTCT rate of the country. However, the efficacy of ARV regimens depends on the extent of their roll-out and their uptake in the population. The CPM, in this case, helped to rapidly roll-out and to optimise the use of the new WHO ARV guidelines in the country.
The EGPAF-CIFF program used the CPM to roll-out 2010 and 2013 PMTCT guidelines to nearly all MNCH facilities of the country within one year. Only non-functional clinics did not implement the new guidelines. Previously, Zimbabwe took more than 4 years to introduce new WHO PMTCT guidelines and rolled them out to only 50% of the MNCH facilities in the country [10]. The rapid roll-out was achieved because activities implemented, such as training nurse HIV testers, supporting sites to order ARVs and redistributing ARVs from one facility to another, procuring and supplying CD4 testing devices, supporting EID courier services and other activities directly improved PMTCT service availability. Consequently, the number of women and children who received PMTCT services increased by two to fourteen-fold comparing the five-year pre- and intervention periods. Similarly, the uptake of all PMTCT services increased significantly during the intervention period.
Various studies corroborate our findings. D’Aquilla and Falconer noted that the CPM can be used to implement public health programmes in ways that optimises health outcomes [15, 18]. Similarly, Paintsil and Andiman, in a systematic review, observed that increased coverage of more efficacious ARV regimens is a key success factor of PMTCT programmes in resource-limited countries. The barriers to success of PMTCT programmes noted by the authors are lack of health care infrastructure, slow integration of PMTCT services into traditional MNCH services, limited manpower, limited funding, competing priorities against limited public health budgets, low ART and MTCT programme coverages, low coverage of PCR-based diagnosis for paediatric HIV and other factors [36]. In their systematic review, Ambia and Mandala found the use of community health workers, tracking HIV-positive women and training midwives in PMTCT integration into routine pregnancy and infant care and lab courier system for CD4 counts to increase PMTCT uptake [3]. Use of the CPM addressed the challenges identified in these reviews and implemented continuous course corrections that included the recommendations of these studies to the success of Zimbabwe’s PMTCT programme.
The RD analysis showed that the interventions implemented for ANC bookings, maternal AZT prophylaxis, CD4 testing, mothers’ ART initiation and EID significantly increased performance for these indicators. The interventions are similar to those recommended in Ambia and Mandal and barriers identified by Paintsil and Andiman in their systematic reviews [3, 36]. RD analysis does not compare results of different interventions but determines if the intervention introduced changed the related indicator results [31, 32]. Knowledge of the various projects implemented in the country at that time enables the attribution of results of the different indicators to the activities of this project. To the best of our knowledge, no other PMTCT support had comparable scale and intensity as the EGPAF-CIFF project.
RD analysis showed no significant increase in HIV testing of pregnant women and infant ARV prophylaxis uptake, likely for two reasons. Although the EGPAF-CIFF project expanded PMTCT services offered using new WHO guidelines from 50% to nearly 100% of MNCH facilities in Zimbabwe, HIV testing uptake in the 50% facilities was already high at about 90% [10]. Consequently, the CPM increased the percentage of sites offering PMTCT using new WHO guidelines but did not drastically increase the uptake of HIV testing in ANC, which was already high. RD analysis may have not detected the impact of interventions implemented on the infant ARV indicator because of challenges with the way that the indicator was measured. The numerator was the number of HIV-exposed infants dispensed ARV prophylaxis and the denominator was the number of HIV-positive pregnant women identified in ANC during each quarter. Given that infant ARV prophylaxis dispensing was done at delivery while the HIV-positive mothers would be identified at ANC booking, which occurred from 14 weeks’ gestation, the women counted in the denominator were not necessarily the mothers of the HIV-exposed infants started on ARV prophylaxis that quarter. This compromised the sensitivity of the indicator, making it difficult to detect the impact of the interventions implemented on it.
We believe that the CPM approach contributed to the rapid decline in Zimbabwe’s MTCT rate from 2011 to 2015. Zimbabwe’s MTCT rate declined from 22 to 6.4%, close to the UNAIDS target of 5% by 2015. Although UNAIDS 2015 spectrum estimates indicate that the MTCT rate was already declining from 31% in 2000/2002 to 22% in 2010, the MTCT rate declined more rapidly from 20% in 2011 to 6.4% in 2015 [20]. Similarly, population-based PMTCT impact studies of Zimbabwe found drastic declines in the MTCT from 10% in 2012 to 4.8% in 2014 [19].
The drastic declines observed by UNAIDS modeling estimates and PMTCT impact studies occurred during the EGPAF-CIFF project. The early declines observed in the MTCT rate may be associated with high HIV mortality, behavior change associated with HIV mortality and prevention efforts and the impact of ART from 2004 onwards, as noted by Mahomva et al. [37]. UNAIDS Spectrum modeling shows a stabilization of the MTCT rate at 6–7% from 2016 to 2019. This suggests that the end of the EGPAF-CIFF project, which scaled down substantially in 2015 and ended in September 2017, may have removed the strong driving force for continued decline of the MTCT rate. Continuation of PMTCT support at the same intensity as 2011–2015 may have reduced the MTCT rate further. The stabilization trend may also indicate the challenge of reaching the last mile of public health targets, which takes more resources for reduced impact.
The CPM is one of various QI approaches that can be used to rapidly achieve programme targets. In other literature, the CPM is also referred to as the Program Evaluation and Review Technique (PERT) [15, 17]. Other approaches include the rapid results initiative (RRI) or rapid results approach (RRA), results-based management (RBM), results-based financing (RBF), continuous quality improvement (CQI), and PDSA cycles. Governments largely use RRI, RRA and RBM strategies to accelerate economic recovery and development programmes [38,39,40,41]. Many sub-Saharan Africa countries use the three strategies in various government programmes [38,39,40,41]. Challenges faced with these approaches include poor management control systems in the public sector, difficulties to change public sector culture, political influence in public sector management and resource inadequacies [40].
To improve health indicators, governments and development partners mostly use RBF, CQI and PDSA cycles [38, 41, 42]. These approaches are more adapted to health systems. Among the three approaches commonly used in health programmes, the CPM has the comparative advantage that it incorporates elements of the other three. The budgeting and financing approach in the CPM incorporates the RBF concept of performance-based resource allocation, while the activity implementation incorporates CQI and PDSAs [15, 17]. The inclusion of PDSA cycles in the CPM encourage programme implementers to use their data and drive their own facilities’ performance. The CPM makes programme performance guide resource allocation in activity budgets.
The CPM provides a systematic method of engagement with government and key health development partners, through joint annual planning and review meetings. In Zimbabwe, the government adopted various new policies recommended during the CPM, including incorporating PMTCT in VHW training curriculum, introducing nurse-led ART initiation, introducing clinical mentorship and ART initiation in MNCH clinics and adopting QI strategies in all HIV programmes using PSDA cycles. Lyons and Pillay documented the impact of approaches used in the EGPAF-CIFF project on country and community leadership to achieve the global plan for elimination of mother-to-child transmission of HIV target [43]. The CPM facilitated this country, community and facility leadership engagement during the project.
This paper has described the use of the CPM in a public health programme where application and documentation of the method is limited. Following the near achievement of the UNAIDS MTCT rate target of 5%, Zimbabwe is applying for WHO ‘path to elimination (PTE)’ award. The WHO PTE award is for countries that have made significant progress towards achievement of the elimination target [44]. CIFF leveraged the lessons of the CPM in Zimbabwe’s Hurungwe district, in the “Accelerating Children’s HIV/AIDS Treatment (ACT) initiative” in 2015 [45]. Together with the President’s Emergency Plan for AIDS Relief (PEPFAR), CIFF also leveraged the CPM in the initiative to improve HIV testing, treatment and care for children and adolescents in 9 priority countries – namely, Cameroon, Democratic Republic of Congo, Kenya, Lesotho, Malawi, Mozambique, Tanzania, Zambia, and Zimbabwe from 2016 to 2019 [46].
The limitations of this study are that it uses retrospective programme data. The authors had limited control on the quality of the data analysed. The EGPAF-CIFF project coincided with the introduction of more efficacious PMTCT regimens like Option B+. This makes it difficult to attribute the decline of Zimbabwe’s MTCT rate entirely to use of the CPM. However, the CPM played a clear role to rapidly roll-out and optimize uptake of the new regimens, which was a challenge in the roll-out of previous regimens. Without this rapid roll-out and the optimization of uptake, it would have been difficult for the regimens to have an impact on the MTCT rate. The strength of this paper is that it is based on field-based public health experience of implementing the CPM and uses a wide range of data to demonstrate the benefits of employing the approach. The approach has been leveraged also in follow-up CIFF projects implemented in other countries, which is evidence of its growing successes.