Chung Amanda Marr, Murungu Joseph, Case Peter, Chitapi Precious, Chikodzore Rudo, Gosling Jonathan, Xaba Sinokuthemba, Ncube Getrude, Mugurungi Owen, Kunaka Patience, Prata Ndola, Gosling Roly Daniel, Bertozzi Stefano M, Auerswald Colette
Center for Innovation in Global Health, Stanford University, Stanford, California, USA
Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA.
BMJ Glob Health. 2025 Aug 11;10(8):e018732. doi: 10.1136/bmjgh-2024-018732.
The transition of voluntary medical male circumcision (VMMC), an HIV prevention service, in Zimbabwe from a donor-funded to a government-owned programme involves the collective efforts and alignment of national and subnational government leaders, managers, healthcare providers, village health workers, community members, donors and implementing partners. We sought to understand stakeholders' perspectives on barriers, facilitators and recommendations as a vertical HIV prevention programme transitioned to an integrated, government-led model.
We conducted 54 semistructured stakeholder interviews at the national and subnational levels. Interviews were audio recorded, transcribed and thematically analysed.
Participants highlighted a range of psychological and structural barriers and facilitators to integrating and sustaining the VMMC programme. Respondents mentioned financing and staffing barriers to integration, particularly a lack of domestic resources, the transition from a fee-for-service to a facility-based performance model and staff attrition. Notably, resistance to changing the VMMC programme's operations was a significant barrier that may be tied to individual psychological barriers such as loss of power and job security. Donors and partners continued to control the funding for VMMC. Ideally, the Ministry of Health and Child Care should have more autonomy over these decisions. At the subnational level, there is an opportunity for increased responsibility and a greater sense of ownership through the decentralisation of governance.
To ensure successful integration and local ownership of VMMC as an HIV prevention programme, stakeholders must address both psychological and structural barriers while aligning their perspectives on the transition. Individual providers have valid concerns about their financial security and the burden of additional responsibilities without adequate compensation. It is crucial for donors and partners to reduce their involvement and oversight. Additionally, resolving the financial barriers that prevent the government from having complete control of the programme will require empowering local government stakeholders to fully take ownership.
在津巴布韦，自愿男性包皮环切术（VMMC）这一预防艾滋病服务项目，从由捐助者资助转变为由政府主导的项目，需要国家和地方各级政府领导人、管理人员、医疗保健提供者、乡村卫生工作者、社区成员、捐助者及实施伙伴共同努力并保持协调一致。随着一项垂直的艾滋病预防项目向由政府主导的综合模式转变，我们试图了解利益相关者对于障碍、促进因素及建议的看法。
我们在国家和地方层面进行了54次半结构化利益相关者访谈。访谈进行了录音、转录并进行了主题分析。
参与者强调了在整合和维持VMMC项目方面存在一系列心理和结构上的障碍及促进因素。受访者提到了整合过程中的资金和人员配置障碍，特别是缺乏国内资源、从按服务收费模式向基于机构的绩效模式转变以及人员流失。值得注意的是，对改变VMMC项目运作的抵制是一个重大障碍，这可能与个人心理障碍有关，如权力丧失和工作安全感缺失。捐助者和合作伙伴继续控制着VMMC的资金。理想情况下，卫生和儿童保健部在这些决策上应拥有更多自主权。在地方层面，通过治理权力下放，有机会增加责任感并增强主人翁意识。
为确保VMMC作为一项艾滋病预防项目成功整合并实现地方自主管理，利益相关者必须解决心理和结构上的障碍，同时在过渡问题上达成共识。个体提供者对自身财务安全以及在没有足够补偿的情况下承担额外责任的负担存在合理担忧。捐助者和合作伙伴减少其参与和监督至关重要。此外，解决阻碍政府完全掌控该项目的资金障碍，需要赋予地方政府利益相关者充分的自主权。
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