BACKGROUND: Global guidance encourages the use of community-led monitoring (CLM) to shape effective health services. Yet, the attribution of CLM to service improvements is often imprecise. To our knowledge, this is the first study that aims to quantify this effect.
METHODS: We implemented a CLM intervention at 33 health facilities in Malawi and South Africa, collecting data from November 2018 – October 2022. We conducted monthly clinic records surveys of HIV and TB services, and interviewed 505 healthcare workers and recipients of care. Data was fed back to facilities on a quarterly basis to discuss gaps and identify solutions. Regular community education sessions generated demand for services. We then compared outcomes at our monitored sites to other facilities.
RESULTS: In 2020, COVID-19 led to a 64% decline in voluntary medical male circumcision in South Africa (nationally), with a similar (66%) decline at our monitored sites. In 2021, circumcisions increased by 126% nationally, and by 156% at our monitored sites. A professional nurse said that CLM encouraged her to “start afresh, giving health education”. In 2019, the TB treatment success rate was comparable at our monitored sites (78%) and in South Africa as a whole (79%). In 2020, it was 85% at our monitored sites and 78% nationally. Recipients of care site improvements to physician and nurse support as a result of the CLM. During COVID-19 in Malawi, HIV testing fell by 39% in facilities without CLM (control study) compared to 25.5% at our monitored sites. Since then, new ART initiations are increasing ten times faster at our monitored sites than the rest of Malawi. Healthcare workers say CLM improved testing and treatment services, prompting them to “start escorting new HIV-positive clients to treatment counseling and potential initiation” and to create “a dedicated private space for client intake and consultations”.
CONCLUSIONS: The CLM intervention was associated with more resilient HIV and TB services. If the CLM effect is extrapolated to a national level, this equates to 48,529 additional circumcisions, 568,308 additional HIV tests, 15,595 additional ART initiations, and 13,285 additional people successfully treated for TB. This is a compelling case for the continued scale-up of CLM.

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