Qualitative analysis of the health system effects o f a community-based malaria elimination program in Rwanda

Purpose: To identify the health system-strengthening role of a community-based malaria elimination program in Ruhuha, Rwanda, and the ways by which health system effects may have been achieved. Materials and methods: Qualitative data were collected through 14 semi-structured in-depth interviews and five focus group discussions with various stakeholders. These data were supported by analysis of project documents. Results: Use of a transdisciplinary approach allowed the program to influence several crosscutting issues spanning four broad areas - social collaboration; capacity building; structural alignment; and knowledge translation. Health system effects were identified mostly at the micro (i.e., district) level, with limited impact on strengthening national and subnational policies. Although systems thinking was not explicitly applied, the project had positive spillover effects on the health system. These include expanding the informal health workforce and introducing innovative approaches aligned to the national malaria strategy for vector control. Findings also show that the elimination program contributed to an increased understanding of the transmission dynamics of malaria in Ruhuha. Conclusion: The community-based malaria elimination program in Ruhuha successfully created a stable foundation for community mobilization toward malaria control, and explored innovative ways for long-term financing for malaria elimination. The transdisciplinary nature of the project, use of horizontal facilitation techniques for community engagement, and the sociocultural context in which the program was implemented are possible mechanisms by which systems strengthening was achieved. The knowledge gained from this assessment can be used to improve future community-focused interventions for malaria control, and develop a sustainable strategy for community engagement in health care.