Community-led monitoring as a results-based strategy for improving rights-based HIV service delivery: A mixed-methods case study from Blantyre, Malawi
- 1University of Malawi
Abstract
Despite Malawis progress toward the UNAIDS 95-95-95 targets, facility-level rights-based challenges in HIV services persist, including stigma, discrimination and limited community participation. Community-led monitoring (CLM) has been promoted as an accountability mechanism, yet independent, facility-level evidence from urban settings remains scarce. This convergent parallel mixed-methods study assessed CLM at Ndirande and Limbe health facilities in Blantyre using a client survey (n=250), key informant interviews (n=12), and focus group discussions (three groups, 15 participants), totalling 277 participants. Chi-square tests (with Cramers V) and binary logistic regression were used for the quantitative data; qualitative data were thematically analysed and triangulated. Analysis was guided by the rights-based approach to health and Arnsteins ladder of citizen participation.
Awareness of CLM was moderate (56.0%) but participation was lower (40.2%), with involvement rated 2.78 out of 5, indicating consultative engagement. Awareness of CLM was the strongest and only robust predictor of participation (adjusted odds ratio {approx} 5.0, 95% confidence interval 2.4-10.6, p<0.001); a bivariate gender association did not survive adjustment. Notably, 41% of participants engaged in monitoring without recognising the term "CLM." CLM strengthened community-provider communication (68.5%) more than responsiveness (36.2%). Accountability mechanisms existed but functioned informally and were inconsistently documented. The two facilities did not differ significantly on any of nine indicators (all p>0.12). Barriers were structural: funding, transport, staff attitudes, fear of reprisal, and cultural norms.
Urban CLM is a real but under-institutionalised accountability practice. The decisive lever is closing the awareness-action gap and formalising existing, unrecognised community monitoring through low-cost documentation, scheduled feedback, and independent, confidential complaint mechanisms. Findings are analytically transferable and offered as hypotheses for national piloting rather than as statistically generalisable conclusions.
Related
- Heterogeneity in Mycobacterium tuberculosis immunoreactivity in young children in Blantyre, Malawi: A community-based survey
- Improving prenatal thalassemia carrier detection with a combined MCV and MCH strategy: a 24-year retrospective cohort study
- Bridging the Gap: A Quality Improvement Project Improving Communication Between Community-Based Inpatient and Outpatient Psychiatric Providers
- 124 Integrated single-cell transcriptomic profiling of urine-derived cells as a strategy for non-invasive therapeutic monitoring in bladder cancer
- Assessing an educational strategy to improve community health provider-led provision of cervical cancer screening services in western Kenya: A secondary analysis of the Elimisha-HPV cluster-randomized controlled trial
BibTeX
@misc{banda2026communityled,
title = {{Community-led monitoring as a results-based strategy for improving rights-based HIV service delivery: A mixed-methods case study from Blantyre, Malawi}},
author = {M. D. Banda and M. Malambo},
howpublished = {medRxiv},
year = {2026},
month = aug,
doi = {10.64898/2026.08.26.26361390},
url = {https://www.medrxiv.org/content/10.64898/2026.08.26.26361390v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Community-led monitoring as a results-based strategy for improving rights-based HIV service delivery: A mixed-methods case study from Blantyre, Malawi
AU - M. D. Banda
AU - M. Malambo
PY - 2026
DA - 2026/08/26
PB - medRxiv
DO - 10.64898/2026.08.26.26361390
UR - https://www.medrxiv.org/content/10.64898/2026.08.26.26361390v1
AB - Despite Malawis progress toward the UNAIDS 95-95-95 targets, facility-level rights-based challenges in HIV services persist, including stigma, discrimination and limited community participation. Community-led monitoring (CLM) has been promoted as an accountability mechanism, yet independent, facility-level evidence from urban settings remains scarce. This convergent parallel mixed-methods study assessed CLM at Ndirande and Limbe health facilities in Blantyre using a client survey (n=250), key informant interviews (n=12), and focus group discussions (three groups, 15 participants), totalling 277 participants. Chi-square tests (with Cramers V) and binary logistic regression were used for the quantitative data; qualitative data were thematically analysed and triangulated. Analysis was guided by the rights-based approach to health and Arnsteins ladder of citizen participation. Awareness of CLM was moderate (56.0%) but participation was lower (40.2%), with involvement rated 2.78 out of 5, indicating consultative engagement. Awareness of CLM was the strongest and only robust predictor of participation (adjusted odds ratio {approx} 5.0, 95% confidence interval 2.4-10.6, p<0.001); a bivariate gender association did not survive adjustment. Notably, 41% of participants engaged in monitoring without recognising the term "CLM." CLM strengthened community-provider communication (68.5%) more than responsiveness (36.2%). Accountability mechanisms existed but functioned informally and were inconsistently documented. The two facilities did not differ significantly on any of nine indicators (all p>0.12). Barriers were structural: funding, transport, staff attitudes, fear of reprisal, and cultural norms. Urban CLM is a real but under-institutionalised accountability practice. The decisive lever is closing the awareness-action gap and formalising existing, unrecognised community monitoring through low-cost documentation, scheduled feedback, and independent, confidential complaint mechanisms. Findings are analytically transferable and offered as hypotheses for national piloting rather than as statistically generalisable conclusions.
ER -