Qualitative raw data and behavioral analysis for understanding VMMC policy decision-making

Faced with declining donor funding for HIV, low- and middle-income
countries must identify efficient and cost-effective ways to integrate HIV
prevention programs into public health systems for long-term
sustainability. In Zambia, donor support to the voluntary medical male
circumcision (VMMC) program, which previously funded non-governmental
organizations as implementing partners, is increasingly being directed
through government structures instead. We developed a framework to
understand how the behaviors of individual decision-makers within the
government could be barriers to this transition. We interviewed key
stakeholders from the national, provincial, and district levels of the
Ministry of Health, and from donors and partners funding and implementing
Zambia’s VMMC program, exploring the decisions required to attain a
sustainable VMMC program and the behavioral dynamics involved at personal
and institutional levels. Using pattern identification and theme matching
to analyze the content of the responses, we derived three core
decision-making phases in the transition to a sustainable VMMC program: 1)
developing an alternative funding strategy, 2) developing a policy for
early-infant (0-2 months) and early-adolescent (15-17 years) male
circumcision, which is crucial to sustainable HIV prevention; and 3)
identifying integrated and efficient implementation models. We formulated
a framework showing how, in each phase, a range of behavioral dynamics can
form barriers that hinder effective decision-making among stakeholders at
the same level (e.g., national ministries and donors) or across levels
(e.g., national, provincial and district). Our research methodology and
the resulting framework offer a systematic approach for in-depth
investigations into organizational decision-making in public health
programs, as well as development programs beyond VMMC and HIV prevention.
It provides the insights necessary to map organizational development and
policy-making transition plans to sustainability, by explaining tangible
factors such as organizational processes and systems, as well as
intangibles such as the behaviors of policymakers and institutional
actors.