Community-Led Monitoring as a Results-Based Approach for Improving Rights-Based HIV Service Delivery: A Mixed-Methods Case Study from Blantyre Malawi

Community-Led Monitoring as a Results-Based Approach for Improving Rights-Based HIV Service Delivery: A Mixed-Methods Case Study from Blantyre Malawi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Community-Led Monitoring as a Results-Based Approach for Improving Rights-Based HIV Service Delivery: A Mixed-Methods Case Study from Blantyre Malawi Misheck Dickson Banda, Maalila Malambo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9565161/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite Malawi's progress toward UNAIDS 95-95-95 targets, facility-level rights-based HIV service challenges persist, including stigma and limited community participation. Community-Led Monitoring (CLM) has emerged as an accountability mechanism, yet evidence on its effectiveness in urban settings remains limited. Methods This mixed-methods study assessed CLM's role at Ndirande and Limbe health facilities in Blantyre, Malawi, using surveys (n = 250), key informant interviews (n = 13), and focus groups (n = 4). The study was guided by the Rights-Based Approach to Health and Arnstein's Ladder of Citizen Participation frameworks. Results CLM awareness was moderate (56.0%), but participation was low (40.2%), with involvement rated 2.78/5, indicating consultative engagement. While 66.7% of CLM members reported service improvements (reduced waiting times, better drug availability), only 28.6% saw feedback led to action, and 22.0% avoided services due to confidentiality fears. A critical finding was the absence of any formal documentation systems (complaint logs, meeting minutes) at either facility. Key barriers included inadequate funding, transport challenges, cultural norms, and staff turnover. Conclusions CLM shows promise for improving service quality and communication but is constrained by consultative participation, absent documentation, and structural barriers. Institutionalizing CLM through scheduled feedback, written action trackers, and independent complaint mechanisms is essential for achieving sustainable rights-based HIV service delivery. Health Policy Health Economics & Outcomes Research Infectious Diseases Other Public Policy Community-Led Monitoring HIV/AIDS Rights-Based Approach Health Service Delivery Citizen Participation Results-Based Management Malawi Project Management Background HIV/AIDS remains a major global public health challenge, with an estimated 40.8 million people living with HIV and 1.3 million new infections annually [ 1 ]. Sub-Saharan Africa bears 65% of this global burden [ 2 ]. Despite expanded antiretroviral therapy (ART) coverage, gaps in service quality, equity, and accountability persist, particularly for marginalized populations [ 1 , 3 ]. The UNAIDS Global AIDS Strategy 2021–2026 emphasizes rights-based, people-centered approaches that prioritize community leadership and address structural barriers, recognizing that stigma and human rights violations impede service uptake and viral suppression [ 4 – 6 ]. Malawi has made commendable progress, achieving the UNAIDS 95-95-95 targets with adult HIV prevalence declining to 8.9% [ 7 , 8 ]. Annual new infections dropped from 56,000 in 2010 to approximately 12,000 in 2023 [ 9 ]. However, national achievements have been masked by persistent facility-level challenges in service quality and rights protection. Despite policy commitments in Malawi's National Strategic Plan for HIV and AIDS (2020–2025), individuals living with HIV continue to report stigma, discrimination, confidentiality breaches, and limited participation in health decisions [ 10 , 11 ] in the services they receive at facility level. These challenges are acute in high-volume urban facilities like Ndirande and Limbe health centres in Blantyre, which serve communities with HIV prevalence estimated at 14–22% [ 12 ]. Community-Led Monitoring (CLM) has emerged as an accountability mechanism positioning communities as active agents in monitoring and improving health service quality [ 15 ]. CLM is a systematic process where community members collect and analyse data on service availability, accessibility, acceptability, and quality to advocate for improvements based on client experiences [ 16 , 17 ]. Grounded in social accountability and the rights-based approach to health specifically the AAAQ framework (Availability, Accessibility, Acceptability, Quality) CLM aims to bridge gaps between policy commitments, service delivery and lived realities [ 18 , 19 ]. International donors including PEPFAR, the Global Fund, and WHO have endorsed CLM as a tool for promoting transparency and real-time feedback [ 20 , 21 ]. In Malawi, CLM has been implemented by civil society organizations including MANASO, CEDEP, and MANET+ [ 22 ]. Initiatives like the Citizen Science Project in rural districts reported positive outcomes including a 25% increase in multi-month ART dispensing [ 23 ]. Despite these developments, significant evidence gaps remain. Most evaluations focus on rural settings, with limited documentation of CLM's facility-level functioning. There is insufficient evidence on whether CLM data systematically improves rights-based service delivery or shifts power dynamics between communities and providers more specifically in urban settings where community committees are not as strong as in rural areas dues to lack of chiefs who are seen as custodians of communities [ 24 ]. This study addresses these gaps by examining CLM as a results-based strategy for improving rights-based HIV/AIDS service delivery at Ndirande and Limbe health facilities in Urban areas of Blantyre district. The objectives are to: (1) assess community involvement in monitoring HIV services; (2) evaluate rights-based service delivery (accessibility, equity, confidentiality); (3) examine CLM's influence on service quality, accountability, and responsiveness; and (4) identify barriers to effective CLM implementation. The study is grounded in two complementary frameworks. The Rights-Based Approach to Health which provides a normative framework for assessing whether services fulfil the right to health, emphasizing non-discrimination, participation, and accountability [ 25 ]. Arnstein's Ladder of Citizen Participation which offers an analytical tool for evaluating the depth of community engagement, ranging from non-participation and tokenism to genuine citizen power [ 26 ]. Methods Study Design This study employed a convergent parallel mixed-methods design, integrating quantitative and qualitative approaches to broadly understand CLM implementation and impact [27]. The pragmatist research philosophy guided the study, recognizing that understanding CLM requires both objective measurement and subjective exploration of stakeholder experiences. Study Setting The research was conducted at Ndirande and Limbe health facilities in Blantyre, Malawi's commercial capital with over 1 million inhabitants and HIV prevalence exceeding the national average [28]. Ndirande Health Centre serves approximately 300,000 people and manages 10,500 ART patients, while Limbe Health Centre serves 85,000 people and manages 6,000 ART patients [29]. Study Population and Sampling The study targeted healthcare workers, community monitors/CLM focal persons, people living with HIV (PLHIV), general service users, and Health Advisory Committee (HAC) members. Purposive sampling selected participants based on knowledge and involvement in CLM and HIV service delivery [30]. Sample sizes were determined using Yamane's formula (95% confidence, 5% margin of error). The achieved sample comprised 250 survey respondents (128 Ndirande, 122 Limbe), 13 key informant interview participants, and 20 focus group discussion participants across 4 groups, totalling 283 respondents. Data Collection Data were collected between March and April 2026. Structured client surveys captured demographic characteristics, CLM awareness and participation, perceptions of service accessibility, equity, confidentiality, and satisfaction. Key informant interviews with health workers, CLM focal persons, and community leaders explored CLM implementation, impact, barriers, and recommendations. Focus group discussions groups with community members captured experiences with HIV service delivery and CLM processes. The structured survey, key informant interview guide, and focus group discussion guide were developed specifically for this study (see Additional File 1). Data Analysis Quantitative data were analysed using RStudio. Descriptive statistics summarized respondent characteristics. Comparative analyses between facilities used chi-square tests and t-tests. Binary logistic regression identified predictors of CLM participation; linear regression examined factors associated with service satisfaction (α = 0.05). Qualitative data were transcribed, translated where necessary, and analysed using thematic content analysis with deductive and inductive coding. Findings were triangulated across sources. Ethical Considerations Ethical clearance was obtained from the University of Malawi Research Ethics Committee (UNIMAREC) and the Blantyre District Health Office. All participants provided written informed consent after receiving study information. Data were securely stored and reported in aggregate without identifiers. Results Socio-Demographic Characteristics A total of 283 respondents participated (250 surveys, 13 KIIs, 20 FGD participants). Survey respondents were predominantly female (62.0%) and youth aged 19–35 (54.4%). Half of the participants (50.4%) were People Living with HIV. Facility representation was balanced (Ndirande 51.2%, Limbe 48.8%). [Table 1 here] Objective 1: Community Involvement in Monitoring The primary need of the study was to establish if the study participants were aware of the existence of CLM committees, if they are involved and if they understand how the CLM committee operates. From the study findings, Awareness of CLM committees was moderate with 56.0% of survey respondent being aware of CLM committee existence. Most of the study participants knew CLM committees through community meetings (31.9%) and NGOs (22.8%). However, participation of the respondent in CLM activities is low with only 40.2% reporting to ever participated in CLM activities. Those that has been involved were moistly through the community meetings (31.9%) or advocacy campaigns activities (30.4%). Mean rating of community involvement was 2.78/5 (SD=1.31). Chi-square analysis showed significant association between gender and participation (χ²=4.00, p=0.045), with females more likely to participate in CLM committee activities than male. Qualitative data confirmed CLM was defined in rights-based terms. A community FGD participant explained: "Ndi njira yomwe anthu ammudzi timayang'anira tokha mautumiki a ntchito zachipatala kuphatikizapo nkhani za HIV kuti asinthe" (It is the way we community members monitor health service delivery including HIV services, so they improve). Though most men, older adults, and some key populations was reported not to actively participate in CLM activities due to cultural norms. Regression identified gender (p=0.042) and CLM awareness (p=0.049) as marginal but significant predictors of participation. Objective 2: Rights-Based Service Delivery To understand the extent at which services that are delivered in urban health facilities adhere to rights-based service delivery, responded were asked to share their perception on service accessibility, equity, confidentiality, and satisfaction in accessing health service delivery. Accessibility: 60.6% of the respondent rated access as easy/very easy, while 39.4% described it as difficult. Main barriers that affected accessibility were lack of privacy (26.9%), transport costs/distance (25.3%), unfriendly staff (24.9%), and long waiting times (24.1%). Notably, 25.4% had missed appointments due to issues related to inaccessibility of the service delivery. Equity: Further to understand if the services are offered in an equal manner, 38.4% of the survey participants felt all clients are treated equally; 60.0% reported inconsistent in equal treatment. Nearly one-third (31.2%) witnessed or experienced discrimination, most based on disability (37.2%), age (33.3%), gender (30.4%), and HIV status (22.5%). Only 42.4% agreed key populations have equal access. Confidentiality: Perceptions in confidentiality were mixed,37.3% reported information "always" kept confidential, but 22.0% avoided services due to fear of their information being shared with external partners particularly within the facility locality breaches such that Health workers' handling of private information was rated disrespectful by 38.9%. Satisfaction: Satisfaction is average with Mean satisfaction of the rights-based approach was rated 3.42/5 (SD=1.22). A critical gap emerged regarding the right to remedy, which contributed to the reduced satisfaction level. For example, while formal complaint channels existed, fear of retaliation prevented the use of formal channels. A community participant stated: "Pena kuti udandaule kwambiri, unkhoza kuvutika kutsogolo pamene ukufuna thandizo lachipata" (If you complain a lot at times, they may mistreat you in the future when you came to seek medical help). Objective 3: CLM Influence on Quality, Accountability, and Responsiveness Among those who have ever been involved in CLM activities , the majority reported improvements, including drug availability, cleanliness, respect for rights, and shorter waiting times. However, few participants reported that CLM has led to these improved observable changes. Regardless of the minor perceived changes, A critical findings of this study were the complete absence of formal CLM documentation (complaint logs), meeting minutes, feedback forms, or action trackers. The suggestion boxes were present but there were non-functional. According to the respondent, Meetings are conducted but irregularly (approximately twice yearly), and they only happen when they have been triggered by specific concerns or issue rather than scheduled for a purpose of handling CLM issues. A community leader confirmed: "Timangokambirana ndi ogwira ntchito tikakumana nawo. Palibe komwe timalemba zokambirana" (We just talk to health workers. There is nowhere we write down the discussions or resolutions). Regarding responsiveness of services which might be triggered by CLM work, 31.5% perceived quick responses while 35.2% perceive low and slow responses. For those who perceive quick response, only 36.2% believed CLM has made workers to be more responsive, while 68.5% of them believed CLM have improved the communication part. Objective 4: Barriers to CLM Implementation Key barriers to the CLM implementation according to KIIs and FGDs responded were lack of funding, lack of stipends, lack of transport for CLM related work, and lack of materials which limit monitor activities; further fear of being stigmatized or speaking up continues to discourage service seekers from making formal complaints. Cultural and gender norms were also noted to have contributed to the limited participation in CLM activities and staff resistance and turnover also contributed to the undermining of CLM work. Discussion This study provides one of the first systematic assessments of CLM at the facility level in urban Malawi. Findings reveal moderate awareness, consultative participation, visible but uneven service improvements, critical accountability gaps, and persistent structural barriers which continues to constrain CLM's transformative potential. Participation- The findings from this study found that participation is more of consultative than citizen being properly empowered. With 56.0% CLM awareness but only 40.2% participation and a 2.78/5 involvement rating, CLM operates at "consultation" on Arnstein's Ladder [26]. Generally, communities are informed but they lack decision-making power, which is consistent with broader literature on participatory governance gaps [31,32]. In addition, the genders effect on association in participation of CLM reflects broader health-seeking patterns but questions CLM's ability to address men's specific barriers to HIV services [33,34]. Service Improvements There is evidence of CLM's being influential in the way health facilities operate, despite limited participation. Among those who have directly participated in CLM activities, 66.7% reported to have noted a reduced waiting times, improved drug availability, and more respectful staff attitudes attributed to the CLM, this results also align with evidence from South Africa and Uganda [35,36] where similar changes were observed after implementation of CLM activities in several communities. However, CLM strategy was found to have very strong influence on communication between the communities and health workers (68.5%) than health workers responsiveness to the issues brought before them (36.2%), this suggests CLM strengthens dialogue more than timely corrective action, which also confirms the reasons why there is absence of formal feedback loops. The Accountability Gap The complete absence of formal CLM documentation is perhaps the most concerning finding. Without complaint logs, meeting minutes, or action trackers, accountability is informal, verbal, and person dependent. This gap represents a fundamental barrier to CLM's effectiveness as a results-based management strategy [37,38] and risks lack of tracking of main issues that affect services seekers in the health facilities. Lack of accountability can also be further applied to the 22.0% of respondents who avoided services due to lack of confidentiality fears, and the fear of retaliation by communities to make formal complaints , this highlights a critical gap in the right to remedy and raise problematic situation where formal complaint exists but cannot be trusted. All these findings are consistent with evidence on power asymmetries and fear of reprisal in health accountability which has been widely documented on many communities within Africa [39,40]. Structural Barriers Lack of resources which can support CLM activities are also a major issue in CLM implementation. The lack of transport raised stigma, influence of cultural norms, staff resistance are consistent with literature on community health worker programs in low-resource settings [41,42] and continue to provide structural barriers which affect the expectation of sustained oversight yet with adequate resources places an unfair burden on volunteers. Implications The First issue that need to be looked on to improve CLM strategy in Blantyre city is to make proper investment in it. Shifting from consultative to empowered participation requires investments in community capacity and formal integration into governance structures and without proper investment desirable results cannot be attained. Second, establishing simple, low-cost documentation systems (complaint registers, meeting minutes, action trackers) is urgent without which details of complaints and resolution cannot be tracked thereby affecting proper and formal follow up of recurring issues that are being identified over time. Third, independent, confidential complaint mechanisms are needed to address fear of retaliation and the anonymous channels like feedback box needs to revamp. Fourth, sustainable funding must be secured by integrating CLM into district and facility budget CLM meetings must be frequented. Limitations: The study was limited to two urban facilities in Blantyre, limiting generalizability. Purposive sampling and self-reported data may introduce bias. The cross-sectional design limits causal inference. The absence of documentary evidence means accountability findings rely on participant recall. Conclusions This study demonstrates that CLM in Ndirande and Limbe health facilities represents a significant but incomplete shift in HIV/AIDS service delivery. CLM has moved service users toward active participation in accountability processes, contributing to measurable improvements in waiting times, drug availability, and communication. However, the persistence of consultative participation, critical gaps in formal accountability documentation, and fear of reprisal mean CLM has not achieved its transformative potential. Accountability is informal, person-dependent, and fragile. For CLM to fulfil its promise as a results-based project management strategy, participation must be deepened, inclusion expanded, and communities supported with resources and authority to influence decisions. Institutionalizing CLM within routine health facility operations through scheduled feedback meetings, written action trackers, independent complaint mechanisms, and sustainable funding is essential for advancing from tokenistic engagement to genuine citizen power. Abbreviations AAAQ: Availability, Accessibility, Acceptability, Quality ART: Antiretroviral Therapy CLM: Community-Led Monitoring FGD: Focus Group Discussion HAC: Health Advisory Committee HIV/AIDS: Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome KII: Key Informant Interview PEPFAR: President's Emergency Plan for AIDS Relief PLHIV: People Living with HIV RBM: Results-Based Management UNAIDS: Joint United Nations Programme on HIV/AIDS WHO: World Health Organization Declarations Ethics approval and consent to participate Ethical approval was granted by the University of Malawi Research Ethics Committee (UNIMAREC) and the Blantyre District Health Office. All methods were carried out in accordance with relevant guidelines and regulations, including Declaration of Helsinki Written informed consent was obtained from all participants. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions MDB and MM conceptualized and designed the study. MDB collected the data, performed the statistical analysis, and drafted the manuscript. MM supervised the study, provided critical revisions, and approved the final manuscript. Both authors read and approved the final version. Acknowledgements The authors gratefully acknowledge the Blantyre District Health Office for facilitating data collection. We thank the health workers, community monitors, Health Advisory Committee members, and service users at Ndirande and Limbe health facilities who generously shared their time and experiences. 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Exploring the integration of community health workers into the national health system: A scoping review of the evidence from low- and middle-income countries. Hum Resour Health. 2022;21:50. Kok MC, Muula AS. Motivation and job satisfaction of health surveillance assistants in Mwanza, Malawi: An explorative study. Malawi Med J. 2013;25:5–11. Table Table 1 is available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files SurveyQuestionnaireGuideKeyInformatinterviewsandFocusgroupdiscussionguides.pdf Survey Questionnaire Guide, Key Informat interviews and Focus group discussion guides Table1.png Table 1 Socio-Demographic Characteristics Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9565161","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631725040,"identity":"a1a5fcc0-6e83-41c2-a55f-eaf5693f8bcf","order_by":0,"name":"Misheck Dickson Banda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYDACCRDBwyDH2N7AwJBAvBYZBmPmngMkabFhSGyfQZx6Bgbd2c3PHjDkMDD2znxj9uBhjh0Df/sB1s08eLSY3TlmbsBwhoFZcnaOuUHitmQGiTMJbLfxarmRYCb9t+c/m+HsHDOJxG3MDAw3GNhu5+DVkv5NgvEfA4/9zTMgLfUM8oS1AA0HBrIE4wwekJbDDAYEtdw5U24A1GLA2JNWBtRynMfwTGLb7T/4tNxu3/YAqKW+sf3wNsmf26rl5I4fPnZzBh4tQMCGwgOGFWMDfg3oWkbBKBgFo2AUYAAAGDxJNFpkBLkAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0006-5229-0814","institution":"University of Malawi","correspondingAuthor":true,"prefix":"","firstName":"Misheck","middleName":"Dickson","lastName":"Banda","suffix":""},{"id":631725041,"identity":"235366aa-946d-4d0c-8ed3-b058ecf49055","order_by":1,"name":"Maalila Malambo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYHACxgMJBQyJDewMDMwMDDYMDBJE6DmQYMBQ3MAM1pJGpBYGA4Z6qJbDhLXoth9+cOCBgV1ufzPz080FFecT+2c3H3zAUGMTjUuL2Zk0A6DDknNnHGYzuz3jzO3EGXeOJRswHEvLbcClBageiJhzGw4zmN3mbbud2HAjx0yCseEwbi3nn38AaqlPnH+Y/RtQy7nE+QS13MgB2XI4ccNhHpAtBxI3ENbypgCo5XjixsM8ZUC/JBtvvJGWbJCAzy/n0zc+/FFRnTjvePu22wUVdrLzbiQffPChxganFgzgCFaZQKxyELAnRfEoGAWjYBSMDAAAx0BrHKhrVKcAAAAASUVORK5CYII=","orcid":"","institution":"University of Malawi","correspondingAuthor":true,"prefix":"","firstName":"Maalila","middleName":"","lastName":"Malambo","suffix":""}],"badges":[],"createdAt":"2026-04-29 11:25:44","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9565161/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9565161/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108182610,"identity":"222842a8-a3c3-42d3-9fc8-b93b47c3de2d","added_by":"auto","created_at":"2026-04-30 08:59:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":200217,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9565161/v1/3acef751-0a48-4c31-a3e2-ddb0a2a3f0a3.pdf"},{"id":108168281,"identity":"c133e40c-6a71-4555-b9a1-9776bcbf28de","added_by":"auto","created_at":"2026-04-30 06:25:48","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":4173543,"visible":true,"origin":"","legend":"\u003cp\u003eSurvey Questionnaire Guide, Key Informat interviews and Focus group discussion guides\u003c/p\u003e","description":"","filename":"SurveyQuestionnaireGuideKeyInformatinterviewsandFocusgroupdiscussionguides.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9565161/v1/85333ef92f7f474ce27879b4.pdf"},{"id":108168280,"identity":"06801a44-80ea-4e20-8f0c-fb5d21e6e8cd","added_by":"auto","created_at":"2026-04-30 06:25:48","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17887,"visible":true,"origin":"","legend":"\u003cp\u003eTable 1 Socio-Demographic Characteristics\u003c/p\u003e","description":"","filename":"Table1.png","url":"https://assets-eu.researchsquare.com/files/rs-9565161/v1/da5e3ac45d895b1a635b7059.png"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eCommunity-Led Monitoring as a Results-Based Approach for Improving Rights-Based HIV Service Delivery: A Mixed-Methods Case Study from Blantyre Malawi\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHIV/AIDS remains a major global public health challenge, with an estimated 40.8\u0026nbsp;million people living with HIV and 1.3\u0026nbsp;million new infections annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Sub-Saharan Africa bears 65% of this global burden [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite expanded antiretroviral therapy (ART) coverage, gaps in service quality, equity, and accountability persist, particularly for marginalized populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The UNAIDS Global AIDS Strategy 2021\u0026ndash;2026 emphasizes rights-based, people-centered approaches that prioritize community leadership and address structural barriers, recognizing that stigma and human rights violations impede service uptake and viral suppression [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMalawi has made commendable progress, achieving the UNAIDS 95-95-95 targets with adult HIV prevalence declining to 8.9% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Annual new infections dropped from 56,000 in 2010 to approximately 12,000 in 2023 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, national achievements have been masked by persistent facility-level challenges in service quality and rights protection. Despite policy commitments in Malawi's National Strategic Plan for HIV and AIDS (2020\u0026ndash;2025), individuals living with HIV continue to report stigma, discrimination, confidentiality breaches, and limited participation in health decisions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] in the services they receive at facility level. These challenges are acute in high-volume urban facilities like Ndirande and Limbe health centres in Blantyre, which serve communities with HIV prevalence estimated at 14\u0026ndash;22% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommunity-Led Monitoring (CLM) has emerged as an accountability mechanism positioning communities as active agents in monitoring and improving health service quality [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. CLM is a systematic process where community members collect and analyse data on service availability, accessibility, acceptability, and quality to advocate for improvements based on client experiences [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Grounded in social accountability and the rights-based approach to health specifically the AAAQ framework (Availability, Accessibility, Acceptability, Quality) CLM aims to bridge gaps between policy commitments, service delivery and lived realities [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. International donors including PEPFAR, the Global Fund, and WHO have endorsed CLM as a tool for promoting transparency and real-time feedback [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Malawi, CLM has been implemented by civil society organizations including MANASO, CEDEP, and MANET+ [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Initiatives like the Citizen Science Project in rural districts reported positive outcomes including a 25% increase in multi-month ART dispensing [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Despite these developments, significant evidence gaps remain. Most evaluations focus on rural settings, with limited documentation of CLM's facility-level functioning. There is insufficient evidence on whether CLM data systematically improves rights-based service delivery or shifts power dynamics between communities and providers more specifically in urban settings where community committees are not as strong as in rural areas dues to lack of chiefs who are seen as custodians of communities [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study addresses these gaps by examining CLM as a results-based strategy for improving rights-based HIV/AIDS service delivery at Ndirande and Limbe health facilities in Urban areas of Blantyre district. The objectives are to: (1) assess community involvement in monitoring HIV services; (2) evaluate rights-based service delivery (accessibility, equity, confidentiality); (3) examine CLM's influence on service quality, accountability, and responsiveness; and (4) identify barriers to effective CLM implementation.\u003c/p\u003e \u003cp\u003eThe study is grounded in two complementary frameworks. The Rights-Based Approach to Health which provides a normative framework for assessing whether services fulfil the right to health, emphasizing non-discrimination, participation, and accountability [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Arnstein's Ladder of Citizen Participation which offers an analytical tool for evaluating the depth of community engagement, ranging from non-participation and tokenism to genuine citizen power [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a convergent parallel mixed-methods design, integrating quantitative and qualitative approaches to broadly understand CLM implementation and impact [27]. The pragmatist research philosophy guided the study, recognizing that understanding CLM requires both objective measurement and subjective exploration of stakeholder experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was conducted at Ndirande and Limbe health facilities in Blantyre, Malawi\u0026apos;s commercial capital with over 1 million inhabitants and HIV prevalence exceeding the national average [28]. Ndirande Health Centre serves approximately 300,000 people and manages 10,500 ART patients, while Limbe Health Centre serves 85,000 people and manages 6,000 ART patients [29].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population and Sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study targeted healthcare workers, community monitors/CLM focal persons, people living with HIV (PLHIV), general service users, and Health Advisory Committee (HAC) members. Purposive sampling selected participants based on knowledge and involvement in CLM and HIV service delivery [30]. Sample sizes were determined using Yamane\u0026apos;s formula (95% confidence, 5% margin of error). The achieved sample comprised 250 survey respondents (128 Ndirande, 122 Limbe), 13 key informant interview participants, and 20 focus group discussion participants across 4 groups, totalling 283 respondents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected between March and April 2026. Structured client surveys captured demographic characteristics, CLM awareness and participation, perceptions of service accessibility, equity, confidentiality, and satisfaction. Key informant interviews with health workers, CLM focal persons, and community leaders explored CLM implementation, impact, barriers, and recommendations. Focus group discussions groups with community members captured experiences with HIV service delivery and CLM processes. The structured survey, key informant interview guide, and focus group discussion guide were developed specifically for this study (see Additional File 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were analysed using RStudio. Descriptive statistics summarized respondent characteristics. Comparative analyses between facilities used chi-square tests and t-tests. Binary logistic regression identified predictors of CLM participation; linear regression examined factors associated with service satisfaction (\u0026alpha; = 0.05). Qualitative data were transcribed, translated where necessary, and analysed using thematic content analysis with deductive and inductive coding. Findings were triangulated across sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the University of Malawi Research Ethics Committee (UNIMAREC) and the Blantyre District Health Office. All participants provided written informed consent after receiving study information. Data were securely stored and reported in aggregate without identifiers.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSocio-Demographic Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 283 respondents participated (250 surveys, 13 KIIs, 20 FGD participants). Survey respondents were predominantly female (62.0%) and youth aged 19\u0026ndash;35 (54.4%). Half of the participants (50.4%) were People Living with HIV. Facility representation was balanced (Ndirande 51.2%, Limbe 48.8%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Table 1 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 1: Community Involvement in Monitoring\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary need of the study was to establish if the study participants were aware of the existence of CLM committees, if they are involved and if they understand how the CLM committee operates. From the study findings, Awareness of CLM committees was moderate with 56.0% of survey respondent being aware of CLM committee existence. Most of the study participants knew CLM committees through community meetings (31.9%) and NGOs (22.8%). However, participation of the respondent in CLM activities is low with only 40.2% reporting to ever participated in CLM activities. Those that has been involved were moistly through the community meetings (31.9%) or advocacy campaigns activities (30.4%). Mean rating of community involvement was 2.78/5 (SD=1.31). Chi-square analysis showed significant association between gender and participation (\u0026chi;\u0026sup2;=4.00, p=0.045), with females more likely to participate in CLM committee activities than male.\u003c/p\u003e\n\u003cp\u003eQualitative data confirmed CLM was defined in rights-based terms. A community FGD participant explained: \u003cem\u003e\u0026quot;Ndi njira yomwe anthu ammudzi timayang\u0026apos;anira tokha mautumiki a ntchito zachipatala kuphatikizapo nkhani za HIV kuti asinthe\u0026quot;\u003c/em\u003e (It is the way we community members monitor health service delivery including HIV services, so they improve). Though most men, older adults, and some key populations was reported not to actively participate in CLM activities due to cultural norms. Regression identified gender (p=0.042) and CLM awareness (p=0.049) as marginal but significant predictors of participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 2: Rights-Based Service Delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo understand the extent at which services that are delivered in urban health facilities adhere to rights-based service delivery, responded were asked to share their perception on service accessibility, equity, confidentiality, and satisfaction in accessing health service delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAccessibility:\u003c/strong\u003e\u0026nbsp; 60.6% of the respondent rated access as easy/very easy, while 39.4% described it as difficult. Main barriers that affected accessibility were lack of privacy (26.9%), transport costs/distance (25.3%), unfriendly staff (24.9%), and long waiting times (24.1%). Notably, 25.4% had missed appointments due to issues related to inaccessibility of the service delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEquity:\u003c/strong\u003e Further to understand if the services are offered in an equal manner, 38.4% of the survey participants felt all clients are treated equally; 60.0% reported inconsistent in equal treatment. Nearly one-third (31.2%) witnessed or experienced discrimination, most based on disability (37.2%), age (33.3%), gender (30.4%), and HIV status (22.5%). Only 42.4% agreed key populations have equal access.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfidentiality:\u003c/strong\u003e Perceptions in confidentiality were mixed,37.3% reported information \u0026quot;always\u0026quot; kept confidential, but 22.0% avoided services due to fear of their information being shared with external partners particularly within the facility locality breaches such that Health workers\u0026apos; handling of private information was rated disrespectful by 38.9%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSatisfaction:\u003c/strong\u003e Satisfaction is average with Mean satisfaction of the rights-based approach was rated 3.42/5 (SD=1.22). A critical gap emerged regarding the right to remedy, which contributed to the reduced satisfaction \u0026nbsp;level. For example, while formal complaint channels existed, fear of retaliation prevented the use of formal channels. A community participant stated: \u003cem\u003e\u0026quot;Pena kuti udandaule kwambiri, unkhoza kuvutika kutsogolo pamene ukufuna thandizo lachipata\u0026quot;\u003c/em\u003e (If you complain a lot at times, they may mistreat you in the future when you came to seek medical help).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 3: CLM Influence on Quality, Accountability, and Responsiveness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong those who have ever been involved in CLM activities , the majority reported improvements, including drug availability, cleanliness, respect for rights, and shorter waiting times. However, few participants reported that CLM has led to these improved observable changes.\u003c/p\u003e\n\u003cp\u003eRegardless of the minor perceived changes, A critical findings of this study were the complete absence of formal CLM documentation (complaint logs), meeting minutes, feedback forms, or action trackers. The suggestion boxes were present but there were non-functional. According to the respondent, Meetings are conducted but irregularly (approximately twice yearly), and they only happen when they have been triggered by specific concerns or issue rather than scheduled for a purpose of handling CLM issues. A community leader confirmed: \u003cem\u003e\u0026quot;Timangokambirana ndi ogwira ntchito tikakumana nawo. Palibe komwe timalemba zokambirana\u0026quot;\u003c/em\u003e (We just talk to health workers. There is nowhere we write down the discussions or resolutions).\u003c/p\u003e\n\u003cp\u003eRegarding responsiveness of services which might be triggered by CLM work, 31.5% perceived quick responses while 35.2% perceive low and slow responses. For those who perceive quick response, only 36.2% believed CLM has made workers to be more responsive, while 68.5% of them believed CLM have improved the communication part.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 4: Barriers to CLM Implementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey barriers to the CLM implementation according to KIIs and FGDs responded were lack of funding, lack of stipends, lack of transport for CLM related work, and lack of materials which limit monitor activities; further fear of being stigmatized or speaking up continues to discourage service seekers from making formal complaints. Cultural and gender norms were also noted to have contributed to the limited participation in CLM activities and staff resistance and turnover also contributed to the undermining of CLM work.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides one of the first systematic assessments of CLM at the facility level in urban Malawi. Findings reveal moderate awareness, consultative participation, visible but uneven service improvements, critical accountability gaps, and persistent structural barriers which continues to constrain CLM\u0026apos;s transformative potential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipation-\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe findings from this study found that participation is more of consultative than citizen being properly empowered.\u003c/strong\u003e With 56.0% CLM awareness but only 40.2% participation and a 2.78/5 involvement rating, CLM operates at \u0026quot;consultation\u0026quot; on Arnstein\u0026apos;s Ladder [26]. Generally, communities are informed but they lack decision-making power, which is consistent with broader literature on participatory governance gaps [31,32]. In addition, the genders effect on association in participation of CLM reflects broader health-seeking patterns but questions CLM\u0026apos;s ability to address men\u0026apos;s specific barriers to HIV services [33,34].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eService Improvements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is evidence of CLM\u0026apos;s being influential in the way health facilities operate, despite limited participation. Among those who have directly participated in CLM activities, 66.7% reported to have noted a reduced waiting times, improved drug availability, and more respectful staff attitudes attributed to the CLM, this results also align with evidence from South Africa and Uganda [35,36] where similar changes were observed after implementation of CLM activities in several communities. However, CLM strategy was found to have very strong influence on communication between the communities and health workers (68.5%) than health workers responsiveness to the issues brought before them (36.2%), this suggests CLM strengthens dialogue more than timely corrective action, which also confirms the reasons why there is absence of formal feedback loops.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Accountability Gap\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe complete absence of formal CLM documentation is perhaps the most concerning finding. Without complaint logs, meeting minutes, or action trackers, accountability is informal, verbal, and person dependent. This gap represents a fundamental barrier to CLM\u0026apos;s effectiveness as a results-based management strategy [37,38] and risks lack of tracking of main issues that affect services seekers in the health facilities.\u003c/p\u003e\n\u003cp\u003eLack of accountability can also be further applied to the 22.0% of respondents who avoided services due to lack of confidentiality fears, and the fear of retaliation by communities to make formal complaints , this highlights a critical gap in the right to remedy and raise problematic situation where formal complaint exists but cannot be trusted. All these findings are consistent with evidence on power asymmetries and fear of reprisal in health accountability which has been widely documented on many communities within Africa [39,40].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructural Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLack of resources which can support CLM activities are also a major issue in CLM implementation. The lack of transport raised stigma, influence of cultural norms, staff resistance are consistent with literature on community health worker programs in low-resource settings [41,42] and continue to provide structural barriers which affect the expectation of sustained oversight yet with adequate resources places an unfair burden on volunteers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe First issue that need to be looked on to improve CLM strategy in Blantyre city is to make proper investment in it. Shifting from consultative to empowered participation requires investments in community capacity and formal integration into governance structures and without proper investment desirable results cannot be attained. Second, establishing simple, low-cost documentation systems (complaint registers, meeting minutes, action trackers) is urgent without which details of complaints and resolution cannot be tracked thereby affecting proper and formal follow up of recurring issues that are being identified over time. Third, independent, confidential complaint mechanisms are needed to address fear of retaliation and the anonymous channels like feedback box needs to revamp. Fourth, sustainable funding must be secured by integrating CLM into district and facility budget CLM meetings must be frequented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations:\u003c/strong\u003e The study was limited to two urban facilities in Blantyre, limiting generalizability. Purposive sampling and self-reported data may introduce bias. The cross-sectional design limits causal inference. The absence of documentary evidence means accountability findings rely on participant recall.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that CLM in Ndirande and Limbe health facilities represents a significant but incomplete shift in HIV/AIDS service delivery. CLM has moved service users toward active participation in accountability processes, contributing to measurable improvements in waiting times, drug availability, and communication.\u003c/p\u003e \u003cp\u003eHowever, the persistence of consultative participation, critical gaps in formal accountability documentation, and fear of reprisal mean CLM has not achieved its transformative potential. Accountability is informal, person-dependent, and fragile.\u003c/p\u003e \u003cp\u003eFor CLM to fulfil its promise as a results-based project management strategy, participation must be deepened, inclusion expanded, and communities supported with resources and authority to influence decisions. Institutionalizing CLM within routine health facility operations through scheduled feedback meetings, written action trackers, independent complaint mechanisms, and sustainable funding is essential for advancing from tokenistic engagement to genuine citizen power.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAAQ: Availability, Accessibility, Acceptability, Quality\u003c/p\u003e\n\u003cp\u003eART: Antiretroviral Therapy\u003c/p\u003e\n\u003cp\u003eCLM: Community-Led Monitoring\u003c/p\u003e\n\u003cp\u003eFGD: Focus Group Discussion\u003c/p\u003e\n\u003cp\u003eHAC: Health Advisory Committee\u003c/p\u003e\n\u003cp\u003eHIV/AIDS: Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome\u003c/p\u003e\n\u003cp\u003eKII: Key Informant Interview\u003c/p\u003e\n\u003cp\u003ePEPFAR: President\u0026apos;s Emergency Plan for AIDS Relief\u003c/p\u003e\n\u003cp\u003ePLHIV: People Living with HIV\u003c/p\u003e\n\u003cp\u003eRBM: Results-Based Management\u003c/p\u003e\n\u003cp\u003eUNAIDS: Joint United Nations Programme on HIV/AIDS\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the University of Malawi Research Ethics Committee (UNIMAREC) and the Blantyre District Health Office. All methods were carried out in accordance with relevant guidelines and regulations, including Declaration of Helsinki Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMDB and MM conceptualized and designed the study. MDB collected the data, performed the statistical analysis, and drafted the manuscript. MM supervised the study, provided critical revisions, and approved the final manuscript. Both authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the Blantyre District Health Office for facilitating data collection. We thank the health workers, community monitors, Health Advisory Committee members, and service users at Ndirande and Limbe health facilities who generously shared their time and experiences.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eUNAIDS. 2024 Global AIDS Report the Urgency of Now: AIDS at a Crossroads. Geneva: Joint United Nations Programme on HIV/AIDS; 2024.\u003c/li\u003e\n \u003cli\u003eUNAIDS/WHO. The Path That Ends AIDS: UNAIDS Global AIDS Update 2024. 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Atlanta: CDC; 2025.\u003c/li\u003e\n \u003cli\u003eKabaghe A, Stephens R, Payne D, Theu J, Luhanga M, Chalira D, et al. HIV recent infection and past HIV testing history among newly HIV-diagnosed 15\u0026ndash;24-year-olds in Malawi. AIDS Educ Prev. 2025;35(Suppl):4\u0026ndash;19.\u003c/li\u003e\n \u003cli\u003eGovernment of Malawi. 2024 Global AIDS Monitoring Report for Malawi (Draft). Lilongwe: National AIDS Commission; 2024.\u003c/li\u003e\n \u003cli\u003eU.S. Department of State. 2023 Country Reports on Human Rights Practices: Malawi.\u0026nbsp;Washington, DC: Bureau of Democracy, Human Rights, and Labor; 2024.\u003c/li\u003e\n \u003cli\u003ePuleni PC, Nyondo-Mipando AL. Strategies for optimising uptake of assisted partner notification services among newly diagnosed HIV positive adults at Ndirande Health Centre, Malawi. Health Syst Reform. 2022;8(1):2151697.\u003c/li\u003e\n \u003cli\u003eGeubbels E, Bowie C. Epidemiology of HIV/AIDS in adults in Malawi. Malawi Med J. 2006;18(3):111\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eRosenthal A. Health on Delivery: The Rollout of Antiretroviral Therapy in Malawi.\u0026nbsp;New York: Taylor \u0026amp; Francis Group; 2017.\u003c/li\u003e\n \u003cli\u003eBaptiste SL. Community-led monitoring: When community data drives implementation strategies. J Int AIDS Soc. 2020;17:415\u0026ndash;21.\u003c/li\u003e\n \u003cli\u003eLauer KJ, Soboyisi M, Kassam CA, Mseu D, Oberth G, Baptiste SL. Defining community-led monitoring and its role in programme-embedded learning: Lessons from the Citizen Science Project in Malawi and South Africa. J Int AIDS Soc. 2024;27(S2):e26277.\u003c/li\u003e\n \u003cli\u003eRambau N, Policar S, Sharp A, Lankiewicz E, Nsubuga A, Chimhanda L, et al. Power, data and social accountability: Defining a community-led monitoring model for strengthened health service delivery. PLOS Glob Public Health. 2024;4(6):e0003294.\u003c/li\u003e\n \u003cli\u003eHunt P, Yamin A, Bustreo F. Making the case: What is the evidence of impact of applying human rights-based approaches to health? Health Hum Rights. 2015;17(2):1\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eYamin AE, Frisancho A. Human rights-based approaches and the right to health: A systematic literature review. J Hum Rights Pract. 2022;14(2):603\u0026ndash;29.\u003c/li\u003e\n \u003cli\u003eSharp A, Mpofu N, Lankiewicz E, Ajonye B, Rambau N, Dringus S, et al. Facilitators and barriers to community-led monitoring of health programs: Qualitative evidence from the global implementation landscape. PLOS Glob Public Health. 2024;4(6):e0003293.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Increasing the voice of the people through community-led monitoring. In: Health Inequality Monitoring: A Practical Guide. Geneva: WHO; 2024.\u003c/li\u003e\n \u003cli\u003eLiu Lathu Mu COP22. Community-Led Monitoring Report: Our Voice Malawi PEPFAR Country Operational Plan 2022 Community Priorities. Lilongwe: MANASO; 2022.\u003c/li\u003e\n \u003cli\u003eOberth G, Bozinovski J, Lauer K, Rafif N, Sithole S, Mwanza H, et al. Service-level effects of HIV funding cuts in Southern Africa: Findings from a community-led early warning system. VeriXiv. 2025;2:94.\u003c/li\u003e\n \u003cli\u003eITPC Global. ITPC and Matahari Launch COPPER Community Toolkits for Pandemic Preparedness, Prevention and Response. Johannesburg: International Treatment Preparedness Coalition; 2025.\u003c/li\u003e\n \u003cli\u003eKapilashrami A, Quinn N, Das A. Strengthening accountability for the right to health. In: Advancing Health Rights and Tackling Inequalities: Interrogating Community Development and Participatory Praxis. Bristol: Bristol University Press; 2025.\u003c/li\u003e\n \u003cli\u003eVarwell S. A literature review of Arnstein\u0026apos;s ladder of citizen participation: Lessons for contemporary student engagement. Exchanges. 2022;10(1):108\u0026ndash;44.\u003c/li\u003e\n \u003cli\u003ePolit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 11th ed. Philadelphia: Wolters Kluwer; 2021.\u003c/li\u003e\n \u003cli\u003eSingogo E, Weir SS, Kudowa E, Chagomerana M, Chapola J, Edwards JK, et al. Characterizing HIV acquisition risk, treatment gaps, and populations reached through venue-based outreach and clinical services in Blantyre, Malawi. J Acquir Immune Defic Syndr. 2024;97(4):315\u0026ndash;24.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Towards an HIV-Free Generation in Malawi Township.\u0026nbsp;Geneva: WHO; 2016.\u003c/li\u003e\n \u003cli\u003eTongco M. Purposive sampling as a tool for informant selection. Ethnobot Res Appl. 2007;5:147\u0026ndash;58.\u003c/li\u003e\n \u003cli\u003eJoshi A. Legal empowerment and social accountability: Complementary strategies toward rights-based development in health? World Dev. 2017;99:160\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003eScott V, Gilson L. Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers\u0026apos; use of information in decision-making: Experience from Cape Town, South Africa. Int J Equity Health. 2017;16:159.\u003c/li\u003e\n \u003cli\u003eUNAIDS. Blantyre City Profile: Fast-Track Cities Initiative. Geneva: Joint United Nations Programme on HIV/AIDS; 2021.\u003c/li\u003e\n \u003cli\u003eAllinder S, Moses E, Enock M, Kawalazira G, Nyirenda R, Gonani A, et al. Using quality improvement to close HIV prevention gaps and strengthen district health systems: Blantyre, Malawi\u0026apos;s approach and early implementation. AIDS Behav. 2025;7:1558630.\u003c/li\u003e\n \u003cli\u003eBeck J, Catanes L, Hebert P, Negelev G, Ayala G. Local languages, global exchange: Digital networking, communication and collaboration for the health and human rights of men who have sex with men. In: Walsh CS, editor. IGI Global Scientific Publishing. Hershey: IGI Global; 2015. p. 20\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eKatongole SP, Nakawesi JS, Bindeeba DS, Ezajobo S, Mugisa A, Senyimba C, et al. Enhancing HIV treatment and support: A qualitative inquiry into client and healthcare provider perspectives on differential service delivery models in Uganda. AIDS Res Ther. 2024;21:1\u0026ndash;16.\u003c/li\u003e\n \u003cli\u003eClinton Foundation. A National Model for Community-Led Health Accountability. New York: Clinton Foundation; 2025.\u003c/li\u003e\n \u003cli\u003eUN-Habitat. Rebuilding Human Resources for Health: A Case Study from Liberia after the Ebola Epidemic. Nairobi: United Nations Human Settlements Programme; 2017.\u003c/li\u003e\n \u003cli\u003eBrummel L. Social accountability between consensus and confrontation: Developing a theoretical framework for societal accountability relationships of public sector organizations. Adm Soc. 2021;53(7):1047\u0026ndash;76.\u003c/li\u003e\n \u003cli\u003eGal T. The right to remedy in international human rights law. Hum Rights Q. 2024;46(1):1\u0026ndash;28.\u003c/li\u003e\n \u003cli\u003eOlaniran A, Briggs J, Pradhan A, Bogue E, Schreiber B, Dini H, et al. Exploring the integration of community health workers into the national health system: A scoping review of the evidence from low- and middle-income countries. Hum Resour Health. 2022;21:50.\u003c/li\u003e\n \u003cli\u003eKok MC, Muula AS. Motivation and job satisfaction of health surveillance assistants in Mwanza, Malawi: An explorative study. Malawi Med J. 2013;25:5\u0026ndash;11.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Malawi","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Community-Led Monitoring, HIV/AIDS, Rights-Based Approach, Health Service Delivery, Citizen Participation, Results-Based Management, Malawi, Project Management","lastPublishedDoi":"10.21203/rs.3.rs-9565161/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9565161/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Despite Malawi's progress toward UNAIDS 95-95-95 targets, facility-level rights-based HIV service challenges persist, including stigma and limited community participation. Community-Led Monitoring (CLM) has emerged as an accountability mechanism, yet evidence on its effectiveness in urban settings remains limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis mixed-methods study assessed CLM's role at Ndirande and Limbe health facilities in Blantyre, Malawi, using surveys (n\u0026thinsp;=\u0026thinsp;250), key informant interviews (n\u0026thinsp;=\u0026thinsp;13), and focus groups (n\u0026thinsp;=\u0026thinsp;4). The study was guided by the Rights-Based Approach to Health and Arnstein's Ladder of Citizen Participation frameworks.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCLM awareness was moderate (56.0%), but participation was low (40.2%), with involvement rated 2.78/5, indicating consultative engagement. While 66.7% of CLM members reported service improvements (reduced waiting times, better drug availability), only 28.6% saw feedback led to action, and 22.0% avoided services due to confidentiality fears. A critical finding was the absence of any formal documentation systems (complaint logs, meeting minutes) at either facility. Key barriers included inadequate funding, transport challenges, cultural norms, and staff turnover.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCLM shows promise for improving service quality and communication but is constrained by consultative participation, absent documentation, and structural barriers. Institutionalizing CLM through scheduled feedback, written action trackers, and independent complaint mechanisms is essential for achieving sustainable rights-based HIV service delivery.\u003c/p\u003e","manuscriptTitle":"Community-Led Monitoring as a Results-Based Approach for Improving Rights-Based HIV Service Delivery: A Mixed-Methods Case Study from Blantyre Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-30 06:24:48","doi":"10.21203/rs.3.rs-9565161/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8529204d-367d-4444-9216-3b7f5285b766","owner":[],"postedDate":"April 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67242086,"name":"Health Policy"},{"id":67242087,"name":"Health Economics \u0026 Outcomes Research"},{"id":67242088,"name":"Infectious Diseases"},{"id":67242089,"name":"Other Public Policy"}],"tags":[],"updatedAt":"2026-04-30T06:24:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-30 06:24:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9565161","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9565161","identity":"rs-9565161","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}