Health workers’ perspectives on barriers and opportunities to optimising quality improvement implementation in urban health facilities in Lilongwe, Malawi

Eliminating vertical HIV transmission requires high-quality Option B+ services, which provide lifelong antiretroviral therapy to pregnant and breastfeeding women living with HIV. In Malawi, coverage has expanded, but quality remains suboptimal, contributing to challenges in sustaining engagement in care. Quality improvement (QI) approaches can strengthen service delivery and evidence-based practices, with healthcare workers (HCWs) central to implementation. This study explores barriers and opportunities HCWs face in implementing QI in Option B+ within high-volume urban facilities in Lilongwe, Malawi. A descriptive phenomenological qualitative study was conducted between March and June 2021 in five health facilities in Lilongwe, Malawi. Semistructured in-depth interviews were conducted with 30 purposively selected HCWs (4–8 per facility) involved in delivering Option B+ services. Thematic analysis was used, with data coded deductively and inductively. The Consolidated Framework for Implementation Research was applied to map the identified themes into relevant domains and constructs. QI practices among HCWs were hindered by resource constraints, lack of incentives/reimbursement for QI activities conducted beyond working hours, poor communication between QI teams and implementers and resistance or negative attitudes towards QI. Opportunities to enhance QI included increasing meeting frequency, providing mentorship, peer-to-peer learning through exchange visits and securing funding from development partners. Improving QI utilisation in Option B+ requires mobilising resources and having a structured feedback and mentorship mechanisms. Targeted incentives/reimbursements for HCWs and peer-to-peer learning through exchange visits between facilities can further enhance QI. Therefore, a blended QI approach incorporating these recommendations is needed to better support HCWs in delivering evidence-based interventions, strengthen the health system and may improve engagement outcomes.