Implications of the fast-evolving scale-up of adult Voluntary Medical

Male Circumcision for quality of services in South Africa

D Rech, S Frade, A Spyrelis, L Perry, M Farrell, R Fertziger, D Castor, E Njeuhmeli, C Toledo, JT Bertrand

Presented by Dr. Dino Rech

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SYMMACS South Africa• SYstematic Monitoring of the voluntary Medical Male Circumcision Scale-up in Eastern and

Southern Africa

• Objective: Assess implementation of VMMC under actual field conditions in four countries, including South Africa. Monitor adoption of WHO six elements of efficiency. Assess quality and safety during scale-up.

• Methods: Data were collected using three instruments during clinicians 2-day visits to sites: 

Abbreviated version of the WHO Quality Assessment of facilities (WHO, 2009) 

Observation and timing of VMMC procedures

Interviews with providers and site managers

• Sample:

  Any site operational in 2011: N = 15 Sample from more than 80 operational sites in 2012: n = 40

Same 15 sites sampled in 2011 and 2012 (repeat sites); 25 new sites in 2012, with a

total of 40 sites (expanded sites)

*Significant differences refer to p values < 0.05

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Results: Table 1. Quality assessment of VMMC sites

Item observed:

2011: n=15 sites2012a: n=15 sites (same site)

2012b: n=40 sites (expanded sites)

Satisfactory %2011 2012a 2012b

Existence of functioning information system (manual/computerized) *

60.0 100 97.5

Monitoring system in place for adverse events ^ 60.0 26.7 22.5

Report of supervisory visits in past 6 months ^ 60.0 40.0 17.5

External monitoring of adverse events in past 6 months ^ 40.0 6.7 2.5

Clinical personnel conduct a basic preoperative assessment * 51.2 20.3 12.3

Demonstrate ‘safety first approach’ to ensure no part of the penis besides the foreskin is in danger of being injured

97.5 97.3 97.2

Mean QA score across all parameters ^ 1.68 1.51 1.36

* Difference is statistically significant in both comparisons^ Difference is statistically significant in expanded sites only

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Results• Challenges Drop in ‘readiness to provide services’ in expanded (not repeat sites) ie.

supplies, equipment, systems etc.– Likely due to the rapid scale-up and the large number of new sites

Drop in ‘quality of surgical services’ in expanded and repeat sites ie. pre- & post-operative procedures

– Likely due to ‘dilution’ of skilled staff across new sites & employment of new and inexperienced staff

• Successes Actual surgical technique scored the highest Almost universal adoption of 3 efficiency elements

• Recommendations1. Independent team to monitor program quality and reporting of AE’s 2. Improve supply chain systems