Systematic Monitoring of Voluntary Medical Male Circumcision Scale-Up: Adoption of Efficiency Elements in Kenya, South Africa, Tanzania, and Zimbabwe

Abstract

BackgroundSYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency— use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery—as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe.Methods and FindingsThis multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays.ConclusionsSYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement.

Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs

“…Examples of such data include the performance of a site (i.e., the number of VMMCs performed) against its functional capacity and projected demand; the demand-creation channels that bring individuals to specific VMMC sites; daily outputs of community members engaged to generate demand; and information on seasonal fluctuations in demand [35].…”

Advancing the strategic use of HIV operations research to strengthen local policies and programmes: the Research to Prevention Project

“…Countries have varied in their approaches to achieving VMMC scale-up targets, including variability in surgical procedures utilized, types of personnel engaged and settings where VMMC services are delivered. The R2P project Systematic Monitoring of the Voluntary Medical Male Circumcision Scale up (SYMMACS) was a facility-based study conducted in four priority countries for VMMC scale-up – Kenya, South Africa, Tanzania and Zimbabwe – that sought to assess the efficiency and quality of VMMC surgical procedures during the scale-up process [20]. SYMMACS included quality assessments of each site, interviews with care providers, direct observations of VMMC procedures and compilation of VMMC clinic data.…”

Implementing voluntary medical male circumcision using an innovative, integrated, health systems approach: experiences from 21 districts in Zimbabwe

“…During implementation, ZAZIC also partnered with local government leaders to support service delivery with periodic community-adapted campaigns, demonstrating a collaborative, contextual approach to implementation in line with guidance for HIV-related differentiated care. Employing this model, overall ZAZIC performance these first years appears similar to early VMMC productivity from other predominantly vertical programs including Kenya, Tanzania, and South Africa [24,50] and appears to exceed output in early program years of other predominantly vertical programs in Botswana, Malawi, and Mozambique [18,51]. Within Zimbabwe, the ZAZIC approach outpaces earlier achievements by the vertical model [30,31].…”