Page 1SYMMACS | Final report ACKNOWLEDGEMENTS

the development and implementation of the SYMMACS project. Drs. Emmanuel Njeuhmeli, Delivett

Implications of the fast-evolving scale-up of adult voluntary medical male circumcision for quality of services in South Africa.

The scale-up of voluntary medical male circumcision (VMMC) services in South Africa has been rapid, in an attempt to achieve the national government target of 4.3 million adult male circumcisions for HIV prevention by 2016. This study assesses the effect of the scale-up on the quality of the VMMC program.This analysis compares the quality of services at 15 sites operational in 2011 to (1) the same 15 sites in 2012 and (2) to a set of 40 sites representing the expanded program in 2012. Trained clinicians scored each site on 29 items measuring readiness to provide quality services (abbreviated version of the WHO Quality Assessment [QA] Guide) and 29 items to assess quality of surgical care provided (pre-op, surgical technique and post-op) based on the observation of VMMC procedures at each site. Declines in quality far outnumbered improvements. The negative effects in terms of readiness to provide quality services were most evident in expanded sites, whereas the declines in provision of quality services tended to affect both repeat sites and expanded sites equally. Areas of notable concern included the monitoring of adverse events, external supervision, post-operative counselling, and some infection control issues. Scores on quality of surgical technique tended to be among the highest across the 58 items observed, and the South Africa program has clearly institutionalized three "best practices" for surgical efficiency.These findings demonstrate the challenges of rapidly developing large numbers of new VMMC sites with the necessary equipment, supplies, and protocols. The scale-up in South Africa has diluted human resources, with negative effects for both the original sites and the expanded program

Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up: adoption of efficiency elements in Kenya, South Africa, Tanzania, and Zimbabwe.

SYMMACS, 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.This 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.SYMMACS 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

Assessment of pre-operative and safety control procedures for VMMC, by year.

<p>Assessment of pre-operative and safety control procedures for VMMC, by year.</p

Assessment of post-operative procedures for VMMC, by year.

<p>Assessment of post-operative procedures for VMMC, by year.</p

Provider characteristics, operating times, and efficiency elements across repeat and expanded sites.

1<p>Based on responses from provider survey;</p>2<p>Based on observation of VMMC procedures.</p

Quality assessment of VMMC sites (measuring readiness to provide quality services), by year.

*<p>Eight sites were visited by external supervisory teams shortly after the SYMMACS data collection, which is not reflected in these data.</p

VMMC provider profile in the four SYMMACS countries.

<p>[A] Primary providers perform VMMC (removes foreskin).</p><p>[B] Secondary providers assist the primary surgical provider.</p><p>[C] full time defined as dedicated ≥90% of working hours to VMMC.</p

Multivariate logistic regression: work fatigue/burnout in Kenya in 2011 and 2012.

<p>Multivariate logistic regression: work fatigue/burnout in Kenya in 2011 and 2012.</p