Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up

Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up (SYMMACS) Zimbabwe Webster Mavhu, Karin Hatzold, Christopher A. Samkange, Dino Rech, Emmanuel Njeuhmeli, Jane Bertrand ICASA Conference - Addis Ababa, 5 December 2011

Background § Male circumcision (MC) reduces HIV transmission by up to 60% § Eastern & Southern Africa have committed to Voluntary Medical Male Circumcision (VMMC) scale-up § Need to increase efficiency & cost-effectiveness of service delivery – while assuring safety & quality

Efficiency models for surgical process § Surgical technique: – Forceps-guided § Haemostatis: – Electrocautery § Task shifting: – Clinical officers or nurses perform MC § Task sharing: – Surgeon performs most complex aspects of operation, others the rest § Allocation of more than 1 surgical bay per surgeon § Bundling of tools: – Prepacking of supplies, tools

Objectives of SYMMACS study § To document the operational scale-up of MC in 4 countries; Kenya, S. Africa, Tanzania & Zimbabwe § Examples: – What % of sites use forceps-guided? – What % of sites have more than 1 bay per surgeon? – What % of sites bundle supplies, tools? § To determine if adoption of these efficiency elements relates to increased productivity – And if so, which elements are most important for increased productivity?

SYMMACS provides feedback § On a particular site § On a network of sites (e. g. military sites) § On site trends in country § On site trends in the 4 participating countries: – Will yield a total of 80 sites in 2011; possibly more in 2012

Zimbabwe: SYMMACS Study § Two co-investigators – To assist with advocating for the study in-country § A country coordinator: – 50% time: oversees project, assists with data collection § A clinician – Works as consultant on days of data collection § A research assistant – Assists with data processing & report generation

Data collection: April-May 2011 § 2 -day visit to each VMMC site § Interviews with clinic administrator and VMMC providers § Observation of quality & hygiene § Timing of pre-defined steps in the operation § Tracking & reviewing adverse effects (data available from each site plus central MIS)

Preliminary Results § Collected data from 10 MC sites – 4 had always offered MC; 6 started April/May 2011 § Observed & scored quality & hygiene at each site (n=10) § Timed 10 operations per site (n=100) § Interviewed 52 service providers (16 doctors; 36 nurses)

Surgical Techniques used § 98. 4% Forceps-Guided § 1. 3% Dorsal slit § 0. 3% Sleeve resection 52 interviewed providers § 100% believed Forceps-Guided was the fastest § 92 % preferred Forceps-Guided § 3. 9% preferred Dorsal Slit § 3. 9% preferred Sleeve Resection

Haemostatis & Bundling of tools § 20% were using ligating sutures only § 80% always/sometimes used electrocautery § Depending on availability of electricity/ generators § Perceptions on electrocautery reducing operating time significantly: § 97. 5% Strongly Agreed/Agreed § 2. 5% Strongly Disagreed/Disagreed § All providers reported having always used pre-bundled instruments & supplies

Allocation of more than 1 surgical bay per surgeon # surgical bays per surgeon #sites (n= 10 sites) 1 0 2 1 3 4 4 3 5 2 Mean number of bays per surgeon: 3. 6

Task-shifting: Would you allow nurses to perform entire procedure? All providers n=52 Doctors n=16 Nurses n=36 % Yes 82. 7 62. 5 91. 7 % No 9. 6 25. 5 2. 8 % Not sure 7. 7 12. 5 5. 6

Job satisfaction: MC a personally fulfilling job? All providers n=52 Doctors n=16 Nurses n=36 77. 0 68. 8 80. 5 Neutral/Don’t know 15. 4 18. 8 13. 9 Strongly Disagree/Disagr ee 7. 7 12. 5 5. 6 Strongly Agree/Agree

Begun to experience burn-out? All providers n=52 Doctors n=16 Nurses n=36 36. 5 43. 8 33. 4 Neutral/Don’t know 11. 5 12. 5 11. 1 Strongly Disagree/Disagree 51. 9 43. 8 55. 6 Strongly Agree/Agree

Implementation of efficiency measures: providers’ preferences (n= 52 providers) If given the choice, providers would apply the following efficiency measures at their MC clinic: Use of forceps guided surgical method Already do (%) Yes (%) Not sure (%) 98. 1 1. 9 0. 0 Electrocautery/diathermy 69. 2 23. 1 1. 9 5. 8 Multiple beds per surgeon 100. 0 0. 0 Bundling of surgical instruments and supplies by clinic staff 0. 0 13. 5 86. 5 0. 0 Task shifting : allowing adequately trained nurses and or clinical officers to perform the entire MC procedure 0. 0 82. 7 9. 6 7. 7 Task sharing: allowing secondary providers to administer local anesthesia 59. 6 34. 6 3. 9 1. 9 Task sharing : allowing secondary providers to complete interrupted sutures 42. 3 46. 2 7. 7 3. 9

Next steps § Collect data from additional sites until end of Dec 2011 § Collect data from a total of 20 sites in 2012 § Compile data (including retrospectively) from the existing health information system on: – – # of procedures performed Adverse events HIV testing uptake Uptake of post-op follow up visits § Further data analysis (to see whether adoption of efficiency elements relates to increased productivity)

Conclusions § This study tracks adoption of efficiency elements in the context of VMMC scale-up in 4 countries § Data from this initiative are of important value to: – local stakeholders – the international HIV prevention community § Findings may help to inform policy review around: – Permitting nurses to perform more tasks safely and officially, thereby reducing doctors’ burn-out – Achieving higher numbers whilst retaining quality and safety

Acknowledgements § Research Participants § Ministry of Health and Child Welfare Zimbabwe § PSI Zimbabwe § Linnea Perry, Margaret Farrell-Ross, Tulane University § PEPFAR – USAID Contract No: GHH-I-00 -07 -0003200 Order No: 02