Implications of the Fast-Evolving Scale-Up of Adult Voluntary Medical Male Circumcision for Quality of Services in South Africa

Abstract

BackgroundThe 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.Methods and FindingsThis 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.ConclusionsThese 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.

Voluntary Medical Male Circumcision Scale-Up in Nyanza, Kenya: Evaluating Technical Efficiency and Productivity of Service Delivery

“…[ 27 , 28 , 29 , 30 , 31 ] Using an arbitrary approach inherently may exclude important performance variables [ 27 , 30 ]. Variables incorporated included clinicians, nurses, surgical beds and total elapsed circumcision time [ 32 , 33 ] as inputs while number of circumcisions, proportions of circumcised receiving HIV tests and quality dimensions [ 34 ] were outputs. The quality variable was constructed using principal component analysis (PCA) and exploratory factor analysis techniques.…”

Scaling-up voluntary medical male circumcision – what have we learned?

“… 17 A quality-of-care assessment in South Africa suggests that the rapid scale-up of the VMMC program has diluted human resources and had an adverse impact on health care delivery with declines in the provision of quality services. 23 With the expansion of services, it is critical to monitor the quality of care and services and to implement quality improvement initiatives to realize the full impact of VMMC on HIV prevention. 24 This highlights the importance of taking a broad health systems perspective when examining VMMC programs.…”

“…5 This is particularly unfortunate, given that the data suggest that the introduction of the VMMC services can yield improvements related to the existence of a functioning information system. 23 …”

“…Programs often give priority to maintaining information systems that capture the number of circumcision procedures performed due to the pressure from stakeholders to meet targets, as opposed to the information systems that record data to guide service delivery and quality of care. 23 The data that is needed for on-the-ground program implementation is not the same as the information needed for overall program monitoring. For example, the data related to the seasonal fluctuations in the VMMC demand may not be meaningful at the national level, but that information is important at the local level for staffing plans and demand creation activities.…”

“… 52 Several papers have highlighted that systems are unsatisfactory for tracking adverse events. 23 , 24 , 53 Efforts are needed to refine and standardize adverse event reporting mechanisms and to ensure that these data are not under-reported for fear of reflecting poorly on a program. 23 …”