Improving the Quality of Voluntary Medical Male Circumcision through Use of the Continuous Quality Improvement Approach: A Pilot in 30 PEPFAR-Supported Sites in Uganda

Abstract

BackgroundUganda adopted voluntary medical male circumcision (VMMC) (also called Safe Male Circumcision in Uganda), as part of its HIV prevention strategy in 2010. Since then, the Ministry of Health (MOH) has implemented VMMC mostly with support from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through its partners. In 2012, two PEPFAR-led external quality assessments evaluated compliance of service delivery sites with minimum quality standards. Quality gaps were identified, including lack of standardized forms or registers, lack of documentation of client consent, poor preparedness for emergencies and use of untrained service providers. In response, PEPFAR, through a USAID-supported technical assistance project, provided support in quality improvement to the MOH and implementing partners to improve quality and safety in VMMC services and build capacity of MOH staff to continuously improve VMMC service quality.Methods and FindingsSites were supported to identify barriers in achieving national standards, identify possible solutions to overcome the barriers and carry out improvement plans to test these changes, while collecting performance data to objectively measure whether they had bridged gaps. A 53-indicator quality assessment tool was used by teams as a management tool to measure progress; teams also measured client-level indicators through self-assessment of client records. At baseline (February-March 2013), less than 20 percent of sites scored in the “good” range (>80%) for supplies and equipment, patient counseling and surgical procedure; by November 2013, the proportion of sites scoring “good” rose to 67 percent, 93 percent and 90 percent, respectively. Significant improvement was noted in post-operative follow-up at 48 hours, sexually transmitted infection assessment, informed consent and use of local anesthesia but not rate of adverse events.ConclusionPublic sector providers can be engaged to address the quality of VMMC using a continuous quality improvement approach.

Adverse events in a large‐scale VMMC programme in Tanzania: findings from a case series analysis

“…Under‐reporting of known AEs is also a concern affecting surgical programmes: in South Africa, 42% of surgeons stated hesitance to report an AE due to the perception of poor performance . Lack of knowledge about reporting and related tools, busy clinic schedules and fear of perceived incompetence have also been documented as reasons surgeons do not report AEs. Anecdotal evidence from Tanzania suggests that in particular mild AEs often go unreported.…”

Counseling Received by Adolescents Undergoing Voluntary Medical Male Circumcision: Moving Toward Age-Equitable Comprehensive Human Immunodeficiency Virus Prevention Measures

“…Consistent use of a checklist in VMMC counseling, with quality assurance and supervision ensured throughout, could potentially increase positive counseling outcomes. In study in Uganda, for instance, the quality of VMMC provision among adults, including patient counseling, improved dramatically after implementation of a quality assessment tool used by VMMC site management [ 19 ]. Such checklists and management tools could help counselors ascertain adolescent sexual activity, better tailor the counseling delivery appropriately, and provide complete and consistent information in every counseling session.…”

The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda

“…The quality of VMMC services is very important for increasing the number of men circumcised for HIV prevention, and improvement interventions have been implemented successfully in other settings [ 10 – 12 ]. Of particular importance in recent times is the focus on delivering such services in sub-Saharan Africa at large scale while still maintaining high quality of services to reduce adverse events and encourage greater uptake among the target population [ 13 – 16 ].…”

“…Of particular importance in recent times is the focus on delivering such services in sub-Saharan Africa at large scale while still maintaining high quality of services to reduce adverse events and encourage greater uptake among the target population [ 13 – 16 ]. While the study was not powered to detect differences in the effects among different regions, the uniformity of results and previous experience suggest the findings are generalizable across Uganda [ 10 ]. Results from this study may be especially relevant in many settings in Africa to guide decision-making for maximal public health benefit.…”