Surgical Efficiencies and Quality in the Performance of Voluntary Medical Male Circumcision (VMMC) Procedures in Kenya, South Africa, Tanzania, and Zimbabwe

Abstract

IntroductionThis analysis explores the association between elements of surgical efficiency in voluntary medical male circumcision (VMMC), quality of surgical technique, and the amount of time required to conduct VMMC procedures in actual field settings. Efficiency outcomes are defined in terms of the primary provider’s time with the client (PPTC) and total elapsed operating time (TEOT).MethodsTwo serial cross-sectional surveys of VMMC sites were conducted in Kenya, Republic of South Africa, Tanzania and Zimbabwe in 2011 and 2012. Trained clinicians observed quality of surgical technique and timed 9 steps in the VMMC procedure. Four elements of efficiency (task-shifting, task-sharing [of suturing], rotation among multiple surgical beds, and use of electrocautery) and quality of surgical technique were assessed as explanatory variables. Mann Whitney and Kruskal Wallis tests were used in the bivariate analysis and linear regression models for the multivariate analyses to test the relationship between these five explanatory variables and two outcomes: PPTC and TEOT. The VMMC procedure TEOT and PPTC averaged 23–25 minutes and 6–15 minutes, respectively, across the four countries and two years. The data showed time savings from task-sharing in suturing and use of electrocautery in South Africa and Zimbabwe (where task-shifting is not authorized). After adjusting for confounders, results demonstrated that having a secondary provider complete suturing and use of electrocautery reduced PPTC. Factors related to TEOT varied by country and year, but task-sharing of suturing and/or electrocautery were significant in two countries. Quality of surgical technique was not significantly related to PPTC or TEOT, except for South Africa in 2012 where higher quality was associated with lower TEOT.ConclusionsSYMMACS data confirm the efficiency benefits of task-sharing of suturing and use of electrocautery for decreasing TEOT. Reduced TEOT and PPTC in high volume setting did not result in decreased quality of surgical care.

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“…There is some precedent to the link between increased scale and quality: in a multicountry study in Eastern and Southern Africa, the scale‐ up of VMMC services was tied to improvements in quality . This is not universal, as another study in South Africa raised questions about the effect of scale on quality . We do feel that quality of service and AE reporting in this programme increased over time, but only with a vigilant focus on systems to prevent and report AEs.…”

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“…For example, at the time of the study, Kenya and Tanzania effectively employed task shifting by allowing nurses to perform the VMMC procedure in place of physicians, but this practice was not allowed in South Africa and Zimbabwe. SYMMACS data confirmed the efficiency benefits of task sharing of suturing and the use of electrocautery for decreasing total operating time without decreasing the quality of care [22]. SYMMACS also identified the factors associated with provider attitudes towards VMMC efficiency elements [23] and provider burnout [24].…”

“…Results from SYMMACS showed that safe, high-quality VMMC can be implemented and sustained at scale, although quality was found to decline in areas where the number of new VMMC sites increased rapidly [21, 22]. Infection control, pre-operative examinations and post-operative patient monitoring and counselling were identified as areas for improvement and future monitoring, though specific findings differed by country.…”

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“…39 Recent reviews of this rollout have found that robust country leadership and existence of a pilot site with government involvement were most predictive of successful adoption; nonphysicians could adequately replace physicians in performing certain tasks such as suturing, and prepackaged VMMC kits can improve efficiency when supplies are limited or missing. 38,40,41 This is particularly true in Kenya, which initially encountered a number of political and implementation challenges in its pilot of VMMC in Nyanza Province in the western part of the country. Not only did it achieve considerable gains within the province (>60% of needed VMMCs were completed within 2 years of the start of implementation), but it was also able to scale to Nairobi and other areas of the country through a combination of effective standardized VMMC packages and kits, task shifting and sharing between front-line cadres of health workers, as well as strong coordination between the public sector and a variety of nonprofit and foreign-supported implementers, including the Centers for Disease Control and Prevention, USAID, and a number of other partners.…”