Quality of service and continuous quality improvement in voluntary medical male circumcision programme across four provinces in South Africa: Longitudinal and cross-sectional programme data.

BACKGROUND: Recent studies in the Sub-Saharan countries in Africa have indicated gaps and challenges for voluntary medical male circumcision (VMMC) quality of service. Less has focused on the changes in quality of service after implementation of continuous quality improvement (CQI) action plans. This study aimed to evaluate the impact of coaching, provision of standard operating procedures (SOPS) and guidelines, mentoring and on-site in-service training in improving quality of VMMC services across four Right to Care (RTC) supported provinces in South Africa. METHOD: This was a pre- and post-interventional study on RTC supported VMMC sites from July 2018 to October 2019. All RTC-supported sites that were assessed at baseline and post-intervention were included in the study. Data for baseline CQI assessment and re-assessments was collected using a standardized National Department of Health (NDoH) CQI assessment tool for VMMC services from routine RTC facility level VMMC programme data. Quality improvement support was provided through a combination of coaching, provision of standard operating procedures and guidelines, mentoring and on-site in-service training on quality improvement planning and implementation. The main outcome measure was quality of service. A paired sample t-test was used to compare the difference in mean quality of service scores before and after CQI implementation by quality standard. RESULTS: A total of 40 health facilities were assessed at both baseline and after CQI support visits. Results showed significant increases for the overall changes in quality of service after CQI support intervention of 12% for infection prevention (95%CI: 7-17; p<0.001) and 8% for male circumcision surgical procedure, (95%CI: 3-13; p<0.01). Similarly, individual counselling, and HIV testing increased by 14%, (95%CI: 7-20; p<0.001), group counselling, registration and communication by 8%, (95%CI: 3-14; p<0.001), and 35% for monitoring and evaluation, (95%CI: 28-42; p<0.001). In addition, there were significant increases for management systems of 29%, (95%CI: 22-35; p<0.001), leadership and planning 23%, (95%CI: 13-34; p<0.001%) and supplies, equipment, environment and emergency 5%, (95%CI: 1-9; p<0.01). The overall quality of service performance across provinces increased by 18% (95%CI: 14-21; p<0.001). CONCLUSION: The overall quality of service performance across provinces was significantly improved after implementation of CQI support intervention program. Regular visits and intensive CQI support are required for sites that will be performing below quality standards.

Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe.

BACKGROUND: Since 2013, the ZAZIC consortium supported the Zimbabwe Ministry of Health and Child Care (MOHCC) to implement a high quality, integrated voluntary medical male circumcision (VMMC) program in 13 districts. With the aim of significantly lowering global HIV rates, prevention programs like VMMC make every effort to achieve ambitious targets at an increasingly reduced cost. This has the potential to threaten VMMC program quality. Two measures of program quality are follow-up and adverse event (AE) rates. To inform further VMMC program improvement, ZAZIC conducted a quality assurance (QA) activity to assess if pressure to do more with less influenced program quality. METHODS: Key informant interviews (KIIs) were conducted at 9 sites with 7 site-based VMMC program officers and 9 ZAZIC roving team members. Confidentiality was ensured to encourage candid conversation on adherence to VMMC standards, methods to increase productivity, challenges to target achievement, and suggestions for program modification. Interviews were recorded, transcribed and analyzed using Atlas.ti 6. RESULTS: VMMC teams work long hours in diverse community settings to reach ambitious targets. Rotating, large teams of trained VMMC providers ensures meeting demand. Service providers prioritize VMMC safety procedures and implement additional QA measures to prevent AEs among all clients, especially minors. However, KIs noted three areas where pressure for increased numbers of clients diminished adherence to VMMC safety standards. For pre- and post-operative counselling, MC teams may combine individual and group sessions to reach more people, potentially reducing client understanding of critical wound care instructions. Second, key infection control practices may be compromised (handwashing, scrubbing techniques, and preoperative client preparation) to speed MC procedures. Lastly, pressure for client numbers may reduce prioritization of patient follow-up, while client-perceived stigma may reduce care-seeking. Although AEs appear well managed, delays in AE identification and lack of consistent AE reporting compromise program quality. CONCLUSION: In pursuit of ambitious targets, healthcare workers may compromise quality of MC services. Although risk to patients may appear minimal, careful consideration of the realities and risks of ambitious target setting by donors, ministries, and implementing partners could help to ensure that client safety and program quality is consistently prioritized over productivity.

Incidentally detected cavernous hemangioma of the glans penis after circumcision: A case report.

RATIONALE: Hemangiomas of the glans penis are very rare. Treatment options include surgical excision, laser therapy, intralesional sclerotherapy, electrofulguration, and cryotherapy. However, there have been no definitive treatment guidelines established to date. PATIENT CONCERNS: A 19-year-old man presented with a mass on the glans penis, incidentally found during a circumcision performed at a local urology clinic 3 months before visiting our department. DIAGNOSES: Histopathological examination identified the specimen as a cavernous hemangioma. INTERVENTIONS: The mass was completely excised and the resulting wound was closed layer by layer. OUTCOMES: The patient was discharged without complications, such as wound dehiscence or infection. Follow-up 14 months after surgery showed that the wound was well healed without recurrence and the patient was satisfied with the aesthetic result. LESSONS: Although there are many options to treat hemangiomas occurring on the glans penis, surgical excision can be considered when they are small in size.

Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets.

INTRODUCTION: Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President's Emergency Plan for AIDS Relief's (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. METHODS AND RESULTS: The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including "mobilizers", HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. CONCLUSION: Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.

The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries.

INTRODUCTION: Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission-the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. METHODS: We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. RESULTS: Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. CONCLUSIONS: No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.

The quality of voluntary medical male circumcision done by mid-level workers in Tshwane District, South Africa: A retrospective analysis.

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces the acquisition of human immunodeficiency virus (HIV) in heterosexual men by up to 60%. One HIV infection is averted for every 5 to 15 VMMCs. To conduct VMMCs in large populations, large numbers of trained healthcare professionals are needed. Countries in Sub-Saharan Africa have a high burden of HIV and a shortage of healthcare professionals, creating a healthcare conundrum. To bridge this gap, South Africa launched a new cadre of mid-level medical worker called Clinical Associates (CA). We assessed the ability of CAs to perform circumcisions of adequate quality and their subsequent usefulness to meet the demands of VMMCs in a population with a high HIV burden. METHODS: We conducted a retrospective analysis, reviewing patient files (n = 4850) of surgical VMMCs conducted over a 16-month period. Patient files were sourced from clinics and hospitals that provided free VMMCs in Tshwane district in South Africa. FINDINGS: Clinical associates performed 88.66% of the circumcisions and doctors performed the remaining 11.34% (p < 0.001). The number of adverse events did not differ between the two groups. Data on intra-operative adverse events were available for 4 738 patients. Of these, 341 (7.2%) experienced intra-operative adverse events. For the whole sample, 44 (8.1%, n = 543) adverse events occurred during circumcisions done by doctors and 297 (7.1%, n = 4195) occurred during circumcisions done by CAs (p = 0.385). Clinical associates performed circumcisions in shorter times (duration: 14.63 minutes) compared to doctors (duration: 15.25 minutes, t = -7.46; p < 0.001). Recorded pain, bleeding, swelling, infection and wound destruction did not differ between clients circumcised by CAs and doctors. This study is limited by the use of data from a single district. CONCLUSIONS: Clinical associates contribute to the demands for high numbers of VMMCs in Tshwane district, South Africa. Clinical associates perform VMMCs at a clinical standard that is comparable to circumcisions performed by doctors.

A prospective cohort study of safety and patient satisfaction of voluntary medical male circumcision in Botswana.

Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces the risk of HIV acquisition in men. However, the rate of complications associated with the surgical procedure varies from 0.7% to 37.4% in real-world settings. We assessed the frequency, type and severity of adverse events following VMMC among 427 adult men surgically circumcised in southeastern Botswana; 97% completed ≥1 follow-up visit within seven days post-circumcision. Thirty moderate AEs were observed in 28 men resulting in an overall AE rate of 6.7%. Patient satisfaction was high: >95% were very or somewhat satisfied with the procedure and subsequent follow-up care.

Is traditional male circumcision effective as an HIV prevention strategy? Evidence from Lesotho.

In many developing countries, male circumcision has been promoted as an effective HIV prevention strategy, and medical randomized controlled trials have indeed shown a causal link. However, there is limited empirical evidence to support this conclusion in countries where individuals can voluntary opt for different types of circumcision. The present study considers male circumcision in Lesotho, where HIV prevalence is among the highest in the world (23%). Here, men can opt for one of two types of circumcision: traditional male circumcision in initiation schools, or the medical option in health clinics. This paper investigates whether the former has medical effects on individual HIV status that are as beneficial as those shown for the latter. Controlling for the potential individual behavioral response after the operation, it was found that circumcision performed in initiation schools wholly offset the medical benefits of the surgical procedure. This supports anecdotal evidence that the operation performed by traditional circumcisers does not have the same protective effect against HIV transmission as the medical operation. No evidence of "disinhibition" behavior among circumcised men was found, nor differential risky sexual behavior among men circumcised, traditionally or medically. Considering that, in Lesotho, traditional male circumcision is undertaken by more than 90% of circumcised men, the findings highlight the need for further research into how the operation in initiation schools is performed and its medical benefits.

The use of multi-criteria decision making models in evaluating anesthesia method options in circumcision surgery.

BACKGROUND: Determining the most suitable anesthesia method for circumcision surgery plays a fundamental role in pediatric surgery. This study is aimed to present pediatric surgeons' perspective on the relative importance of the criteria for selecting anesthesia method for circumcision surgery by utilizing the multi-criteria decision making methods. METHODS: Fuzzy set theory offers a useful tool for transforming linguistic terms into numerical assessments. Since the evaluation of anesthesia methods requires linguistic terms, we utilize the fuzzy Analytic Hierarchy Process (AHP) and fuzzy Technique for Order Preference by Similarity to Ideal Solution (TOPSIS). Both mathematical decision-making methods are originated from individual judgements for qualitative factors utilizing the pair-wise comparison matrix. Our model uses four main criteria, eight sub-criteria as well as three alternatives. To assess the relative priorities, an online questionnaire was completed by three experts, pediatric surgeons, who had experience with circumcision surgery. RESULTS: Discussion of the results with the experts indicates that time-related factors are the most important criteria, followed by psychology, convenience and duration. Moreover, general anesthesia with penile block for circumcision surgery is the preferred choice of anesthesia compared to general anesthesia without penile block, which has a greater priority compared to local anesthesia under the discussed main-criteria and sub-criteria. CONCLUSIONS: The results presented in this study highlight the need to integrate surgeons' criteria into the decision making process for selecting anesthesia methods. This is the first study in which multi-criteria decision making tools, specifically fuzzy AHP and fuzzy TOPSIS, are used to evaluate anesthesia methods for a pediatric surgical procedure.

Improving voluntary medical male circumcision standards adherence and post-procedure follow-up in Uganda: A mixed methods study

Voluntary medical male circumcision (VMMC) has been demonstrated to reduce the transmission of HIV by 60%. Scaling up VMMC services requires that they be of high quality, socially accepted, and effective. We evaluated an intervention aimed at improving VMMC standards adherence and patient follow-up rates in nine facilities in Uganda. We also qualitatively explored why some men return for follow-up care and others do not. The completeness and quality of clinical documentation was poor at baseline, but significantly improved at endline. We observed significant improvements in management systems; supplies, equipment, and environment; and monitoring and evaluation. Due to the volume of missing data, results were less clear for registration, group education, and information, education and communication; individual counselling and HIV testing; and infection prevention. Significant improvements were also observed in follow-up rates at 48 hours and 7 days, and 6 weeks. Interviews revealed the importance of peers, including female partners, in deciding to get circumcised and in seeking follow-up care. Among the men who did not return for follow-up services, most reported they had no problems and did not see it as necessary. For those who did have mild or moderate adverse events, follow-up care was often sought at a facility closer to the patients' home rather than the circumcising facility. However, information systems were unable to capture this. Applying improvement approaches to VMMC services can promote improved standards adherence and follow-up rates and should be integrated into scale-up plans

Aspirations and realities in a North-South partnership for health promotion: lessons from a program to promote safe male circumcision in Botswana.

BACKGROUND: International donors support the partnership between the Government of Botswana and two international organisations: U.S. Centers for Disease Control and Prevention and Africa Comprehensive HIV/AIDS Partnership to implement Voluntary Medical Male Circumcision with the target of circumcising 80 % of HIV negative men in 5 years. Botswana Government had started integration of the program into its health system when international partners brought in the Models for Optimizing Volume and Efficiency to strengthen delivery of the service and push the target. The objective of this paper is to use a systems model to establish how the functioning of the partnership on Safe Male Circumcision in Botswana contributed to the outcome. METHODS: Data were collected using observations, focus group discussions and interviews. Thirty participants representing all three partners were observed in a 3-day meeting; followed by three rounds of in-depth interviews with five selected leading officers over 2 years and three focus group discussions. RESULTS: Financial resources, "ownership" and the target influence the success or failure of partnerships. A combination of inputs by partners brought progress towards achieving set program goals. Although there were tensions between partners, they were working together in strategising to address some challenges of the partnership and implementation. Pressure to meet the expectations of the international donors caused tension and challenges between the in-country partners to the extent of Development Partners retreating and not pursuing the mission further. CONCLUSION: Target achievement, the link between financial contribution and ownership expectations caused antagonistic outcome. The paper contributes enlightenment that the functioning of the visible in-country partnership is significantly influenced by the less visible global context such as the target setters and donors.

Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study.

BACKGROUND: The American Academy of Pediatrics (AAP) Task Force on Circumcision has called for the development of standards of trainee proficiency in regards to evaluation and technique for neonatal clamp circumcision (NCC). At the present time, there is no standardized or general consensus on patient selection for NCC. An improved method to evaluate newborns for NCC is an important first step in this process. Therefore, the authors collaborated to identify criteria useful in the evaluation of newborns for suitability for NCC, and for assessment of success after NCC and have named it "Checklist Assessment for Neonatal Clamp Circumcision Suitability." METHODS: A national multi-institutional collaboration was created to obtain consensus on objective criteria for use in determining patient suitability for NCC, and for assessing post-circumcision success outcomes. Criteria included elements from detailed medical history, bedside physical examination, and post-circumcision follow-up. Patients desiring NCC were enrolled consecutively and prospectively. The Checklist was followed to determine which newborns were suited to NCC, and NCC was done in those cases. The patients' caretakers were given post-circumcision care instructions and a follow-up appointment. Post circumcision, the Checklist was followed to determine if the procedure resulted in a successful circumcision or if there were complications. RESULTS: A total of 193 cases were enrolled prospectively and consecutively from January 2014 through October 2014. The mean age was 15 days (1-30 days). Of those 193 patients, 129 (67%) were deemed suitable for circumcision and underwent NCC. Post-circumcision assessment showed a 100% success rate with no complications. A total of 64 (23%) cases were deemed unsuitable for NCC because at least one checklist criterion was not satisfied, most commonly: penile torsion (n = 25), chordee (n = 19), and penoscrotal webbing (n = 19). DISCUSSION: Use of the Checklist in the present study has demonstrated a method of patient screening resulting in a 100% success rate with no complications. A high proportion of patients (33%) was identified as unsuited for NCC; however, the patient population consisted of newborn males referred to pediatric urology, and thus does not represent the general population, which is expected to have a lower proportion of unsuited patients. Regardless, the Checklist has the potential to enhance the decision-making process for both urologic and non-urologic care providers. CONCLUSIONS: The use of the "Checklist Assessment for Neonatal Clamp Circumcision Suitability" assessment tool improves identification of patients unsuited for NCC and thereby potentially decreases the likelihood of circumcision-related complications.

Can the Heterosexual HIV Epidemic be Eliminated in South Africa Using Combination Prevention? A Modeling Analysis.

Little is known about how combining efficacious interventions for human immunodeficiency virus (HIV) prevention could lead to HIV elimination. We used an agent-based simulation model, the HIV calibrated dynamic model, to assess the potential for HIV elimination in South Africa. We examined several scenarios (from continuation of the current status quo to perfect achievement of targets) with differing combinations of male condom use, adult male circumcision, HIV testing, and early antiretroviral therapy (ART). We varied numerous parameters, including the proportion of adult males circumcised, the frequency of condom use during sex acts, acceptance of HIV testing, linkage to health care, criteria for ART initiation, ART viral suppression rates, and loss to follow-up. Maintaining current levels of combination prevention would lead to increasing HIV incidence and prevalence in South Africa, while the perfect combination scenario was projected to eliminate HIV on a 50-year time scale from 2013 to 2063. Perfecting testing and treatment, without changing condom use or circumcision rates, resulted in an 89% reduction in HIV incidence but not elimination. Universal adult male circumcision alone resulted in a 21% incidence reduction within 20 years. Substantial decreases in HIV incidence are possible from sufficient uptake of both primary prevention and ART, but with continuation of the status quo, HIV elimination in South Africa is unlikely within a 50-year time scale.

Common urological problems in children: prepuce, phimosis, and buried penis.

Parents often bring their children to the family doctor because of urological problems. Many general practitioners have received little training in this specialty. In this review, we aimed to provide a concise and informative review of common urological problems in children. This review will focus on the prepuce.

Classification and rates of adverse events in a Malawi male circumcision program: impact of quality improvement training.

BACKGROUND: Assessing safety outcomes is critical to inform optimal scale-up of voluntary medical male circumcision (VMMC) programs. Clinical trials demonstrated adverse event (AE) rates from 1.5 to 8 %, but we have limited data on AEs from VMMC programs. METHODS: A group problem-solving, quality improvement (QI) project involving retrospective chart audits, case-conference AE classification, and provider training was conducted at a VMMC clinic in Malawi. For each identified potential AE, the timing, assessment, treatment, and resolution was recorded, then a clinical team classified each event for type and severity. During group discussions, VMMC providers were queried regarding lessons learned and challenges in providing care. After baseline evaluation, clinicians and managers initiated a QI plan to improve AE assessment and management. A repeat audit 6 months later used similar methods to assess the proportions and severity of AEs after the QI intervention. RESULTS: Baseline audits of 3000 charts identified 418 possible AEs (13.9 %), including 152 (5.1 %) excluded after determination of provider misclassification. Of the 266 remaining AEs, the team concluded that 257 were procedure-related (8.6 AEs per 100 VMMC procedures), including 6 (0.2 %) classified as mild, 218 (7.3 %) moderate, and 33 (1.1 %) severe. Structural factors found to contribute to AE rates and misclassification included: provider management of post-operative inflammation was consistent with national guidelines for urethral discharge; available antibiotics were from the STI formulary; providers felt well-trained in surgical skills but insecure in post-operative assessment and care. After implementation of the QI plan, a repeat process evaluating 2540 cases identified 115 procedure-related AEs (4.5 AEs per 100 VMMC procedures), including 67 (2.6 %) classified as mild, 28 (1.1 %) moderate, and 20 (0.8 %) severe. Reports of AEs decreased by 48 % (from 8.6 to 4.5 per 100 VMMC procedures, p < 0.001). Reports of moderate-plus-severe (program-reportable) AEs decreased by 75 % (from 8.4 to 1.9 per 100 VMMC procedures, p < 0.001). CONCLUSIONS: AE rates from our VMMC program implementation site were within the range of clinical trial experiences. A group problem-solving QI intervention improved post-operative assessment, clinical management, and AE reporting. Our QI process significantly improved clinical outcomes and led to more accurate reporting of overall and program-reportable AEs.

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.

BACKGROUND: Uganda 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 FINDINGS: Sites 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. CONCLUSION: Public sector providers can be engaged to address the quality of VMMC using a continuous quality improvement approach.

Voluntary medical male circumcision scale-up in Nyanza, Kenya: evaluating technical efficiency and productivity of service delivery.

BACKGROUND: Voluntary medical male circumcision (VMMC) service delivery is complex and resource-intensive. In Kenya's context there is still paucity of information on resource use vis-à-vis outputs as programs scale up. Knowledge of technical efficiency, productivity and potential sources of constraints is desirable to improve decision-making. OBJECTIVE: To evaluate technical efficiency and productivity of VMMC service delivery in Nyanza in 2011/2012 using data envelopment analysis. DESIGN: Comparative process evaluation of facilities providing VMMC in Nyanza in 2011/2012 using output orientated data envelopment analysis. RESULTS: Twenty one facilities were evaluated. Only 1 of 7 variables considered (total elapsed operation time) significantly improved from 32.8 minutes (SD 8.8) in 2011 to 30 minutes (SD 6.6) in 2012 (95%CI = 0.0350-5.2488; p = 0.047). Mean scale technical efficiency significantly improved from 91% (SD 19.8) in 2011 to 99% (SD 4.0) in 2012 particularly among outreach compared to fixed service delivery facilities (CI -31.47959-4.698508; p = 0.005). Increase in mean VRS technical efficiency from 84% (SD 25.3) in 2011 and 89% (SD 25.1) in 2012 was not statistically significant. Benchmark facilities were #119 and #125 in 2011 and #103 in 2012. Malmquist Productivity Index (MPI) at fixed facilities declined by 2.5% but gained by 4.9% at outreach ones by 2012. Total factor productivity improved by 83% (p = 0.032) in 2012, largely due to progress in technological efficiency by 79% (p = 0.008). CONCLUSIONS: Significant improvement in scale technical efficiency among outreach facilities in 2012 was attributable to accelerated activities. However, ongoing pure technical inefficiency requires concerted attention. Technological progress was the key driver of service productivity growth in Nyanza. Incorporating service-quality dimensions and using stepwise-multiple criteria in performance evaluation enhances comprehensiveness and validity. These findings highlight site-level resource use and sources of variations in VMMC service productivity, which are important for program planning.

Skills training of health workers in the use of a non surgical device (PrePex) for adult Safe Male Circumcision.

BACKGROUND: Safe Male Circumcision (SMC) is a proven approach for partial protection of men from acquisition of HIV infection. Several sub-Saharan African countries have a target to circumcise 80% of males aged 15 to 49. The use of devices such as PrePex would aid scaling up of SMC. Since most health workers would have no prior experience with use of devices, skills training is needed. This paper explores a skills transfer model at an urban site in Uganda. OBJECTIVE: To assess the practicability and feasibility of rapid short duration training for safe PrePex device use. METHODS: A prospective study, conducted over 8 weeks (August-October 2012) at International Hospital Kampala, an urban Kampala hospital, examining the performance of various health worker cadres after training in the use of a non-surgical device (PrePex). The prospective study obtained approval from the Makerere School of Medicine Research and Ethics Committee and the Uganda National Council of Science and Technology. If eligible, and after the subject signed the informed consent form, they were enrolled into the study. RESULTS: Ten health workers were successfully trained in use of PrePex during a 3 day non-residential on-the-job training course. After the first three days of training, the trained health workers performed 561 placements and 529 device removals successfully. Over all adverse events (AE) rates were below ≤ 2%; however, there were some differences in AE rates across the cadres trained but not significant (p>0.25 for moderate AEs). CONCLUSION: Rapid training for safe use of the PrePex device is feasible for the range of health workers available for SMC in resource limited settings, but among those with past SMC experience.