The Anatomy of Success
The Anatomy of Success How the Tanzanian Voluntary Medical Male Circumcision (VMMC) Program Became One of the Most Efficient in the Region Hally Mahler, MCHIP/Jhpiego/Tanzania Presented at OGAC, 6 July 2011 Mafinga District Hospital 20 June 2010 First Day of Campaign Correlation of Male Circumcision Rates and HIV Prevalence among Men 15-49 in Tanzania 3 Major MC Milestones in Tanzania 2007 National MC TWG Formed 2009 Study on Traditional Circumcision conducted WHO/UNAIDS/Jhpiego Training Materials Adapted for TZ MC demonstration sites launched National Situation Assessment Conducted 2010 MOVE Introduced 2011 Scale up in priority regions First MC campaign conducted Cost study underway Official Launch of National National MC Strategy and Strategy (July) Implementation Plan Finalized Campaigns/outreach Expansion of regions/sites in all priority regions First outreach activities conducted Some Background About the Tanzania Program National target: 2.8 million circumcisions Target age: 10 to 34 year-olds Eight priority regions – spilt between USG agencies/partners Task shifting and sharing fully backed GOT directive that the program should be within the public sector – hub with spokes Background – MCHIP/Jhpiego in Tanzania Program objectives Program timeline To scale up safe, Activities began April quality VMMC in Iringa region To initiate safe, quality VMMC in Tabora region To provide technical, training, and programmatic support to other MC partners (as requested) and the GOT 2009 First service launched October 2009 No specific end-date (other than MCHIP project end) Background Funding for the program to date Funding Obligated Expenditure Estimated Accruals Pipeline 3,675,026 2,739,833 (149,758) 1,084,951 Expected COP 11 Funding: $2.4 Million Important Numbers From October 2009 to March 31, 2011 21,134 adult circumcisions performed* 99% of clients tested for HIV as part of services 0.9% AE rate (190/195 were mild or moderate) 86% post-op follow up at 48 hours 41% post-op follow up at 7 days 338 MC providers trained (nationally) 25000 21134 20000 18094 15000 10000 8624 5000 195 0 Total 48hrs follow Circumcisions up 7days follow up AE More Interesting Statistics Age Breakdown Service Delivery Mode Age at Circumcision Under 15 15 and Over Type of Service Static Campaign 25% 30% 70% 75% Data to December 31, 2010 – prior to initiation of outreach activities. 9 25,000th Client in Iringa (May) 25,000th Client at His Clothing Stand in Makambako Market One Week Post-Op Service Delivery in Iringa From pilot to scale in a year May 2011 at Makambako Health Centre 11 static sites established 2 MC campaigns held in Iringa (June/July 2010, Nov/Dec 2010) Now use mix of static, monthly outreach and campaign to maximize service mix Tanzania’s First MC Campaign Planned for Iringa region in three districts in June 21July 31 in 5 facilities – mix of hospitals and health centres, public, FBO and private Set target of 6,000 adolescents and men to be circumcised Decided to use MOVE efficiencies and match them with TZ-developed demand efficiencies What Are MOVE Efficiencies? Surgical technique: Forceps-guided Dorsal slit Sleeve resection Haemostatis: Electrocautery Ligating sutures 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 Limitations in MOVE Primarily surgical techniques Supply driven – help you to serve more clients more efficiently Don’t speak to the demand side – or management of the large number of clients you can serve Challenge: How to Create and Manage Demand to Meet Supply? Set a target of 6,000 circumcisions – 33 circs per facility per day Worried about controlling demand – to have ways to adjust for more or less than we anticipated To manage the demand side the Iringa team developed a set of (nonsurgical) demand-oriented efficiencies (1) Ensure Adequate Client Demand via Existing Local Structures, NGOs in the Field, Supplemented with BCC Demand creation committees formed in each district Other USG partners restructured activities to support MC Print, radio, loud speakers Men Women Youth & Guardians (2) Decongest Service Delivery Sites Prepare/followup clients in their communities (education, counseling, preop exams, follow up exams) (3) Overcome the Counseling and Pre-Op Exam Bottleneck (4) Advance Schedule Clients Helped us to more easily anticipate and match supplies (commodities, providers) with demand (5) Effectively Manage HR Recognized extreme conditions of campaign situation Provided tea, lunch, transport to sites, overtime pay Paid attention to motivation/interpersonal relationships (7) Collect and Manage Real-Time Data With sites spread across a large geographic area, needed to know how many clients vs. circs to manage supply and demand Developed webenabled database, hired clerks, placed them at each site Result: 10,352 Circumcisions SMS Program – Added November 2010 TOHARA – For general info WAPI – To find out where BAADA – Triggers series of post-operative messages After analysis of Nov/Dec campaign – statistically significant association between WAPI and BAADA 23 Formative Assessment of Adult MC Opinions/Preferences 18 FGDs and participatory exercises 3 districts of Iringa region Disaggregated by age/sex (all age 18 or above) Selection of Key Findings (1) Strong bias for MC to happen before or during puberty. Stigma associated with having it done older – especially after a man’s first child has been born. Misinformation about postsurgical erections causing permanent damage. Older men find it unacceptable to queue with younger men. Older men want separate services (day or rooms). Tremendous loss of face to expose genitals in room with younger boys. Clients at Kibena Hospital June 2011 Selection of Key Findings (2) Female providers are a moderate-level barrier, especially for men in their 20s who fear having an erection during service provision. Seasonality is even more important than anticipated. Older men wouldn’t even consider being circumcised outside of the cold season. Makambako Health Centre July 2011 Campaign June/July/August 2011 Target: 20,000 circs All eight districts of Iringa 24 facilities Eight weeks 27 MC Campaign in Iringa – 2 weeks, 2 days (of 8 weeks) Facility /Date 20.06 21.06 22.06 23.06 24.06 25.06 27.06 28.06 29.06 30.06 1.07 2.07 4.07 5.07 Cumulative Kibena DH 63 82 85 102 100 50 111 106 116 115 110 55 117 118 1330 Makambako HC 75 79 68 94 84 47 79 97 80 98 86 50 152 153 1242 Ilembula DDH 50 82 80 80 80 51 82 101 81 105 105 58 102 99 1156 Makete DH 61 55 69 65 78 56 93 93 88 73 75 59 76 86 865 Ludewa H 60 72 82 71 70 54 87 88 77 68 45 24 52 90 940 Bulongwa H 0 0 13 36 50 39 54 35 60 53 61 32 58 61 552 Matamba HC 0 0 0 0 0 0 33 35 35 37 40 21 43 43 287 Lugalawa H 0 0 31 46 45 41 64 70 74 71 72 39 81 82 716 Manda HC 0 0 0 0 51 50 64 71 70 72 84 48 86 80 676 309 370 428 494 558 388 667 696 681 692 678 386 767 812 7764 Total Half Days on Saturdays 29 30 The Demand Creation Team for 2011 Campaign 31 Number of Circumcisions, By Site, June 20 to July 3, 2011 Site MC done Kibena Town Hospital Makambako Health Centre 1095 941 Ludewa District Hospital Ilembula Mission Hospital 798 953 Manda Health Centre 512 Makete District Hospital 868 Bulongwa Hospital Matamba Health Centre 433 200 Lugalawa Hospital 513 Grand Total Now averaging around 700 circumcisions per day in nine sites 6313 Number of Circumcisions, By Site, Weeks One and Two Manda HC Lugalawa H Matamba HC Bulongwa H Ludewa H Second week First week Makete DH Ilembula DDH Makambako HC Kibena DH 0 200 400 600 Number of Circumcisions 800 Age at Circumcision – July 2011 3000 2806 2637 2500 2000 1500 1000 620 500 0 181 6 Under 10 10 to 14 15 to 19 20 to 24 25 to 34 63 35 and Above Age at Circumcision – July 2011 35 and Above 25 to 34 Under 10 20 to 24 10 to 14 15 to 19 Nearly 60% of clients are currently aged 15 and above. We expect younger clients earlier in campaign, especially since these are first-time sites HIV Testing Age < 10 Not Negative Tested Positive A few interesting points: 7 Higher percentage of 10-‐14, 2833 15-‐19 2666 20-‐24 623 3 25-‐34 168 10 35+ Grand Total 55 12 6352 30 1 1 14 69 10-14 year-olds testing HIV+ than 15-19 year olds. 22% of 35+ are HIVpositive First Follow-Up Visit 7000 6313 6000 5173 5000 4000 3000 2000 1000 0 Total Circumcised First Follow-Up 82% first follow up return rate Adverse Events by Site and Severity MC Site Lugalawa Hospital Bulongwa Hospital Ilembula Mission Hospital Kibena Town Hospital Ludewa District Hospital Makambako Health Centre Makete District Hospital Manda Health Centre Matamba Health Centre Total Moderate Severe Total 1 2 3 6 3 2 13 4 1 2 3 8 3 17 Adverse Events, By Type Type of AE Type of AE # of AEs Bleeding or blood soiling of the BANDAGE 5 Infection 10 Swelling of the penis or scrotum 1 Persistent pain 1 No AE 6296 Grand Total 6313 % of AEs 0.08 0.14 0.02 0.02 99.74 100 Of 6313 MC performed – AE rate is currently 0.26% What Makes Iringa Work? (1) Strong and committed regional and district authorities Invested political capital Made more than 200 providers and 24 facilities available Invested in task shifting/sharing Created district-level demand creation committees Strong demand for VMMC services by adolescent and adult males – particularly during the cold season and school holidays Makembako Health Centre July 2011 What Makes Iringa Work? (2) Regional and District Officials Inspect Kibena Hospital June 2011 Little to no opposition in the community to the introduction of VMMC into this traditionally non-circumcising region. The ability to carefully match supply and demand (due to one organization being responsible for both elements) Partnership of other USG prevention orgs, including HTCs General enthusiasm for the intervention among health providers, regional and district officials, and the population of the region What Are Iringa’s Challenges? Attracting and serving adult men (particularly those over the age of 24) Procuring adequate equipment and commodities for scaled up services in Tanzania Electricity Lack of funding adequate to achieve the 80% coverage target Opportunities and Way Forward (1) Take advantage of tremendous energy/commitment in Iringa to achieve 80% circumcision level Try out new service delivery models that will attract more adult male clients Adult-only days/facilities Male providers Look at more ways to engage female partners of potential clients Opportunities and Way Forward (2) Introduce early infant male circumcision (EIMC) in Iringa Regional Hospital as pilot and then to scale Continue to document/share experiences/look for opportunities for study Assist the GOT in development of national trainers, roll-out of additional regions Work with GOT to finalize national documents and strategies 46 Thank You
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