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Systematic Monitoring of the Voluntary Medical
Male Circumcision Scale-up in
Eastern and Southern Africa:
Surgical Efficiencies and Provider
Attitudes & Experiences
Webster Mavhu on behalf of the SYMMACS team
AIDS 2014 – Stepping Up The Pace
Background
• 14 African countries scaling up Voluntary Medical
Male Circumcision (VMMC)
• The Systematic Monitoring of the VMMC Scale-up
(SYMMACS) assessed scale-up in:
– Kenya
– South Africa
– Tanzania
– Zimbabwe
Models for Optimizing the Volume and
Efficiency of MC Services (2010)
Practitioners identified six elements of surgical efficiency
that SYMMACS monitored:
1. “Task-shifting”
2. “Task-sharing”
3. Pre-bundling of surgical supplies with disposable
instruments (MC kits)
4. Rotation among multiple bays in operating theatre
5. Use of electrocautery/diathermy for hemostasis
6. Use of forceps-guided surgical method
SYMMACS Methodology
• Process evaluation conducted in 4 countries
– Kenya, South Africa, Tanzania & Zimbabwe
• 2 serial cross-sectional samples of VMMC sites
– Data collected in 2011 and 2012 using same
instruments
• Included fixed, outreach and mobile sites
– Kenya: only country that had mobile sites
RESULTS: Summary of Adoption of the 6
Efficiency Elements 2011-2012
Kenya
2011-2012
South Africa Tanzania
Zimbabwe
2011-2012
2011-2012
2011-2012
Multiple bays in operating
theatre
X/X
X/X
X/X
Purchase of pre-bundled kits with
disposable instruments
X/X
X/X
Task-shifting
X/X
Task-sharing
X/X
X/X
X/X
X/X
Surgical method: forceps-guided
X/X
X/X
X/X
X/X
Electrocautery to stop bleeding
X/X
X/X
(x)* / X
RESULTS
• Task-sharing & electrocautery associated with:
– Reduced provider time with a client
– Reduced operating time
• Quality of surgical technique not significantly related
to time spent with client or operating time (except in
S.Africa in 2012)
• Factors related to operating time varied by country
and year, but task-sharing reduced operating time in
S.Africa & Zimbabwe, and so did electrocautery
Regressions by Year & by Country, to Predict
Primary Provider Time with Client (PPTC) in Seconds
South Africa
Coefficien
t
Tanzania
CI
Coefficient
Zimbabwe
CI
Coefficient
CI
Data for sites in 2011
Type of hemostasis
- Ligating sutures
t
--
t
--
178.40**
(92.65, 264.15)
257.16**
(-362.19, 152.13)
-347.84**
(-466.23, 227.44)
(-235.53**)
(-312.67, -158.43)
Task-sharing: who performed
suturing
Primary & secondary
Data for sites in 2012
Type of hemostasis
- Ligating sutures
t
--
t
--
166.59**
(100.33, 232.85)
Primary & secondary
t
--
-264.02**
(-468.15, 59.89)
-184.51**
(-249.43, -119.6)
Task-sharing: non-physician
t
--
-146.00**
(-315.18, 23.18)
t
--
-48.60**
(-61.67, 35.53)
65.42**
(17.94,
112.90)
-16.75
(-51.33, 17.82)
Task-sharing: who performed
suturing
Mean number of beds
RESULTS:
• High concordance between each country’s policies
and provider attitudes toward the efficiency
elements
• However, providers expressed frustration over lack
of provision for the conduct of certain practices
(e.g., task-shifting in S.Africa & Zimbabwe)
RESULTS: Work Experience, Job Fulfillment
& Burnout among VMMC Providers
– Perry et al. (2014)
• Providers in all countries reported high levels
of personal job-fulfillment
• However, many providers reported work
fatigue & burnout among themselves and
their colleagues
• Burnout was highest in Kenya (country with
longest running VMMC program)
Provider Burnout and Job Satisfaction
Kenya
South Africa
Tanzania
Zimbabwe
2011
n=85
2012
n=82
2011
n=105
2012
n=209
2011
n=93
2012
n=206
2011
n= 74
2012
n=94
Performing (or assisting in
performing) VMMC is a
personally fulfilling job
87.1
84.0
82.9
79.9
100
99.0
81.1
77.7
I personally have begun to
experience work fatigue or
burnout from performing
(or assisting in
performing) VMMC
repeatedly
70.6
69.5
36.2
32.5
53.8
14.6
27.0
17.0
% who agree or strongly
agree that:
Recommendations
• No amount of surgical efficiency can compensate for
weak demand for VMMC services (Rech et al. 2014a)
• Countries should consider how best to support &
motivate its providers to maintain job-fulfillment and
reduce burnout (Perry et al. 2014)
• Countries should consult providers & ensure greater
understanding of policies to ensure compliance with
efficiency elements (Mavhu et al. 2014)
Acknowledgment to Country Teams
Kenya
South Africa
Tanzania
Zimbabwe
Implementing
Agency
FHI360/Kenya
CHAPS
MCHIP Jhpiego/Tanzania
PSI/Zimbabwe, with ZAPPUZ as subcontractor
Co-investigator
Dr. Nicholas Muraguri, Dr.
Peter Cherutich, Dr.
Kawango Agot, Dr. Walter
Obiero, Dr. Jackson Kioko
Dr. Dirk Taljaard,
Dr. James McIntyre
Dr. Bennet Fimbo, Dr.
Eleuter Samky
Dr. Karin Hatzold,
Christopher Samkange
Country
Coordinator
Dr. Mores Loolpapit,
Mathews Onyango
Sasha Frade
Michael D. Machaku
Webster Mavhu
Clinician (data
collection)
Omondi Dickens,
Social Scientist for
data collection
Rosemary Owigar, Dr. Violet
n/a
Naanyu
n/a
n/a
Data Manager
Omondi Dickens
Alexandra Spyrelis
Flora Hezwa, Dr. Obadia
Venance Nyongole
Dudzai Mureyi
USAID Mission
Anne Murphy
Wendy Benzerga, Rebecca
Fertziger
Duncan Onditi, Seth
Greenberg, Eric Mlanga
William Jansen
Technical assistance
and/or sampling
Dr. Kate McIntyre, Zebedee
Mwandi
Carlos Toledo, Lisa
Mulwenga
Koku Kasaura
n/a
Manuscript review
n/a
n/a
Hally Mahler
Dr Karin Hatzold
Nicolas Pule
Mulashi Biola, Daniel
Dr. Sifuni Koshuma,
Shabangu, Sindiswe Zwane,
Milton Kabiligi
Sindiswe Maseko
Dr. Tendai Mutwirah
Dr. Eric Nyazika
Dr. Kelvin Nemayire
Acknowledgement - Other Collaborators
Principal investigators
Jane T. Bertrand (PI), Dino Rech (co-PI)
Co-investigators
Emmanuel Njeuhmeli, Delivette Castor, Jason Reed
Technical Advisory Group to
the R2P Project for VMMC
(convened in 2010)
Bertran Auvert, Stella Babalola, Robert Bailey, Kelly Curran, Kim Eva
Dickson, Timothy Farley, Ron Gray, Jason Reed, Caroline Ryan; also
present from USAID: Benny Kottiri, David Stanton, Alison Cheng,
Timothy Mah, Emmanuel Njeuhmeli.
USAID/Washington:
Emmanuel Njeuhmeli, Delivette Castor, Alison Cheng, Benny Kottiri,
Sarah Sandison, Timothy Mah
PEPFAR/CDC/Atlanta:
Jason Reed (at the time of initiation of the study)
Center for Communication
Programs (CCP), Johns
Hopkins Bloomberg School of
Public Health:
Susan Krenn, William Glass, and Mark Beisser; and from R2P staff
(CCP): Deanna Kerrigan, Caitlin Kennedy, Brandon Howard, Emily
Hurley, Heena Brahmbhatt, Andrea Vazzano, ‘Kuor Kumoji, Erica Layer,
Jessica Spielman and Margie Wild
Technical and administrative
support / Tulane SPTHM
Alan Czaplicki, Bobbie Garner-Coffie, Frances Mather, Christopher
Swalm.
Research support / Tulane
SPTHM
Linnea Perry, Margaret Farrell, Nicholas Thomas
The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for
International Development under Contract No. GHH-I-00-07-00032-00, beginning
September 30, 2008, and supported by the President’s Emergency Plan for AIDS
Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins
Center for Global Health and managed by the Johns Hopkins Bloomberg School of
Public Health Center for Communication Programs (JHUCCP).