title: Quality of voluntary medical male circumcision services during scale-up: a comparative process evaluation in Kenya, South Africa, Tanzania and Zimbabwe.
abstract: BACKGROUND
  The rapid expansion of voluntary medical male circumcision (VMMC) has raised concerns whether health systems can deliver and sustain VMMC according to minimum quality criteria.
  
  
  RESULTS
  A comparative process evaluation was used to examine data from SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-Up, among health facilities providing VMMC across two years of program scale-up. Site-level assessments examined the availability of guidelines, supplies and equipment, infection control, and continuity of care services. Direct observation of VMMC surgeries were used to assess care quality. Two sample tests of proportions and t-tests were used to examine differences in the percent of facilities meeting requisite preparedness standards and the mean number of directly-observed surgical tasks performed correctly. Results showed that safe, high quality VMMC can be implemented and sustained at-scale, although substantial variability was observed over time. In some settings, facility preparedness and VMMC service quality improved as the number of VMMC facilities increased. Yet, lapses in high performance and expansion of considerably deficient services were also observed. Surgical tasks had the highest quality scores, with lower performance levels in infection control, pre-operative examinations, and post-operative patient monitoring and counseling. The range of scale-up models used across countries additionally underscored the complexity of delivering high quality VMMC.
  
  
  CONCLUSIONS
  Greater efforts are needed to integrate VMMC scale-up and quality improvement processes in sub-Saharan African settings. Monitoring of service quality, not just adverse events reporting, will be essential in realizing the full health impact of VMMC for HIV prevention.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: Larissa
authors.initials: L
authors.lastname: Jennings
authors.affiliation: Tulane University School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
authors.forename: Jane
authors.initials: J
authors.lastname: Bertrand
authors.affiliation: The Centre for HIV and AIDS Prevention Studies, Johannesburg, South Africa.
authors.forename: Dino
authors.initials: D
authors.lastname: Rech
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Harvey
authors.affiliation: Population Services International, Harare, Zimbabwe.
authors.forename: Karin
authors.initials: K
authors.lastname: Hatzold
authors.affiliation: Institute of Continuing Health Education, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Samkange
authors.affiliation: Impact Research and Development Organization, Kisumu, Kenya.
authors.forename: Dickens S
authors.initials: DS
authors.lastname: Omondi Aduda
authors.affiliation: Ministry of Health and Social Welfare, National AIDS Control Programme, Dar es Salaam, Tanzania.
authors.forename: Bennett
authors.initials: B
authors.lastname: Fimbo
authors.affiliation: National AIDS and Sexually Transmitted Infections Control Program, Nairobi, Kenya.
authors.forename: Peter
authors.initials: P
authors.lastname: Cherutich
authors.affiliation: Tulane University School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
authors.forename: Linnea
authors.initials: L
authors.lastname: Perry
authors.affiliation: United States Agency for International Development, Washington, D.C., United States of America.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: United States Agency for International Development, Washington, D.C., United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D002944:Circumcision, Male / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007630:Kenya; D008297:Male; D011787:Quality of Health Care / Q000592:standards* / Q000706:statistics & numerical data; D013019:South Africa; D013636:Tanzania; D015030:Zimbabwe