title: Implications of the fast-evolving scale-up of adult voluntary medical male circumcision for quality of services in South Africa.
abstract: BACKGROUND
  The scale-up of voluntary medical male circumcision (VMMC) services in South Africa has been rapid, in an attempt to achieve the national government target of 4.3 million adult male circumcisions for HIV prevention by 2016. This study assesses the effect of the scale-up on the quality of the VMMC program.
  
  
  RESULTS
  This analysis compares the quality of services at 15 sites operational in 2011 to (1) the same 15 sites in 2012 and (2) to a set of 40 sites representing the expanded program in 2012. Trained clinicians scored each site on 29 items measuring readiness to provide quality services (abbreviated version of the WHO Quality Assessment [QA] Guide) and 29 items to assess quality of surgical care provided (pre-op, surgical technique and post-op) based on the observation of VMMC procedures at each site. Declines in quality far outnumbered improvements. The negative effects in terms of readiness to provide quality services were most evident in expanded sites, whereas the declines in provision of quality services tended to affect both repeat sites and expanded sites equally. Areas of notable concern included the monitoring of adverse events, external supervision, post-operative counselling, and some infection control issues. Scores on quality of surgical technique tended to be among the highest across the 58 items observed, and the South Africa program has clearly institutionalized three "best practices" for surgical efficiency.
  
  
  CONCLUSIONS
  These findings demonstrate the challenges of rapidly developing large numbers of new VMMC sites with the necessary equipment, supplies, and protocols. The scale-up in South Africa has diluted human resources, with negative effects for both the original sites and the expanded program.
authors.affiliation: Centre for HIV/AIDS Prevention Studies (CHAPS), Johannesburg, South Africa.
authors.forename: Dino
authors.initials: D
authors.lastname: Rech
authors.affiliation: Centre for HIV/AIDS Prevention Studies (CHAPS), Johannesburg, South Africa.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Spyrelis
authors.affiliation: Centre for HIV/AIDS Prevention Studies (CHAPS), Johannesburg, South Africa.
authors.forename: Sasha
authors.initials: S
authors.lastname: Frade
authors.affiliation: Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America.
authors.forename: Linnea
authors.initials: L
authors.lastname: Perry
authors.affiliation: Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America.
authors.forename: Margaret
authors.initials: M
authors.lastname: Farrell
authors.affiliation: United States Agency for International Development, Pretoria, South Africa.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Fertziger
authors.affiliation: Centers for Disease Control and Prevention, Pretoria, South Africa.
authors.forename: Carlos
authors.initials: C
authors.lastname: Toledo
authors.affiliation: United States Agency for International Development, Washington, DC, United States of America.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: United States Agency for International Development, Washington, DC, United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
authors.affiliation: South African National Department of Health, South Africa.
authors.forename: Dayanund
authors.initials: D
authors.lastname: Loykissoonlal
authors.affiliation: Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America.
authors.forename: Jane T
authors.initials: JT
authors.lastname: Bertrand
mesh_terms: D002944:Circumcision, Male / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D011787:Quality of Health Care / Q000592:standards / Q000706:statistics & numerical data*; D013019:South Africa