title: Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up: adoption of efficiency elements in Kenya, South Africa, Tanzania, and Zimbabwe.
abstract: BACKGROUND
  SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency-use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery--as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe.
  
  
  RESULTS
  This multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays.
  
  
  CONCLUSIONS
  SYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement.
authors.affiliation: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
authors.forename: Jane T
authors.initials: JT
authors.lastname: Bertrand
authors.affiliation: Centre for HIV/AIDS Prevention Studies, Johannesburg, South Africa, Nairobi, Kenya.
authors.forename: Dino
authors.initials: D
authors.lastname: Rech
authors.affiliation: FHI 360, Nairobi, Kenya.
authors.forename: Dickens
authors.initials: D
authors.lastname: Omondi Aduda
authors.affiliation: Centre for HIV/AIDS Prevention Studies, Johannesburg, South Africa, Nairobi, Kenya.
authors.forename: Sasha
authors.initials: S
authors.lastname: Frade
authors.affiliation: FHI 360, Nairobi, Kenya.
authors.forename: Mores
authors.initials: M
authors.lastname: Loolpapit
authors.affiliation: Jhpiego, Dar es Salaam, Republic of Tanzania.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Machaku
authors.affiliation: FHI 360, Nairobi, Kenya.
authors.forename: Mathews
authors.initials: M
authors.lastname: Oyango
authors.affiliation: Zimbabwe AIDS Prevention Project, Department of Community Medicine UZ, Harare, Zimbabwe.
authors.forename: Webster
authors.initials: W
authors.lastname: Mavhu
authors.affiliation: Centre for HIV/AIDS Prevention Studies, Johannesburg, South Africa, Nairobi, Kenya.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Spyrelis
authors.affiliation: Tulane 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: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
authors.forename: Margaret
authors.initials: M
authors.lastname: Farrell
authors.affiliation: United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D002944:Circumcision, Male / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data*; D017598:Efficiency, Organizational; D006801:Humans; D007630:Kenya; D008297:Male; D013019:South Africa; D013636:Tanzania; D015030:Zimbabwe