1. Implications of the fast-evolving scale-up of adult Voluntary Medical Male Circumcision for quality of services in South Africa D Rech, S Frade, A Spyrelis, L Perry, M Farrell, R Fertziger, D Castor, E Njeuhmeli, C Toledo, JT Bertrand Presented by Dr. Dino Rech

2. SYMMACS South Africa SYstematic Monitoring of the voluntary Medical Male Circumcision Scale-up in Eastern and Southern Africa Objective: Assess implementation of VMMC under actual field conditions in four countries, including South Africa. Monitor adoption of WHO six elements of efficiency. Assess quality and safety during scale-up. Methods: Data were collected using three instruments during clinicians 2-day visits to sites:  Abbreviated version of the WHO Quality Assessment of facilities (WHO, 2009)  Observation and timing of VMMC procedures  Interviews with providers and site managers Sample:  Any site operational in 2011: N = 15  Sample from more than 80 operational sites in 2012: n = 40  Same 15 sites sampled in 2011 and 2012 (repeat sites); 25 new sites in 2012, with a total of 40 sites (expanded sites) *Significant differences refer to p values < 0.05 2

3. Results: Table 1. Quality assessment of VMMC sites Item observed: 2011: n=15 sites 2012a: n=15 sites (same site) 2012b: n=40 sites (expanded sites) Satisfactory % 20112012a2012b Existence of functioning information system (manual/computerized) * 60.010097.5 Monitoring system in place for adverse events ^ 60.026.722.5 Report of supervisory visits in past 6 months ^ 60.040.017.5 External monitoring of adverse events in past 6 months ^ 40.06.72.5 Clinical personnel conduct a basic preoperative assessment * 51.220.312.3 Demonstrate ‘safety first approach’ to ensure no part of the penis besides the foreskin is in danger of being injured 97.597.397.2 Mean QA score across all parameters ^ 1.681.511.36 3 * Difference is statistically significant in both comparisons ^ Difference is statistically significant in expanded sites only

4. Results Challenges  Drop in ‘readiness to provide services’ in expanded (not repeat sites) ie. supplies, equipment, systems etc. –Likely due to the rapid scale-up and the large number of new sites  Drop in ‘quality of surgical services’ in expanded and repeat sites ie. pre- & post-operative procedures –Likely due to ‘dilution’ of skilled staff across new sites & employment of new and inexperienced staff Successes  Actual surgical technique scored the highest  Almost universal adoption of 3 efficiency elements Recommendations 1.Independent team to monitor program quality and reporting of AE’s 2.Improve supply chain systems 4