VMMC Continuous Quality Improvement (CQI) Resources

Below are resources for continuous quality improvement of VMMC services:


VMMC CQI and EQA Toolkit: This toolkit was designed for voluntary medical male circumcision (VMMC) program managers, supervisors, providers, and implementing partners, to guide efforts to improve the quality of VMMC services through continuous quality improvement (CQI) and external quality assessment (EQA).  The toolkit is divided into eight sections:

  • Introduction: key quality issues in VMMC programming; how quality assurance and quality improvement approaches improve VMMC program effectiveness and efficiency, results from applying CQI in PEPFAR-supported VMMC programs.
  • Stages in VMMC CQI Roll-out: 12 discrete stages of developing and rolling out CQI in VMMC programs
  • External Quality Assessment: describes the EQA process; explains the tools used in US Government-led VMMC external quality assessments
  • Addressing Key VMMC Quality Issues: critical patient safety issues; specific resources to address them
  • Tools: tools to support CQI in VMMC programs
  • Change Ideas and Common Solutions: tested change ideas from 200+ QI teams for common problems in meeting VMMC quality standards
  • Case Studies, Articles & Reports: descriptive reports about applications of CQI to VMMC; links to peer-reviewed journal articles related to VMMC CQI and EQA
  • Multimedia: video clips, webinar recordings, and conference presentations related to VMMC CQI and EQA

Peer-reviewed publications

Improving the quality of voluntary medical male circumcision through use of the continuous quality improvement approach: A pilot in 30 PEPFAR-supported sites in Uganda: This article, published in PLoS ONE, describes the results of applying improvement methods in 30 VMMC sites supported by 10 different implementing partners across Uganda.  PEPFAR and USAID supported this work through the USAID ASSIST Project, to engage the Ministry of Health of Uganda, implementing partners, and site-level staff to identify barriers in achieving national VMMC standards, identify possible solutions to overcome the barriers, and carry out improvement plans to test these changes, while collecting performance data to objectively measure whether they had bridged gaps. 


"Medical male circumcision offers a gateway to HIV testing and medical check-ups," published in the Mail and Guardian newspaper on November 30, 2016, authored by Donna Jacobs of USAID ASSIST and Collen Bonnecwe of the South African Department of Health.


VMMC Continuous Quality Improvement Results: What’s New in Implementation, Research, and Tools?: This PEPFAR-sponsored webinar shared the latest results, research, and tools in continuous quality improvement (CQI) in PEPFAR-supported voluntary medical male circumcision (VMMC) programs. Hosted by the USAID ASSIST Project, the webinar featured five presentations from USAID, USAID ASSIST, AIDSFree, and the Health Communications Capacity Collaborative (HC3), showcasing VMMC quality improvement efforts in Mozambique, Uganda, Tanzania, South Africa, Malawi, Lesotho, Namibia, and Swaziland.  Jackie Sallet, AIDSFree Project Director (JSI), moderated the webinar.  Speakers included:  Emmanuel Njeuhmeli (USAID);  Patrick Devos (Johns Hopkins Center for Communication Programs); John Byabagambi (ASSIST/URC); Saidi Mkungume (AIDSFree/Jhpiego) and Joseph Kundy (ASSIST/URC); and Lani Marquez (ASSIST/URC).

Webinar: Rolling out continuous quality improvement in voluntary medical male circumcision: Lessons learned from the USAID ASSIST pilot projects in Uganda, South Africa, Malawi and Tanzania: Moderated by Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at USAID Office of HIV/AIDS, this webinar shared, through short presentations and panel discussions, the experiences and lessons learned from introducing continuous quality improvement (CQI) activities in support of VMMC services in USG-supported programs.

PEPFAR Webinar: Women and Voluntary Medical Male Circumcision: PEPFAR hosted a webinar in November 2014 on the importance of women's role in the success of Voluntary Male Medical Circumcision (VMMC). The webinar discussed: 1) The impact of VMMC on women, including new and established data on medical impact; 2) women's perceptions of VMMC; and 3) Women's roles in scale-up.

Guidance Products

A Guide to Improving the Quality of Safe Male Circumcision: Through its introduction of continuous quality improvement activities in the Safe Male Circumcision (SMC) program in Uganda, the ASSIST Uganda team developed a guide that draws on the recommendations and insights to advise health units on how to get started on improvement of SMC services and assess performance against the MoH quality standards.  It also gives specific ideas for changes to improve in each area covered by the standards, based on the experiences of the 30 sites. It is designed for frontline health workers offering safe male circumcision services and is intended to serve as a resource for every health unit providing SMC services in Uganda, to help improve the quality of SMC services and ensure that all patients benefit from safe and effective SMC care.

Voluntary Medical Male Circumcision In-service Communication Best Practices Guide: This reference guide, developed by the Health Communication Capacity Collaborative, outlines the minimum essential in-service communications and counseling content across the VMMC service continuum and can be used to check content of job aids and training resources.

Integrating Gender in Voluntary Medical Male Circumcision Programs to Improve Outcomes: This short report shows how it is an important opportunity to apply improvement methods, including gender integration, in the scale-up of VMMC in order to learn how to effectively implement the intervention. The USAID ASSIST Project is currently working to integrate gender in the Safe Male Circumcision Project in Uganda.


Systematic approach to improving six-week post voluntary medical male circumcision follow-up at Moroto Regional Referral Hospital in Uganda: Moroto Regional Referral Hospital located in Uganda’s Karamoja Region had been struggling to improve the post-circumcision follow-up rate beyond seven days (six weeks) for some time.  The hospital’s VMMC quality improvement team looked at the root causes and came up with various possible solutions to improve the six-week post-operative follow-up, including the idea of making phone calls to remind clients, which was adopted and facilitated by the implementing partner, SUSTAIN. Through these calls, two clients were identified with complications and managed in time when they would otherwise have been missed. This case study explains the process this team followed to test and implement strategies to increase client post-operative follow-up.

Safe male circumcision: Improving client follow-up at Gulu Regional Referral Hospital, Uganda: Gulu Regional Referral Hospital provides safe male circumcision (SMC) services as a part of its comprehensive strategy for HIV prevention. Post-operative clients are offered care on return to the facility. However, clinicians were not aware of standard follow-up guidelines for post-operative care and informed clients to return only for complications or adverse events. As a result, clients did not have information on post-operative follow-up. This case study illustrates the need for facility-based improvement in standardized documentation of client forms and registers to increase and improve post-operative client follow-up.

The role of improvement teams in managing male circumcision-related adverse events: The experience of the mobile van clinic in Uganda: This case study demonstrates the importance of quality improvement teams in identifying, investigating and dealing with moderate to severe adverse events secondary to safe male circumcision.

A Fast Turn-around for Mengo Hospital: Improving the Quality of Safe Male Circumcision Services: This case study describes how the hospital’s SMC quality improvement (QI) team took quick action to address the performance gaps with support from coaches from the Inter-religious Council of Uganda (IRCU) and the USAID ASSIST Project.

Changes tested to improve quality of Safe Male Circumcision Services in Uganda: This report describes changes tested by USAID ASSIST-supported sites to close gaps identified using the Ministry of Health safe male circumcision quality standards tool.