A Guide to Improving the Quality of Safe Male Circumcision

In 2013, the USAID ASSIST Project was asked by PEPFAR to provide technical assistance to introduce continuous quality improvement activities in the Safe Male Circumcision (SMC) program in Uganda, assisting initially 30 sites—three supported by each of 10 PEPFAR-funded implementing partners supporting SMC.  Over the course of 18 months, the 30 sites succeeded in making large improvements in the quality of SMC services, measured by a self-assessment tool developed by the Ministry of Health (MoH) with PEPFAR support that measures how well care and procedures in the unit meet 53 SMC standards established by the MoH.

In June 2014, USAID ASSIST and the Ministry of Health convened a three-day harvest meeting to systematically gather and document lessons from improving SMC services.  Over the course of the meeting, teams were able to identify changes that led to improvement and those that did not lead to improvement based on the site-specific results achieved. In addition to discussing the changes, the teams shared experiences on how to initiate CQI in SMC at the health unit level.

Client in Uganda receiving individual counseling prior to VMMC procedure

This guide draws on the recommendations and insights from the harvest meeting 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.

The guide is structured into four main sections:

  1. Section 2: How to get started with SMC improvement work, including forming the team, obtaining necessary clinical training, conducting the baseline assessment, and identifying and prioritising gaps for improvement work.
  2. Section 3: Addressing quality gaps in meeting SMC service standards as the first step to better care
    1. Improving management systems
    2. Improving supplies, equipment, and the work environment
    3. Improving registration, group education, and information, education, and communication (IEC)
    4. Improving counselling and HIV testing
    5. Improving male circumcision surgical procedure
    6. Improving monitoring and evaluation
    7. Improving infection prevention
  3. Section 4: Focus on process improvement: Improving follow-up of SMC clients beyond 7 days after circumcision and reducing rates of moderate to severe adverse events.
  4. Section 5: Gender integration in SMC improvement work: Involving female partners in SMC.

Appendices to the guide include the MoH assessment tool, short case studies of how individual sites made improvements in SMC services, and other tools that can help new facilities get starting on SMC improvement work.

Report Author(s): 
John Byabagambi | Angella Kigonya | Anna Lawino | Jude Thaddeus Ssensamba | Albert Twinomugisha | Esther Karamagi-Nkolo | Humphrey Megere | Pamela Marks | Barbara Nanteza | Alex Opio
Ministry of Health and USAID Applying Science to Strengthen and Improve Systems Project/URC
ASSIST publication: 
ASSIST publication
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