2. Adapt standards and tools
The WHO Male Circumcision Quality Assurance Guide defines 10 standards for male circumcision which have served as the basis for the development of national VMMC standards in many countries:
- An effective management system is established to oversee the provision of male circumcision services.
- A minimum package of male circumcision services is provided.
- The facility has the necessary medicines, supplies, equipment and environment for providing safe male circumcision services of good quality.
- Providers are qualified and competent.
- Clients are provided with information and education on HIV prevention and male circumcision.
- Assessments are performed to determine the condition of clients.
- Male circumcision surgical care is delivered according to evidence-based guidelines.
- Infection prevention and control measures are practiced.
- Continuity of care is provided.
- A system for monitoring and evaluation is established.
WHO also developed a Male Circumcision Services Quality Assessment Tool, with 36 verification criteria assessed through some 134 questions to measure a site’s compliance with the 10 standards. The WHO VMMC assessment tool has been the basis for the development of national VMMC assessment tools in many countries.
In Uganda, the Ministry of Health developed its own Safe Male Circumcision (SMC) Quality Standards tool, drawing on the WHO tool but adapting criteria to the context of Uganda. The MOH identified the need to adapt the WHO tool to national policies and standards. A small team led by the MOH and including USAID ASSIST and implementing partner staff reviewed the WHO tool, section by section, to harmonize it with existing national guidelines and adjust certain verification criteria to the Uganda context. Several meetings were convened by the MOH, involving service providers, MOH departments, and implementing partners, to gain feedback on the tool. The Uganda Quality Improvement Assessment Tool for SMC covers seven areas, encompassing 153 standards. The seven areas are:
- Area 1: Management Systems – 10 standards
- Area 2: Supplies, Equipment and Environment – 6 standards
- Area 3: Registration, Group Education and IEC – 4 standards
- Area 4: Individual Counseling and HIV Testing for MC Clients – 6 standards
- Area 5: Male Circumcision Surgical Procedure – 10 standards
- Area 6: Monitoring and Evaluation – 4 standards
- Area 7: Infection prevention – 11 standards
The adapted tool was piloted at five sites to verify usability and ensure that the tool when applied yielded the desired information.
When CQI activities for VMMC were initiated in South Africa in 2014, detailed national VMMC standards existed but there was not a nationally accepted CQI assessment tool. The WHO VMMC quality assessment tool and the Uganda VMMC CQI assessment tool were reviewed as examples, but an important aspect of VMMC program was deemed missing: leadership and planning. The South Africa CQI assessment tool added an eighth standard (Leadership and Planning) to address how well a VMMC site coordinated its activities with district and provincial Department of Health authorities. This adaptation was important to address a recognized weakness in how PEPFAR-funded VMMC programs had been functioning.
VMMC CQI assessment tools developed by the Ministries of Health in Tanzania and Malawi also drew on both the WHO VMMC quality assessment tool and the Uganda VMMC CQI assessment tool, as did the CQI assessment tool developed by ASSIST for use in Namibia.
Why local adaptation is needed: Local review, adaptation, and pilot testing of any assessment tool by national authorities and stakeholders is necessary to align it with national policies, ensure local ownership of the tool, and adapt it to the local VMMC program context. In Uganda, the tool adaptation process took approximately eight months to ensure that all stakeholders understood and felt comfortable with the tool. The participatory approach adopted proved useful during the later national roll-out of the tool, since all implementing partners had been involved in the initial application of the tool. In South Africa, a section was added to ensure that the CQI assessment tool addressed an area deemed important for successful VMMC program performance in the country.