Addressing quality in VMMC programming

Since 2007, the World Health Organization (WHO) and United National Programme on AIDS (UNAIDS) have recommended that voluntary medical male circumcision (VMMC) services be adopted as part of comprehensive HIV prevention in countries with a generalized epidemic. Similarly, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) cites VMMC as one of the core biomedical prevention interventions to achieve an AIDS-free generation. 

With the expansion of VMMC programs, the importance of addressing quality issues affecting patient safety and outcomes has also gained greater attention. These quality issues cut across the continuum of VMMC services, including demand creation, counseling and client communications, supply logistics, staff competency, infection prevention, surgical procedure, waste management, referral and linkages to care and treatment, client follow-up, and management of adverse events.

As part of comprehensive VMMC services, the WHO has sought to address quality through the development of detailed service standards and assuring the competence of VMMC service providers through training and supervision.  WHO’s Male Circumcision Quality Assurance Guide, published in 2008, outlined steps for improving VMMC quality by assessing compliance with 10 male circumcision standards and encouraging the development of site-level improvement teams to implement interventions to improve quality.

PEPFAR has also recommended both internal and external quality assurance activities as part of its best practices for site operations, including continuous quality improvement activities, internal supervision, periodic external supervision, and external quality assessment. Initially, PEPFAR emphasized quality assurance approaches such as external quality assessment (EQA) and input-driven measures such as training and provision of guideline as its major quality strategies for VMMC.

And yet, even with competency-based training of health care providers and evidence-based standards and guidelines, VMMC services, like other health services, often fail to meet standards in practice.  This situation is largely because standards and training alone simply address the inputs to health care, without necessarily leading to quality in the processes of care delivery.  Experience over the past 20 years with health care quality improvement has demonstrated that addressing only inputs (e.g., standards, training) without attention to service delivery processes has not yielded strong results.  Another way to think about improving quality of care is that assessments identify gaps but do not necessarily provide a strong mechanism for addressing the gaps—other actions are needed that go beyond assessments.

For this reason, PEPFAR has turned to continuous quality improvement or CQI to provide a strong engine for improving the quality of VMMC services. CQI is the combined and ongoing efforts of stakeholders in the health system to make changes that lead to better patient outcomes and better system performance.  Health system stakeholders include health care providers, site managers, patients, civil society organizations, and implementing partners. CQI is led by teams of health workers who are empowered to use tools such as process analysis and self-assessment against standards to define priorities for improvement based on gaps identified, develop and test changes to close gaps, and monitor results using pre-defined quality indicators.

The next section of the VMMC CQI toolkit examines the differences between quality assurance (QA) and quality improvement (QI) approaches and discusses how both have an important role to play in assuring high-quality performance in VMMC programs.