The Anatomy of Success How the Tanzanian Voluntary Medical Male Circumcision (VMMC) Program Became One of the Most Efficient in the Region

Transcription

1 The Anatomy of Success How the Tanzanian Voluntary Medical Male Circumcision (VMMC) Program Became One of the Most Efficient in the Region Hally Mahler, MCHIP/Jhpiego/Tanzania Presented at OGAC, 6 July 2011

2 Mafinga District Hospital 20 June 2010 First Day of Campaign

3 Correlation of Male Circumcision Rates and HIV Prevalence among Men in Tanzania 3

4 Major MC Milestones in Tanzania National MC TWG Formed Study on Traditional Circumcision conducted WHO/UNAIDS/Jhpiego Training Materials Adapted for TZ MC demonstration sites launched National Situation Assessment Conducted MOVE Introduced First outreach activities conducted Scale up in priority regions First MC campaign Cost study underway conducted Official Launch of National National MC Strategy and Strategy (July) Implementation Plan Finalized Campaigns/outreach Expansion of regions/sites in all priority regions

5 Some Background About the Tanzania Program National target: 2.8 million circumcisions Target age: 10 to 34 year-olds Eight priority regions spilt between USG agencies/partners Task shifting and sharing fully backed GOT directive that the program should be within the public sector hub with spokes

6 Background MCHIP/Jhpiego in Tanzania Program objectives To scale up safe, quality VMMC in Iringa region To initiate safe, quality VMMC in Tabora region To provide technical, training, and programmatic support to other MC partners (as requested) and the GOT Program timeline Activities began April 2009 First service launched October 2009 No specific end-date (other than MCHIP project end)

7 Background Funding for the program to date Funding Obligated Expenditure Estimated Accruals Pipeline 3,675,026 2,739,833 1,084,951 (149,758) Expected COP 11 Funding: $2.4 Million

8 Important Numbers From October 2009 to March 31, ,134 adult circumcisions performed* % of clients tested for HIV as part of services % AE rate (190/195 were mild or moderate) % post-op follow up at 48 hours % post-op follow up at 7 days 338 MC providers trained (nationally) Total Circumcisions 48hrs follow up 7days follow up 195 AE

9 More Interesting Statistics Age Breakdown Age at Circumcision Under and Over Service Delivery Mode Type of Service Static Campaign 30% 25% 70% 75% Data to December 31, 2010 prior to initiation of outreach activities. 9

10 25,000 th Client in Iringa (May) 25,000 th Client at His Clothing Stand in Makambako Market One Week Post-Op

11 Service Delivery in Iringa From pilot to scale in a year 11 static sites established 2 MC campaigns held in Iringa (June/July 2010, Nov/Dec 2010) Now use mix of static, monthly outreach and campaign to maximize service mix May 2011 at Makambako Health Centre

12 Tanzania s First MC Campaign Planned for Iringa region in three districts in June 21- July 31 in 5 facilities mix of hospitals and health centres, public, FBO and private Set target of 6,000 adolescents and men to be circumcised Decided to use MOVE efficiencies and match them with TZ-developed demand efficiencies

13 What Are MOVE Efficiencies? Surgical technique: Forceps-guided Dorsal slit Sleeve resection Haemostatis: Electrocautery Ligating sutures Task shifting: Clinical officers or nurses perform MC Task sharing: Surgeon performs most complex aspects of operation, others the rest Allocation of more than 1 surgical bay per surgeon Bundling of tools: Prepacking of supplies, tools

14 Limitations in MOVE Primarily surgical techniques Supply driven help you to serve more clients more efficiently Don t speak to the demand side or management of the large number of clients you can serve

15 Challenge: How to Create and Manage Demand to Meet Supply? Set a target of 6,000 circumcisions 33 circs per facility per day Worried about controlling demand to have ways to adjust for more or less than we anticipated To manage the demand side the Iringa team developed a set of (nonsurgical) demand-oriented efficiencies

16 (1) Ensure Adequate Client Demand via Existing Local Structures, NGOs in the Field, Supplemented with BCC Demand creation committees formed in each district Other USG partners restructured activities to support MC Print, radio, loud speakers Men Women Youth & Guardians

17 (2) Decongest Service Delivery Sites Prepare/followup clients in their communities (education, counseling, preop exams, follow up exams)

18 (3) Overcome the Counseling and Pre-Op Exam Bottleneck

19 (4) Advance Schedule Clients Helped us to more easily anticipate and match supplies (commodities, providers) with demand

20 (5) Effectively Manage HR Recognized extreme conditions of campaign situation Provided tea, lunch, transport to sites, overtime pay Paid attention to motivation/interpersonal relationships

21 (7) Collect and Manage Real-Time Data With sites spread across a large geographic area, needed to know how many clients vs. circs to manage supply and demand Developed webenabled database, hired clerks, placed them at each site

22 Result: 10,352 Circumcisions

23 SMS Program Added November 2010 TOHARA For general info WAPI To find out where BAADA Triggers series of post-operative messages After analysis of Nov/Dec campaign statistically significant association between WAPI and BAADA 23

24 Formative Assessment of Adult MC Opinions/Preferences 18 FGDs and participatory exercises 3 districts of Iringa region Disaggregated by age/sex (all age 18 or above)

25 Selection of Key Findings (1) Strong bias for MC to happen before or during puberty. Stigma associated with having it done older especially after a man s first child has been born. Misinformation about postsurgical erections causing permanent damage. Older men find it unacceptable to queue with younger men. Older men want separate services (day or rooms). Tremendous loss of face to expose genitals in room with younger boys. Clients at Kibena Hospital June 2011

26 Selection of Key Findings (2) Female providers are a moderate-level barrier, especially for men in their 20s who fear having an erection during service provision. Seasonality is even more important than anticipated. Older men wouldn t even consider being circumcised outside of the cold season. Makambako Health Centre July 2011

27 Campaign June/July/August 2011 Target: 20,000 circs All eight districts of Iringa 24 facilities Eight weeks 27

28 MC Campaign in Iringa 2 weeks, 2 days (of 8 weeks) Facility /Date Cumulative Kibena DH Makambako HC Ilembula DDH Makete DH Ludewa H Bulongwa H Matamba HC Lugalawa H Manda HC Total Half Days on Saturdays

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31 The Demand Creation Team for 2011 Campaign 31

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34 Number of Circumcisions, By Site, June 20 to July 3, 2011 Site MC done Kibena Town Hospital 1095 Makambako Health Centre 941 Ludewa District Hospital 798 Ilembula Mission Hospital 953 Manda Health Centre 512 Makete District Hospital 868 Bulongwa Hospital 433 Matamba Health Centre 200 Lugalawa Hospital 513 Grand Total 6313 Now averaging around 700 circumcisions per day in nine sites

35 Number of Circumcisions, By Site, Weeks One and Two Manda HC Lugalawa H Matamba HC Bulongwa H Ludewa H Makete DH Ilembula DDH Makambako HC Kibena DH Second week First week Number of Circumcisions

36 Age at Circumcision July Under to to to to and Above 63

37 Age at Circumcision July and Above 25 to 34 Under to to to 19 Nearly 60% of clients are currently aged 15 and above. We expect younger clients earlier in campaign, especially since these are first-time sites

38 HIV Testing Age Negative < 10 7 Not Tested Positive 10-14, Grand Total A few interesting points: Higher percentage of year-olds testing HIV+ than year olds. 22% of 35+ are HIVpositive

39 First Follow-Up Visit Total Circumcised 5173 First Follow-Up 82% first follow up return rate

40 Adverse Events by Site and Severity MC Site Moderate Severe Total Lugalawa Hospital Bulongwa Hospital 1 1 Ilembula Mission Hospital 2 2 Kibena Town Hospital 3 3 Ludewa District Hospital Makambako Health Centre 3 3 Makete District Hospital Manda Health Centre Matamba Health Centre Total

41 Adverse Events, By Type Type of AE Type of AE # of AEs % of AEs Bleeding or blood soiling of the BANDAGE Infection Swelling of the penis or scrotum Persistent pain No AE Grand Total Of 6313 MC performed AE rate is currently 0.26%

42 What Makes Iringa Work? (1) Strong and committed regional and district authorities Invested political capital Made more than 200 providers and 24 facilities available Invested in task shifting/sharing Created district-level demand creation committees Strong demand for VMMC services by adolescent and adult males particularly during the cold season and school holidays Makembako Health Centre July 2011

43 What Makes Iringa Work? (2) Regional and District Officials Inspect Kibena Hospital June 2011 Little to no opposition in the community to the introduction of VMMC into this traditionally non-circumcising region. The ability to carefully match supply and demand (due to one organization being responsible for both elements) Partnership of other USG prevention orgs, including HTCs General enthusiasm for the intervention among health providers, regional and district officials, and the population of the region

44 What Are Iringa s Challenges? Attracting and serving adult men (particularly those over the age of 24) Procuring adequate equipment and commodities for scaled up services in Tanzania Electricity Lack of funding adequate to achieve the 80% coverage target

45 Opportunities and Way Forward (1) Take advantage of tremendous energy/commitment in Iringa to achieve 80% circumcision level Try out new service delivery models that will attract more adult male clients Adult-only days/facilities Male providers Look at more ways to engage female partners of potential clients

46 Opportunities and Way Forward (2) Introduce early infant male circumcision (EIMC) in Iringa Regional Hospital as pilot and then to scale Continue to document/share experiences/look for opportunities for study Assist the GOT in development of national trainers, roll-out of additional regions Work with GOT to finalize national documents and strategies 46

47 Thank You