In this case study, a coalition between a private hospital and public organization formed a dual implementation partnership (PPP) that successfully carried out SMC at a rate of 111 per day with an adverse events rate of 2.1% at a single urban site in the heart of the city of Kampala. This AE rate is comparable to experiences elsewhere [12
]. This PPP model is one of the ways resources may be distributed in the country in order to realize the enormous task of mass SMC that lies ahead of Uganda and the 12 other sub Saharan African countries. This approach may be scaled up in a number of ways by increasing sites with a different geographical and location by increasing the output at this urban site. Embracing Public Private Partnerships and collaboration (PPP & PPC) in the Health sector is important in light of the challenges the public sector faces in health care, finance, management and provision.
Turning to the private sector can, when appropriately structured and executed, help address specific cost and investigative challenges, deliver improvements in efficiency (e.g. improved service provision and management at reduced costs) and enhance service quality (e.g. increased expertise, more rapid and substantial investments in infrastructure, a potential to attract and retail better performing staff [13
Leveraging partnerships to address public sector challenges may not be easy; these may take long to establish and make functional. In this case study of IDI/IHK, the establishment took four months of back and forth discussions but after that the implementation was immediate. The establishment was based on a contract that outlined common objectives, risks and rewards. The Private provider in this case was responsible for all the project operations at its site. It was a service contract for a defined service quality and efficiency was catered for through output and adverse events monitoring.
The perceived benefits of PPPs include: reduced spending, greater efficiency, leveraging expertise, performance based monitoring and incentives, technology transfer and reduced/better allocation of risk. IDI did not need to train IHK staff, IHK trained them, though technical support by way of providing reporting formats and data collection tools was provided. PPP arrangements are not without risks; the perceived risks included: creation of excess capacity and new capacity in the wrong place. There is indeed a risk of excess capacity in case uptake reduces or contracts terminate. However, with SMC this is unlikely to happen soon given the large national targets existing. In addition this trained workforce at IHK is employable wherever they may wish to go. IHK a leading health care provider had a proven track record of service delivery of high quality and had the public visibility and acceptance.
For implementers the choice of which private provider to chose may depend on the specific need and context. Financial stability of the potential partner, proven track record, expertise in the field and monitoring and evaluation capabilities are factors that should be considered. Shared values of work ethic, mutual trust and integrity also play a part.
Operating time and preferred technique
Even though the overall mean operating time was 32 minutes while using the more technically challenging sleeve resection method and using ligatures for achieving haemostasis. With more practice (experience), the time reduced to less than 30 minutes as demonstrated in . Apart from a few individuals nearly all operators were doing circumcision for the first time. Introduction of diathermy cauterization may further reduce this operating time which may be critical for improving work rate, though this needs to be scientifically investigated. The average work rate was 14 clients SMCs per bed. However this started as 7 clients and rose up to 23 over the weeks. A consistent 15 - 18 SMCs per table was realized in the last half of the period. This level of output was realized with more practice. The operating time dropped over the course of time from an average of 55 minutes to 29 minutes.
Number of patients and mean operating time for safe male circumcision at International Hospital Kampala, Kampala, 2012
The fastest sleeve resection operator did so in 14 minutes. Most operators rejected the forceps guided method for two reasons: first there was more bleeding and hence taking up more time for meticulous haemostasis (and more use of suture materials, two pieces of vircyl rapide would be used in this situation - at a cost of $ 5 a piece) and secondly the forceps guided method seemed to leave behind excess mucosal cuff, which looked less cosmetically pleasing.
We are not sure what the impact of excess mucosal cuff could be in terms of HIV transmission after circumcision nor do we know how much “cuff” is safe to leave behind. It is reasonable to hypothesize that the more cuff left behind, the more HIV target cells are left and therefore more risk of HIV transmission [14
Adverse events and penile anomalies
With all methods of male circumcision, we expected adverse events to occur. What is important is that these were few mild and completely reversible with minimal or no intervention. We recorded a 2.1% adverse events rate which is comparable to experiences else where. All events were mild and reversible, the majority occurring within 24 - 48 of the operation.
A hotline was available to all clients. Those that came back to the facility found a nurse waiting for them. Some only required a change of dressing, others release of stitches and others haemostasis. A number called back to complain of multiple and frequent uncomfortable erections; this could be due to initial hypersensitivity of the “naked” glans. This complaint faded away with the passage of time (4-6 weeks). Balaritis Xerotica Obliterans (BXO) [16
] is a chronic sclerotic dermatitis involving the genital skin of men. Clinically patients with balanitis xerotica obliterans develop discrete, angular, white atrophic macules and patches on the glans, prepuce and foreskin of the penis with only rare involvement of the shaft. The prepuce is often thickened with fissures, erosions appear over the glans. Phimosis is a known sequel and there were two patients. BXO causes are unknown; however autoimmune and genetic factors are implicated. Even though BXO is confirmed by histologic evaluation in these cases the clinical picture was classic. Xeroderma Balanitis rate was 0.2% higher than that recorded in the literature [16
]. Tight phimosis with failure to retract the foreskin was found in 0.5%. There was no incidence of un-descended testis. Penile Peyronie's disease is a tissue disorder which affects 1-4% of men [18
], in this case study, 2 patients were identified who had curved penises with visible scars at the mid shaft with no history of trauma.
Participants, VCT and HIV prevalence
Participants were young men mostly in their early twenties. The HIV prevalence was 0.2%, much lower than the 7% for Kampala residents. This could have been because of the age bracket, young single men and mostly in school, though there could be other reasons that may need investigating. This presents as a window of opportunity for HIV prevention among this age group cohort in the communities they came from.
Mobilization for mass SMC is a crucial ingredient for success. Mobilization was done through word of mouth, SMS, radio and Facebook. The majority of clients who turned up indicated that they were encouraged by a friend who had already undergone SMC. A satisfied client brought in the next client. And therefore the need to focus on the SMC client's experience was important. Improving the client's experience may be achieved by making local anaesthesia (LA) infiltrations painless by using a small gauge needle (G25-6), by providing sufficient information and handling clients with courtesy and dignity during and after the procedure. In addition a hotline was available 24/7; (overnight cover) to attend to any on site post operative review by a physician was possible if and when needed.
Lessons and gaps
It was possible to task shift the entire circumcision process to a pair of non physician cadre mostly clinical officers and graduate nurses. However this was preceded by a 6 week long training course spread over several weekends. Supervision, mentoring and coaching were sustained during the follow up period. The more challenging freehand sleeve resection method was mostly used with an average operating time of 32 minutes (without diathermy). Task shifting is possible and it worked. The general sense of employing non-physicians was one of empowerment and a great sense of job satisfaction. The appreciation of the responsibility of being in charge of an entire procedure of SMC was welcome.
The demand for SMC was prevalent in this urban setting site. In order to fulfill the demands for scale up aggressive mobilization needs to be done. This involves consideration of the convenience of the clients for example the time of week when SMC services are available for this urban population.
Scale up will impact and will require more operators, therefore more training. The absolute number of AE will increase implying more resources for AE management. More counselors shall be needed. The scale up will mean a need to procure large quantities of supplies for use as well as prepare the sites to accommodate large numbers of men e.g. (toilet facilities).
Central and bulk procurement for all consumables by implementation partners (IPs) is important to reduce cost and ensure availability of goods. Goods for use e.g. reusable kits may be centrally sterilized and distributed according to need. Exploration and adoption of surgical devices such as Prepex or Shang ring are recommended.