Task Shifting Works: Doctors, Clinical Officers and Nurses Perform Equally Well in Voluntary Medical Male Circumcision (VMMC) Service Delivery in Iringa and Njombe Regions, Tanzaniaby: Augustino Hellar1, Dorica Boyee1, Marya Plotkin1, Tigistu Adamu Ashengo2, Hally Mahler1, KellyCurran2, Abadallah Maganga1, Ramadhani Mbagani1, Saidi Mkungume1, Michael Machaku1, Sifuni Koshuma3 and Flora Hezwa1 affiliate: 1Jhpiego/Tanzania; 2Jhpiego/USA; 3Iringa Regional Hospital

BackgroundnTanzania Ministry of Health and Social Welfare initiated

VMMC using the WHO package in Sept 2009:

n First VMMC services offered in Iringa region

n Subsequent health provider trainings from 2010–2012 as services were rolled out in Iringa and Njombe regions

nVMMC training is followed by start-up support in high-volume settings where providers quickly gain skills; quality assurance and mentorship as needed

nOverall, in Iringa and Njombe, 141 surgeons trained (63% nurses); 47 counselors trained (all of them nurses)

Ensuring Proficiency in VMMC

TANZANIANS AND AMERICANSIN PARTNERSHIP TO FIGHT HIV/AIDS

VMMC PROVIDER TRAINING- Competency-based- Focus on knowledge, skills and attitudes- Adult learning principles- Humanistic training approach

START-UP SUPPORT IN RESPECTIVE SITES

- Trainer/supervisor (proficient in VMMC) supports start-up of services

- Helps to set pace with providers in their own sites while observing adherence to standards

HIGH-VOLUME VMMC ACTIVITY- Provider gains skills quickly from competency toward proficiency

- Mix of providers with various levels of skills

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Adapted from: PEPFAR’s Best Practices for Voluntary Medical Male Circumcision Site Operations, March 2013.

HIV and Male Circumcision Prevalence by Region (2011–12 THMIS)nIringa and Njombe regions are among the highest HIV prevalence and lowest circumcision prevalence regions in the country.

Mwanza 4.2%

Tabora 5.1%

Singida3.3%

Shinyanga 7.4%

Mara4.5%

Arusha 3.2%

Manyara1.5%

Kilimanjaro3.8%

Dodoma2.9%

Morogoro3.8%

Pemba0.3%

Unguja1.2%

DSM6.9%

Tanga2.4%

Pwani5.9%

Lindi 2.9%

Ruvuma7.0%

Iringa9.1%

Mbeya9.0%

Rukwa6.2%

Kigoma3.4%

Mtwara 4.1%

Kagera4.8%

Njombe14.8%

Katavi5.9%

Simiyu3.6%

Mwanza 64%

Tabora56%

Singida88%

Shinyanga 32%

Mara88%

Arusha 3.2%

Manyara1.5%

Kilimanjaro97%

Dodoma95%

Morogoro88%

Pemba>99%

Unguja>99%

DSM99%

Tanga99%

Pwani99%

Lindi 99%

Ruvuma78%

Mbeya38%

Kigoma77%

Mtwara >99%

Kagera4.8%

Njombe49%

Simiyu30%

Katavi44%

Rukwa28%

Iringa60%

HIV Prevalance by RegionPercenage of women and men, age 15–49, who are HIV-positive

Male Circumcision by RegionPercentage of women and men, age 15–49 who are circumcised

Tanzania 5.1% Tanzania 72%

Note: The MC prevalence in Iringa was 37% in 2009 when the program started and Iringa and Njombe were one region, but rose to 60% in Iringa and 49% in Njombe in the latest THMIS report (2011/12).

Special Features of VMMC ProgramnScale: Number of VMMCs performed September 2009–

April 2013 was 129,252 (49% of the regional target).

nSafety: The overall Adverse Event rate was 0.15%, which is low and comparable to other settings that use only doctors.

nTask shifting: Over half of the circumcisions performed were performed by nurses.

Humanistic Approach to Training

Nurses Performing Surgery

(Use of Anatomic Models before Clinical Exposure)

VMMCs (September 2009–April 2013)

74,154

55,098

129,252

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Iringa Region Njombe Region Total

Cumulative target for Iringa and Njombe regions is 264,000 VMMCs by 2016.

High-Volume VMMC Services during the Campaign

MethodsnProspective data on provider performance using a WHO

standardized checklist were collected in the September–October 2012 period during a high-volume outreach event.

nEvery provider was assessed once (with one client).

nTwo experienced trainers conducted the assessment.

nThe sample was a census of all providers who participated in outreach activities in Iringa and Njombe facilities from September–October 2012 (n=53).

nProcedure time was measured from the first cut to the last stitch.

nANOVA was used to test for statistical significance in the observed mean differences.

Mean Performance by CadreCADRE SCORE TIME OF

PROCEDURE (minutes)

Nurse 87% 16.34Clinical Officer 86% 16.36Doctor 88% 15.90

The difference in performance score by cadre was not statistically significant, p=0.73.

Performance by Duration since Training DURATION SCORE TIME OF

PROCEDURE (minutes)

Less than 1 year 82% 18.201–2 years 87% 16.36More than 2 years 89% 16.29

The difference in performance score by duration since training was not statistically significant, p=0.71

Nurse60%

Clinical Officer

21%

Doctor19%

Chart Title

60% of the providers in this analysis were nurses. Overall, more than two-thirds of the providers trained in MCHIP’s VMMC program in Tanzania are nurses.

ResultsnCadre: 19% doctors, 21% clinical officers, 60% nurses

nMean duration since training: 20.5 months; median 17 months; range 6–36 months

nMean performance score: 87% (range 70–100%)

nMean procedure time: 16 minutes (range 13–21 minutes)

VMMC Providers in Analysis (n=53)

Mean Duration since Training by CadreDURATION CADRE TOTAL

DOCTOR CLINICAL OFFICER

NURSE

Less than 1 year 2 (20.0%) 2 (18.1%) 1 (3.1%) 5 (11.6%)

1–2 years 6 (60.0%) 5 (45.5%) 17 (53.1%) 28 (65%)

More than 2 years 2 (20.0%) 4 (36.4%) 14 (43.8%) 20 (46.5%)

TOTAL 10 (100%) 11 (100%) 32 (100%) 53 (100%)

Although the majority of the nurses who participated in this out-reach had more than one year of experience since training, there is no evidence for statistical significance on the differences in duration since training by cadres; p value=0.4.

ConclusionnProviders showed a high level of compliance with a

standardized checklist, a proxy indicator for competency/proficiency.

nTask shifting remains a dominant feature of the program, with nurses performing all surgical tasks to a high level of competency.

nHowever, performance did not differ statistically by cadre or by duration since training.

nNurses performed at a similar level to both doctors and clinical officers.

nContinuous mentorship and supportive supervision are critical to support this level of adherence to standards.

This poster was fusnded by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development’s (USAID’s) Maternal and Child Health Integrated Program (MCHIP), under Cooperative Agreement #GHS-A-00-08-00002-000. The opinions herein are those of the authors and do not necessarily reflect the views of USAID.