1. Authors: James Nkale, Susan Wandera, Florence Anobe, Stephen Oboth, James Kayizzi Health systems strengthening; an effective approach to scaling up voluntary medical male circumcision in six districts in central Uganda

2. Background In Uganda, where HIV prevalence is 7.3% Voluntary medical male circumcision (VMMC) is a proven biomedical intervention with up to 60% efficacy Circumcision coverage about 26%. A five year target of providing medical circumcision to four million men (2010-2015).

3. The VMMC package Medical officers, Clinical officers, Nurses Clinicians Nurses, Labtechs Counselors Medical officers, Clinical officers, Nurses Nurse counsellors Lab techs HCT BCC STI treatment, Circumcision procedure, Follow up Reproductive health services

4. The issue Health systems capacity to handle the task is a main constraint Infrastructure, HR, supplies, HMIS).

5. Project scope A five year project for Scaling up HIV/AIDS Prevention (SCHAP) in six districts in the central region of Uganda; Wakiso, Luwero, Nakasongola, Nakaseke, Mityana, and Mubende. Health system strengthening model used to respond to the challenge

6. Scope, population RegionDistrict Uncircumcised 15+ Uncircumcised HIV– 15+ CentralWakiso267436243367 CentralMubende110926100942 CentralMityana5757252391 CentralLuwero7673869832 CentralNakaseke35,15032,023 CentralNakasongola2871226,127 Total/Male Population 576534524682

7. Health facility levels Level of facility CharacteristicsGaps HC IITarget population: 20,000 Geo. Coverage: Parish Maternity, OPD Skilled staff: 10 Infrastructure Human resource Skills Demand creation HC IIITarget population: 50,000 Geo coverage: Sub county Mat., OPD, Ward, Lab Skilled staff: 16 Infrastructure Human resource Skills Demand creation HC IVTarget Pop. : 100,000 Geo. Service: County Mat., OPD, Wards, theater, Lab VMMC Skills Demand creation

8. Process Collaborative approach of implementation MOH/ District health teams (DHO, DHE, DNO, HIV focal person) Community systems (womens groups, VHT, developmental groups etc.) Other health stake holders (CBOs, FBOs, other NGOs with complementary roles.

9. Infrastructure Minor refurbishments (paint, window replacement, plambing) Partitioning/ temporary shelters Equipment (surgical bed, trolleys)

10. Human resource Identified and oriented six district focal persons Hands on training for 169 health workers in surgical skills (Surgery, assisting and counseling) Trained 499 peer educators, 366 VHTs Oriented 18 health information/ records officers Supported district to fill up HR gaps

11. A hands on training session

12. Service delivery Provided supplies and facilitation Static clinics held at HC IV and III. Outreaches held at health center II Camps organised by combined teams at under served populations Schedules developed by facility incharge. Support supervision done with DHT

13. Key outcomes Collaborative service delivery/ supervision Phased reduction of sites demonstrate sustainable service delivery Improved M&E, capture into HMIS New innovations for mobilisation and waste management A total of 227721 circumcisions done

14. VMMC outputs District Uncircumcised Men 15+ Circumcised in 4years by Project Wakiso243367 105625 Mubende100942 43811 Mityana52391 22739 Luwero69832 30308 Nakaseke32,023 13898 Nakasongola26,127 11340 Total 524682227721

15. Challenges Competing priorities Staff transfers Need intense supervision to ensure quality Availability of utilities (water and electricity) Referral mechanisms

16. Lessons learned The approach increased coverage Enhances multiple partner involvement Enables sustainability Involvement of DHT supports supervision Men are able to support their families to utilize other health services.

17. THANK YOU