1. Dr. Walter Obiero Clinical Manager Nyanza Reproductive Health Society

2. Mobilization Initial Contact Repeated Contacts Transport Group Counseling 20-45 min (optional) Individual Counseling /consenting 5-20 min HIV CT (PITC) 20-60 min Pre-Surgery 3-5 min Surgery 15-45 min Follow-up 5-30 min Post Surgery 3-5 min Total Time: 76 – 215 minutes Surgery : 8% - 45% of total time Registration 5 min

3. Introduction Facility assessments done across priority districts. <10% able to provide services due to resource constraints. Currently 90% of all MCs done through mobile and outreach approaches. Achieving an optimal balance between service delivery capacity and client flow requires coordination of mobilization, fleet management, supply chain management, task-shifting, team mobility. Mobilization considerations: seasonality in client flow; client geographical distribution variation; difficulty of client booking systems; difficulty in mobilizing older clients; remuneration of mobilizers; involvement of women; dedicated clinic MC days.

4. Considerations in Outreach/Mobile Settings Availability and pre-operative preparation of clients have largest impact on number of procedures, not intra-operative time Infrastructure limitations: counselling, theatre, recovery, storage, power and incineration. HTC approaches: VCT versus PITC (increase in uptake of testing from 37% to 93.6%) Client post-op follow-up visits poor (Return rate 30% June 2010) Handling emergencies after routine working hours challenging. Infection prevention in mobile and outreach settings including operating theatre, waste disposal, water supply Data handling

5. Lessons learned / Future directions Task-shifting and task-sharing; multi-tasking; highly mobile teams; use of locum staffs during high season; staff motivation to reduce burn-out Group and individual counselling, consenting and screening on eve of surgery useful in enhancing efficiency on day of surgery. Proper planning including bundling of consumables saves time Multiple couches per clinical team reduces table turn-over time. Use of tents, classrooms, community halls. Mobile theatre trailers? Client emergency hotlines MOH community strategy for mobilization Strong MoH leadership through Taskforces/steering committees is critical for programme success.

6. General SRH session Mobile clinic set up Individual MC counseling / VCT Group MC education Surgery ongoing Mobile Services

7. Acknowledgements Ministry of Public Health and Sanitation, Kenya Ministry of Medical Services, Kenya National AIDS &STI Control Programme, Kenya National Male Circumcision Taskforce, Kenya Nyanza Male Circumcision Taskforce, Kenya Centres for Disease Control and Prevention Family Health International Impact Research & Development Organization, Kenya