A Mapping of Medical Male Circumcision Services in Uganda

Transcription

1 A Mapping of Medical Male Circumcision Services in Uganda Results of a Nationwide Survey June 2009 Ministry of Heath Health Communication Partnership Uganda Report prepared by Nazarius Mbona Tumwesigye, PhD

2 ACKNOWLEDGEMENT This report presents findings from a survey of health facilities conducted on behalf of the Ministry of Health by Johns Hopkins Centre for Communications Programs, Health Communication Partnership (HCP) in collaboration with Makerere University School of Public Health (MUSPH). Financial assistance was provided by the United States Agency for International Development (USAID) and the President s Emergency Plan for AIDS Relief (PEPFAR). We are grateful to the consultant Dr. Nazarius Mbona Tumwesigye who conducted the study and prepared the report. Special gratitude goes to Dr. Alex Opio, Assistant Commissioner for Diseases Control, Ministry of Health and Dr. Freddie Ssengooba of Makerere University School of Public Health for their technical input in implementation of the study; and all District Health Officers, Medical Superintendents, and Officers in charge of Health Centers who provided the information we needed. The consultant s assignment was supervised and report reviewed by HCP staff namely, Cheryl Lettenmaier, Robert Kalyebara, Venansio Ahabwe, and Emmanuel Kayongo. Additional information about the study may be obtained from Health Communication Partnership (HCP), Uganda; The Johns Hopkins University Bloomberg School of Public Health, Centre for Communication Programs; Plot 77 Luthuli Avenue; P.O. Box 3495 Kampala, Uganda. Phone: / / ; cheryll@hcpuganda.org ii

3 List of acronyms Acronym ACP AIDS DHO HC HCP HSD HIV IN-CHARGE JHU LC MMC PFP PNFP STD Description AIDS Control Program Acquired-Immuno Deficiency Syndrome District Health Officer Health centre. This is in levels of II, III and IV for Parish, Sub county and Health Sub-district Health Communication Partnership Health Sub-District Human-Immuno Deficiency Virus A health personnel in charge of a health centre. This applies only for health centre levels II to IV Johns Hopkins University Local Council- This is in Levels I, II, V for Village, parish, sub-county and District respectively Medical male circumcision Private For Profit. This refers to commercial health facilities Private-Not-For Profit. This refers mostly to NGO health facilities Sexually Transmitted Infections iii

4 Table of Contents ACKNOWLEDGEMENT...ii List of acronyms...iii Table of Contents... iv List of Tables... v List of figures... v EXECUTIVE SUMMARY... vi 1.0 INTRODUCTION Background Objective Scope of the study METHODS AND MATERIALS Design, study units and respondents Method of data collection and key variables Training research assistants Data management and analysis Limitations for the study Quality assurance Ethical consideration RESULTS AND DISCUSSION Respondents and description of the facilities Respondents Description of the facilities contacted Location of facilities that offer MMC services Facilities that offer circumcision services Cadre of personnel that circumcise Utilization of Circumcision services Reasons for unavailability of MMC and Challenges of providing the services CHALLENGES AND LESSONS LEARNT FROM THE TELEPHONE INTERVIEWS Challenges Lessons learnt SUMMARY, CONCLUSIONS AND RECOMMENDATIONS Summary Conclusions Recommendations REFERENCES ANNEX A: NUMBER OF HC IVs, HOSPITALS AND LARGE PRIVATE CLINICS THAT OFFER CIRCUMCISION SERVICES BY DISTRICT ANNEX B: HEALTH FACILITIES AT THE LEVEL OF HEALTH CENTRE IV OR HOSPITAL: LOCATION AND AVAILABILITY OF MMC SERVICES ANNEX C: SCOPE OF WORK AND EXPECTED OUTPUTS ANNEX D: A SHORT ENQUIRY TARGETING DISTRICT HEALTH OFFICERS ANNEX E: QUESTIONNAIRE FOR THE MMC MAPPING STUDY ANNEX F: RESEARCH ASSISTANTS AND DATA ENTRANTS iv

5 List of Tables Table 3. 1: Distance from the nearest town... 7 Table 3. 2: Level of facility by ownership... 8 Table 3. 3: Distribution of health facilities that offer MMC by region, level and ownership Table 3. 4: Distance of facilities that offer MMC to nearest town Table 3. 5: Age of the youngest person who can be circumcised at the facility Table 3. 6 Facilities that charge a fee Table 3. 7: Charges by kind of facility Table 3. 8: Days of circumcision by category of health facility Table 3. 9 Counseling services offered to MMC clients Table 3. 10: Cadre of staff that carry out circumcision Table 3. 11: Number of circumcisions conducted in February and March 2009 by category of health facilities Table 3. 12: Reasons for not offering MMC Table 3. 13: Challenges of providing MMC List of figures Figure 3. 1: Distribution of respondents by position at health facilities... 5 Figure 3. 2: Distribution of the health facilities by region... 6 Figure 3. 3 Circumcision services by level of health facility Figure 3. 4 Circumcision services by ownership of health facility Figure 3. 5: Relative percent of facilities that offer MMC by region Figure 3. 6: Days for circumcision v

6 EXECUTIVE SUMMARY Introduction The evidence of protective effect of Medical Male Circumcision (MMC) against HIV and Sexual Transmitted Diseases (STD) has generated interest in the general public. A study to determine acceptability and feasibility of MMC found out that there is a high stakeholder support and at least 59% of uncircumcised men were most likely to support circumcision in each of the districts surveyed. Despite high level of awareness and acceptability of MMC there has been no central source of information on availability of the services at each major facility. A study has been carried out to map out location of MMC services in the country and identify factors that affect access to MMC in Uganda in Health centre IVs, and hospitals in public and private sector. Large private clinics were also included in the study. The country is planning to scale up of MMC services and this information is important for policy makers and implementers. Methods The mapping exercise used telephone interviews for data collection and covered 308 health facilities from all over the country. Each interview was administered using a short questionnaire and the interview lasted on average 10 minutes. The major variables in the study were availability of MMC services, number of circumcisions carried out, fees charged, function status of the theatre and personnel that carry out circumcision. Prior to data collection the data collectors and the investigator were trained in telephone interviewing by an external expert. All data collected were coded and entered in EPIDATA V.3.1 and later exported to STATA V.10 for analysis. The analysis mainly involved charts, frequency tables and cross-tabulations. The documents entitled Ministry of Health Facilities Inventory and the Situation analysis to determine acceptability and feasibility of Male Circumcision Promotion in Uganda were reviewed to supplement the survey data. Results The results showed that most facilities (68%) offer circumcision services. In all regional/national hospitals circumcision is carried out but in HC IVs slightly less than a half circumcise. In private facilities circumcision is more common than in public facilities. vi

7 The number of circumcisions done depend on the size of the facility. The median number of circumcisions carried out in February 2009 per facility was 5 in private clinics, 3 in HC IVs, 5 in hospitals and 10 in regional hospitals. Some HC IVs still don t have fully operational theatres. The same pattern was evident in March Slightly over a third of circumcisions are carried out anytime in the week including weekend while 22% take place between Monday and Friday. The difference in distribution of facilities by days of circumcision and category of facilities is not statistically significant (p>0.2). However, in each category of health facility the proportion of facilities that offer circumcision at specific days tends to be higher compared to the proportions of those that offer the service on week days and all time. In slightly more than a half of the facilities clients get counselled about HIV (52%) or circumcision (56%) but in less than a third clients are advised about testing for HIV. A higher proportion of private clinics provided HIV counselling and circumcision counselling compared to HC IV, general hospitals and regional/national hospitals. However the small number of private clinics makes the comparison unfair. In most facilities (81%) circumcision is carried out by doctors while in fewer facilities (61%) the service is carried out by clinical officers. While the chance of being circumcised by doctors and clinical officers is equal in HC IVs (70%) it differs in other kinds of facilities. In general hospitals circumcision is less likely to be carried out by clinical officers (58%) compared to doctors (90%). In Private-Not-For-Profit (PNFP) and Private-For-Profit (PFP) there is less chance of being circumcised by a clinical officer. In 2% and 7% of the facilities circumcision is carried out by nurses and anaesthetist respectively. The circumcision charges are generally highest among PFP facilities and minimum among public facilities. For children the median cost ranges from Ug Shs 15,000 in PNFP to 40,000 in private facilities. For adults the charges range from 20,000 in public to 60,000 in PNFP facilities. These costs are within range of what was found in the acceptability and feasibility study of Major reasons for not carrying out MMC at the facilities are lack of skills/qualified personnel (50%), lack of a functional theatre (36%) or having no theatre at all (18%), lack of equipment vii

8 (27%), and lack of demand for MMC services in the community (14%). In those facilities where circumcision is carried out the commonest challenges of carrying out MMC are lack of enough surgical equipments and lack of manpower. In the acceptability and the feasibility study the same issues of lack of trained personnel, equipment, medication and theatre raised as hindrances to scaling up MMC. Conclusion It is clear that MMC services are wide spread in the country and they are most times available. The fact that clinical officers carry out the services calls for task shifting in delivery of MMC services. The country still has a shortage of doctors and shifting MMC services to lower ranks would be commendable as long as proper retraining and appropriate guidelines are provided. However, the training should be limited to cadres with minimum acceptable qualification determined by the Ministry of health and medical council. The study further shows that there is a gap in provision of counselling services on HIV and circumcision which can be filled through training. Charges for MMC services vary a lot and in some facilities they are quite high. In case the government wants to scale up the MMC services it has to devise means of subsidizing the costs of the inputs in the service. Otherwise most people will not afford the service and it will force them to go to unauthorised service providers which can result into adverse events. There is a need for community sensitization about MMC, its benefits and why it should be carried out in a safe way. The number of MMC clients is still low and lack of sensitization was one of the challenges the facilities face. Many people prefer going to untrained service providers for MMC. There is a need to address several challenges that health facilities face in trying to offer MMC. The major challenges faced by facilities that offer MMC such as lack of supplies and skilled manpower are the reasons why some facilities don t offer MMC. Recommendations For program and policy the following recommendations are drawn from results in the study: viii

9 Provide information on MMC for HIV prevention, limitations, benefits and other correct facts about the service Design and execute mass sensitization campaign about MMC Provide information materials on how to carry out MMC Carry out a more thorough needs assessment that will include quality of service. As MMS is popularised the demand will increase. The number of service providers will also increase but the quality may reduce Train more health personnel through short refresher and new courses provide sufficient supplies and equipment necessary for MMC, provide more counselling service through training subsidize inputs into the MMC services to make the costs affordable ix

10 1.0 INTRODUCTION 1.1 Background Health Communication Partnership (HCP) with funding from USAID is working with the Ministry of Health AIDS Control Programme (ACP) Makerere University School of Public Health and other partners to implement a public awareness campaign on Medical Male Circumcision (MMC) and HIV prevention. This campaign is focused on sexually active circumcised and uncircumcised men, health care providers as well as policy makers and opinion leaders including the media and government officials. Whereas individuals have been seeking MMC services from various facilities in Uganda there is no central source of referral information about MMC services such as location of facilities that offer the services, the availability of the services and their costs. In addition, the ability and readiness of the health sector to meet increasing demand for MMC services is not known. In view of lack of a central source of information, the Johns Hopkins Bloomberg School of Public Health Centre for Communications Program (JHU/CCP) under its Health Communication Partnership (HCP) contracted a consultant to conduct a mapping of all health facilities in Uganda. The focus was on hospitals and Health Centre IVs (HC IVs) in public and private sector. Large private clinics were also to be covered in the study. The data collection process started on 7 th April and ended on 6 th May Objective The objectives of the study were: 1. To map the current locations of MMC services in Uganda, 2. To identify the factors that affect access to MMC in Uganda. 1.3 Scope of the study This report presents findings from a census of all private and public hospitals, HCIVs, and clinics at the level of HCIV in Uganda. The results include a mapping of facilities, distance from the nearest town, availability of MMC services, type of medical staff who conduct MMC, costs and fees, availability of counseling services, challenges, and recommendations. 1

11 2.0 METHODS AND MATERIALS 2.1 Design, study units and respondents The main study output was a mapping of circumcision services in the country and therefore a census survey of health facilities was the most appropriate. The number of health facilities in the country was estimated 300 since an inventory of health facilities in 2006 reported 274 facilities at the level of Health Centre IV or hospital 1. It was expected that by 2009 a few lower level facilities could have been upgraded to HC IV or hospital level. Of the 274 facilities, 161 were health centre IVs while 113 were hospitals but the number has since increased. Contact information for the eligible facilities was obtained from the District Health Officers (DHOs) while the contact information for the DHOs was obtained from the Ministry of Health. 2.2 Method of data collection and key variables Since the task involved mapping of MMC services in the whole country telephone interviews were found to be the best option for data collection given the time and cost constraints. Telephone interviews can be quick and effective if interviewers are trained appropriately 2. The interviewers can speak with maximum number of people in the shortest period while maintaining representative sample. A study carried out in Hawai in the USA found that many respondents were comfortable discussing on telephone than in face-to-face interviews 3. Telephone interviews are not without problems. There are reported cases of high non-response in some studies 4 and delays in fixing appointments and unreliability of telephone network in some parts are expected in this country. In addition, refusal rates can double when interviews last more than 5 minutes 5 and intonation may also affect the outcome of yes/no or agreed/disagree questions 6. Short semi-structured questionnaires were used in the telephone interviews (Annex E). The respondents were medical superintendents or officers in charge of government and private health facilities. In the absence of the superintendents or officers in charge senior medical staff at the health facilities were interviewed. All telephone interviews were conducted from HCP offices in Kampala 2

12 Key variables in the study included location of the facilities in terms of district, health sub district and Sub County, offer of circumcision services, cost of the services, days for circumcision, staff that circumcise and challenges faced when offering the services. 2.2 Training research assistants Six research assistants were selected based on their previous data collection experience. Training for the research assistants, the Principal Investigator and HCP staff on telephone interviewing was carried out for 2 days by an external firm called British Communications. Nobody on the research team had had prior exposure to telephone interviewing. The training mainly involved communication skills on a telephone. On the second day a pre-test was carried out on some facilities in Jinja district and it was successful. 2.3 Data management and analysis Data management and analysis took place at Makerere University School of Public Health. All data collected were entered in EPIDATA v.3.1. The data entry screen was fitted with consistence and range checks. The consultant supervised the data entry. All data were then exported to STATA v.10 for cleaning and analysis. Data analysis involved constructing frequency distribution tables for all key variables and crosstabulation of some important outcome variables with explanatory variables such as category of health facilities, offering circumcision services, charges for the services and minimum age for circumcision. 2.4 Limitations for the study In addition to limitations of telephone interviews mentioned earlier in section 2.2 there are other constraints to accuracy and amount of data one is able to collect. These include inability to verify the information being given by the respondent and lack of classification of private health facilities. The nature of the interview surveys doesn t allow the respondent to verify the identity of the caller nor does it allow the caller to understand the respondent more through gestures and body 3

13 language. This leaves some uncertainty over the kind of person the respondent is talking to and the outcome of the information provided. In effect, the respondent may not provide as much information and detail he or she would have provided as in a face-to-face interviews. To counteract this problem the study team kept re-assuring the respondent about authenticity of the study and referring the respondent to the Ministry of health in case of any doubt. In addition, the research design involved verification of the identities and telephone contacts of respondents by the ministry of health officials, and where necessary an MOH official was requested to reassure problematic respondents. The skills acquired during training were also very helpful in ensuring quality and good amount of data collected. Private health facilities are not classified and this makes it difficult to tell whether a facility is equivalent to HC IV or not. Some respondents could not provide information on private health facilities because they weren t sure whether the facilities were equivalent to Health centre IV. This study may not have captured all Private health facilities due to incompleteness of the census frame. This was minimised by asking information on health facilities that were privately owned but few respondents knew about them. 2.5 Quality assurance Measures were taken to ensure quality of data collected and proper data management. All questionnaires were checked for completeness and consistency by a supervisor immediately the interview was completed; and call backs were made where necessary. Validity checks and further cleaning of data were carried out after data entry using STATA software. 2.6 Ethical consideration Since the study unit was a health facility rather than a human being it was not necessary to seek approval through Institutional Review Boards (IRB). In addition, the study can be classified as an operational study with the aim of scaling up circumcision services in the country. This way, the need for ethical approval is reduced. 4

14 3.0 RESULTS AND DISCUSSION The results section is split into three subsections. The first subsection provides description of respondents and the facilities covered in the study. The second sub-section describes the facilities in terms of distance from nearest town, level of facility and ownership. The third subsection discusses the provision of circumcision services by level of facility and ownership. Others discussed in subsection three are the charges for the circumcision, days for circumcision, minimum age and counseling services. 3.1 Respondents and description of the facilities Respondents The respondents for 72% of the facilities were medical superintendents of hospitals or incharges of health centres. The rest were deputy superintendents/in-charges (2%) and other staff (26%) (Figure 3.1). The other staff included medical offices, nurses and other categories of health staff. Figure 3. 1: Distribution of respondents by position at health facilities 5

15 Other staff 26% Deputy Superintendant/ In_ch arge 2% Med.superitendant/ I n-charge 72% Description of the facilities contacted The survey covered 308 facilities in all the 80 districts in the four main regions of the country. Central region has the highest proportion of facilities (29%) while Northern region has the least proportion (17%) (Figure 3.2). Figure 3. 2: Distribution of the health facilities by region 6

16 Percent Northern Eastern Central Western Region The districts with the largest number of HC IV or hospitals are Kampala (8%), Bushenyi (3%), and Jinja (3%) Masaka (4%) and Mukono (3%) (See Annex 1). This can be attribution to higher urbanization level in these districts compared to others. Nearly 70% of the facilities surveyed are located less than 20 km from town. Forty six percent are within 4 km of the town (Table 3.3). Table 3. 1: Distance from the nearest town Distance Number of Percent facilities 0_ _ _ _ Total

17 More than a half of the facilities (55%) are HCIVs. Seventy percent of all facilities surveyed are government owned but 57% of general hospital category facilities are in hands of the private sector. Table 3. 2: Level of facility by ownership Level of health Ownership Facility Public Private Not for Profit (PNFP) Private for Profit (PFP) Total n % n % n % n % HC IV General Hospital Regional/National Referral Hospital Private Clinic Total Location of facilities that offer MMC services The map below shows locations of facilities that offer MMCs services and those that don t. It is clear that the highest concentration of MMC services is along Kampala-Jinja-Tororo-Mbale axis, West Nile and Mbarara-Bushenyi. The same areas have high population densities and urbanization levels with the exception of West-Nile region where there is large Muslim population. 8

18 Map of Uganda showing location of facilities that offer MMC 9

19 3.3 Facilities that offer circumcision services In all 308 facilities surveyed 68% offer circumcision services (Figure 3.3). In all regional/national hospitals circumcision is carried out but in HC IVs slightly less than a half circumcise. This can be attributed to more availability of supplies and skilled personnel in regional/national hospitals compared to HC IVs and general hospitals. Figure 3. 3 Circumcision services by level of health facility Percent HC IV General Hospital Region/ Nation.Ref.Hosp Level of health unit Private clinic All facilities In private facilities circumcision is more prevalent (PNFP: 89%, PFP: 77%) than in public facilities (61%) (Figure 3.4). 10

20 Figure 3. 4 Circumcision services by ownership of health facility Percent Public Private Not for Profit Private for Profit Ownership Figure 3.5 shows the percent of facilities that offer MMC by region. It is clear that central region has the highest proportion of facilities (77%) that offer MMC. This may again be attributed to the high urbanization level which attracts doctors and relevant skilled labour. Figure 3. 5: Relative percent of facilities that offer MMC by region Percent Northern Eastern Central Western Region 11

21 Of the facilities that offer MMC in each region, general hospitals constitute the highest proportion followed by HC IVs (Table 3.3). Public health facilities constitute larger proportions that offer MMC compared to Private Not-For Profit (PNFP) and Private-for-Profit (PFP) facilities. Table 3. 3: Distribution of health facilities that offer MMC by region, level and ownership Category Region All Northern Eastern Central Western n % n % n % n % n % Level HC IV General hospital Regional referral Private clinic Ownership Public PNFP PFP Total More than a half (54%) of the facilities that offer MMC are within 0-4 km from the nearest town (Table 3.4). This is consistent to earlier findings that shows higher concentration of MMC services in more urbanised areas. Table 3. 4: Distance of facilities that offer MMC to nearest town Distance Number of Percent facilities 0_ _ _ _ Total

22 Nine percent of the facilities (18) that offer MMC reported lack of functioning theatre. Of the 18 facilities 12 (71%) were health centre IVs while 5 (29%) were general hospitals. This means that MMC was carried out in an improvised setting. The respondents were asked the minimum age of a person who could be circumcised at the facilities. The answer was expected to be policy oriented but responses were about the age of the youngest person that had been circumcised at the facility. Respondents from 11 facilities could not recall the age of the youngest person circumcised at their facilities. The age of circumcision clients was much lower for Private-Not-For-Profit Facilities (1.5 months) compared to Private for Profit (5 months) and Public facilities (12 months) (Table 3.5). The range of age of the clients in private for profit was much higher than that in PFP and Public sectors. Table 3. 5: Age of the youngest person who can be circumcised at the facility Category <1 year 1-4 yrs 5+ All n % n % n % n % Level Private clinic HC IV General Hosp Region/Nat.Ref. Hosp Ownership Public Private_Not-For_Profit Private for profit All Slightly over a half (51%) of the facilities surveyed charge a fee for circumcision (Table 3.6). In other words about 49% of health facilities offer MMC free of charge. Understandably all private facilities charge a fee because they have to support themselves. They need to pay their own costs of maintenance. The tool did not have a question on whether it is the private or general wards that charge in public facilities. 13

23 Table 3. 6 Facilities that charge a fee Category % that charge Total No. of facilities Level of facility HC IV General Hospital Regional/Nat. Referral Hosp. Private Clinic/Other Ownership Public Public Not For Profit (PNFP) Private Total Expectedly, the circumcision charges were generally highest among PFP facilities and minimum among public facilities (Table 3.7). For children, the median cost ranged from Ug Shs 15,000(US$7.0) in PNFP to 40,000 (US$18.6) in private facilities. For adults the charges ranged from 20,000 (US$ 9.3) in public to 60,000 (US$ 27.9) in PNFP facilities. These costs are within range of what was found in the acceptability and feasibility study of In the study a half of health practitioners thought MMC would between Shs 10,000-20, It is evident that the range of the costs was widest in PFP facilities. This may be attributed to different standards of service and different operational costs among facilities. Table 3. 7: Charges by kind of facility Category Public Public not for profit Private for Profit All All (costs in US$) Children n =12 n =37 n =11 n =60 n =60 Median 20,000 15,000 40,000 20,000 9 Min-Max 5, , ,000 10, , , Adults n =13 n =38 n =11 n =62 n =62 Median 20,000 25,000 60,000 30, Min-Max 5, ,000 5,000-80,000 15, ,000 5, , Same for n =15 n =20 n =9 n =44 n =62 Young &Adults Median 10,000 15,000 45,000 15, Min-Max 5, ,000 2,000-80,000 10,000-90,000 2, ,

24 The exchange rate for US$ was UgShs 2150 to 1 US$ Slightly over a third (35%) of the facilities carry out circumcisions anytime in the week including weekend while 22% of them circumcise only on official working days from Monday to Friday (Figure 3.6 and Table 3.8). That means that 57% of the facilities do offer MMC from Monday to Friday. The difference in distribution of facilities by days of circumcision and category of facilities was not statistically significant (p>0.2). However, in each category of health facility the proportion of facilities that offer circumcision at specific days tends to be higher compared to the proportions of those that offer the service on week days and all time. Figure 3. 6: Days for circumcision Monday-Friday 22% All Days 35% Specific days 43% Table 3. 8: Days of circumcision by category of health facility Category Mon-Fri All days Specific days All n % n % n % n % Level of facility HC IV General Hospital Regional/Nat. Referral Hosp Private Clinic/Other Ownership Public Public Not For Profit (PNFP)

25 Private Total In slightly more than a half of the facilities clients receive HIV (52%) or circumcision (56%) counselling and in less than a third of the facilities clients are specifically advised to test for HIV (Table 3.9). A higher proportion of private clinics provided HIV counselling and Circumcision counselling compared to HC IV, general hospitals and regional/national hospitals. However the small number of private clinics makes the comparison inconclusive. It is evident that counselling service are still lacking in the facilities. A seemingly high proportion that offers HIV and circumcision counselling is partly due to low number of facilities in the sector compared to the public sector. Table 3. 9 Counseling services offered to MMC clients Category Provide HIV counselling Clients advised to test for HIV Clients are counselled on circumcision Tot. no of facilities that offer MMC n % n % n % Level of facility HC IV General Hospital Regional/Nat. Referral Hosp. Private Clinic/Other Ownership Public Public Not For Profit (PNFP) Private Total Cadre of personnel that circumcise The results show that MMC is carried out by doctors (81%), clinical officers (61%), nurses (2%) and anaesthetic assistants (7%) (Table 3.10). In 70% of the HC IVs circumcision is carried out by clinical officers. In nearly the same proportion (71%) of facilities doctors carry out the circumcision. In general hospitals, circumcision is less likely to be carried out by clinical officers (58%) compared to doctors 16

26 (90%). In PNFP and PFP there is less chance of being circumcised by a clinical officer. In one in ten of public facilities anaesthetic assistants carry out circumcision while in one in 20 facilities nurses carry out the circumcision. Table 3. 10: Cadre of staff that carry out circumcision Category Doctors Clinical officers Nurses Anaesthetic Assistants Total number of n % n % n % n % facilities Level of facility HC IV General Hospital Regional/Nat. Refer.Hosp Private Clinic/other Ownership Public Public_Not For_Profit Private for Profit Total Utilization of Circumcision services The number of circumcisions done depend on the size of the facility. The median number of circumcisions carried out per facility in Feb 2009 was 5 in private clinics, 3 in HC IVs, 5 in hospitals and 10 in regional hospitals (Table 3.11). They included lack of supplies and skilled manpower. The same range and pattern of number of circumcisions by category of facility was reported for March Note that there was a wide variation in the range of circumcisions carried out. The variation in number of circumcisions can be attributed to difference in size of the facility. 17

27 Table 3. 11: Number of circumcisions conducted in February and March 2009 by category of health facilities Private HC General Regional/Nat. All clinic IV Hospital Hospital Feb 2009 n =9 n =82 n =103 n =12 n =206 Median Min Max March 2009 n =9 n =82 n =103 n =11 n =206 Median Min-Max Reasons for unavailability of MMC and Challenges of providing the services Reasons for not offering MMC Major reasons for not carrying out MMC at the facilities were lack of skills/qualified personnel (50%), lack of a functional theatre (36%) or having no theatre at all (18%), lack of equipment (27%), and lack of demand for MMC services in the community (14%) (Table 3.12). Table 3. 12: Reasons for not offering MMC Reason No of facilities where the reason was given % of all facilities that don t offer MMC (98) No qualified personnel Theatre is not functional No equipment No theatre No demand Not in their area of specialisation/service Costly to run a theatre No running water/no electricity No time/no motivation No information on MMC

28 Challenges for offering MMC In facilities where circumcision is carried out, the commonest challenges of carrying out MMC are lack of enough supplies like surgical equipment and drugs (41%) and lack of manpower (23%) (Table 3.13). About 13% of health facilities reported that there were no challenges. The numerous challenges faced by facilities that offer MMC contribute to the low number of circumcisions carried out. Table 3. 13: Challenges of providing MMC Challenges 1. Lack of enough supplies like surgical equipments and drugs Number of % of 210 facilities Understaffing/lack of manpower Lack of sensitization about MMC in the community Some people cannot afford the costs Circumcising children is challenging Work overload/high demand for MMC Poor mobilization of resources for MMC such as money and personnel 8. For coughing children it is difficult to control it when children are sedated during circumcision 9. Anesthesia is a problem for children Difficult to control over bleeding Lack of refresher courses on MMC Fear of slow healing process in high HIV prevalence areas There is Cultural influence- for example people prefer mosque 14. Patients normally don t come back Lack of standardization of procedures Children get cardiac arrest- A few cases have been linked Death of kids- Some deaths have been linked to circumcision 18. Turn up is low No challenges

29 NB: The question was multiple response. The percentages don t add up to CHALLENGES AND LESSONS LEARNT FROM THE TELEPHONE INTERVIEWS Overall the data collection exercise was highly successful with 100% response rate. However, there are challenges the research team met that one needs to be aware of before a new telephone interview based study is carried out. This section presents the challenges of telephone interviews and lessons learnt from them. 4.1 Challenges The following are the challenges the study team met a. Phobia against phone interviews Some respondents explicitly said they could not be interviewed on phone despite all assurances that the interview was sanctioned by the Ministry of Health. Some respondents requested that the questionnaires be sent by so that they understand the questions before they could be interviewed. This was done and interviews were conducted later on. b. Non-existent telephone numbers There were cases where the telephone number in the records at the Ministry of Health or from other contacts was found to be non-existent. This came about when the target respondent changed telephone numbers. There were others cases where the telephone lines given where official lines and the target respondent left the job. However in the later situation the interview would be carried out with the new contact person. c. Research fatigue 20

30 Some respondents expressed unhappiness at lack of feedback to all information they always give to researchers. Others said they were tired of giving information that did not translate into action. The research team explained to the respondents that the results from this study will be published and distributed to districts. Hence a relief for those that were tired. 4.2 Lessons learnt The following are lessons learnt from the above challenges a. Training and rehearsals The whole research team underwent a two day training and pre-test. The skills acquired were very useful during data collection especially with complicated respondents. b. Short and clear questions For a successful phone interview the questionnaire had to be short with brief, clear and concise questions. All questions should be perceived to be useful and applicable to the respondent. The respondent can easily stop the interview if asked a question that does not meet the criteria mentioned. One had to avoid asking wrong questions and any other action that would annoy the respondent by following instructions. During the interview in this study an interviewer asked a doctor of a hospital whether the theatre was operational and he (doctor) told him not to ask similar questions again and switched off the phone. This question was directed to the HC IVs and private clinics but the interviewer had forgotten. A health facility in the country must have a functioning theatre if it is to be called and hospital. c. Most important questions first It was very helpful to first ask most important questions first. Within a short time the most important information on circumcision had been obtained. The rest of the information such as location of the facility and knowledge of other facilities that offer circumcision could be obtained anywhere else in case the interview ended abruptly. 21

31 d. Short length of interview The interview in this study was short enough. The average length of interview was 10.2 minutes with a standard deviation of 4.7 minutes. This was short enough to keep the respondent interested. e. Telephone etiquette Telephone interviews require patience, politeness and clarity among other attributes. For some respondents, several calls and several appointments had to be made to be able to get them. This is not possible when one is not patient enough. Another thing to note is that whereas interviewers underwent training on telephone interviewing respondents did not. The research team endured a few rude responses and comments. f. Costs of carrying out research The costs of carrying out research were very much reduced. The total study cost US$. The same study had been planned to cost if face-to-face interview method was used. 22

32 5.0 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS The study has revealed important information regarding availability of MMC services, their cost, the kind of health staff that carry out MMC and challenges which the health facilities face in trying to offer the service. 5.1 Summary The study has found out that 68% of all facilities at the level of HC IV or hospital in the country do offer Medical Male circumcision (MMC) services. The proportion of facilities that offer MMC services is highest in Private_Not_For_ Profit (PNFP) and lowest in public facilities. Central region has the highest proportion (77%) of facilities that offer MMC while Northern region has the least (64%). Over half of the facilities (57%) offer circumcision services from Monday to Friday. Others (43%) offer the services on specific days or on appointment. Slightly over a half of facilities provide counselling services for HIV and MMC. Slightly less than a third of facilities advise clients to test for HIV. Those who carry out circumcision are mainly doctors (81%) and clinical officers (61%) but in few facilities nurses (2%) and anaesthetic assistants (7%) carry out the circumcision. A half of the facilities charge a fee for circumcision. Slightly over a fifth of the public facilities charge a fee for circumcision. All PNFP and PFP facilities charge a fee. The amount charged range from a median of 10,000 (US$ 4.7) in public to 45,000 (US$20.9) in PFP facilities. The median number of circumcisions per facility depends on category and they range from 3 in HC IV to 10 in regional/national referral hospitals. For those facilities that don t carry out MMC the major reasons for not providing the service were lack of skills/qualified personnel (50%), lack of a functional theatre (36%) or having no theatre at all (18%), lack of equipment (27%), and lack of demand for MMC services in the 23

33 community (14%). In facilities that offer MMC the main challenges health workers face include lack of enough supplies (41%), understaffing/lack of manpower (23%) and lack of sensitization about MMC (11%). 5.2 Conclusions From the above results it is clear that MMC services are wide spread in the country and they are mostly available during normal working days. This should be an encouragement to people who seek the services. The fact that clinical officers carry out the services calls for task shifting in delivery of MMC services. The country still has a shortage of doctors and shifting MMC services to lower ranks would be commendable as long as proper retraining and appropriate guidelines are provided. However, the training should be limited to cadres with minimum acceptable qualification determined by the Ministry of health and medical council. Involvement of nurses and anaesthetic assistants in MMC to an extent of actually carrying the operation is not allowed in the country and it can be a sign of acute shortage of qualified staff for MMC or poor standard of service delivery. There is a gap in provision of counselling services on HIV and circumcision calls which can be filled through training. Charges for MMC services vary a lot and in some facilities they are quite high. In case the government wants to scale up the MMC services it has to devise means of subsidizing the costs of the inputs in the service. Otherwise most people will not afford the service and it will force them to go to unauthorised service providers which can result into adverse events. There is a need for community sensitization about MMC, its benefits and why it should be carried out in a safe way. The number of MMC clients is still low and lack of sensitization was one of the challenges the facilities face. Many people prefer going to untrained service providers for MMC. There is a need to address several challenges that health facilities face in trying to offer MMC. The major challenges faced by facilities that offer MMC such as lack of supplies and skilled manpower are the reasons why some facilities don t offer MMC. 24

34 5.3 Recommendations For program and policy the following recommendations are drawn from results in the study: i. Provide information on MMC for HIV prevention, limitations, benefits and other correct facts about the service ii. Design and execute mass sensitization campaign about MMC iii. Provide information materials on how to carry out MMC iv. Carry out a more thorough needs assessment that will include quality of service. As MMS is popularised the demand will increase. The number of service providers will also increase but the quality may reduce v. Train more health personnel through short refresher and new courses vi. provide sufficient supplies and equipment necessary for MMC, vii. provide more counselling service through training viii. subsidize inputs into the MMC services to make the costs affordable 25

35 REFERENCES 1. MOH. Ministry of Health: Health facilities Survey. Kampala, Dillman DA, Gallegos JG, JH F. Reducing refusal rates for telephone interviews. Public Opin Q 1976: L.Lyu, J.Hankin, L.Liu, L.Wilkens, J.Lee, M.Goodman, et al. Telephone vs Face-to-Face Interviews for Quantitative Food Frequency Assessment. Journal of the American Dietetic Association 2009;98( 1): Brehm J. The Phantom Respondents: Opinion Surveys and Political Representation. Ann Arbor University of Michigan Press., CASRO. Your opinion counts. Chicago, IL:CASRO 1986; Barath A, CF C. Effect of interviewer's voice intonation.. Public Opin Q, 1976: Baine S, Opio A, Tumwesigye NM, Thomsen S, Akol A. Situation analysis to determine the acceptability and feasibility of Male circumcision promotion in Uganda. Kampala,

36 ANNEX A: NUMBER OF HC IVs, HOSPITALS AND LARGE PRIVATE CLINICS THAT OFFER CIRCUMCISION SERVICES BY DISTRICT DISTRICT No of facilities % of national total Number that circumcise Percent that offer MMC per district 1. ABIIM ADJUMANI AMOLATAR AMURIA AMURU APAC ARUA BUDAKA BUDUDA BUGIRI BUKEDEA BUKWO BULIISA BUNDIBUGYO BUSHENYI BUSIA BUTALEJA DOKOLO GULU HOIMA IBANDA IGANGA ISINGIRO JINJA KAABONG KABALE KABAROLE KABERAMAIDO KALANGALA KALIRO KAMPALA KAMULI KAMWENGE KANUNGU KAPCHORWA KASESE KATAKWI KAYUNGA KIBAALE KIBOGA

37 41. KIRUHURA KISORO KITGUM KOBOKO KOTIDO KUMI KYENJOJO LIRA LUWEERO LUWERO LYANTONDE MANAFWA MARACHA TEREGO 54. MASAKA MASINDI MAYUGE MBALE MBARARA MITYANA MOROTO MOYO MPIGI MUBENDE MUKONO NAKAPIRIPIRIT NAKASEKE NAKASONGOLA NAMUTUMBA NEBBI NTUNGAMO OYAM PADER PALLISA RAKAI RUKUNGIRI SEMBABULE SIRONKO SOROTI TORORO WAKISO YUMBE Total

38 ANNEX B: HEALTH FACILITIES AT THE LEVEL OF HEALTH CENTRE IV OR HOSPITAL: LOCATION AND AVAILABILITY OF MMC SERVICES DISTRICT COUNTY/HEALTH SUB-DISTRICT SUB-COUNTY PARISH NAME OF HEALTH UNIT OFFICIAL TEL. LEVEL OWNERSHIP OFFERS MMC DAYS MMC OFFRED ABIIM ABIIM ABIIM KALAKALA ABIIM HOSPITAL ADJUMANI ADJUMANI ADJUMANI TOWN COUNCIL CENTRAL ADJUMANI HOSPITAL ADJUMANI ADJUMANI OFUA ODU MUNGULA (NGO) HOSPITAL PUBLIC YES ON APPOINTMENT HOSPITAL PUBLIC YES HOSPITAL PNFP NO TUESDAYS & THURSDAYS AMOLATAR KIOGA APUTI ANYWALI AMURIA KAPELEBYONG KAPELEBYONG PAPELEBYONG AMAI COMMUNITY HOSPITAL PFP YES TWICE A WEEK KAPELEBYONG HC IV HC IV PUBLIC NO AMURIA AMURIA KUJU KUJU AMURIA HC IV HC IV PUBLIC YES TUESDAY & FRIDAY AMURU KILAK ATIAK KAL ATIAK ATIAK HCIV HC IV PUBLIC NO AMURU KILAK PABBO KAL PABBO HC III HC III BUT WITH LACOR HOSP. SERVICES PNFP YES ON APPOINTMENT AMURU NWOYA ANAKA PADUNY APAC KOLE ABOKE ANAKA HOSPITAL HOSPITAL PUBLIC YES ALL DAYS OGWANGA CUMU ABOKE HC IV HC IV PUBLIC YES MON-FRI APAC KWANIA ADUKU ONGOCENG ADUKU HCIV HC IV PUBLIC YES WEDNESDAY & FRIDAY APAC MARUZI APAC TOWN COUNCIL WESTERN WARD APAC HOSPITAL HOSPITAL PUBLIC YES MON-FRI ARUA AYIVU ADUMI OMBACHI ADUMI HCIV HC IV PUBLIC YES TUESDAY & FRIDAY 29