Swaziland-VMMC-And-EIMC-Strategy

T ABLE OF C ONTENTS

Table of Contents ...... i List of Tables ...... iii List of Figures ...... iii List of Boxes ...... iii List of Acronyms ...... iv Foreword ...... vi Acknowledgements...... vii EXECUTIVE SUMMARY ...... viii 1 CHAPTER I: BACKGROUND AND INTRODUCTION ...... 1 1.1 MALE CIRCUMCISION TERMINOLOGY ...... 1 1.2 HIV AND AIDS IN SWAZILAND ...... 1 1.3 THE RATIONALE FOR MALE CIRCUMCISION ...... 2 1.4 BACKGROUND AND OVERVIEW OF THE MALE CIRCUMCISION PROGRAM IN SWAZILAND ...... 5 1.5 STRATEGIC AND OPERATIONAL PLAN DEVELOPMENT PROCESS ...... 6 2 CHAPTER II: OVERVIEW OF STRATEGIC DIRECTION ...... 8 2.1 INTRODUCTION ...... 8 2.2 ALIGNMENT WITH THE EXTENDED NATIONAL MULTISECTORAL HIV AND AIDS FRAMEWORK (eNSF) 2014 - 2018 ...... 8 2.3 ALIGNMENT WITH OTHER NATIONAL HEALTH AND HIV/AIDS STRATGIES AND OPERATIONAL GUIDELINES ...... 10 2.4 ALIGNMENT WITH INTERNATIONAL MALE CIRCUMCISION STRATEGIES AND GUIDELINES ...... 11 3 CHAPTER III: OVERVIEW OF STRATEGIC APPROACH ...... 12 3.1 INTRODUCTION ...... 12 3.2 A TEN-YEAR PHASED APPROACH ...... 12 3.3 AGE DISAGGREGATED TARGETING ...... 14 3.4 GEOGRAPHIC TARGETING...... 15 3.5 SCALE UP PLAN FOR EIMC ...... 15 3.6 MALE CIRCUMCISION STRATEGIES ...... 16 4 CHAPTER IV: SERVICE DELIVERY ...... 18 4.1 SERVICE DELIVERY OVERVIEW ...... 18 4.2 MC SERVICE DELIVERY STRATEGIES ...... 21 4.3 VMMC SERVICE DELIVERY STRATEGIES ...... 22 4.4 EIMC SERVICE DELIVERY STRATEGIES ...... 23 5 CHAPTER V: HUMAN RESOURCES FOR SERVICE DELIVERY ...... 24 5.1 OVERVIEW OF HUMAN RESOURCES ...... 24 5.2 MC HUMAN RESOURCES STRATEGIES ...... 26 5.3 VMMC HUMAN RESOURCES STRATEGIES ...... 26 5.4 EIMC HUMAN RESOURCES STRATEGIES ...... 27 6 CHAPTER VI: DEMAND CREATION ...... 29 6.1 OVERVIEW OF DEMAND CREATION ...... 29 6.2 MC DEMAND CREATION STRATEGIES ...... 31 6.3 VMMC DEMAND CREATION STRATEGIES ...... 32 6.4 EIMC DEMAND CREATION STRATEGIES ...... 33 7 CHAPTER VI: SUPPLY CHAIN MANAGEMENT ...... 34 7.1 OVERVIEW OF SUPPLY CHAIN MANAGEMENT ...... 34 7.2 MC SUPPLY CHAIN MANAGEMENT STRATEGY ...... 34 8 CHAPTER VIII: WASTE MANAGEMENT ...... 36 8.1 OVERVIEW OF WASTE MANAGEMENT...... 36 8.2 MC WASTE MANAGEMENT STRATEGY ...... 36 9 CHAPTER IX: QUALITY ASSURANCE ...... 37 9.1 OVERVIEW OF QUALITY ASSURANCE ...... 37 i

9.2 MC QUALITY ASSURANCE STRATEGY ...... 38 10 CHAPTER X: NEW TECHNOLOGIES AND DEVICES ...... 39 10.1 OVERVIEW OF NEW TECHNOLOGIES AND DEVICES ...... 39 10.2 MC STRATEGY FOR NEW TECHNOLOGIES AND DEVICES ...... 40 11 CHAPTER X1: STRATEGIC INFORMATION ...... 41 11.1 STRATEGIC INFORMATION OVERVIEW ...... 41 11.2 MC STRATEGIC INFORMATION STRATEGY ...... 42 12 CHAPTER X11: PROGRAM COORDINATION AND MANAGEMENT ...... 43 12.1 PROGRAM COORDINATION AND MANAGEMENT OVERVIEW ...... 43 12.2 MC PROGRAM COORDINATION AND MANAGEMENT STRATEGY ...... 43 13 CHAPTER X111: COST ESTIMATES ...... 45 REFERENCES AND DOCUMENTS CONSULTED ...... 46 ANNEX I: NATIONAL AND REGIONAL MC COVERAGE ...... 49 ANNEX II: ORGANIZATIONS THAT PARTICIPATED IN CONSULTATION MEETINGS ...... 52 ANNEX III: MALE CIRCUMCISION OPERATIONAL PLAN 2014 - 2018 ...... 56

L IST OF T ABLES Table 1: Key MC Strategic Plan Strategies Aligned to the eNSF MC Strategies ...... 10 Table 2: MC National Targets by Age Group 2014-2018 ...... 13 Table 3: Manzini Region MC Targets by Age Group 2014-2018 ...... 14 Table 4: Hhohho Region MC Targets by Age Group 2014-2018 ...... 14 Table 5: Lubombo Region MC Targets by Age Group 2014-2018 ...... 14 Table 6: Shiselweni Region MC Targets by Age Group 2014-2018 ...... 14 Table 7: MCs Undertaken by specific MC Database Categories from January 2013-May 2014 ...... 19 Table 8: Current EIMC Service Delivery Sites ...... 20 Table 9: MC Strategic Plan Cost Estimates 2014-2018 ...... 45

L IST OF F IGURES Figure 1: Key Drivers of the HIV Epidemic in Swaziland ...... 2 Figure 2: Modeling the Potential Impact of MC Coverage on HIV Prevalence among 15-49 year olds 1990-2012 ...... 4 Figure 3: Swaziland MC Scale up Scenario 2014-2035 ...... 13 Figure 4: Male Circumcision Strategies ...... 16

L IST OF B OXES Box 1: Service Delivery Strategies ...... 21 Box 2: Human Resources for Service Delivery Strategies ...... 26 Box 3: Demand Creation Strategies ...... 30 Box 4: Supply Chain Management Strategy ...... 34 Box 5: Waste Management Strategy ...... 36 Box 6: Quality Assurance Strategy ...... 38 Box 7: New Technologies and Devices Strategy ...... 39 Box 8: Strategic Information Strategy ...... 41 Box 9: Program Coordination and Management Strategy ...... 43

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L IST OF A CRONYMS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal care ASI Accelerated Saturation Initiative BTS Back to School CBO Community based organization CDC Centers for Disease Control and Prevention CHIMSHACC Multi-sectoral HIV and AIDS Coordinating Committee CHAI Clinton Health Access Initiative CMS Central Medical Stores CNO Chief Nursing Officer CSO Central Statistics Office DHS Demographic Health Survey DMPPT Decision Makers’ Program Planning Tool EGPAF Elizabeth Glaser Pediatric AIDS Foundation EIMC Early infant male circumcision EPI Expanded Program on Immunization eNSF Extended National Multisectoral HIV and AIDS Framework FBO Faith based organization FGD Focus group discussion FLAS Family Life Association of Swaziland GBV Gender-based violence GOKS Government of the Kingdom of Swaziland HCWM Health care waste management HIV Human Immunodeficiency Virus HMIS Health Management Information System HPP Health Policy Project HPV Human Papilloma Virus HSV Herpes Simplex Virus HTC HIV testing and counseling ICT4D Information, Communication, Technology for Development IHM Institute for Health Measurement IMCI Integrated Management of Childhood Illnesses IPC Interpersonal communication M&E Monitoring and evaluation MC Male circumcision MCP Multiple and concurrent (sexual) partnerships MC-TWG Male Circumcision Technical Working Group MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MNCH Maternal, newborn and child health MOD Ministry of Defense MOE Ministry of Education MOVE Models for Optimizing Volume and Efficiency MOH Ministry of Health MP Member of Parliament iv

MSH Management Sciences for Health MSI Marie Stopes International MSM Men who have sex with men NERCHA National Emergency Response Council on HIV and AIDS NGO Non-governmental organization OVC Orphans and vulnerable children PEPFAR President’s Emergency Plan for AIDS Relief PITC Provider initiated testing and counseling PLHIV People living with HIV PMTCT Prevention of mother-to-child transmission PSHACC Public Sector HIV and AIDS Coordinating Committee PSI Population Services International QA Quality assurance REMSHACC Regional Multi-sectoral HIV and AIDS Coordinating Committee RESAR Regional Semi-Annual Review RFM Raleigh Fitkin Memorial (Hospital) RHM Rural health motivators RHMT Regional Health Management Teams SBC Social and behavior change SCMS Supply Chain Management Services SDHS Swaziland Demographic Health Survey SHIMS Swaziland HIV Incidence Measurement Survey SID Strategic Information Department SNAP Swaziland National AIDS Program SRHU Sexual and Reproductive Health Unit STI Sexually transmitted infection SWABCHA Swaziland Business Coalition on HIV and AIDS SWADNU Swaziland Democratic Nurses Union SWAZIMED Swaziland Medical Aid Fund TB Tuberculosis TIMSHACC Tinkhundla Multisectoral HIV and AIDS Coordinating Committee TLC The Luke Commission TMC Traditional male circumcision ToT Trainer of trainers TWG Technical working group UNAIDS Joint United Nations Program on HIV/AIDS UNICEF United Nations Children’s Fund USAID United States Agency for International Development VMMC Voluntary medical male circumcision WHO World Health Organization

F ORE WORD The Swaziland Male Circumcision Strategic and Operational Plan for HIV Prevention 2014-2018, developed under the leadership of the Ministry of Health, outlines the next phase of the national program to scale up male circumcision for HIV prevention. Voluntary medical male circumcision (VMMC) is a critical pillar of Swaziland’s HIV response. VMMC has been shown to be a safe and effective method of reducing female-to-male HIV transmission by approximately 60% in randomized controlled trials. Swaziland’s Ministry of Health adopted VMMC for HIV prevention in 2009, supported by a national male circumcision policy and strategy. The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018 details a rapid expansion of adolescent and adult VMMC, and also outlines ambitious goals for Swaziland’s early infant male circumcision (EIMC) program, an intervention intended to sustain the long-term HIV prevention benefits of VMMC.

Preparation for the Swaziland Male Circumcision Strategic and Operational Plan for HIV Prevention 2014- 2018 involved a highly participatory process with both VMMC and EIMC stakeholders. The goal of this process was to identify lessons learned and gather critical feedback in order to create a Swaziland-specific roadmap to achieving the male circumcision outcome level results set in the eNSF. These results include that by 2018:

• The percentage of males aged 10-49 years who are circumcised is increased to 70% • The percentage of males under 5 years who are circumcised is increased to 50% • The percentage of parents who support their sons to be circumcised is increased to 60%

The strategic planning process was also informed by the achievements and lessons learned from implementation of the VMMC for HIV prevention program since 2009 and modeling data produced by the Decision Maker’s Program Planning Tool 2.0. The Kingdom of Swaziland is one of the first countries to use this recently developed model for male circumcision strategic and operational planning. The model enables male circumcision coverage targets to be set for specific age groups at the national, regional and Inkhundla level. This results in better targeting for male circumcision strategies. According to this model, circumcision of 353,000 adolescents and adults and 169,000 infants would avert 56,000 HIV infections and provide cost savings of US$370 million by 2035.

The Kingdom of Swaziland is the first country to develop a Male Circumcision Strategic and Operational Plan, that provides for the comprehensive integration of VMMC and EIMC based on the latest international research and guidelines. It is the Ministry of Health’s desire that stakeholders continue to work together to ensure the successful implementation of a continued, expanded male circumcision program as part of Swaziland’s holistic response to the HIV and AIDS epidemic in the country.

A CKNOWLEDGEMENTS The Ministry of Health would like to express its gratitude to the many individuals and organizations who contributed to the development of the Swaziland Male Circumcision Strategic and Operational Plan for HIV Prevention 2014-2018. This document is the product of extensive consultation with government, private, and development sector stakeholders, whose valuable input ensured the most appropriate, considered, and evidence-based approach to scaling up male circumcision for HIV prevention in the Kingdom of Swaziland. The Ministry particularly acknowledges the generous financial support from the Bill & Melinda Gates Foundation as well as the US President’s Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID) in the development of this plan. The Ministry is also grateful to Management Sciences for Health (MSH) and the Maternal and Child Health Integrated Program (MCHIP) for their technical assistance. Further, the Ministry thanks all of the Regional Administrators for their engagement and is extremely appreciative of the pivotal roles played by their Royal Highnesses, Prince Tjekedi and Prince Gcokoma (in their capacities as Regional Administrators), in ensuring that bobabe Tikhulu and Bantfwabenkhosi lababuke imimango were involved in the consultative process. While it is not possible to individually name each of the many valuable contributors to this process, the following are especially noteworthy: • Clinton Health Access Initiative (CHAI) • Family Life Association of Swaziland (FLAS) • Male Circumcision Technical Working Group • National Emergency Response Council on HIV and AIDS (NERCHA) • Population Services International (PSI) Swaziland • Regional Health Management Teams • Regional Multi-sectoral HIV and AIDS Coordinating Committee (REMSHACC) • Sexual and Reproductive Health Unit, MOH • Swaziland Democratic Nurses Union • Swaziland National AIDS Program, MOH • The Luke Commission • The Swaziland Nursing Council • The USAID Health Policy Project • Joint United Nations Program on HIV/AIDS (UNAIDS) • United Nations Children’s Fund (UNICEF) • World Health Organization (WHO) We look forward to working together in the next five years to ensure effective, coordinated implementation of this important strategy.

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EXECUTIVE SUMMARY The Swaziland Male Circumcision Strategic and Operational Plan for HIV Prevention 2014-2018 builds on the achievements of the Strategy and Implementation Plan for Scaling up Safe Male Circumcision for HIV Prevention 2009-2013. Developed under the leadership of the Ministry of Health, the 2014-2018 plan outlines the next phase of the national program to scale up male circumcision (MC) for HIV prevention. Voluntary medical male circumcision (VMMC) is a critical pillar of Swaziland’s HIV response. VMMC has been shown to be a safe and effective method of reducing female-to-male HIV transmission by approximately 60% in randomized controlled trials. Early infant male circumcision (EIMC) is an intervention intended to sustain the long-term HIV prevention benefits of VMMC. The Kingdom of Swaziland is the first country to develop Male Circumcision Strategic and Operational Plan, which provides for the comprehensive integration of VMMC and EIMC based on the latest international research and guidelines.

The Male Circumcision Strategic and Operational Plan for HIV Prevention 2014 -2018 is designed to achieve the male circumcision outcome level results set out in the Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. These results include that by 2018:

The plan also provides a comprehensive framework for the implementation of the eNSF male circumcision strategies, and are aligned with other important health and HIV and AIDS strategies and policy guidelines.

Preparation for the Swaziland Male Circumcision Strategic and Operational Plan for HIV Prevention involved a highly participatory process with both VMMC and EIMC stakeholders and modeling data produced by the Decision Maker’s Program Planning Tool 2.0. The Kingdom of Swaziland is one of the first countries to use this recently-developed model for male circumcision strategic and operational planning.

Based on the model’s results and the experience of higher male circumcision demand among younger age groups, Swaziland determined that prioritizing the 10-29 year group (first priority and the 30-34 year group (second priority) is the most cost effective approach with the greatest magnitude of impact to meet the eNSF 70% male circumcision coverage target. No coverage target has been set for the 35+ year age group. However, men in this age group will NOT be excluded from male circumcision services. Many important opinion leaders fall into this age group and their support will be critical to the success of the strategic and operational plan.

Modeling shows that the adopted approach will produce the following outcomes: • Over 31,000 new HIV infections averted (approximately 43%) by 2028 • Over 56,000 new infections averted (approximately 52%) by 2035 • Discounted cost savings of approximatey US$370 million by 2035 • Disccounted cost savings of over US$840 million by 2050

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In order to prioritize younger males and achieve the male circumcision coverage targets related to this age group, a comprehensive set of service delivery, human resources, demand creation and other strategies have been developed. Among the key strategies outlined in the documents are the following: • Age disaggregated and Inkhundla-based targeting to maximize the impact on priority age groups • Prioritization of outreach and mobile service delivery models • Development of a comprehensive MC service delivery plan linked to demand creation and human resources planning • Increased private sector participation in MC services • Strengthening of VMMC referral and follow up capacity in public sector health facilities • Scaling up of EIMC in existing service delivery sites and decentralization of EIMC services to lower level facilities • Development of a MC demand creation plan to guide demand creation interventions • Engagement of traditional leaders and other key opinion leaders • Empowerment of women to support MC scale up • Strengthening of VMMC uptake among relevant key populations and vulnerable groups • Strengthening quality assurance at all MC sites according to national standards and guidelines • Strengthening of MC strategic information systems and transfer of the MC database to the MOH • Strengthening of MC program coordination and management at the national, regional and community level

1 CHAPTER I: BACKGROUND AND INTRODUCTION

1.1 MALE CIRCUMCISION TERMINOLOGY The term ‘voluntary medical male circumcision’ (VMMC) has been used in some country contexts to encompass circumcisions performed by trained healthcare providers for early infants, adolescents and adult males for preventative healthcare reasons. In other contexts, VMMC only refers to adolescent and adult male circumcision services, and a separate term, ‘early infant male circumcision’ (EIMC), is used to describe circumcision for healthy baby boys, which takes place during the first 60 days of life. Swaziland uses the latter terminology, where VMMC denotes adolescent and adult male circumcision and is distinguished from EIMC, which encompasses circumcision that takes place between birth and eight weeks of age. The term ‘male circumcision’ (MC) is used when referring to both VMMC and EIMC.

1.2 HIV AND AIDS IN SWAZILAND Figures from the Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-20181, indicate that Swaziland has a generalized HIV epidemic, with a prevalence rate of 26% among 15-49 year olds, and 31% among those aged 18-49 years. New HIV infections are declining, and the HIV incidence rate among those aged 18-49 years is estimated at 2.38% (1.7% among men; 3.1% among women). HIV incidence is highest among women aged 18-19, 20-24 and 30-34 years, and among men aged 30-34 years. The gender disparity in HIV incidence is also reflected in HIV prevalence, with an estimated 38% prevalence among women compared to 23% among men. Studies show that the HIV epidemic is stabilizing and shifting to older population groups. Reported HIV prevalence among female sex workers is high at 70%. HIV prevalence among men who have sex with men (MSM), is 17%, which is slightly lower than the general male population aged 15-49 years (19%). Like a number of countries in the region, Swaziland is confronting the dual epidemics of HIV and tuberculosis (TB). The risk of acquiring TB is estimated to be between 20-37 times higher among people living with HIV (PLHIV). About 80% of TB patients are also HIV-positive, and TB is responsible for more than 25% of deaths among PLHIV. Swaziland is making progress in tackling the co-epidemics, with 66% of TB/HIV co-infected patients receiving treatment for both diseases in 2012, an improvement from 35% in 2010.

1 NERCHA 2014. Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018 1 | Page

The eNSF has identified 12 key drivers of the HIV epidemic in Swaziland as follows.

Figure 1: Key Drivers of the HIV Epidemic in Swaziland • High average viral load among people living with HIV2 • Low and inconsistent condom use • Gender inequality • Multiple and concurrent sexual partnerships • Early sexual debut • Intergenerational sex • Gender-based violence • Low levels of male circumcision • Low levels of HIV testing and counseling • HIV stigma and discrimination • Sex work • Men who have sex with men

1.3 THE RATIONALE FOR MALE CIRCUMCISION

Evidence in Support of Voluntary Medical Male Circumcision for HIV Prevention

Scale-up of VMMC is critically important to reduce the future burden of HIV in eastern and southern Africa. The urgency of scaling up stems both from the continuing high rate of new HIV infections and from the proven effectiveness of MC in reducing the risk of female-to-male sexual transmission of HIV. In 2005 and 2006, randomized controlled trials in three African countries demonstrated that MC reduces the risk of female-to-male sexual transmission by approximately 60%. Therefore, VMMC is an exceptional HIV prevention method, offering life-long, substantial (albeit partial) protection against female-to-male sexual transmission of HIV as well as other sexually transmitted infections (STIs).

In light of this evidence, the World Health Organization (WHO) and the Joint United Nations Program on HIV and AIDS (UNAIDS) recommended in 2007 that countries with high HIV prevalence and low prevalence of MC urgently begin VMMC programs for HIV prevention. WHO and UNAIDS identified 13 priority countries, including Swaziland, for scale up of VMMC. This number was subsequently increased to 16 countries3.

In 2009, mathematical modeling demonstrated that VMMC for HIV prevention was a cost-effective intervention, with 5-15 circumcisions averting one HIV infection in high HIV prevalence settings. Further epidemiological and economic modeling commissioned by PEPFAR and UNAIDS in 2011 determined that scale up of VMMC in appropriate settings constitutes a high-impact intervention

2 Viral load is highest among those who are not on ART, who do not know their status, and who know their HIV status but are not enrolled in care, a majority of those being men. 3 The 16 countries are: Botswana, Central African Republic, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, South Sudan, Swaziland, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe. UNAIDS. 2013. Global Report: UNAIDS Report on the Global AIDS epidemic 2013. 2 | Page

with excellent value for money. Various models have suggested that VMMC scale up would reduce HIV incidence in eastern and southern Africa by approximately 30-50% over 10 years4.

There is currently not enough evidence to support a recommendation to promote VMMC as an HIV prevention intervention for MSM and transgender people.

In addition to decreasing men’s risk of acquiring HIV through heterosexual sexual transmission, VMMC also confers other substantial health benefits. MC has been shown to reduce ulcerative STIs, human papilloma virus (HPV), which causes cervical cancer in women, and bacterial vaginosis and trichomonas in the female partners of circumcised men.

Evidence in Support of Early Infant Male Circumcision for HIV Prevention

In order to provide the protective benefits discussed above, MC is recommended either in adolescence/adulthood or within the first 60 days of life for healthy baby boys. There are programmatic benefits of providing MC in early infancy. Firstly, EIMC can be integrated into existing reproductive and maternal, neonatal and child health services. Contrary to some beliefs, adding HIV prevention, care and treatment services within the MNCH setting does not compromise quality of those services but rather increases the use of reproductive health services and improves infant outcomes5. Further, since MNCH services are decentralized and well-utilized throughout Swaziland, an integrated EIMC/MNCH package of services optimizes opportunities for strong EIMC coverage. EIMC offers fewer supply chain management challenges. Lastly, EIMC is less expensive to perform than VMMC, and provides long-term cost savings at national level. As EIMC is part of the the long- term sustainability plan for HIV prevention, a strong EIMC program means that targeted adult/adolescent MC programs will not have to continue indefinitely. At the individual level, undergoing MC in early infancy has some important advantages over having the procedure later in life. Since infant foreskin is thinner and less vascular than adult foreskin, EIMC is a simpler procedure: no suturing is required; healing is faster; and complication rates are lower as compared to VMMC. An additional benefit includes the reduced risk of urinary tract infections.

4 UNAIDS et al. 2009. Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine, 2009, 6: e1000109. doi:10.1371/journal.pmed.1000109. 5 Van den Akker, T. et. Al. 2012. HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi, Jan 2012 3 | Page

Potential Impact of Male Circumcision

A recent modeling exercise attempted to estimate the extent of the HIV epidemic in Swaziland if the country had had 80% MC coverage from the beginning of the epidemic. Using the Swaziland Goals Model, two HIV prevalence scenarios were created: one with MC coverage as estimated from the DHS and other local sources between 1990 and 2012; and the other one with an MC coverage of 80% projected in all years throughout the same period. The modeling exercise showed that approximately 200,000 people in Swaziland were estimated to be living with HIV in 2012, whereas this figure would have been around 15,000 if Swaziland had had an 80% MC coverage from the onset of the epidemic. Similarly, the estimated HIV prevalence as of 2012 was about 25% nationally, whereas it would have been around 2% in the 80% MC coverage scenario (see Figure 2).

Figure 2: Modeling the Potential Impact of MC Coverage on HIV Prevalence among 15-49 year olds 1990-2012

Estimated HIV prevalence based on MC coverage estimates 1990-2012 (Goals Model)

Projected HIV prevalence based on MC coverage of 80% in all years 1990-2012 (Goals Model)

Source: Kripke, K. et al (2014)6

6 Kripke, K. et al. 2014. Introducing Early Infant Male Circumcision (EIMC) in Southern and Eastern Africa – DMPPT 2.0 Modeling. 4 | Page

1.4 BACKGROUND AND OVERVIEW OF THE MALE CIRCUMCISION PROGRAM IN SWAZILAND

1.4.1 VMMC Program Overview In 2008, Swaziland adopted the WHO recommendations on MC and developed the Policy on Safe Male Circumcision for HIV Prevention7 and the Strategy and Implementation Plan for Scaling up Safe Male Circumcision for HIV Prevention 2009-20138. In 2011, the Accelerated Saturation Initiative (ASI), also known as Soka Uncobe (meaning ‘Circumcise and Conquer’ in SiSwati), was formally launched with the goal of circumcising 80% of the 15-49 years age group within one year. While the ambitious ASI targets were not met, important lessons were learned, especially about demand creation and the need to have strong community engagement and government coordination. Furthermore, during the ASI, the Ministry of Health (MOH) established important systems to support the MC program, including waste management and quality assurance standards and tools. A database was also established to capture data on the number of males circumcised, disaggregated by age and Inkhundla.

Since the end of ASI, the MOH has taken a stronger coordination and leadership role in MC, with the establishment of a VMMC unit within the Swaziland National AIDS Program (SNAP), which forms part of the Public Health Department within MOH. In partnership with the National Emergency Response Council on HIV and AIDS (NERCHA), MOH convenes the Male Circumcision - Technical Working Group (MC-TWG), which provides technical guidance and oversight of the MC program. Day-to-day responsibility for the management of the program is in the hands of the Senior Program Officer: VMMC, who coordinates both the VMMC and the EIMC programs. Financial and technical support for the VMMC program has been provided by a number of development partners, including PEPFAR, Bill & Melinda Gates Foundation, UNICEF and UNAIDS.

Since 2010, the principal VMMC service delivery providers have been MOH, the Ministry of Defense (MOD), Populations Services International (PSI), Family Life Association of Swaziland (FLAS), the Luke Commission (TLC) and Marie Stopes International (MSI). Swaziland has adopted a hybrid approach to service delivery, using a combination of mobile, outreach, fixed and integrated sites. Mobile sites provide services through mobile clinics, outreach sites erect tents and/or convert space at schools and other buildings to run services in different parts of the country, fixed sites are comprised of static government and NGO facilities, and integrated sites represent government facilities that have integrated VMMC into routine healthcare services. Demand at the different sites is created through interpersonal communication (IPC) agents, community dialogues, and major campaigns targeting youth, such as the Back to School (BTS) campaign and MC Fridays. BTS campaigns run through the school holidays, whereas MC Fridays take place at selected sites during the school term on Fridays.

VMMC scale up in the country demonstrated that there was a significant demand for circumcision coming from the 10-15 years age group, despite the fact that the program was targeting 15-49 year- olds. In response, MOH made a decision to reduce the minimum age for MC from 15 to 10 years old.

7 MOH. 2009. Policy On Safe Male Circumcision For HIV Prevention 8 Swaziland Male Circumcision Task Force. 2009. Strategy and Implementation Plan for Scaling Up Safe Male Circumcision for HIV Prevention in Swaziland 2009-2013 5 | Page

This was a sound decision from a public health perspective, as approximately 50% of the population in Swaziland is under the age of 20 years, a high percentage of adolescents are HIV-negative, and younger age groups do not experience the same barriers to VMMC services as older men (abstinence during the healing period, time off from work, etc.). By April 2014, approximately 21% of males circumcised were between the ages of 10-14 years, 23% were 15-19, 24% were 20-24, and most of the remaining 32% were over age 25. The percentage of eligible males circumcised by April 2014 was 24% (See Annex 1).

1.4.2 EIMC Program Overview EIMC serves as a long-term sustainability plan for the protective benefits of MC. Within sub-Saharan Africa, Swaziland stands at the forefront of EIMC programming, with over 4,000 EIMCs conducted by March 2014. As noted above, Swaziland’s 2009 National MC Policy specifically named neonates as a target group. Additionally, the eNSF specified ambitious targets for EIMC: 50% of male newborns will be circumcised by 2018. The National MC Policy envisioned EIMC service delivery integrated within the Maternal Neonatal Child Health (MNCH) platform.

In October 2009, the MOH began laying the foundation for EIMC programming by hosting an international expert consultation on EIMC. The resulting EIMC surgical guidelines endorsed the Mogen clamp as the preferred EIMC method for Swaziland, and these guidelines were incorporated into the national MC surgical protocol.

In 2010, Raleigh Fitkin Memorial (RFM) Hospital initiated EIMC services, and Mankayane Hospital and two affiliated clinics finalized plans for an EIMC pilot. The same year, EIMC indicators were integrated into national monitoring tools, including the antenatal care (ANC) register, ANC card, child welfare card, child welfare register, and postnatal register. In April 2010, the Minister of Health officially launched the EIMC program. In February 2011, the first EIMC clinical training course for nurses and doctors took place. Swaziland also developed and piloted EIMC quality assurance and supportive supervision tools and developed a quality assurance implementation plan. Between 2011 and 2013, integrated EIMC services were scaled up to all six hospitals and five health centers countrywide, as well as three NGO sites and three private clinics. In 2013, the public sector sites together circumcised an average of 15% of eligible male babies.

Creating client demand for EIMC services has taken place through multiple means at both the community and the facility level. At public facility level, trained healthcare workers as well as NGO- supported EIMC motivators and mentor mothers have delivered client education at multiple entry points, including antenatal care, labor and delivery, postnatal care, and child welfare clinics. At community level, IPC agents sensitized and mobilized target communities for both EIMC and VMMC. Structured community dialogues have also included educational content on EIMC.

1.5 STRATEGIC AND OPERATIONAL PLAN DEVELOPMENT PROCESS

This Male Circumcision Strategic and Operational Plan for HIV Prevention 2014-2018 (MC Strategic Plan) was commissioned by the Government of the Kingdom of Swaziland (GOKS) in order to provide a roadmap for the achievement of MC targets set in the eNSF. Commencing in November

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2013, the MC strategic and operational planning process was comprised of five phases with strong MOH leadership during each phase:

Phase 1: Situation Analysis The purpose of the Situation Analysis was to assess the accessibility, availability and effectiveness of VMMC services in Swaziland; map and assess activities, coverage, capacities, and collaborative arrangements of the stakeholders involved in VMMC; extract lessons from the findings of the assessment; and develop recommendations to inform the MC strategic and operational planning process9. The main deliverable of Phase 1, the Situation Analysis Report, provides much of the background information in this MC Strategic Plan.

Phase 2: Stakeholder Consultation and Engagement The Stakeholder Consultation and Engagement phase involved document review, the development of consultation tools, and the organization of national and regional consultation meetings and key informant interviews with critical stakeholders. These activities were designed to generate strategic themes that would constitute the main pillars of the MC Strategic Plan. Consultation meetings were held at national and regional level with all key VMMC and EIMC role-players, including: the MC TWG, NERCHA, development partners, traditional leaders, traditional healers, civil society organizations (CSOs), community-based organizations (CBOs), faith-based organizations (FBOs), VMMC and EIMC service providers, government ministries, the Sexual and Reproductive Health Unit (SRHU), youth organizations, women’s organizations, the private sector, and professional medical and nursing bodies.

Phase 3: Draft Male Circumcision Strategic Plan Development Two separate consultation processes were used to develop the VMMC and EIMC components of the MC Strategic Plan. These distinct processes were then brought together in order to develop an integrated VMMC/EIMC, i.e. MC Strategic Plan. The draft Plan was presented to regional and national stakeholder meetings, the MOH senior management team, the MC TWG and NERCHA for review and initial validation.

Phase 4: Costed Operational Plan and Final MC Strategic Plan Development Key stakeholder inputs on the draft MC Strategic Plan were addressed, and the revised plan was used to develop a costed operational plan to provide details of activities, implementation timelines, roles and responsibilities, and cost estimates. The final draft MC Strategic Plan and Costed Operational Plan were then presented to national stakeholders for final validation.

Phase 5: Dissemination and Capacity Building for MC Strategic and Operational Plan Implementation Phase 5 was designed to ensure that copies of the MC Strategic and Operational Plan were disseminated to all key MC stakeholders, and provide capacity building activities to equip MC stakeholders with the skills necessary to ensure effective implementation of the plan.

Over 170 organizations were involved in the development of the MC Strategic Plan (See Annex 2).

9 MSH. 2014. Situation Analysis: Voluntary Medical Male Circumcision (VMMC) in Swaziland 7 | Page

2 CHAPTER II: OVERVIEW OF STRATEGIC DIRECTION

2.1 INTRODUCTION

The strategic direction for the MC Strategic Plan is informed by the eNSF, other national health and HIV/AIDS strategies and guidelines, and international MC strategies, best practices and guidelines.

2.2 ALIGNMENT WITH THE EXTENDED NATIONAL MULTISECTORAL HIV AND AIDS FRAMEWORK (eNSF) 2014 - 2018 The national HIV and AIDS response is guided by the eNSF. The goal of the eNSF is to halt the spread of HIV and reverse its impact on Swazi society. The national multisectoral response on HIV and AIDS recognizes the local context and has set strategic priorities to invest in high-impact interventions and sustain the gains made since the response began.

Through the implementation of the eNSF, Swaziland aims to achieve the following impact-level results: • A 50% reduction of new HIV infections among adults and children by 2015. • A reduction in mortality and morbidity among PLHIV and in particular those with TB/HIV co-infection. • Alleviate socio-economic impacts of HIV and AIDS among vulnerable groups. • Improve the efficiency and effectiveness of the national response planning, coordination and service delivery. The eNSF adopts the “combination prevention approach”10, which combines biomedical, behavioral, social, and structural interventions for maximum impact to prevent new infections. Swaziland has prioritized nine core programs as critical for implementation during the eNSF 2014-2018. These core programs were selected based on evidence of their effectiveness and the magnitude of their impact on the gains already made. The prioritization is also aligned to the global investment approach to HIV programming11. The eNSF core programs include: • HIV testing and counseling • Social and behavior change (SBC) • Condom promotion and distribution • Prevention of mother-to-child transmission (PMTCT) • Male circumcision • Customized interventions for key populations • Treatment, care and support for PLHIV • Care and support for orphans and vulnerable children (OVC) • Addressing gender-based violence

10 UNAIDS. 2010. Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections. A UNAIDS Discussion Paper. 11 UNAIDS. 2011. A new investment framework for the global HIV response. UNAIDS, Geneva. 8 | Page

HTC and SBC are considered cross-cutting themes in all core programs. HTC provides a critical entry point to most programs such as care and treatment, VMMC, and PMTCT, while SBC is deployed as a key strategy for increasing uptake of HIV services and behavior change. Swaziland’s approach to combination prevention is further elaborated in the HIV Prevention Strategy.

The objective of the MC program, as stipulated in the eNSF, is to increase the uptake of MC among all eligible males in Swaziland. The following outcome level results will be used to track the performance of the program: • Percentage of males aged 10-49 years who are circumcised is increased to 70% by 2018 • Percentage of males under 5 years old who are circumcised is increased to 50% by 2018 • Percentage of parents who support their sons being circumcised is increased to 60% by 2018

To meet the eNSF MC targets, approximately 227,670 circumcisions will need to be performed by 2018. The eNSF highlights four strategies considered essential for effective MC scale up: (i) Strengthen and decentralize MC services, especially for neonates and males aged 10-35 years in health and non-health facilities. (ii) Intensify education, awareness and community mobilization to generate demand and increased benefits of MC for both men and women. (iii) Address socio-cultural norms, myths and misconceptions of MC that create barriers to service uptake. (iv) Integrate MC services with other health services.

This MC Strategic Plan is designed to achieve the MC outcome-level results set out in the eNSF and provides a comprehensive framework for the implementation of the eNSF MC strategies. It includes detailed strategies for service delivery, human resources, demand creation, quality assurance, strategic information, and program coordination and management, among others (See Figure 4). The MC Operational Plan provides details of the activities, implementation schedule and implementing organization for each strategy (see Annex 3). Table 1 highlights the key MC Strategic Plan strategies aligned to the eNSF MC strategies.

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Table 1: Key MC Strategic Plan Strategies Aligned to the eNSF MC Strategies eNSF MC Strategies Key MC Strategic Plan Strategies Aligned to the eNSF MC Strategies (i) Strengthen and decentralize MC services, • Scale up EIMC in existing service delivery especially for neonates and males aged 10-35 sites years in health and non-health facilities. • Decentralize EIMC services to lower level (ii) Intensify education, awareness and facilities community mobilization to generate • Strengthen VMMC referral and follow up demand and increased benefits of MC for capacity in public sector health facilities both men and women. • Strengthen MC demand creation framework (iii) Address socio-cultural norms, myths and • Engage traditional leaders and other opinion misconceptions of MC that create barriers to leaders in creating demand for MC service uptake. • Develop and implement national and local MC multimedia campaigns (iv) Integrate MC services with other health • Deploy information and communication services. technologies to promote MC • Utilize multiple platforms to promote VMMC and EIMC messaging • Empower women to support MC scale up • Refocus VMMC demand creation to address men’s reproductive health and new social norms that appeal to men and women

2.3 ALIGNMENT WITH OTHER NATIONAL HEALTH AND HIV/AIDS STRATGIES AND OPERATIONAL GUIDELINES In addition to the eNSF, the MC Strategic Plan is aligned with other important national health and HIV and AIDS strategies and guidelines. These include: • Health Sector Response to HIV/AIDS Plan 2014-2018 (2014) • HIV Prevention Strategy (2014) • SRH Strategy (2014) • Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (2011) • Health Care Waste Management Guidelines and Standard Operating Procedures (2014) • National Quality Guidelines (2011)

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2.4 ALIGNMENT WITH INTERNATIONAL MALE CIRCUMCISION STRATEGIES AND GUIDELINES

The development of the MC Strategic Plan has also been informed by international MC strategies, guidelines, and best practices. In 2011, UNAIDS, WHO, the World Bank, PEPFAR and the Bill & Melinda Gates Foundation developed the Joint Strategic Action Framework12 to guide MC scale up efforts in the priority MC countries of eastern and southern Africa. The Joint Strategic Action Framework is based on six underlying principles:

(i) Country leadership and ownership. To ensure the acceptablibity, success and sustainability of MC programs, countries themselves should own and lead efforts to bring MC to scale. The role of development partners should be to support national programs by aligning their interventions with MC national strategic and operational plans. (ii) Human rights. Medical MC should in all cases be voluntary, based on informed consent, non-coercive and carried out under safe conditions. (iii) Gender dimensions. The effects of VMMC scale-up on women should be taken into account in national planning and program implementation and will be monitored as services are expanded. (iv) A comprehensive package of services for HIV prevention. VMMC provides men with only partial protection from HIV acquisition and should always be understood as but one element of a comprehensive HIV prevention package. (v) Combination of dedicated and integrated approaches to maximize public health benefits. While dedicated VMMC services may be essential during the initial phase of scale up, over the long term these services must be carefully integrated into planning for comprehensive HIV prevention and sexual and reproductive health programming and for the health sector’s response to HIV. (vi) Strategic, coordinated action: Strategic and coordinated action at all levels (local, national, regional, global) is essential to achieving success in an efficient manner.

The Joint Strategic Action Framework is also based on seven strategic pillars: (i) leadership and advocacy; (ii) country implementation; (iii) innovations for scale-up; (iv) communication; (v) resource mobilization; (vi) monitoring and evaluation; and (vii) coordination and accountability. The MC Strategic Plan adheres to the important principles and strategic pillars outlined in the Joint Strategic Action Framework. Since 2011, further strategic and operational guidelines have been developed by international development partners, including: • Framework for Clinical Evaluation of Devices for Male Circumcision (WHO, 2012) • Best Practices for Voluntary Medical Male Circumcision Site Operations (PEPFAR, 2013) • Voluntary Medical Male Circumcision (VMMC) Demand Creation Toolkit (PEPFAR, 2014)

The MC Strategic Plan is aligned with these documents, and international MC guidance developed since 2007.

12 UNAIDS and WHO (2011) Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa 2012–2016. 11 | Page

3 CHAPTER III: OVERVIEW OF STRATEGIC APPROACH

3.1 INTRODUCTION

The MC Strategic Plan is designed to achieve the 70% VMMC and 50% EIMC coverage targets outlined in the eNSF. Considering the demographics of Swaziland, with a large proportion of the male population under the age of 20 years, and the current MC age-disaggregated coverage data, the MOH recognized the need for revised modeling to assist the country in better defining the scale up plan required to achieve the eNSF targets. Targeting different age groups was considered necessary to understand the potential impact on incidence reduction and other key HIV variables. The MOH reached out to USAID and the Bill & Melinda Gates Foundation, and subsequently the Health Policy Project (HPP) was commissioned to apply their new MC model, the Decision Makers Program Planning Tool version 2.0 (DMPPT 2.0).

The new DMPPT 2.0 model can be used to examine the HIV incidence impact of different age and geographic prioritization scenarios for circumcision programs.

DMPPT 2.0 modeling shows that in the context of Swaziland13: • the highest level of effectiveness will be obtained by circumcising 15-29 year-olds; • the highest immediacy of impact will result from circumcising 20-29 year-olds; • the greatest magnitude of impact will be obtained by circumcising 10-24 year-olds; and • program costs will be the lowest if the 15-29 age group is circumcised.

3.2 A TEN-YEAR PHASED APPROACH

Swaziland will adopt a phased approach to MC scale up, comprised of two distinct phases: the catch- up phase and the sustainability phase. The catch-up phase will cover the period 2014-2018 and will prioritize VMMC for adolescents and adults with the goal of achieving the 70% eNSF target. The catch-up phase will be a once-off, intensive intervention. It will seek to sharply accelerate the pace of VMMC scale up by building on lessons learned and successes to improve access to services and increase demand, while addressing the barriers that have limited uptake to date. The sustainability phase will involve the progressive scale up of EIMC to 50% of all newborn males by 2018. Adolescent circumcisions will continue beyond 2018 as part of the sustainability phase to maintain VMMC coverage at 70%, and will be undertaken through BTS and other campaigns at fixed, outreach and mobile facilities. EIMC will be completely integrated and sustained within the MNCH platform.

Figure 3 provides an illustration of the phased scale up approach. It shows the downward trend in adult and adolescent circumcisions that have taken place since 2010, the extensive scale up planned for 2014-2018, and the tapering of the number of circumcisions envisaged after 2018.

13 Results are reported for the time period 2014-2028, using scenarios in which circumcision is scaled up to 80% coverage among the indicated age groups by 2018 and maintained at 80% coverage within those age groups into the future. 12 | Page

Figure 3: Swaziland MC Scale up Scenario 2014-2035

Number of MCs by Age and Year

Table 2 provides figures for the age-disaggregated coverage targets at the national level. Progress against these targets will be monitored on a quarterly basis by the MC TWG and MOH. Tables 3-6 show figures for each of the regions. Regional Multi-sectoral HIV and AIDS Coordinating Committees (REMSHACCs) and Regional Health Management Teams (RHMTs) will review performance against regional figures on a quarterly basis.

Table 2: MC National Targets by Age Group 2014-201814 Year Circumcisions EIMC 10–14 15–19 20–24 25–29 30–34 Total 2014 1,802 8,710 8,773 8,372 7,359 3,107 38,123 2015 3,608 10,866 8,758 8,228 7,729 2,665 41,855 2016 5,403 13,120 8,741 7,997 8,037 2,245 45,543 2017 7,188 15,524 8,658 7,764 8,194 1,837 49,165 2018 8,969 18,289 8,451 7,623 8,208 1,446 52,985

Total 26,970 66,508 43,382 39,984 39,527 11,300 227,670

14 Regional totals may not add up to national total due to rounding 13 | Page

Table 3: Manzini Region MC Targets by Age Group 2014-2018 Year Circumcisions EIMC 10–14 15–19 20–24 25–29 30–34 Total 2014 549 2,612 2,680 2,474 2,099 825 11,238 2015 1,100 3,269 2,675 2,430 2,211 690 12,376 2016 1,647 3,956 2,670 2,360 2,305 562 13,501 2017 2,192 4,689 2,645 2,288 2,353 438 14,605 2018 2,735 5,533 2,581 2,245 2,357 319 15,770

Total 8,224 20,059 13,250 11,797 11,326 2,834 67,491

Table 4: Hhohho Region MC Targets by Age Group 2014-2018 Year Circumcisions EIMC 10–14 15–19 20–24 25–29 30–34 Total 2014 516 2,570 2,603 2,557 2,243 933 11,423 2015 1,034 3,188 2,599 2,516 2,349 806 12,492 2016 1,548 3,834 2,594 2,450 2,437 686 13,548 2017 2,059 4,522 2,570 2,383 2,482 569 14,586 2018 2,569 5,314 2,511 2,343 2,486 457 15,680

Total 7,725 19,429 12,876 12,250 11,998 3,451 67,728

Table 5: Lubombo Region MC Targets by Age Group 2014-2018 Year Circumcisions EIMC 10–14 15–19 20–24 25–29 30–34 Total 2014 367 1,658 1,664 1,592 1,463 650 7,395 2015 736 2,098 1,661 1,563 1,538 560 8,156 2016 1,102 2,558 1,658 1,516 1,601 474 8,908 2017 1,466 3,048 1,641 1,468 1,633 391 9,647 2018 1,829 3,612 1,599 1,439 1,636 311 10,427

Total 5,501 12,975 8,223 7,578 7,870 2,387 44,534

Table 6: Shiselweni Region MC Targets by Age Group 2014-2018 Year Circumcisions EIMC 10–14 15–19 20–24 25–29 30–34 Total 2014 369 1,869 1,827 1,748 1,555 699 8,067 2015 739 2,310 1,823 1,719 1,630 609 8,831 2016 1,106 2,772 1,820 1,672 1,694 522 9,585 2017 1,471 3,264 1,803 1,624 1,726 439 10,327 2018 1,836 3,830 1,761 1,595 1,729 359 11,109

Total 5,520 14,045 9,034 8,358 8,333 2,628 47,918

3.3 AGE DISAGGREGATED TARGETING Based on this analysis and the experience of high MC demand among younger age groups, Swaziland has decided to pursue its 2018 eNSF target of 70% coverage among males aged 10-49 years by prioritizing the 10-29 years age group (first priority, with an 80% coverage target) and 30-34 years age group (second priority, with a 55% coverage target). The EIMC coverage target is 50% by 2018. No coverage target has been set for the 35+ years age group. However, men in this age group will NOT 14 | Page

be excluded from MC services. Since many important opinion leaders fall into this age group, it will be essential for the MC Strategic Plan to enlist the support of a critical mass of men over the age of 35 years who have undergone circumcision or are prepared to undergo circumcision to serve as role models for the younger age groups. Nevertheless, the primary focus of demand creation and service delivery efforts will be the 10-29 years age group, with a secondary focus on 30-34 year-olds. Modeling shows that the adopted approach will produce the following outcomes:

• Over 31,000 new HIV infections averted (approximately 43%) by 2028 • Over 56,000 new infections averted (approximately 52%) by 2035 • Discounted cost savings of approximatey US$370 million by 203515 • Discounted cost savings of over US$840 million by 205016..

3.4 GEOGRAPHIC TARGETING

Swaziland will also pursue an Inkhundla-based geographic targeting approach. As noted above, the MC database provides comprehensive information, disaggregated by age and Inkhundla. This data shows MC coverage varying across the country from a high of 60.5%, to a low of 6.2% (See Annex 1). A detailed analysis of this data will be conducted to determine the factors responsible for such variations, and the results of this analysis will be used to inform Inkhundla-based targeting. Information on coverage rates and age disaggregation will be used with information on population size, the attitude of local chiefs and other opinion leaders towards MC, and other enabling factors to determine which Tinkhundla should be prioritized first to achieve ‘quick wins’ and create a favorable momentum towards MC scale up throughout the country. MC scale up strategies have been designed to ensure the implementation of high quality, comprehensive, effective VMMC and EIMC service delivery according to WHO and GOKS quality standards and guidelines, with clearly defined quarterly coverage targets for the specified target populations in each Inkhundla.

Access to Services

Given that more than 70% of Swaziland’s population lives in rural areas where access to health services can be challenging, a variety of service delivery approaches for VMMC, such as mobile outreach teams, will be implemented to make services more accessible to the population (see Chapter 4). In addition, the scale up plan will strongly promote community engagement to increase demand for services, normalize circumcision among men, and shift social and gender norms to support the reduction of risky sexual behaviors (see Chapter 6).

3.5 SCALE UP PLAN FOR EIMC

Since the MOH’s long-term goal is that EIMC will become an integrated, sustainable, and routine component of the MNCH package of services for healthy baby boys, the concept of a “rapid scale up” does not apply to EIMC in the same way that it does to VMMC. The focus of the EIMC

15 Cost savings in this case represents the treatment costs averted by scaling up VMMC, minus the cost of scaling up the VMMC program. 16 PEPFAR and Bill and Melinda Gates Foundation. 2014. Presentation on Focusing Demand Creation Strategies for the Voluntary Medical Male Circumcision for HIV Prevention Program in Swaziland: New Modeling Exercise Approach and Preliminary Results Sharing. April 8, 2014 version. 15 | Page

program will be increasing EIMC acceptability at both facility and community level to institutionalize the intervention, and promoting a change in MC social norms. Increasing client demand and availability of EIMC services through capacity building, increasing facility ownership, and intensified community mobilization and demand creation for people accessing current EIMC sites will be the priority. EIMC will also be introduced at any additional public or private facilities where deliveries take place and where doctors are present. Lastly, after legislation is passed to authorize nurses to perform EIMC independently, the MOH will develop a strategy for decentralizing EIMC services to lower level facilities (i.e. Public Health Units and peripheral clinics) to improve access in hard-to- reach areas.

3.6 MALE CIRCUMCISION STRATEGIES Figure 4 provides details of the MC strategies that will be pursued to achieve the MC scale up plan targets.

Figure 4: Male Circumcision Strategies Strategic Strategic Action Action # Strategy Element 1: Service Delivery 1.1 MC Service Delivery Strategies Develop a comprehensive MC service delivery plan linked to demand creation and human 1.1.1 resources planning Engage experienced MC service delivery providers to scale up innovative service delivery 1.1.2 models 1.1.3 Strengthen linkages and referrals between communities and VMMC and EIMC facilities 1.1.4 Increase private sector participation in MC services 1.2 VMMC Service Delivery Strategies Strengthen, scale up and sustain mobile and outreach sites linked to campaigns and 1.2.1 community-based demand creation Strengthen, scale up and sustain selected existing NGO fixed sites linked to campaigns 1.2.2 and community-based demand creation 1.2.3 Strengthen VMMC referral and follow up capacity in public sector health facilities 1.3 EIMC Service Delivery Strategies 1.3.1 Scale up EIMC in existing service delivery sites 1.3.2 Decentralize EIMC services to lower level facilities Strategy Element 2: Human Resources for Service Delivery 2.1 MC Human Resources Strategies 2.1.1 Strengthen MC HR planning to support MC scale up 2.2 VMMC Human Resources Strategies 2.2.1 Strengthen MC VMMC HR capacity to support MC scale up 2.3 EIMC Human Resources Strategies 2.3.1 Increase the number of EIMC trained healthcare providers 2.3.2 Develop, endorse, and implement EIMC Task Shifting Regulations 2.3.3 Explore the feasibility of introducing EIMC into nursing pre-service education Continue to roll out the on-the-job EIMC counseling module at all healthcare facilities 2.3.4 providing services to pregnant women

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Strategic Strategic Action Action # Strategy Element 3: Demand Creation 3.1 MC Demand Creation Strategies 3.1.1 Strengthen MC demand creation framework 3.1.2 Engage traditional leaders and other key opinion leaders in creating demand for MC 3.1.3 Develop and implement national and local MC multimedia campaigns 3.1.4 Deploy information and communication technologies to promote MC 3.1.5 Utilize multiple platforms to promote VMMC and EIMC messaging 3.1.6 Empower women to support MC scale up 3.2 VMMC Demand Creation Strategies Scale up existing VMMC campaigns and develop new campaigns targeted at places and 3.2.1 occasions where young men congregate in large numbers Refocus VMMC demand creation to address men’s reproductive health and new social 3.2.2 norms that appeal to men and women 3.2.3 Strengthen VMMC uptake among relevant key populations and vulnerable groups 3.3 EIMC Demand Creation Strategies Increase ownership of EIMC services by public facility providers as part of a 3.3.1 comprehensive MNCH package 3.3.2 Strengthen the informed consent process for EIMC 3.3.3 Increase involvement of fathers (and fathers to be) in EIMC Strategy Element 4: Supply Chain Management 4.1 MC Supply Chain Management Strategy Strengthen the existing national Central Medical Stores supply chain management system 4.1.1 to meet the increased requirements of MC scale up Strategy Element 5: Waste Management 5.1 MC Waste Management Strategy Ensure compliance with the Health Care Waste Management guidelines and Standard 5.1.1 Operating Procedures at all MC sites Strategy Element 6: Quality Assurance 6.1 MC Quality Assurance Strategy Strengthen Quality Assurance at all MC sites according to national standards and 6.1.1 guidelines Strategy Element 7: New Technologies and Devices 7.1 MC New Technologies and Devices Strategy Review developments in MC new technologies and devices and implement findings that 7.1.1 could enhance MC scale up Strategy Element 8: Strategic Information 8.1 MC Strategic Information Strategy 8.1.1 Strengthen MC Strategic Information Systems Strategy Element 9: Program Coordination and Management 9.1 MC Program Coordination and Management Strategy Strengthen MC program coordination and management at the national, regional and 9.1.1 community level

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4 CHAPTER IV: SERVICE DELIVERY

4.1 SERVICE DELIVERY OVERVIEW

4.1.1 Current VMMC Service Delivery Models and Approaches WHO, UNAIDS17 and other international guidelines place strong emphasis on the need for VMMC to be linked to a combination prevention approach and implemented as part of a comprehensive HIV prevention package, which includes the following key elements: • Pre-operative provider initiated testing and counseling routinely provided on-site for all men and, where possible, their female partners; • Active exclusion of men with symptomatic STIs and provision of syndromic treatment when indicated, with re-appointment for VMMC once treatment is concluded; • Provision and promotion of correct and consistent use of male and female condoms; • Post-operative wound care and abstinence instructions during the wound healing period; • Age-appropriate counseling (including couples’ counseling) on risk reduction, including reducing the number and concurrency of sexual partners, delaying/abstaining from sex, and provision and promotion of correct and consistent use of male and female condoms; and • Active linkage to other HIV prevention, treatment, care, and support services as needed. Swaziland has followed these guidelines and has adopted a hybrid approach to service delivery comprised of a combination of mobile, outreach, fixed, and integrated sites. Mobile sites provide services through mobile clinics, outreach sites erect tents and/or convert space at schools and other buildings to run services in different parts of the country, fixed sites are static government and NGO facilities, and integrated sites represent government facilities that have integrated VMMC into routine healthcare services. A number of the fixed sites are also used as outreach sites during demand creation campaigns such as BTS and MC Fridays, and some fixed sites are only used for outreach campaigns. The MC database currently captures the number of MCs undertaken using the following categories: • NGO Fixed: the figures in this category represent the number of routine VMMCs undertaken at five static NGO clinics and do not include the circumcisions undertaken at these facilities during BTS • NGO Outreach including BTS: the figures in this category capture VMMCs undertaken during BTS campaigns • NGO Outreach excluding BTS: this represents VMMCs performed on an outreach basis outside of BTS campaigns • NGO Mobile: this captures the VMMCs performed by TLC, a local NGO which uses a mobile surgical unit and offers VMMC as one of the components of its comprehensive health service package • Public Integrated: the figures that emanate from government health facilities that have integrated VMMC into routine health services

17 WHO and UNAIDS. 2007. New data on male circumcision and HIV prevention: policy and program implications. Available at: http://libdoc.who.int/publications/2007/9789241595988_end.pdf.

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• MC Friday: this category includes all the male circumcisions undertaken during MC Friday campaigns (these figures are also included in the NGO Fixed and NGO Outreach categories) • Sweeping the Zone: this is a MC geographical concentration strategy that involves three main stages: (i) community identification to determine eligible communities based on MC coverage rates and local information; (ii) community mobilization ahead of providing services; and (iii) intense service delivery based on the volume of clients mobilized. So far this approach has only been undertaken on a pilot basis.

As the MC database captures only a small fraction of the MCs undertaken in the private sector, its figures on private sector MCs cannot be used for comparative purposes.

Table 7 provides figures for the number of circumcisions undertaken between January 2013 and May 2014 by each of the service delivery categories used in the MC database. It shows that the biggest single category is the NGO Fixed, but when added together the NGO Outreach and NGO Mobile make up a bigger proportion of the total number of MCs. BTS makes a major contribution to NGO Outreach, and the figures for the MC Friday campaign represent a substantial proportion of the circumcisions performed in NGO Fixed facilities. The figures for NGO Mobile are very promising because it represents the output of one surgical team, whereas the figures for NGO Fixed are produced by five established clinics. The NGO Mobile service delivery model is currently witnessing the highest number of circumcisions per month for a single facility, with 377 circumcisions performed in March 2014.

The Public Integrated model has produced a low number of MCs in the past year. Little can be read into the figures for the Sweeping the Zone approach because, as stated above, this operation only began recently and has so far been run on a pilot basis.

Table 7: MCs Undertaken by specific MC Database Categories from January 2013-May 2014 MC DATABASE CATEGORIES TOTAL NGO Fixed 4,919 NGO Outreach Including Back to School Campaigns 2,565 NGO Outreach Excluding Back to School Campaigns 879 NGO Mobile 2,501 Public Integrated 329 MC Friday 1,213 Sweeping the Zone 76

The figures captured in the MC database clearly show the effectiveness of outreach and mobile service delivery models, and the value of organized campaigns in increasing VMMC uptake. The service delivery strategies for VMMC scale up will build upon the success of the outreach and mobile service delivery models, and new demand creation strategies will be developed, informed by the achievements of the BTS and MC Friday campaigns.

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4.1.2 EIMC Service Delivery Swaziland’s EIMC program primarily focuses on strengthening service delivery systems at government health facilities, NGO clinics, and several private clinics. Swaziland’s MOH recognizes that the provision of EIMC services should not be an isolated and vertical intervention. As outlined in its 2009 MC Policy, Swaziland’s EIMC program is integrated into the MNCH platform. This integration starts during the pregnancy period and continues through to the postnatal period. EIMC messages accompany messages of birth preparedness, proper prenatal and antenatal care, and comprehensive ‘Day of Birth’ care for the mother and the newborn. The focus of healthcare providers should continue to be to provide comprehensive information and education for parents and guardians so that they can make informed choices about EIMC, to provide high quality and safe EIMC services, and to provide families the opportunity to access other health care needs when they are in contact with the health system. EIMC demand creation uses interpersonal EIMC communication activities at both the facility and community levels. EIMC trainings are provided using the 2010 WHO/Jhpiego learning resource package; supportive supervision and mentorship are also an integral part of the programming.

Table 8: Current EIMC Service Delivery Sites Swaziland EIMC Service Delivery Sites Type of Facility Mankayane Public Hospital Nhlangano Public Health Center Hlathikulu Public Hospital Raleigh Fitkin Memorial (RFM) Faith-based Hospital Mbabane Government Public Hospital Piggs Peak Public Hospital Dvokolwako Public Health Center Good Shepherd Faith-based Hospital Emkhuzweni Public Health Center Sithobela Public Health Center Matsanjeni Public Health Center FLAS Mbabane NGO Clinic FLAS Manzini NGO Clinic Litsemba Letfu NGO Clinic Medisun clinic Private Clinic Mkhiwa Clinic Private Clinic Women and Children Clinic Private Clinic

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Service Delivery Strategies

Box 1 provides a list of the strategies that will be employed to address the service delivery challenges that have been identified. Details of each of the strategies are provided in Sections 4.2, 4.3 and 4.4.

Box 1: Service Delivery Strategies MC Service Delivery Strategies

Develop a comprehensive MC service delivery plan linked to demand creation and human resources planning

Engage experienced MC service providers to scale up innovative service delivery models

Strengthen linkages and referrals between communities and VMMC and EIMC facilities

Increase private sector participation in MC services

VMMC Service Delivery Strategies

Strengthen, scale up and sustain mobile and outreach sites linked to campaigns and community based demand creation

Strengthen, scale up and sustain selected existing NGO fixed sites linked to campaigns and community based demand creation

Strengthen VMMC referral and follow up capacity in public sector health facilities

EIMC Service Delivery Strategies Scale up EIMC at existing service delivery sites Decentralize EIMC services to lower level facilities

4.2 MC SERVICE DELIVERY STRATEGIES

4.2.1 Develop a comprehensive MC service delivery plan linked to demand creation and human resources planning A comprehensive MC service delivery plan will be developed, identifying details of the outreach and mobile service delivery models that will be prioritized in the scale up of VMMC, and the schedule for the expansion of service delivery outlets within existing facilities to enable scale up of EIMC. The MC Service Delivery Plan will use age-disaggregated Inkhundla VMMC coverage rates, population size, the attitude of local chiefs and other opinion leaders towards MC, and other enabling factors to determine the timetable for service delivery using outreach, mobile and fixed platforms for VMMC. The MC Service Delivery Plan will detail the roles that will be played by outreach, mobile, private sector, and NGO and government fixed sites in VMMC scale up, as well as the roles of government facilities and private sector providers in EIMC scale up. The MC Service Delivery Plan will also provide guidelines on the organization and location of VMMC services to maximize their appeal to the first priority (10-29 year-olds) and second priority (30-34 year-olds) target populations. The guidelines will also stipulate the mechanisms needed to deliver the HIV prevention minimum package at all VMMC sites, including special service delivery hours and staffing arrangements to address

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generational, cultural and gender issues, as well as barriers presented by normal working hours. Service roll out for both VMMC and EIMC will be linked to demand creation campaigns and effective human resources planning.

4.2.2 Engage experienced MC service delivery providers to scale up innovative service delivery models To enhance cost effectiveness, service quality, and innovative approaches to the achievement of VMMC and EIMC coverage targets, MC service delivery providers with a proven track record of MC scale up will be engaged. These service providers will work in partnership with local, regional and international organizations that have developed MC best practices. The service delivery providers will develop implementation plans outlining: the services to be established to reach the age-disaggregated MC coverage targets in specific Tinkhundla; plans to ensure that all MCs are done according to WHO and national quality standards; and the mechanisms that will be used to ensure service delivery coordination at the local level.

4.2.3 Strengthen linkages and referrals between communities and VMMC and EIMC facilities A well-structured, coordinated MOH system for community referrals to public sector facilities, as well as facility-to-facility referrals, has recently been introduced for all stakeholders. VMMC and EIMC will be among the services to which clients can be referred and followed up to ensure linkages. HTC referral and linkages programs, which trace clients with mobile phones and confirm referrals with facilities, are demonstrating promising results. These innovations will be tested to support the scale up of VMMC and EIMC.

4.2.4 Increase private sector participation in MC services So far, only limited attempts have been made to engage the private sector in MC scale up efforts. The private sector includes both private practice service providers and the business community. These groups can make a considerable contribution to the program, either through a contribution to MC targets or by facilitating MCs in the target groups during campaign or outreach activities. The business community can also enhance scale up by promoting VMMC as a prevention measure through existing corporate wellness programs; implementing EIMC and VMMC services in corporate healthcare clinics; and introducing policies that permit VMMC clients to take leave from work to recover from the surgical procedure. Building demand among privately insured and self-paying clients, as well as introducing EIMC services to all private facilities within ANC, labor and delivery, and postpartum services, will have a significant impact on reaching EIMC targets.

4.3 VMMC SERVICE DELIVERY STRATEGIES

4.3.1 Strengthen, scale up and sustain mobile and outreach sites linked to campaigns and community based demand creation Drawing on the past successes of outreach and mobile service delivery models, resources will be provided to strengthen existing capabilities and introduce additional mobile clinics and outreach facilities. The objective will be to put in place sufficient outreach and mobile service delivery infrastructure to achieve medium to high volume circumcision numbers at all mobile and outreach

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sites. These sites will contribute the overwhelming majority of the circumcisions that are required to reach the eNSF targets. MC service delivery providers will use a variety of proven and innovative approaches to engage community leaders and generate demand including but not limited to: use of community-based agents and champions, community dialogues, localized campaigns and other demand creation techniques to generate demand ahead of and during service roll out.

4.3.2 Strengthen, scale up and sustain selected existing NGO fixed sites linked to campaigns and community based demand creation An assessment will be made of the clinical infrastructure, human resources capacity and demand creation techniques used at the NGO Fixed sites. Based on this assessment, additional resources will be provided to strengthen, scale up and sustain a selected number of sites. MC service delivery providers at these sites will also use IPC agents, community dialogue, campaigns and other demand creation techniques to generate demand ahead of and during service roll out.

4.3.3 Strengthen VMMC referral and follow-up capacity in public sector health facilities The capacity of selected government health facilities will be strengthened to enable them to make and track referrals and provide VMMC follow-up services. This will allow outreach and mobile sites to operate with greater flexibility, as they will not be required to provide follow-up services to all of their clients, but refer clients to nearby public health facilities for follow up.

4.4 EIMC SERVICE DELIVERY STRATEGIES 4.4.1. Scale up EIMC at existing service delivery sites EIMC client volume will be scaled up through the introduction of EIMC services in expanded service delivery outlets within existing EIMC service provision sites including outpatient departments, family planning units, and HIV testing and counseling units. EIMC content will be incorporated into client education materials and provider job aids in Integrated Management of Childhood Illnesses (IMCI) and Expanded Programs for Immunization (EPI) as well. Further, adequate numbers of providers will be trained in the MNCH units as well as other units, so that as staff undergo regular rotations, new MNCH staff will already have been exposed to the basics of EIMC. Lastly, any new public sector facilities which offer labor and delivery services and have doctors on-site (such as the new health center in Lubombo), will be added as EIMC service delivery sites.

4.4.2. Decentralize EIMC services to lower level facilities One key principle of healthcare service delivery in Swaziland is to bring services closer to where community members live to improve healthcare access and equity for all families. As presented in the eNSF, EIMC services will follow the same decentralization principle. In order to implement a considered plan for decentralized EIMC services following the approval of the Nurses Bill, the MOH will lead a comprehensive decentralization strategy development process complete with facility readiness assessments, standardized QA and site preparation processes, and EIMC orientation and clinical training. This process will encourage the ‘routinization’ of integrated EIMC services in more places where clients access sexual and reproductive health services.

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5 CHAPTER V: HUMAN RESOURCES FOR SERVICE DELIVERY

5.1 OVERVIEW OF HUMAN RESOURCES

Overview of VMMC Human Resources

According to the Swaziland National Male Circumcision Policy, only doctors are authorized to perform VMMC surgical procedures. Nurses are authorized to provide a supportive function and assist with aspects of VMMC, such as client counseling and pre-operative screening, surgical preparation, suturing, and post-operative care. The current number of doctors and nurses who have completed the competency-based VMMC training are insufficient to support VMMC scale up to meet eNSF goals. Furthermore, due to annual staff rotations, even those doctors and nurses who have been trained in VMMC are often transferred to non-VMMC facilities, thereby limiting the availability of trained staff. In addition, the Public Integrated Model of VMMC service delivery in government health facilities does not allow for the creation of dedicated VMMC teams as a part of regular operational duties. As a result, staff trained in VMMC who work at government facilities are often pressured by multiple competing demands and priorities. These limitations can result in situations where clients who go to health facilities seeking VMMC may be subject to long waiting times and/or the cancellation of surgical procedures. When this happens, clients may abandon their attempts to undergo VMMC, and/or undermine the credibility of public sector VMMC services by spreading word of their negative experiences to other community members. This presents a particular challenge for VMMC demand creation.

At present, the conversation around task shifting in Swaziland has been limited to EIMC. Moving forward, the MOH will continue to explore the possibility of VMMC task shifting in consultation with nursing stakeholders.

To address the various human resources challenges that have been encountered in VMMC human resources, comprehensive strategies will be developed aligned to the MC service delivery plan. VMMC human resources strategies may include the creation of dedicated high volume clinical teams that can be used across the country to provide services at outreach, mobile and fixed sites. Given the priority that will be given to outreach and mobile service delivery models, these teams would spend the majority of their time at outreach and mobile sites. Models for Optimizing Volume and Efficiency (MOVE) clinical teams will be established and structures according to the latest best practice guidelines.

Based on an average of 40+ circumcisions each day, it is estimated that 4-5 clinical teams would be required at outreach and mobile sites to achieve 80-90% of the eNSF 2018 VMMC coverage target. The remaining 10-20% of the target would be carried out by clinical teams based at NGO and government fixed sites and private sector facilities. The mobile clinical teams will be managed by MC service delivery providers with an appropriate complement of program management staff. Mentors, supervisors and trainers will also be required to provide the necessary mentoring, supervision, and clinical and counseling training.

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During the scale up phase, MOH will actively assess and review the effectiveness and efficiencies of the various models and teams and will adjust accordingly.

Overview of EIMC Human Resources

By March 2014, 123 health care workers (45 doctors; 78 nurses) had been trained on EIMC, five of whom were trained as EIMC Trainer of Trainers (TOTs). Like the VMMC program, the EIMC program is challenged by regular staff rotations. It is further challenged by limited numbers of EIMC- trained providers in the context of understaffed facilities facing high client volumes. At present, despite client demand, EIMC services may not be available when trained staff members are absent or are performing other essential functions.

EIMC is currently offered in all MOH facilities where doctors are available for EIMC back up and supervision - that is, EIMC is available in all public sector hospitals and health centers. While EIMC has been introduced as a nurse/midwife-led intervention, regulations are not yet in place to legally protect the nursing cadre in independently performing the procedure. This has led to a concern that should a severe adverse event happen, the nurse provider who performed the procedure would be legally vulnerable.

Swaziland has already built a strong policy framework necessary for EIMC task shifting. The Swaziland Task Shifting Implementation Framework, drafted in 2011 and based on principles outlined in the WHO task shifting guidelines, has been endorsed. However, the associated Nurses Bill – which would authorize nurses to perform surgical procedures - has not yet been passed by Parliament. Once the Bill is passed, the Swaziland Nursing Council can move forward with the development of regulations for qualified nurses and midwives to independently perform EIMC.

With regard to EIMC staffing and training, a determination will be made about the type of support that is needed from MOH and MC service delivery providers respectively, and human resources will be mobilized accordingly.

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Human Resources for Service Delivery Strategies

Box 2 provides a list of the strategies that will be employed to address the human resources for service delivery challenges that have been identified. Details of each of the strategies are provided in Sections 5.2, 5.3 and 5.4.

Box 2: Human Resources for Service Delivery Strategies MC Human Resources (HR) Strategies

Strengthen MC HR planning to support MC scale up

VMMC Human Resources Strategies

Strengthen MC VMMC HR capacity to support MC scale up

EIMC Human Resources Strategies

Increase the number of healthcare providers trained in EIMC

Develop, endorse, and implement EIMC Task Shifting Regulations

Explore the feasibility of introducing EIMC into nursing pre-service education

Continue to roll out the on-the-job EIMC counseling module at all healthcare facilities providing services to pregnant women

5.2 MC HUMAN RESOURCES STRATEGIES

5.2.1 Strengthen MC human resources planning to support MC scale up A MC human resources plan will be developed detailing VMMC and EIMC staffing requirements in alignment with the MC service delivery plan. The human resources plan will outline the staffing and training roles and responsibilities of MOH and MC service delivery providers.

5.3 VMMC HUMAN RESOURCES STRATEGIES

5.3.1 Strengthen MC VMMC human resources capacity to support MC scale up High volume MOVE, or modified MOVE, VMMC mobile clinical teams will be established to support service delivery by outreach and mobile models. MOH will actively assess and review the effectiveness and efficiencies of the various models and teams and will adjust accordingly. Capacity building and human resources strengthening will be provided at selected NGO and government fixed facilities to enable them to contribute to circumcision targets and referral mechanisms as required. Guidelines and training will be provided to private sector VMMC service delivery providers to ensure compliance with quality standards and VMMC staffing requirements.

The number of doctors and nurses to be trained each year will be determined by the VMMC coverage targets and scale up plans that are agreed at national and regional level, and the outcomes of local demand creation activities. Measures will be undertaken to ensure that the time between training and

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service delivery for doctors and nurses is minimized so that clinical skills are of a high level and quality standards are maintained.

5.4 EIMC HUMAN RESOURCES STRATEGIES

5.4.1 Increase the number of EIMC trained healthcare providers

EIMC in-service training will be scaled up for regional mentors and supervisors as well as strategically selected nurses and midwives in a phased, continuous manner in facilities where EIMC is – or will be – offered. It is critical that newly trained EIMC providers receive ongoing mentorship and supportive supervision at site level as they move from competency to proficiency. Existing regional infrastructure, though the RHMTs, will be capacitated to support this process.

The MOH will lead a consensus development process between MOH nursing leadership, the Nursing Council and SWADNU around the reintroduction of the Nurses Bill. Subsequently, the MOH and the portfolio review committee will reintroduce the Nurses Bill to the new parliament. Following the passage of the Nurses Bill, the following strategies will commence:

5.4.2 Draft, endorse, and implement EIMC Task Shifting regulations

Utilize existing forums such as Chief Nursing Officer (CNO)-led monthly nurse manager meetings, and “quad meetings” (regular meetings between the Nursing Council, SWADNU, the CNO, and the principals of all nursing institutions) to catalyze the EIMC task-shifting process. The MOH will ensure that all service providers have adequate information on the goals and objectives of incorporating EIMC within the comprehensive MNCH services package, including the ways in which EIMC integration strengthens the provision of MNCH services overall. All facilities will also be oriented to the introduction of the task-shifting regulations.

5.4.3 Explore the feasibility of introducing EIMC into nursing pre-service eduction

The long-term goal of EIMC programming in Swaziland is that the service is fully integrated into the MNCH “package” for healthy infant baby boys. Ideally, EIMC would be included in the national midwifery curriculum as a core competency, so that all qualified midwives are able to provide safe early infant circumcision services upon graduation. Routine refreshers and supportive supervision would then ensure that EIMC clinical competencies are maintained in-service.

5.4.4 Continue to roll out the on-the-job EIMC counselling module at all healthcare facilities providing services to pregnant women

Implementing partners are currently supporting on-the-job EIMC updates to clinical and support staff working in all facilities where pregnant women, mothers, and families access care. This short orientation module enables facility staff to educate expecting parents about the risks and benefits of

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EIMC and link clients with EIMC referral sites. As a result, parents are not only prepared to make informed decisions by the time of birth but know where and how to access EIMC services.

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6 CHAPTER VI: DEMAND CREATION

6.1 OVERVIEW OF DEMAND CREATION

Demand creation in the MC context involves the use of evidence-based communication and community engagement to promote the uptake of MC services. Demand creation goes beyond simply raising awareness or providing information. To be effective, demand creation must address barriers and enlist key motivators to convince eligible males to undergo MC. Experience from Swaziland shows that the supply of MC services must be closely associated and balanced with community demand for those services. Increasing demand requires interventions that are tailored to the local context and use local community leaders and gatekeepers.

In 2009, an MC communication strategy was developed to support the MC scale up objectives of the 2009-2013 MC strategy. The communication strategy was informed by extensive stakeholder consultation and a number of local acceptability studies undertaken in 2007 and 2008. It provides a detailed review of attitudes towards MC from a number of key audiences. The implementation of the strategy yielded important successes, which provide lessons for demand creation. In particular, the consistency, accuracy, and quality of MC messaging to all stakeholders are critical.

With regard to VMMC, as noted in Chapter 4, the BTS campaigns have been responsible for a substantial proportion of MCs that have been undertaken, and IPC agents, champions, teachers, principals, and peer educators have been used successfully in the BTS and other campaigns. The engagement of the Ministry of Education (MOE) and champions has been a successful model that will be strengthened going forward. Also, engaging community and traditional leaders to promote MC has proven extremely effective.

To date, demand creation efforts for EIMC have been largely led by healthcare providers within facilities, with some supplemental community-based education. Swaziland’s EIMC demand creation has been deliberately conservative. For example, the MOH has not yet launched a mass media campaign for EIMC. However, in order for Swaziland to achieve the ambitious EIMC targets set in the eNSF, a more intensive demand creation effort will be required.

Ensuring the expansion of EIMC services requires building upon existing opportunities and addressing key community concerns, including:

• Concerns regarding consent by one or both parents • Concerns regarding children’s rights and/or later relationships between children and parents

These issues will be addressed through ongoing community education and improved consent procedures for the EIMC program. Local research underscores the fact that health facilities remain the main source of information on EIMC for women and mothers, while men find meetings with other men to be optimal sources of MC information.18 Therefore, a multifaceted communication

18 PSI. 2013. Early Infant Male Circumcision, FoQus for Marketing Planning Summary Report.

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approach is required. Facility capacity needs to be further strengthened to deliver consistent, accurate, and ongoing information to clients at multiple points of care, and their reach needs to extend to community level in order to access men and fathers. The MOH will also promote communication materials that stress parents’ roles as protectors of their children by making informed decisions on early life health interventions such as immunization, growth monitoring, nutritional counseling and EIMC.

Demand Creation Strategies

Box 3 provides a list of the strategies that will be employed to address the demand creation challenges that have been identified. Details of each of the strategies are provided in Sections 6.2, 6.3 and 6.4.

Box 3: Demand Creation Strategies MC Demand Creation Strategies

Strengthen MC demand creation framework

Engage traditional leaders and other key opinion leaders in creating demand for MC

Develop and implement national and local MC multimedia campaigns

Deploy information and communication technologies to promote MC

Utilize multiple platforms to promote VMMC and EIMC messaging

Empower women to support MC scale up

VMMC Demand Creation Strategies

Scale up existing VMMC campaigns and develop new campaigns targeted at places and occasions where young men congregate in large numbers

Refocus VMMC demand creation to address men’s reproductive health and new social norms that appeal to men and women

Strengthen VMMC uptake among relevant key populations and vulnerable groups

EIMC Demand Creation Strategies

Increase ownership of EIMC services by public facility providers as part of a comprehensive MNCH package

Strengthen the informed consent process for EIMC

Increase involvement of fathers (and fathers to be) in EIMC

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6.2 MC DEMAND CREATION STRATEGIES

6.2.1 Strengthen the MC demand creation framework A comprehensive MC demand creation plan will be developed and aligned to the MC service delivery plan, building on lessons learned and successful demand creation efforts of the past several years. In addition, Swaziland will adapt international best practices to the local context. The demand creation plan will develop specific age segmented advocacy and communication initiatives targeting the two primary audiences for focused VMMC demand creation; (i) the 10-29 years age group; and (ii) the 30- 34 years age group. Methods and techniques will be outlined regarding supporting secondary audiences and opinion leaders to encourage and motivate primary audiences to seek VMMC services. Key VMMC secondary audiences include: youth organizations, chiefs, FBO leaders, partners (wives, girlfriends, lovers etc.), caregivers, parents, guardians, teachers, organizations serving men, and women’s organizations. The demand creation plan will also identify the primary and secondary audiences for EIMC, and outline specific campaigns and messages targeting these groups. The plan will include MC messaging guidelines aligned to national health promotion messaging guidelines, explain how social and cultural events can be used to promote MC, and outline the roles and responsibilities of key demand creation stakeholders, such as the SBC Technical Working Group (TWG), MC-TWG, MC communication and service delivery providers, MOH, MOE, and other government departments. Clear attention to supply and demand in relation to achieving coverage according to the national, regional and Tinkhundla targets will be critical for the success of the demand creation plan.

6.2.2 Engage traditional leaders and other key opinion leaders in creating demand for MC Key opinion leaders, such as chiefs and other traditional leaders, are willing to support MC messaging in communities if given adequate preparation and authorization. Traditional leaders will be provided with MOH-led structured education sessions on MC to enable them to share this information within their constituencies, correctly address questions, and refer community members for more detailed clinical advice as well as MC services. Members of Parliament (MPs) will also be empowered to provide education on MC. Similar approaches will be used to engage other opinion leaders including: youth organizations, rural health motivators (RHM), the Parliamentary Portfolio Committee on HIV and Health, national celebrities, women’s organizations, FBO leaders, business leaders and MNCH leaders.

6.2.3 Develop and implement national and local MC multimedia campaigns National and local multimedia campaigns (TV, press, radio, etc.) will be undertaken with messages targeting primary audiences and secondary audiences. MC will be featured in such forums as the Health Promotion Unit’s weekly radio program. Sports and other TV and radio programs that are known to have large audiences of young males will be specifically targeted for commercial advertising.

6.2.4 Deploy information and communication technologies to promote MC Agreements will be made with internet and telecommunication companies to facilitate mass messaging campaigns targeting young males and the relevant secondary audiences using social media,

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SMS messaging, and other information, communication, technology for development (ICT4D) innovations.

6.2.5 Utilize multiple platforms to promote VMMC and EIMC messaging Multiple platforms will be used to promote MC messaging. Sensitization events will be held in selected public health facilities and government and private sector organizations. VMMC platforms will be used to promote EIMC, and EIMC platforms will be used to promote VMMC. PMTCT, family planning, and other MNCH platforms will be used to educate couples and families about both EIMC and VMMC. The Primary Healthcare Unit outreach program will be used to promote VMMC and EIMC messaging

6.2.6 Empower women to support MC scale up Women—as grandmothers, mothers, mothers-in-law, sisters, and sexual partners, among others— while not the direct consumers of circumcision services, play a key role in influencing and supporting circumcision for the males in their lives. Empowered and MC-educated women are better prepared to advocate for circumcision for their male children and sexual partners. They are also better able to understand and support the period of sexual abstinence during wound healing. Lastly, empowered and educated women are well positioned to respond positively to children or partners who receive MC messaging in school, the workplace, or other locations. For this reason, VMMC/EIMC messages will be strengthened to meet the unique informational needs and societal roles of women in community and facility settings. Forums such as Lutsango, Imbita Savings collectives, faith-based women’s groups, and industrial groups will be explored as potential venues to reach women with these messages.

6.3 VMMC DEMAND CREATION STRATEGIES

6.3.1 Scale up existing VMMC campaigns and develop new campaigns targeting places and events where young men congregate in large numbers The successful BTS and MC Friday campaigns will be strengthened and new campaigns launched targeting places and events where young men congregate in large numbers, such as sporting events, Lusekwane, Dip Tanks, and Buganu through culturally appropriate means.

6.3.2 Refocus VMMC demand creation to address men’s reproductive health and new social norms that appeal to men and women The primary objective of MC is to prevent new HIV infections and reduce HIV incidence, and this message will be communicated consistently and correctly. However, experience in Swaziland and elsewhere shows that in order to be embraced on a large scale this message must be linked to messages related to social norms and behaviors that appeal to different segments of the male and female population. Therefore, efforts will be made to determine how best to increase the appeal of VMMC to important segments of the key primary and secondary audiences.

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6.3.3 Strengthen VMMC uptake among relevant key populations and vulnerable groups The eNSF identifies women and girls, youth, sex workers, MSM, prison inmates, injecting drug users, and mobile groups as key populations at higher risk of HIV infection. The MC Strategic Plan includes numerous strategies targeting women, girls, and the youth. Alongside these strategies, specific initiatives will be introduced to remove barriers and promote VMMC uptake among other vulnerable groups.

6.4 EIMC DEMAND CREATION STRATEGIES

6.4.1 Increase ownership of EIMC services by public facility providers as part of a comprehensive MNCH package

To date, EIMC client mobilization/demand creation has been supported by development partners. That assistance has included the provision of support staff, called EIMC motivators, to public sector facilities to assist in client education and some supportive aspects of service delivery. During the next phase of EIMC program implementation, the MOH will increasingly take the lead in the design and provision of EIMC services within respective facilities, with ongoing advisory support from the GOKS and its partners.

6.4.2 Strengthen the informed consent process for EIMC

EIMC program implementation demonstrates that the immediate postnatal period – in many ways the optimal time to perform EIMC – is too late to introduce the subject to mothers/parents. Parents need sufficient time to discuss the issue among themselves and with their families before they are ready to authorize consent. The MC demand creation plan will outline processes for providing EIMC information before or during pregnancy – via entry points including family planning and ANC/PMTCT - so that parents are prepared to make informed decisions about EIMC service utilization.

6.4.3 Increase involvement of fathers (and fathers to be) in EIMC

While the MNCH platform will continue to strive to involve male partners, the MOH intends to expand its reach to men and fathers by enhancing community engagement, expanding, and strengthening male-to-male community based interventions that reach men where they work, live, and socialize.

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7 CHAPTER VI: SUPPLY CHAIN MANAGEMENT

7.1 OVERVIEW OF SUPPLY CHAIN MANAGEMENT Ensuring that adequate commodities are available for MC is a critical element of providing quality services. Currently, the bulk of VMMC supplies are procured vertically through development partners, and the Central Medical Stores (CMS) plays a limited role in the VMMC supply chain. As development partners enhance their logistics to meet the increased need for supplies for large-scale VMMC scale up, steps will be undertaken to strengthen the capacity of the CMS and a plan will be developed to transfer the VMMC supply chain management system to CMS at an appropriate stage.

As with VMMC supplies, EIMC procedure kits have been procured by development partners. This material support is expected to scale down towards the end of 2014 as services transition fully to government systems. In preparation for this transition, the MOH will ensure public sector sites are supplied with a substantial buffer stock of EIMC procedure kits and consumables. While facilities expect that buffer stock may last one or more years at current EIMC service delivery levels, the MOH and individual facilities will actively prepare to include EIMC surgical instruments and consumables in the routine logistics and procurement processes.

As EIMC is integrated within the MNCH platform, procurement of EIMC equipment and consumables will be incorporated into existing systems, with the national budget accommodating the needs of EIMC services. As procurement of EIMC supplies transitions from development partners to government mechanisms, the MOH will strengthen the existing public sector supply chain to prevent and mitigate supply chain uncertainties such as stock-outs.

Supply Chain Management Strategy

The strategy that will be employed to address the supply chain management challenges that have been identified is depicted in Box 4, and details of the strategy are provided in Section 7.2.

Box 4: Supply Chain Management Strategy MC Supply Chain Management Strategy

Strengthen the existing national Central Medical Stores supply chain management system to meet the increased requirements of MC scale up

7.2 MC SUPPLY CHAIN MANAGEMENT STRATEGY

7.2.1 Strengthen the existing national Central Medical Stores supply chain management system to meet increased requirements of MC scale up While current MC supply chain logistics will be enhanced to meet the requirements of VMMC and EIMC scale up, steps will be undertaken to strengthen the capacity of CMS to provide VMMC and EIMC supplies. The role of CMS in the EIMC supply chain management system will be strengthened progressively in line with the integration of EIMC into the MNCH platform. A plan will be

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developed to transfer the VMMC supply chain management system to CMS in a more concerted manner in line with the requirements of large-scale VMMC scale up.

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8 CHAPTER VIII: WASTE MANAGEMENT

8.1 OVERVIEW OF WASTE MANAGEMENT Swaziland has developed a comprehensive strategy and set of guidelines to ensure effective health care waste management (HCWM). The HCWM National Implementation Strategy provides a five- year overview of key activities, timelines, deliverables and institutional responsibilities. The National HCWM Guidelines outline the procedures for the classification, segregation, safe packaging, color- coding, storage, transport, treatment, and disposal of healthcare and related waste. A set of Standard Operating Procedures were developed to complement the guidelines by providing further guidance on HCWM best practices at the facility level. These guidelines and procedures apply to all facilities that generate health care waste, including MC sites and facilities.

In 2013, Supply Chain Management Services (SCMS) developed the VMMC HCWM Toolkit to address the specific issues relating to HCWM in the MC context. The toolkit elements are based on the Swaziland MC experience, WHO and South African National Standards (SANS 10248, in particular) and the SCMS Health Care Waste Management Model.

MC scale up will be undertaken in strict compliance with the National HCWM Guidelines, Standard Operating Procedures and the VMMC HCWM toolkit.

Waste Management Strategy

The strategy that will be employed to address the waste management challenges that have been identified is depicted in Box 5, and details of the strategy are provided in Section 8.2.

Box 5: Waste Management Strategy MC Waste Management Strategy

Ensure compliance with the Health Care Waste Management Guidelines and Standard Operating Procedures at all MC sites

8.2 MC WASTE MANAGEMENT STRATEGY

8.2.1 Ensure Compliance with the Health Care Waste Management Guidelines and Standard Operating Procedures at all MC sites Capacity building and quality assurance assessment visits will be used to ensure strict compliance with the HCWM guidelines, standard operating procedures, and the VMMC HCWM toolkit at all MC sites. Effective use will be made of the HCWM systems and protocols that have been established in recent years.

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9 CHAPTER IX: QUALITY ASSURANCE

9.1 OVERVIEW OF QUALITY ASSURANCE

WHO defines quality assurance as a systematic process for closing the gap between actual performance and desired outcomes. In order to close this gap and achieve the outcomes, a set of standards is required, and in 2008, WHO developed the 10 core standards for quality, safe MC services as follows: 1. An effective management system is established to oversee the provision of MC services. 2. A minimum package of male circumcision services is provided. 3. Facility has necessary medicines/supplies/equipment/environment for providing safe quality MC. 4. Providers are qualified and competent. 5. Clients are provided with information and education for HIV prevention and MC. 6. Assessments are performed to determine the client’s condition. 7. Male circumcision surgical care is delivered according to evidence-based guidelines. 8. Infection prevention and control measures are practiced. 9. Continuity of care is provided. 10. A system for monitoring and evaluation is established.

Swaziland has adopted these standards and developed national guidelines to assist health facilities with implementation. In addition to the national quality guidelines, MOH has developed tools for site readiness assessment, routine service assessment, external quality assurance, and supervision. The tools set the desired level of performance, measure performance, and identify gaps between actual and desired level of performance. Providers and supervisors can then identify solutions to address identified gaps. MC facilities are required to have an MC quality assurance focal person and conduct internal quality assurance assessments quarterly, with external assessments once or twice yearly.

An external quality assurance assessment undertaken in 2013 found good compliance with the MC standards. Going beyond the actual requirements of the MC quality standards, three best practices were identified during the assessment: (i) orientation and workshop days prior to campaigns; (ii) youth friendly services; and (iii) the use of expert clients for disclosure of HIV-positive results, referrals, care planning, and tracing clients to ensure linkages to care.

The MOH has developed a MC Quality Assurance Strategy as an integral component of the National Health Sector Response to HIV and AIDS 2014-2018. The MC Strategic Plan is aligned to the MC Quality Assurance Strategy as outlined in the National Health Sector Response.

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Quality Assurance Strategy

The strategy that will be employed to address the quality assurance challenges that have been identified is depicted in Box 6, and details of the strategy are provided in Section 9.2.

Box 6: Quality Assurance Strategy MC Quality Assurance Strategy

Strengthen quality assurance at all MC sites according to national standards and guidelines

9.2 MC QUALITY ASSURANCE STRATEGY

9.2.1 Strengthen quality assurance at all MC sites according to national standards and guidelines An adverse event monitoring and reporting mechanism will be introduced to strengthen quality assurance assessment in this area. Capacity building will be conducted to ensure all MC sites comply with the national quality standards and make effective use of the existing assessment tools, including the site readiness assessment tool, the routine service assessment tool, the external assessment tool, quality assurance training evaluation procedures, and the MC Quality Assurance Tracker system. Management of the MC Quality Assurance Tracker system will be transferred from the development partner to the MOH.

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10 CHAPTER X: NEW TECHNOLOGIES AND DEVICES

10.1 OVERVIEW OF NEW TECHNOLOGIES AND DEVICES Recent innovations in VMMC device technologies are currently being studied in other countries to determine their safety, costs of implementation, use by non-physician healthcare providers, and acceptable to clients and providers. These devices may have potential to expand coverage of MC. Swaziland’s MC scale up plan will need to keep abreast of such developments.

In May 2013, WHO prequalified the PrePex device for VMMC. The use of the PrePex device was demonstrated to be efficacious in MC and safe for use among healthy men 18 years and older when used by trained physicians and mid-level providers19. Swaziland has developed a proposal for a PrePex acceptability study. This proposal is still under review.

In terms of EIMC, countries currently choose between three WHO-recommended surgical techniques and devices: the Plastibell, the Mogen Clamp, and the Gomco Clamp. The WHO/ Jhpiego Manual for Early Infant Circumcision Under Local Anesthesia recommends that “surgeons (nurse specialists, clinical or medical officers) should become experts in the nationally recommended technique most suited to the circumstances of their practice”. Swaziland has opted to use the Mogen Clamp.

A sterile, pre-packaged, and disposable EIMC device, called the AccuCirc, has recently undergone a successful clinical trial in Botswana20. This may be a desirable surgical option, especially for those countries facing supply chain or instrument disinfection challenges. However, AccuCirc is not yet prequalified by WHO. Should there be a change in WHO policy, Swaziland will investigate the potential of the AccuCirc as well as any other new technologies to enhance EIMC scale up.

New Technologies and Devices Strategy

The strategy that will be employed to address the new technologies and devices challenges that have been identified is depicted in Box 7, and details of the strategy are provided in Section 10.2.

Box 7: New Technologies and Devices Strategy MC Strategy for New Technologies and Devices

Review developments in MC new technologies and devices and implement findings that could enhance MC scale up

19 WHO. 2013. Guideline on the Use of Devices for Adult Male Circumcision for HIV Prevention 20 Plank R et al. 2014. Single-Arm Evaluation of the AccuCirc Device for Early Infant Male Circumcision in Botswana. JAIDS. 2008, 66:1.

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10.2 MC STRATEGY FOR NEW TECHNOLOGIES AND DEVICES

10.2.1 Review developments in MC new technologies and devices and implement findings that could enhance MC scale up Developments in MC new technologies and devices will be kept under review and any findings that are deemed safe, appropriate, and feasible for MC scale up will be implemented in compliance with WHO guidelines.

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11 CHAPTER X1: STRATEGIC INFORMATION

11.1 STRATEGIC INFORMATION OVERVIEW Swaziland has a robust database that captures all of the MCs done by age, by year and by Inkhundla, and through which approaches. This information is extremely useful for program planning, monitoring and target setting and is invaluable for understanding MC coverage and tracking progress towards age disaggregated targets. To strengthen the MC strategic information system and the data used for programming a number of areas need attention. The MOH and key stakeholders will need to analyze the information that is currently collected through the database and the information needs of different users at various levels and develop a MC M&E framework. Further, the current design of the database does not allow it to be integrated into the Health Management Information System (HMIS) that is being developed. Critical elements of the database will need to be integrated into the National HMIS. Existing structures and mechanisms for centralized and decentralized use of data will be exploited. Finally, the database, which is supported by a development partner, will be transitioned to MOH.

Although standardized data collection tools have been developed for the EIMC program as part of the MNCH M&E system, such tools have yet to be developed for the VMMC program. As discussed in Chapter 1, EIMC indicators were integrated into maternal and child health cards, registers, and monthly reporting forms in 2010 when these tools were under revision in light of changes in national guidelines for PMTCT. In addition to streamlining reporting and data collection processes, this significant step has led to additional positive outcomes. Integrated monitoring tools prompt nurses and midwives to counsel pregnant women and mothers of male babies about EIMC at multiple points of contact.

To strengthen the MC SI work, it will be important to give responsibility for MC M&E to an official in the MOH Strategic Information Department (SID), increase the support provided by the M&E TWG, and develop the MC M&E framework.

Strategic Information Strategy

The strategy that will be employed to address the strategic information management challenges that have been identified is depicted in Box 8, and details of the strategy are provided in Section 11.2.

Box 8: Strategic Information Strategy MC Strategic Information Strategy

Strengthen MC Strategic Information Systems

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11.2 MC STRATEGIC INFORMATION STRATEGY

11.2.1 Strengthen MC Strategic Information Systems The M&E TWG will be reconvened to enable it to support SID and SNAP in providing oversight over MC strategic information systems, MC program evaluation, and MC operational research in collaboration with SID and SNAP. Key priorities for MC operational research will be identified, and a timetable for undertaking this research will be developed and implemented. To strengthen MC strategic information capacity, the vacant position of M&E Program Officer with responsibility for MC and HIV Prevention in SID will be filled. A MC M&E Framework will be developed in accordance with SID guidelines, and will include MC indicators and MC data collection tools. Routine MC program monitoring and review will be undertaken through a variety of regular meetings including but not limited to the National Semi-Annual HIV Program Review, the Regional Semi- Annual HIV Program Review, and the MOH Senior Manager's meetings. The MC database will be enhanced to enable it to capture private sector MCs and be used continuously at various levels for program learning and management. Critical elements of the database will be integrated into the HMIS, and management of the database will be transferred to MOH.

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12 CHAPTER X11: PROGRAM COORDINATION AND MANAGEMENT

12.1 PROGRAM COORDINATION AND MANAGEMENT OVERVIEW As discussed in Chapter 1, the national MC program has had significant capacity constraints, and this has been a major impediment to effective leadership and coordination of the program. In order for the scale up plan to succeed, these challenges will need to be addressed. Effective leadership, management, and coordination of MC and related HIV prevention, MNCH, and other health activities are critical for successful and sustainable scale up of MC services in Swaziland. This will require the strengthening of institutional arrangements and the development of more effective partnerships involving key stakeholders at national, regional, Tinkhundla and community levels.

Program Coordination and Management Strategy

The strategy that will be employed to address the program coordination and management challenges that have been identified is depicted in Box 4, and details of the strategy are provided in Section 7.2.

Box 9: Program Coordination and Management Strategy MC Program Coordination and Management Strategy

Strengthen MC program coordination and management at the national, regional and community level

12.2 MC PROGRAM COORDINATION AND MANAGEMENT STRATEGY

12.2.1 Strengthen MC program coordination and management at the national, regional and community levels Strengthening leadership and coordination of the MC program at the policy level will be promoted through advocacy at high-level meetings with Under Secretaries and Principal Secretaries and the Parliamentary Portfolio Committee on HIV and Health. A national launch event for the MC Strategic Plan will be used to build stronger partnerships with key national MC stakeholders, including government departments that have a strong interface with young people and important MC secondary audiences. A review will be undertaken of the membership of the MC-TWG, and key opinion leaders will be appointed to MC-TWG sub-committees and/or ad hoc committees to provide guidance on how best to engage community leaders and others.

In order to strengthen human resources capacity in the current VMMC unit and enhance its capacity to provide effective management and coordination of MC scale up, consideration will be given to renaming the unit to ‘MC Unit’ or some other designation that is inclusive of both VMMC and EIMC. A human resources capacity assessment will be conducted by the public service ministry and MOH to address the gaps in human resources in critical areas such as MC coordination at national, regional, and community levels; EIMC; M&E; and clinical technical support. Based on the findings of 43 | Page

the human resources capacity assessment, a determination will be made concerning the MC staffing requirements necessary to support MC scale up during the catch up and sustainability phases of the MC Strategic Plan, and the necessary appointments will be made. Until the staffing constraints are resolved, technical assistance will be provided to support critical areas of shortage. Technical assistance will also be provided to support the development of the MC service delivery, human resources, and demand creation plans; MC clinical and counseling training; MC modeling; and other specialist MC technical areas.

The major tasks to be performed by the national MC team (the Male Circumcision Unit and the MC- TWG) will include: • Mobilizing resources for the program to complement government funding; • Consultation and collaboration with development partners and other key stakeholder to ensure the alignment of their activities with the national program; • Orientating and supporting the RHMTs and REMSHACCs to plan and implement MC activities. This will include supporting the development of regional MC implementation plans, which will be used to guide the activities required to achieve the regional and Inkhundla MC coverage targets; • Identifying best practices within the country and sharing these among the regions and MC stakeholders; • Organizing regular coordination and program planning meetings with MC service delivery providers; and, • Organizing national and regional MC stakeholders meetings to review the performance of the program and develop recommendations to strengthen collaboration and coordination of the activities of national stakeholders.

Since EIMC is offered as part of a comprehensive package of services for healthy infant boys within the MNCH platform, it is essential that all stakeholders who deliver MNCH services are actively involved in EIMC decision-making. Strong linkages between the SRHU and SNAP are necessary to ensure smooth EIMC program coordination. Existing forums – such as RHMT meetings, related national TWGs, MOH monthly clinical forums, and national nursing “quad meetings” - will be harnessed to promote dialogue and solidify these linkages. Further, a review of the membership of the MC-TWG will be made in consideration of the need to enhance SRH/MNCH stakeholder involvement.

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13 CHAPTER X111: COST ESTIMATES

13.1 COSTING METHODOLOGY AND ASSUMPTIONS METHODOLOGY: Full costing of all components of strategy elements using standard cost units. Some sources of standard unit costs include NERCHA, CHAI and PSI

ASSUMPTIONS: Major Assumptions include the following; Exchange rate: $1/E10.58 Inflation rate: 6% Compounded quarterly

13.2 COST ESTIMATES

Table 9: MC Strategic Plan Cost Estimates 2014-2018 Strategic Actions 2014 2015 2016 2017 2018 TOTAL Strategy Element 1: 3,206,983 2,405,358 2,618,728 2,833,079 3,077,603 14,141,751 Service Delivery Strategy Element 2: 157,721 155,636 179,240 195,445 186,082 874,124 Human Resources for Service Delivery Strategy Element 3: 366,424 354,188 375,923 398.991 423,474 1,918,999 Demand Creation Strategy Element 4: 254,364 267,617 284,039 301,468 319,968 1,427,456 Supply Chain Management Strategy Element 5: 10,285 10,916 11,586 12,297 13,051 58,134 Waste Management Strategy Element 6: 106,979 97,809 101,027 107,227 113,806 526,848 Quality Assurance Strategy Element 7: 36,589 23,099 24,516 26,021 27,617 137,841 New Technologies and Devices Strategy Element 8: 60,978 48,985 51,500 37,455 58,015 256,933 Strategic Information Strategy Element 9: 119,077 376,929 82,363 87,417 92,782 758,569 Program Coordination and Management TOTAL 4,319,399 3,740,537 3,728,922 3,999,399 4,312,397 20,100,655

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REFERENCES AND DOCUMENTS CONSULTED

Ackerson S. et al (2013) Health Care Waste Management Guidebook. Submitted to the US Agency for International Development by the Supply Chain Management System (SCMS). Auvert B et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med, 2005, 2:e298. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. (2006) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. Nov. 2005; 2(11):e298. Erratum in: PLoS Med. 2006 May: 3(5):e298. Bailey RC et al. (2007) Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet, 2007, 369:643-656. Banieghbal B. (2009) Optimal time for neonatal circumcision: An observation-based study. J Ped Urol. 2009; 5:359-62. Castellsague X et al. (2002) Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. New England Journal of Medicine, 2002, 346:1105. Central Statistical Office (CSO, 2008), Swaziland Demographic Health Survey, CSO, Mbabane, Swaziland, Macro International Inc., Maryland, USA. Collins S, Upshaw J, Rutchik S, et al. (2002) Effects of circumcision on male sexual function: debunking a myth? J Urol. 2002; 167:2111-2. Futures Group, Health Policy Initiative (2009) Male Circumcision: Decision Makers’ Program Planning Tool, Calculating the Costs and Impacts of a Male Circumcision Program. Washington, DC: Futures Group. GOKS, NERCHA, UNFPA, UNAIDS & UNICEF (2010) Multiple Indicator Cluster Survey (MICS) – 2010, Monitoring the situation of women, children and men. Government of Swaziland, Ministry of Health (2012) Swaziland HIV Incidence Measurement Survey (SHIMS). Gray RH et al. (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet, 2007. 369:657–666. Gray RH et al. (2009) The effects of male circumcision on female partners’ genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. American Journal of Obstetrics and Gynecology, 2009, 200(1):42,e1-42,e7. Kigozi G, Gray RH, Wawer MJ, et al. (2008) The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda. PLoS Med. 2008; 5:e116. Kigozi G, Watya S, Polis CB, et al. (2008) The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int. Jan. 2008; 101(1):65-70. Kingdom of Swaziland (2013) 2011 UN General Assembly Political Declaration On HIV/AIDS Mid-Term Review Report Of The “Ten Targets”. Krieger JN, Bailey RC, Opeya JC, et al. (2007) Adult male circumcision outcomes: experience in a developing country setting. Urol Int. 2007; 78(3):235-40. Kripke, K. et al. (2014) Introducing Early Infant Male Circumcision (EIMC) in Southern and Eastern Africa – DMPPT 2.0 Modeling. Lissouba P. (2011) Adult male circumcision as an intervention against HIV: An operational study of uptake in a South African community (ANRS 12126). BMC Infectious Diseases, 2011, 11:253, 2011 Masood S, Patel HRH, Himpson RC, et al. (2004) Penile sensitivity and sexual satisfaction after 46 | Page

circumcision: are we informing men correctly? Urol Int. 2004; 75:62-6. Ministry of Health and Social Services, Namibia (2013) Strategy and Implementation Plan for Voluntary Medical Male Circumcision Scale Up in Namibia. MOH (2009) Policy On Safe Male Circumcision For HIV Prevention. MOH (2011) Preliminary Results of the Bio-Behavioural Surveillance Survey for Most at Risk Populations (BSS MARPS). MSH (2014) Situation Analysis: Voluntary Medical Male Circumcision (VMMC) in Swaziland. NERCHA (2010). Swaziland National Multisectoral HIV and AIDS Monitoring and Evaluation Framework (2009-2014). NERCHA (2013) The National Multisectoral HIV and AIDS Framework For HIV and AIDS Extension 2014-2018 (eNSF). Njeuhmeli E et al. (2011) Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Medicine, 2011, 8: e1001132. doi:10.1371/journal.pmed.1001132. PEPFAR (2013) PEPFAR’s Best Practices for Voluntary Medical Male Circumcision Site Operations: A service guide for site operations. PEPFAR (2014). Voluntary Medical Male Circumcision (VMMC) Demand Creation Toolkit. PSI (2013). Swaziland External Quality Assurance. Senkul T, Iseri C, Sen B, et al. (2004) Circumcision in adults: effect on sexual function. Urology. 2004; 63:155-8. Shaikh N et al. (2008) Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatric Infectious Disease Journal, 2008, 27:302. Sorrells ML, Snyder JL, Reiss MD, et al. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int. 2007 Apr;99(4):864-9. Erratum in: BJU Int. 2007 Aug;100(2):481. Swaziland Male Circumcision Task Force (2009) Strategy and Implementation Plan for Scaling Up Safe Male Circumcision for HIV Prevention in Swaziland 2009/2013. The Luke Commission (TLC) (2014) The Luke Commission 5 Year Plan 2013-2017. UNAIDS (2010) Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioral and Structural Strategies to Reduce New HIV Infections. A UNAIDS Discussion Paper. UNAIDS (2011) A new investment framework for the global HIV response. UNAIDS, Geneva. UNAIDS (2013) Global Report: UNAIDS Report on the Global AIDS epidemic 2013. UNAIDS and WHO (2011) Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa 2012–2016. UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention (2009). Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine, 2009, 6: e1000109. doi:10.1371/journal.pmed.1000109. UNICEF (2007) A National Study on Violence Against Children and Young Women in Swaziland. Van den Akker, T. et. Al. 2012. HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi, Jan 2012. Wawer M et al. (2011) Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomized trial in Rakai, Uganda. Lancet Online,

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January 7, 2011. DOI:10.1016/S0140–6736(10)61967–8. Weiss HA. (2010) Complications of circumcision in male neonates, infants and children in a systematic review. BMC Urol. 2010; 10:2. WHO (2011) Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: recommendations for a public health approach. Geneva, WHO. WHO and UNAIDS (2007) New data on male circumcision and HIV prevention: policy and program implications. Available at: http://libdoc.who.int/publications/2007/9789241595988_end.pdf.

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ANNEX I: NATIONAL AND REGIONAL MC COVERAGE

National MC Coverage by Age Group April 2014 9 years 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 >50 Total Eligible % old Circum- Population Coverage cised Manzini 300 4,738 4,780 5,336 3,698 2,046 929 423 229 241 22,737 75,981 29.9% Hhohho 108 3,635 3,451 3,015 1,849 1,089 513 252 131 150 14,202 69,927 20.3% Lubombo 120 3,705 3,991 3,161 1,316 710 338 205 110 133 13,798 59,373 23.2% Shiselweni 69 2,479 2,896 2,694 1,088 523 236 113 65 85 10,259 45,371 22.6%

National Total 596 14,556 15,118 14,205 7,951 4,368 2,017 993 536 610 60,996 250,651 National % 0.45% 21% 23% 24% 16% 11% 7% 4% 3% 4% 24.3%

Regional MC Coverage April 2014

Region P_Inkhundla Total Circumcised Eligible Population % Coverage Ludzeludze 2,265 4,310 52.5% Kwaluseni 4,787 10,577 45.3% Manzini South 1,412 3,986 35.4% Mkhiweni 1,756 5,056 34.7% Manzini North 3,452 10,098 34.2% LaMgabhi 918 3,063 30.0% Mafutseni 1,341 4,938 27.2% MANZINI Ekukhanyeni 1,175 4,511 26.1% Lobamba Lomdzala 1,275 5,042 25.3% Ntondozi 894 3,824 23.4% Mahlangatsha 895 4,120 21.7% Ngwempisi 1,363 6,615 20.6% Nhlambeni 622 3,340 18.6% Mangcongco 213 1,721 12.4% Mthongwaneni 369 4,780 7.7%

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Region P_Inkhundla Total Circumcised Eligible Population % Coverage Mbabane East 2,231 3,689 60.5% Mhlangatane 1,005 2,427 41.4% Motshane 1,616 5,667 28.5% Mayiwane 1,069 3,819 28.0% Lobamba 1,761 6,531 27.0% Ntfonjeni 1,033 5,030 20.5% Pigg's Peak 854 4,773 17.9% HHOHHO Madlangempisi 775 4,484 17.3% Mphalaleni 621 4,213 14.7% Ndzingeni 660 4,516 14.6% Hhukwini 339 2,526 13.4% Mbabane West 1,274 9,754 13.1% Timpisini 231 2,065 11.2% Nkhaba 340 4,071 8.3% Mhlambanyatsi 393 6,361 6.2%

Region P_Inkhundla Total Circumcised Eligible Population % Coverage Lomahasha 1,748 3,749 46.6% Lugongolweni 1,273 3,938 32.3% Siphofaneni 1,878 5,921 31.7% Mhlume 1,609 5,301 30.3% Dvokodvweni 1,725 6,716 25.7% LUBOMBO Sithobela 1,580 6,866 23.0% Hlane 371 1,725 21.5% Nkilongo 799 4,331 18.4% Mpolonjeni 1,377 8,022 17.2% Matsanjeni North 921 5,694 16.2% Lubuli 517 7,109 7.3%

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Region P_Inkhundla Total Circumcised Eligible Population % Coverage Kubuta 573 1,475 38.8% Shiselweni1 918 2,993 30.7% Mbangweni 1,846 6,176 29.9% Maseyisini 1,349 4,762 28.3% Gege 1,174 4,158 28.2% Sandleni 898 3,190 28.2% Matsanjeni South 618 2,969 20.8% SHISELWENI Hosea 785 3,941 19.9% Somntongo 209 1,092 19.2% Mtsambama 664 4,592 14.5% Zombodze Emuva 537 3,734 14.4% Sigwe 323 2,717 11.9% Nkwene 175 1,621 10.8% Ngudzeni 189 1,950 9.7%

Source: MC Database, April 2014

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ANNEX II: ORGANIZATIONS THAT PARTICIPATED IN CONSULTATION MEETINGS

1. Alliance of Mayors’ Initiative for Community Action on AIDS at the Local Level 2. Auditor General 3. Baylor International Pediatric AIDS Initiative 4. Bhawini Royal Kraal 5. Bhekinkosi Royal Kraal 6. Building Local Capacity 7. Bulandzeni Royal Kraal 8. Cabrini Ministries 9. Central Medical Stores 10. Children's Cup 11. Church Forum 12. Civil Service Commission 13. Clinton HIV/AIDS Initiative 14. Community Health Engagement 15. Compassionate Swaziland 16. Conference of Churches 17. Coordinating Assembly Of Non-Governmental Organization 18. Correctional Services 19. Deputy Prime Minister’s Officer 20. Dlangeni Royal Kraal 21. Dvokolwako Health Center 22. Ebuhleni Royal Kraal 23. Edvwaleni Royal Kraal 24. Egebeni Royal Kraal 25. Ejubukweni Royal Kraal 26. Ekupheleni Royal Kraal 27. Elangeni Royal Kraal 28. Elizabeth Glaser Pediatric AIDS Foundation 29. Elwandle Royal Kraal 30. Emergency Preparedness and Response 31. Emgofelweni Royal Kraal 32. Emkhuzweni Royal Kraal 33. Emshingishingini Royal Kraal 34. Emvuma Royal Kraal 35. Entsanjeni Royal Kraal 36. Expanded Program on Immunizations 37. Family Life Association of Swaziland 38. Gege Hospital 39. Global Scenario Group 40. Good Shepherd Hospital 41. GSMH 42. Health Communication Capacity Collaborative 43. Integrated Management of Childhood Illnesses - Ministry of Health

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44. International Centre for AIDS Care and Treatment Programs 45. International Tabernacle 46. JHPIEGO 47. Joint United Nations Program on HIV/AIDS 48. Joint United Nations Program on HIV/AIDS 49. KaHhelehhele Royal Kraal 50. Khulisa Umntfwana 51. King Sobhuza 11 Public Health Unit 52. LaMgabhi Royal Kraal 53. Litsemba Letfu 54. Lobamba Clinic 55. Ludlawini Royal Kraal 56. Ludzeludze Royal Kraal 57. Lusweti 58. Lutsango 59. Luyengo Royal Kraal 60. Maguga Clinic 61. Malkerns Royal Kraal 62. Management Sciences for Health 63. Mankayane Government Hospital 64. Mantabeni Royal Kraal 65. Manzini Regional Government Administration 66. Maphalaleni Royal Kraal 67. Maternal and Child Health Integrated Program 68. Mbabane Government Hospital 69. Mdzimba Royal Kraal 70. Medicins Sans Frontiers 71. Medisun Clinic 72. Mgazini Royal Kraal 73. Ministry of Agriculture 74. Ministry of Communication and Information Technology 75. Ministry of Defense 76. Ministry of Economic Planning and Development 77. Ministry of Education 78. Ministry of Finance 79. Ministry of Foreign Affairs 80. Ministry of Health – Deputy Chief Nursing Office 81. Ministry of Health – Hhohho Region 82. Ministry of Health – Legal Advisor 83. Ministry of Health – Public Health Unit 84. Ministry of Health – Sexual Reproductive Health Unit 85. Ministry of Health – Training Office 86. Ministry of Health - Swaziland National AIDS Program 87. Ministry of Health- Lubombo Region 88. Ministry of Health Lumbombo Clinics 89. Ministry of Health Shiselweni Region 90. Ministry of Health -Strategic Information Department 53 | Page

91. Ministry of Home Affairs 92. Ministry of Justice 93. Ministry of Labour & Social Security 94. Ministry of Public Works and Transport 95. Ministry of Tinkhundla Administration and Development 96. Mkhiwa Clinic 97. Mkhuzweni Health Center 98. Mlindazwe Army Camp 99. Mothers 2 Mothers 100. Motshane Royal Kraal 101. Mphini Royal Kraal 102. Mpolonjeni Royal Kraal 103. Municipal Council of Mbabane 104. Mvembili Royal Kraal 105. NATICC/AHF 106. National Emergency Response Council on HIV/AIDS 107. National Health Council 108. National Spiritual Assembly - Baha’i Faith 109. National Tuberculosis Hospital 110. Natural Resources 111. NBC 112. Nhlambeni Royal Kraal 113. NHO RHO 114. Nkamazi Royal Kraal 115. Nkiliji Royal Kraal 116. Ntontozi Royal Kraal 117. Nyakatfo Royal Kraal 118. Phocweni USDF Clinic 119. Piggs Peak Government Hospital 120. Population Services International 121. President’s Emergency Plan for AIDS Relief 122. Private Providers Association 123. Public Sector HIV and AIDS Coordinating Committee 124. Raleigh Fitkin Memorial Hospital 125. Red Cross 126. Regional Health Management Team – Hhohho 127. Regional Health Management Team – Lubombo 128. Regional Health Management Team – Manzini 129. Regional Health Management Team – Shiselweni 130. Regional Multi-sectoral HIV and AIDS Coordinating Committee - Hhohho 131. Regional Multi-sectoral HIV and AIDS Coordinating Committee - Lubombo 132. Regional Multi-sectoral HIV and AIDS Coordinating Committee - Manzini 133. Regional Multi-sectoral HIV and AIDS Coordinating Committee - Shiselweni 134. REO Manzini 135. Royal Swazi Police 136. SASO 137. Scripture Union 54 | Page

138. Seventh-Day Adventist 139. Sigombeni Royal Kraal 140. Siphocosini Royal Kraal 141. Siteki Public Health 142. Sithobela Health Centre 143. SNFES 144. SOS Children Villages 145. Southern Africa HIV and AIDS information Dissemination Services 146. Swazi Observer 147. Swaziland and Democratic Nurses Union 148. Swaziland Broadcasting and Information Services 149. Swaziland Business Coalition on HIV and AIDS 150. Swaziland Conference of Churches 151. Swaziland Fire and Emergency Services 152. Swaziland Government Treasury 153. Swaziland National Association of Government Accounting Personnel 154. Swaziland National Association of Teachers 155. Swaziland National Network of People Living with HIV/AIDS 156. Swaziland National Youth Council 157. Swaziland Nursing Council 158. Swaziland Scouts Association 159. The Luke Commission 160. The United Nations Children’s Fund 161. Tiyeni AOG Projects 162. Traditional Healers Organization 163. Ubuntu Institute 164. Umbutfo Swaziland Defense Force 165. UNHI 166. United Nations Children’s Fund 167. United State Agency for International Development 168. University Research CO 169. URSA 170. Voice of the Church 171. World Bank 172. World Health Organization 173. World Vison 174. Worms and Bilharzias Clinic 175. Zimbabwe Voluntary Medical Male Circumcision Program

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ANNEX III: MALE CIRCUMCISION OPERATIONAL PLAN 2014 - 2018

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Element 1: Service Delivery MC Service Delivery 1.1 Strategies Strategy Develop a comprehensive MC Element 1: service delivery plan linked to 1.1.1 Service demand creation and human Delivery resources planning Strategy Develop a comprehensive MC Element 1: Develop a comprehensive MC service MC Service 1.1.1 service delivery plan linked to 1.1.1.1 X X X X X MOH Service delivery plan Delivery Provider demand creation Delivery Strategy Develop a comprehensive MC Element 1: Disseminate copies of the MC Service MC Service 1.1.1 service delivery plan linked to 1.1.1.2 X MOH Service Delivery Plan Delivery Provider demand creation Delivery Strategy Develop a comprehensive MC Monitor and evaluate MC service delivery Element 1: 1.1.1 service delivery plan linked to 1.1.1.3 plan implementation and make X X X X X MC-TWG Service demand creation recommendations as necessary Delivery Strategy Engage experienced MC Element 1: service delivery providers to 1.1.2 Service scale up innovative service Delivery delivery models Strategy Engage experienced MC Element 1: service delivery providers to MC Service 1.1.2 1.1.2.1 Issue Tender/Request for Application X MOH Service scale up innovative service Delivery Provider Delivery delivery models Strategy Engage experienced MC Element 1: service delivery providers to MC Service 1.1.2 1.1.2.2 Appoint MC service delivery provider X MOH Service scale up innovative service Delivery Provider Delivery delivery models Strategy Engage experienced MC Element 1: service delivery providers to Implement innovative VMMC and EIMC MC Service 1.1.2 1.1.2.3 X X X X X MOH Service scale up innovative service service delivery models Delivery Provider Delivery delivery models 56 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Strengthen linkages and Element 1: referrals between 1.1.3 Service communities and VMMC and Delivery EIMC facilities Strategy Work with Community TWG to develop Strengthen linkages and Element 1: and strengthen MC community referral MC Service 1.1.3 referrals between communities 1.1.3.1 X MOH Service processes, plans, and roles and Delivery Provider and VMMC and EIMC facilities Delivery responsibilities Strategy Strengthen linkages and Integrate MC into the existing tracking Element 1: MC Service 1.1.3 referrals between communities 1.1.3.2 process for VMMC and EIMC linkage and X MOH Service Delivery Provider and VMMC and EIMC facilities referral data Delivery Strategy Strengthen linkages and Element 1: Pilot client tracing and facility referral MC Service 1.1.3 referrals between communities 1.1.3.3 X MOH Service system for VMMC and EIMC Delivery Provider and VMMC and EIMC facilities Delivery Strategy Strengthen linkages and Element 1: Review and update the HIV services MC Service 1.1.3 referrals between communities 1.1.3.4 X MOH Service directory to include MC Delivery Provider and VMMC and EIMC facilities Delivery Strategy Strengthen linkages and Element 1: Implement client tracing and facility 1.1.3 referrals between communities 1.1.3.5 X X X X X MOH Service referral system for VMMC and EIMC and VMMC and EIMC facilities Delivery Strategy Element 1: Increase private sector 1.1.4 Service participation in MC services Delivery Strategy Organize consultation workshop with Element 1: Increase private sector 1.1.4 1.1.4.1 medical aid schemes and private X MOH Service participation in MC services healthcare providers Delivery Strategy Develop and sign MOU with medical aid Element 1: Increase private sector 1.1.4 1.1.4.2 schemes and private healthcare X X MOH Service participation in MC services providers Delivery Strategy Identify private sector VMMC sites and Private VMMC Element 1: Increase private sector implement VMMC minimum package 1.1.4 1.1.4.3 X X X X X MOH Service Service participation in MC services services in accordance with national Providers Delivery quality guidelines

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Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Identify private sector EIMC sites and Private EIMC Element 1: Increase private sector 1.1.4 1.1.4.4 implement services in accordance with X X X X X MOH Service Service participation in MC services national quality guidelines Providers Delivery VMMC Service 1.2 Delivery Strategies Strengthen, scale up and Strategy sustain mobile and outreach Element 1: 1.2.1 sites linked to campaigns and Service community based demand Delivery creation Strengthen, scale up and Strategy sustain mobile and outreach Element 1: Set up mobile sites according to the MC MC Service 1.2.1 sites linked to campaigns and 1.2.1.1 X X X X X MOH Service service delivery plan Delivery Provider community based demand Delivery creation Strengthen, scale up and Strategy sustain mobile and outreach Element 1: MC Service 1.2.1 sites linked to campaigns and 1.2.1.2 Procure vehicles X X X X X MOH Service Delivery Provider community based demand Delivery creation Strengthen, scale up and Strategy sustain mobile and outreach Element 1: MC Service 1.2.1 sites linked to campaigns and 1.2.1.3 Operate mobile sites X X X X X MOH Service Delivery Provider community based demand Delivery creation Strengthen, scale up and Strategy sustain mobile and outreach Element 1: MC Service 1.2.1 sites linked to campaigns and 1.2.1.4 Procure VMMC commodities X X X X X MOH Service Delivery Provider community based demand Delivery creation Strengthen, scale up and Strategy sustain mobile and outreach Element 1: MC Service 1.2.1 sites linked to campaigns and 1.2.1.5 Distribute VMMC commodities X X X X X MOH Service Delivery Provider community based demand Delivery creation Strategy Strengthen, scale up and Element 1: sustain mobile and outreach MC Service 1.2.1 1.2.1.6 Recruit staff X X X X X MOH Service sites linked to campaigns and Delivery Provider Delivery community based demand 58 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department creation Strengthen, scale up and Strategy sustain mobile and outreach Element 1: MC Service 1.2.1 sites linked to campaigns and 1.2.1.7 Manage waste X X X X X MOH Service Delivery Provider community based demand Delivery creation Strengthen, scale up and Strategy sustain mobile and outreach Element 1: Incorporate VMMC into existing PHU MC Service 1.2.1 sites linked to campaigns and 1.2.1.8 X X X X X MOH Service outreach plan/schedule Delivery Provider community based demand Delivery creation Strengthen, scale up and Strategy sustain selected existing Element 1: 1.2.2 NGO fixed sites linked to Service campaigns and community- Delivery based demand creation Strategy Strengthen, scale up and Element 1: Undertake VMMC readiness assessments MC Service 1.2.2 sustain selected existing NGO 1.2.2.1 X X X X X MOH Service according to the MC service delivery plan Delivery Provider fixed sites Delivery Strategy Strengthen, scale up and Element 1: Refurbish clinics according to the MC MC Service 1.2.2 sustain selected existing NGO 1.2.2.2 X X X X X MOH Service service delivery plan Delivery Provider fixed sites Delivery Strategy Strengthen, scale up and Element 1: MC Service 1.2.2 sustain selected existing NGO 1.2.2.3 Procure VMMC commodities X X X X X MOH Service Delivery Provider fixed sites Delivery Strategy Strengthen, scale up and Element 1: MC Service 1.2.2 sustain selected existing NGO 1.2.2.4 Distribute VMMC commodities X X X X X MOH Service Delivery Provider fixed sites Delivery Strategy Strengthen, scale up and Element 1: MC Service 1.2.2 sustain selected existing NGO 1.2.2.5 Manage waste X X X X X MOH Service Delivery Provider fixed sites Delivery Strategy Strengthen, scale up and Element 1: MC Service 1.2.2 sustain selected existing NGO 1.2.2.7 Operate and maintain clinics and utilities X X X X X MOH Service Delivery Provider fixed sites Delivery Strategy 1.2.3 Strengthen VMMC referral 59 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Element 1: and follow up capacity in Service public sector health facilities Delivery Strategy Strengthen VMMC referral and Element 1: Develop and implement VMMC referral MC Service 1.2.3 follow up capacity in selected 1.2.3.1 X X X X X MOH Service and follow up guidelines Delivery Provider public sector facilities Delivery EIMC Service 1.3 Delivery Strategies Strategy Element 1: Scale up EIMC in existing 1.3.1 Service service delivery sites Delivery Selection, assessment, preparation, and Strategy MOH, SNAP. introduction of EIMC services in any Element 1: Scale up EIMC in existing SRHU, 1.3.1 1.3.1.1 additional public facilities where X Service service delivery sites Regional deliveries are taking place and doctors Delivery Focal Person are present Strategy Addition of EIMC messaging in IMCI and MOH, SNAP. Element 1: Scale up EIMC in existing EPI training modules and provider job SRHU, 1.3.1 1.3.1.2 X Service service delivery sites aids, other HIV/AIDS and SRHU program Regional Delivery training modules and job aids Focal Person Strategy Element 1: Decentralize EIMC services to 1.3.2 Service lower level facilities Delivery MOH, Strategy Regional Element 1: Decentralize EIMC services to Completion of EIMC expansion 1.3.2 1.3.2.1 X Focal Service lower level facilities situational analysis persons, Delivery SRHU MOH, Strategy Regional Element 1: Decentralize EIMC services to Selection of additional EIMC service 1.3.2 1.3.2.2 X Focal Service lower level facilities delivery outlet(s) persons, MC- Delivery TWG Strategy MOH, SNAP, Decentralize EIMC services to Site strengthening, preparation for, and Element 1: 1.3.2 1.3.2.3 X SRHU, lower level facilities initiation of services in new EIMC sites Service Regional 60 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Delivery Focal persons, MC- TWG

Strategy Element 2: Human Resources for Service Delivery

MC Human Resources 2.1 Strategies Strategy Element 2: Strengthen MC HR planning 2.1.1 Human to support MC scale up Resources Strategy Develop MC HR plan detailing VMMC and Element 2: Strengthen MC HR planning to MC Service 2.1.1 2.1.1.1 EIMC staffing and training requirements X X X X X MOH Human support MC scale up Delivery Provider aligned to MC service delivery plan Resources VMMC Human 2.2 Resources Strategies Strategy Strengthen MC VMMC HR Element 2: 2.2.1 capacity to support MC scale Human up Resources Strategy Element 2: Strengthen MC VMMC capacity Recruit, train and deploy dedicated MC Service 2.2.1 2.2.1.1 X X X X X MOH Human to support MC scale up VMMC service delivery teams Delivery Provider Resources Strategy Element 2: Strengthen MC VMMC capacity Recruit, train and deploy additional MC Service 2.2.1 2.2.1.2 X X X X X MOH Human to support MC scale up VMMC trainers Delivery Provider Resources Strategy Element 2: Strengthen MC VMMC capacity Provide refresher training for existing MC Service 2.2.1 2.2.1.3 X X X X X MOH Human to support MC scale up VMMC trainers Delivery Provider Resources Strategy Element 2: Strengthen MC VMMC capacity MC Service 2.2.1 2.2.1.4 Recruit, train and deploy IPC agents X X X X X MOH Human to support MC scale up Delivery Provider Resources 61 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department EIMC Human 2.3 Resources Strategies Strategy Element 2: Increase the number of EIMC 2.3.1 Human trained healthcare providers Resources MOH, SNAP, Strategy Provide clinical training for EIMC service SHRU, Element 2: Increase the number of EIMC MC Service 2.3.1 2.3.1.1 providers, and regional mentors and X X X X X Regional Human trained healthcare providers Delivery Provider supervisors Focal Resources Persons Strategy Develop, endorse, and Element 2: 2.3.2 implement EIMC Task Human Shifting Regulations Resources Strategy Nursing leadership and key national MOH, SRHU, Develop, endorse, and Element 2: stakeholders meeting to review Swaziland 2.3.2 implement EIMC Task Shifting 2.3.2.1 X Human reintroduction of Nurses Bill to Nursing Regulations Resources Parliament Council MOH, MC- Strategy TWG, Develop, endorse, and Support Swaziland Nursing Council to Element 2: Swaziland MC Service 2.3.2 implement EIMC Task Shifting 2.3.2.2 draft regulations to detail task-shifting Human Nursing Delivery Provider Regulations for EIMC Resources Council, SRHU MOH, SNAP, Swaziland Strategy Develop, endorse, and Nursing Element 2: Present regulations to stakeholders for 2.3.2 implement EIMC Task Shifting 2.3.2.3 X Council, Human approval and adoption Regulations nursing Resources leadership, SRHU MOH, Regional Strategy Focal People, Develop, endorse, and Element 2: Dissemination of regulations through Nursing 2.3.2 implement EIMC Task Shifting 2.3.2.4 X X Human national and regional forums institutions, Regulations Resources Swaziland Nursing Council, 62 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department nursing leadership, SRHU Strategy Explore the feasibility of Element 2: 2.3.3 introducing EIMC into Human nursing pre-service education Resources MOH, Visits to Swaziland nursing pre-service Regional Strategy Explore the feasibility of training institutions and healthcare Focal People, Element 2: 2.3.3 introducing EIMC into nursing 2.3.3.1 facilities where students undergo X Nursing Human pre-service education practical training for orientation and institutions, Resources needs assessment Swaziland Nursing MOH, Regional Focal People, Strategy Explore the feasibility of Nursing Element 2: Explore introduction of EIMC into PSE MC Service 2.3.3 introducing EIMC into nursing 2.3.3.2 X X institutions, Human training curriculum Delivery Provider pre-service education Swaziland Resources Nursing Council, SRHU MOH, Strategy Explore the feasibility of Regional Element 2: Procure EIMC materials for PSE training 2.3.3 introducing EIMC into nursing 2.3.3.3 X Focal People, Human skills labs pre-service education Nursing Resources institutions MOH, Strategy Explore the feasibility of Regional Element 2: Facilitate EIMC training for pre-service MC Service 2.3.3 introducing EIMC into nursing 2.3.3.4 X X Focal People, Human training providers Delivery Provider pre-service education Nursing Resources institutions Continue to roll out the on- the-job EIMC counseling 2.3.4 module at all healthcare facilities providing services to pregnant women Strategy Continue to roll out the on-the- On-the-job training for nursing and MOH, Element 2: 2.3.4 job EIMC counseling module at 2.3.4.1 support staff in all Swazi facilities that X X X X X Regional Human all healthcare facilities providing provide ANC, PNC, FP, and/or IMCI/EPI Focal People, 63 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Resources services to pregnant women services RHMTS

Strategy Element 3: Demand Creation MC Demand Creation 3.1 Strategies Strategy Element 3: Strengthen MC demand 3.1.1 Demand creation framework Creation MC Service MOH, SBC Strategy Delivery Develop a comprehensive MC demand TWG, Element 3: Strengthen MC demand Provider, MC 3.1.1 3.1.1.1 creation plan linked to the MC service X X X X X Ministry of Demand creation framework Demand delivery plan Tinkhundla, Creation Creation Service NERCHA Provider MC Service MOH, SBC Strategy Delivery Develop MC messaging guidelines TWG, Element 3: Strengthen MC demand Provider, MC 3.1.1 3.1.1.2 aligned to health promotion messaging X X X X X Ministry of Demand creation framework Demand guidelines Tinkhundla, Creation Creation Service NERCHA Provider Strategy Engage traditional leaders Element 3: 3.1.2 and other key opinion leaders Demand in creating demand for MC Creation MC Service MOH, SBC Strategy Delivery Engage traditional leaders and Engage youth in demand creation TWG, Element 3: Provider, MC 3.1.2 other key opinion leaders in 3.1.2.1 through the national and regional youth X X X X X Ministry of Demand Demand creating demand for MC organizations Tinkhundla, Creation Creation Service NERCHA Provider MC Service MOH, SBC Strategy Delivery Engage traditional leaders and Engage politicians in demand creation TWG, Element 3: Provider, MC 3.1.2 other key opinion leaders in 3.1.2.2 through the parliamentary HIV sub- X X X X X Ministry of Demand Demand creating demand for MC committee Tinkhundla, Creation Creation Service NERCHA Provider

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Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department MC Service MOH, SBC Strategy Delivery Engage traditional leaders and TWG, Element 3: Engage chiefs in demand creation Provider, MC 3.1.2 other key opinion leaders in 3.1.2.3 X X X X X Ministry of Demand through the CHEMSHAACS Demand creating demand for MC Tinkhundla, Creation Creation Service NERCHA Provider MC Service Engage national and regional traditional MOH, SBC Strategy Delivery Engage traditional leaders and institutions in demand creation, and use TWG, Element 3: Provider, MC 3.1.2 other key opinion leaders in 3.1.2.4 IEC and other promotional materials to X X X X X Ministry of Demand Demand creating demand for MC create MC demand (separate EIMC and Tinkhundla, Creation Creation Service VMMC activities and costs) NERCHA Provider MC Service MOH, SBC Strategy Delivery Engage traditional leaders and TWG, Element 3: Engage RHMTs and REMSHACCS in MC Provider, MC 3.1.2 other key opinion leaders in 3.1.2.5 X X X X X Ministry of Demand demand creation Demand creating demand for MC Tinkhundla, Creation Creation Service NERCHA Provider MC Service MOH, SBC Strategy Delivery Engage traditional leaders and Engage government departments in TWG, Element 3: Provider, MC 3.1.2 other key opinion leaders in 3.1.2.6 demand creation through the national X X X X X Ministry of Demand Demand creating demand for MC and regional PSHCACCs Tinkhundla, Creation Creation Service NERCHA Provider MC Service MOH, SBC Strategy Sensitize church forums regarding Delivery Engage traditional leaders and TWG, Element 3: VMMC and EIMC to enable church Provider, MC 3.1.2 other key opinion leaders in 3.1.2.7 X X X X X Ministry of Demand leaders to educate fathers/couples and Demand creating demand for MC Tinkhundla, Creation young people about MC Creation Service NERCHA Provider MC Service Engage private sector leaders in demand MOH, SBC Strategy Delivery Engage traditional leaders and creation through business associations TWG, Element 3: Provider, MC 3.1.2 other key opinion leaders in 3.1.2.8 and private healthcare networks with a X X X X X Ministry of Demand Demand creating demand for MC particular focus on 'harder to reach' Tinkhundla, Creation Creation Service males NERCHA Provider MC Service MOH, SBC Strategy Delivery Engage traditional leaders and TWG, Element 3: Engage MNCH leaders in VMMC and Provider, MC 3.1.2 other key opinion leaders in 3.1.2.9 X X X X X Ministry of Demand EIMC demand creation Demand creating demand for MC Tinkhundla, Creation Creation Service NERCHA Provider 65 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department MC Service MOH, SBC Strategy Delivery Engage traditional leaders and TWG, Element 3: Use MC motivators to counsel and Provider, MC 3.1.2 other key opinion leaders in 3.1.2.10 X X X X X Ministry of Demand educate families to create demand Demand creating demand for MC Tinkhundla, Creation Creation Service NERCHA Provider Strategy Develop and implement Element 3: 3.1.3 national and local MC Demand multimedia campaigns Creation MC Service MOH, SBC Strategy Delivery Develop and implement national Develop and implement national TWG, Element 3: Provider, MC 3.1.3 and local MC multimedia 3.1.3.1 multimedia campaigns (TV, press, radio X X X X X Ministry of Demand Demand campaigns etc.) Tinkhundla, Creation Creation Service NERCHA Provider MC Service MOH, SBC Strategy Delivery Develop and implement national TWG, Element 3: Develop and implement local multimedia Provider, MC 3.1.3 and local MC multimedia 3.1.3.2 X X X X X Ministry of Demand campaigns (TV, press, radio etc.) Demand campaigns Tinkhundla, Creation Creation Service NERCHA Provider Strategy Deploy information and Element 3: 3.1.4 communication technologies Demand to promote MC Creation MC Service MOH, SBC Strategy Develop and implement innovative Delivery Deploy information and TWG, Element 3: information and communication Provider, MC 3.1.4 communication technologies to 3.1.4.1 X X X X X Ministry of Demand technologies to promote VMMC and Demand promote MC Tinkhundla, Creation EIMC Creation Service NERCHA Provider Strategy Utilize multiple platforms to Element 3: 3.1.5 promote VMMC and EIMC Demand messaging Creation MC Service MOH, SBC Strategy Use VMMC platforms to promote EIMC; Delivery Utilize multiple platforms to TWG, Element 3: use EIMC platforms to promote VMMC; Provider, MC 3.1.5 promote VMMC and EIMC 3.1.5.1 X X X X X Ministry of Demand and use PMTC, FP and other MNCH Demand messaging Tinkhundla, Creation platforms to promote EIMC and VMMC Creation Service NERCHA Provider 66 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Element 3: Empower women to support 3.1.6 Demand MC scale up Creation Develop and implement VMMC/EIMC MC Service Strengthen MC messaging and messages to meet the unique MOH, SBC Strategy Delivery sensitization in all public health informational needs and societal roles of TWG, Element 3: Provider, MC 3.1.6 facilities and selected 3.1.6.1 women – both in community and facility X X X X X Ministry of Demand Demand government and private sector settings through fora such as Lutsango, Tinkhundla, Creation Creation Service organizations Imbita Savings collectives, faith-based NERCHA Provider women’s groups, and industrial groups VMMC Demand 3.2 Creation Strategies Scale up existing VMMC Strategy campaigns and develop new Element 3: campaigns targeted at places 3.2.1 Demand and occasion where young Creation men congregate in large numbers MC Service Scale up existing VMMC MOH, SBC Strategy Develop and implement campaigns Delivery campaigns and develop new TWG, Element 3: targeted at places and occasions where Provider, MC 3.2.1 campaigns targeted at places 3.2.1.1 X X X X X Ministry of Demand young men congregate in large numbers Demand and occasion where young men Tinkhundla, Creation such as sporting events Creation Service congregate in large numbers NERCHA Provider Refocus VMMC demand Strategy creation to address men's Element 3: 3.2.2 reproductive health and new Demand social norms that appeal to Creation men and women MC Service Refocus VMMC demand MOH, SBC Strategy Develop and implement campaign to Delivery creation to address men's TWG, Element 3: address men's reproductive health and Provider, MC 3.2.2 reproductive health and new 3.2.2.1 X X X X X Ministry of Demand new social norms that appeal to men and Demand social norms that appeal to men Tinkhundla, Creation women Creation Service and women NERCHA Provider Strategy Strengthen VMMC service Element 3: delivery to relevant key 3.2.3 Demand populations and vulnerable Creation groups 67 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department MC Service MOH, SBC Strategy Strengthen VMMC service Develop and implement strategies to Delivery TWG, Element 3: delivery to relevant key improve VMMC service delivery to Provider, MC 3.2.3 3.2.3.1 X X X X X Ministry of Demand populations and vulnerable relevant key populations and vulnerable Demand Tinkhundla, Creation groups groups, such as mobile populations Creation Service NERCHA Provider EIMC Demand 3.3 Creation Strategies Increase ownership of EIMC Strategy services by public facility Element 3: 3.3.1 providers as part of a Demand comprehensive MNCH Creation package MOH, MC focal people, Strategy Increase ownership of EIMC Orient nurse managers, unit leads, regional focal Element 3: services by public facility 3.3.1 3.3.1.1 nursing institution faculty, and clinical X X X x x people, MC- Demand providers as part of a preceptors on EIMC TWG, SRHU, Creation comprehensive MNCH package nursing leadership Strategy Element 3: Strengthen the informed 3.3.2 Demand consent process for EIMC Creation MOH, MC focal people, Strategy Distribution of EIMC information and regional focal Element 3: Strengthen the informed 3.3.2 3.3.2.1 consent forms via ANC as part of routine X X X X X people, MC- Demand consent process for EIMC package of services TWG, SRHU, Creation nursing leadership MOH, MC focal people, Strategy Distribution of EIMC information and regional focal Element 3: Strengthen the informed 3.3.2 3.3.2.2 consent forms via other service delivery X X X X X people, MC- Demand consent process for EIMC outlets - i.e. FP, HTC, and VMMC TWG, SRHU, Creation nursing leadership Strategy Increase involvement of 3.3.3 Element 3: fathers (and fathers to be) in 68 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Demand EIMC. Creation MOH, MC focal people, Strategy Expand community dialogues and group regional focal Element 3: Increase involvement of fathers 3.3.3 3.3.3.1 discussions via partners providing X X X X X people, MC- Demand (and fathers to be) in EIMC. community level programming TWG, Creation Community TWG MOH, MC focal people, Strategy regional focal Element 3: Increase involvement of fathers Support the intregration of EIMC into 3.3.3 3.3.3.2 X X X X X people, MC- Demand (and fathers to be) in EIMC. M2M and fathers-to-fathers interventions TWG, Creation Community TWG MOH, MC Strategy focal people, Pilot father/son "package deal" (aka Element 3: Increase involvement of fathers regional focal 3.3.3 3.3.3.3 discounting program or other father/son X Demand (and fathers to be) in EIMC. people, innovation) Creation facility level focal people Strategy MOH, MC Element 3: Increase involvement of fathers Pilot morning health talks for men by a focal people, 3.3.3 3.3.3.4 X Demand (and fathers to be) in EIMC. male nurse facility level Creation focal people Strategy Element 4: Supply Chain Management MC Supply Chain 4.1 Managemen t Strategy Strengthen existing national Central Medical Stores supply 4.1.1 chain management system to meet the increased requirements of MC scale up Strategy Strengthen existing national Enhance current MC supply chain Element 4: Central Medical Stores supply Supply Chain management logistics to meet the Supply 4.1.1 chain management system to 4.1.1.1 X MOH Management requirements of VMMC and EIMC scale Chain meet the increased Service Provider up Managemen requirements of MC scale up 69 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department t

Strategy Strengthen existing national Element 4: Central Medical Stores supply Build the capacity of CMS in line with the Supply Chain Supply 4.1.1 chain management system to 4.1.1.2 integration of EIMC into the MNCH X X X X X MOH Management Chain meet the increased platform Service Provider Managemen requirements of MC scale up t Strategy Strengthen existing national Element 4: Develop and implement a plan to transfer Central Medical Stores supply Supply Chain Supply the VMMC supply chain management 4.1.1 chain management system to 4.1.1.3 X X X X X MOH Management Chain system to CMS in line with VMMC scale meet the increased Service Provider Managemen up requirements of MC scale up t Supply Chain Procure and distribute supplies for waste 4.1.1 4.1.1.4 X X X X X MOH Management management Service Provider Strategy Element 5: Waste Management MC Waste Managemen 5.1 t Strategy Ensure compliance with the Healthcare Waste 5.1.1 Management Guidelines and Standard Operating Procedures at all MC sites Strategy Ensure compliance with the Element 5: Healthcare Waste Management Conduct training sessions for staff MC Service Waste 5.1.1 Guidelines and Standard 5.1.1.1 responsible for handling MC healthcare X X X X X MOH Delivery Provider Managemen Operating Procedures at all MC waste t sites Strategy Ensure compliance with the Assess compliance with HCWM Element 5: Healthcare Waste Management guidelines and SOPs during VMMC/EIMC Waste 5.1.1 Guidelines and Standard 5.1.1.2 site visits to assess adherence to QA X X X X X MOH Managemen Operating Procedures at all MC standards during service provision at all t sites levels Strategy Element 6: Quality Assurance MC Quality Assurance 6.1 Strategy 70 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strengthen Quality Assurance at all MC sites 6.1.1 according to national standards and guidelines Strategy Strengthen Quality Assurance Develop and implement a clear AE Element 6: at all MC sites according to 6.1.1 6.1.1.1 reporting mechanism (Incidence Report) X MOH Quality national standards and for MOH Assurance guidelines Strategy Strengthen Quality Assurance Element 6: at all MC sites according to Conduct external QA visits during BTS 6.1.1 6.1.1.2 X X X X X MOH Quality national standards and and other campaigns Assurance guidelines Strategy Strengthen Quality Assurance Facilitate and participate in Internal and Element 6: at all MC sites according to External QA assessments during routine 6.1.1 6.1.1.3 X X X X X MOH Quality national standards and EIMC/VMMC service delivery and Assurance guidelines targeted campaigns Strategy Strengthen Quality Assurance Element 6: at all MC sites according to Conduct site readiness assessments for MC Service 6.1.1 6.1.1.4 X X X X MOH Quality national standards and new VMMC sites Delivery Provider Assurance guidelines Conduct facility readiness assessments Strategy Strengthen Quality Assurance for potential new decentralized EIMC Element 6: at all MC sites according to sites (including assessment of MC Service 6.1.1 6.1.1.5 X X X X X MOH Quality national standards and components for strengthening the labor Delivery Provider Assurance guidelines & birth, and immediate post-partum care for mother/baby pair). Strategy Strengthen Quality Assurance Evaluate VMMC/EIMC training sessions Element 6: at all MC sites according to 6.1.1 6.1.1.6 to ensure compliance to QA training X X X X X MOH Quality national standards and protocols Assurance guidelines Strategy Strengthen Quality Assurance Element 6: at all MC sites according to Conduct pre-campaign QA orientation MC Service 6.1.1 6.1.1.7 X X X X X MOH Quality national standards and sessions for trained MC providers Delivery Provider Assurance guidelines Strategy Strengthen Quality Assurance Conduct VMMC/EIMC site visits to Element 6: at all MC sites according to 6.1.1 6.1.1.8 assess adherence to QA standards X X X X X MOH Quality national standards and during service provision at all levels Assurance guidelines Strategy Strengthen Quality Assurance Assist VMMC/EIMC sites to institute MC Service Element 6: 6.1.1 at all MC sites according to 6.1.1.9 quality improvement activities during X X X X X MOH Delivery Provider Quality national standards and service provision at all levels 71 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Assurance guidelines

Strategy Strengthen Quality Assurance Transfer management of the VMMC/EIMC Element 6: at all MC sites according to MC Service 6.1.1 6.1.1.10 QA Tracker system from the MC service X X X MOH Quality national standards and Delivery Provider provider to the MOH Assurance guidelines Strategy Strengthen Quality Assurance Develop and post job aids at all service Element 6: at all MC sites according to MC Service 6.1.1 6.1.1.11 delivery sites to ensure compliance with X X MOH Quality national standards and Delivery Provider national quality standards and guidelines Assurance guidelines Strategy Element 7: New Technologies and Devices MC New Technologi es and 7.1 Devices Strategy Review developments in MC new technologies and 7.1.1 devices and implement findings that could enhance MC scale up Strategy Element 7: Review developments in MC Conduct safety and acceptability study New new technologies and devices 7.1.1 7.1.1.1 on the PrePex device and implement X SID, MOH Technologie and implement findings that findings of the study s and could enhance MC scale up Devices Strategy Conduct annual reviews of WHO Element 7: Review developments in MC recommendations on new technologies New new technologies and devices and devices for MC and introduce 7.1.1 7.1.1.2 X X X X X SID, MOH Technologie and implement findings that recommendations that could enhance s and could enhance MC scale up MC scale up according to WHO Devices guidelines Strategy Element 8: Strategic Information MC Strategic 8.1 Information Strategy Strengthen MC Strategic 8.1.1 Information Systems 72 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Element 8: Strengthen MC Strategic Revive M&E TWG and conduct quarterly 8.1.1 8.1.1.1 X X X X X SID, MOH Strategic Information Systems meetings Information Strategy Fill vacant position of M&E Program Element 8: Strengthen MC Strategic 8.1.1 8.1.1.2 Officer with responsibility for MC and HIV X X X X X SID, MOH Strategic Information Systems Prevention in SID Information Strategy Develop MC M&E Framework including Element 8: Strengthen MC Strategic 8.1.1 8.1.1.3 finalization of MC indicators and X SID, MOH Strategic Information Systems finalization of data collection tools Information Strategy Element 8: Strengthen MC Strategic Enhance MC database and integrate into 8.1.1 8.1.1.4 X X SID, MOH Strategic Information Systems HMIS Information Undertake MC program monitoring and Strategy review during NASAR, RESAR and MOH Element 8: Strengthen MC Strategic 8.1.1 8.1.1.5 Senior Manager's meetings, including X X X X X MOH Strategic Information Systems annual implementation plan review and Information revised plan for the following year Strategy Undertake MC program evaluation, Element 8: Strengthen MC Strategic including lessons learned and 8.1.1 8.1.1.6 X X SID, MOH Strategic Information Systems documentation of successful and Information innovative service delivery models Strategy Identify MC priority areas for operational Element 8: Strengthen MC Strategic 8.1.1 8.1.1.7 research, develop research schedule and X X X X X SID, MOH Strategic Information Systems implement research Information Strategy Element 9: Program Coordination and Management MC Program Coordinatio 9.1 n & Managemen t Strategy Strengthen MC program coordination and 9.1.1 management at the national, regional and community levels 73 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Element 9: Strengthen MC program Program Organize high-level MC Meeting with the coordination and management Coordination 9.1.1 9.1.1.1 Under Secretaries and Principal x SNAP, MOH at the national, regional and and Secretaries community levels Managemen t Strategy Element 9: Strengthen MC program Program Organize high-level meetings with coordination and management Coordination 9.1.1 9.1.1.2 Parliamentary Portfolio Committee on x SNAP, MOH at the national, regional and and HIV and Health community levels Managemen t Strategy Element 9: Strengthen MC program Program coordination and management Coordination 9.1.1 9.1.1.3 Organize National MC Strategy Launch x SNAP, MOH at the national, regional and and community levels Managemen t Strategy Element 9: Strengthen MC program Review membership of MC-TWG and Program coordination and management appoint key opinion leaders to sub- Coordination 9.1.1 9.1.1.4 X MC-TWG at the national, regional and committees and/or ad hoc committees as and community levels necessary Managemen t Strategy Element 9: Strengthen MC program Program Organize regional MC orientation coordination and management Coordination 9.1.1 9.1.1.5 workshshops on MC Strategy and x SNAP, MOH at the national, regional and and operational plans for Chiefs community levels Managemen t Strategy Element 9: Strengthen MC program Program coordination and management RHMT and REMCHACC MC orientation Coordination 9.1.1 9.1.1.6 x SNAP, MOH at the national, regional and meetings and community levels Managemen t 74 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Element 9: Strengthen MC program Program coordination and management Coordination 9.1.1 9.1.1.7 CHEMSHACC MC orientation meetings x SNAP, MOH at the national, regional and and community levels Managemen t Strategy Element 9: Undertake MC HR capacity assessment Strengthen MC program Department Program in critical areas of national MC coordination and management of Public Coordination 9.1.1 9.1.1.8 coordination, MC M&E, clinical technical X at the national, regional and Service; and support and regional and community community levels SNAP, MOH Managemen level coordination t Strategy Element 9: Strengthen MC program Program coordination and management Implement findings of the HR capacity Coordination 9.1.1 9.1.1.9 X X X X SNAP, MOH at the national, regional and assessment and community levels Managemen t Strategy Element 9: Strengthen MC program Program Appoint consultants to facilitate MC coordination and management Coordination 9.1.1 9.1.1.10 national coordination and MC regional X X SNAP, MOH at the national, regional and and coordination community levels Managemen t Strategy Element 9: Strengthen MC program Program coordination and management Undertake national MC stakeholders Coordination 9.1.1 9.1.1.11 X X X X X SNAP, MOH at the national, regional and meetings and community levels Managemen t Strategy Element 9: Strengthen MC program Program coordination and management Undertake regional MC stakeholders Coordination 9.1.1 9.1.1.12 X X X X X SNAP, MOH at the national, regional and meeting and community levels Managemen t 75 | Page

Responsible Responsible Strategic Strategic Activity Y5 Government Strategic Action Activity Y1 Y2 Y3 Y4 Implementing Element Action # # Ministry/ Partner Department Strategy Element 9: Strengthen MC program Program coordination and management Provide logistic support for MC Coordination 9.1.1 9.1.1.13 X X X X SNAP, MOH at the national, regional and coordination-vehicles and community levels Managemen t Strategy Element 9: Strengthen MC program Program coordination and management Provide logistic support for MC Coordination 9.1.1 9.1.1.14 X X X X SNAP, MOH at the national, regional and coordination-computers and community levels Managemen t

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