The government has nearly achieved the ambitious goals it set for itself in 2008. It aimed to see 860,000 boys and men between the ages of 15 to 49 years, circumcised over the coming five years.
By 2013, they had achieved more than 90 per cent of that goal. This was made possible through donor support.
While the funding has been good, dependence can create problems too. Furthermore, some strategies that contributed to early successes now complicate the achievement of long-term goals.
One issue is the use of mobilizers to persuade men to undergo the procedure.
Though effective, it has set circumcision apart from other health care services. There aren’t special, paid mobilizers for pregnant women to attend antenatal care clinics, and certainly no one needs to persuade a person to visit a health centre if he has a bout of diarrhea or simply isn’t feeling well. Today, that distinctive status for circumcision complicates possible efforts to integrate it into mainstream health programs.
A second complication arises from the fact that the circumcision services have been run mostly by non-governmental organizations. Rarely short of funds, they generally pay better salaries than government institutions, and often have better facilities and their employees enjoy better working conditions. While good for the circumcision project in the short-run, this disparity works against the goal of making circumcision an ongoing, routine health priority.
Government workers are more than willing to take locum in private facilities offering circumcision, since it presents an extra source of revenue. In fact, even though they are fully trained to perform circumcisions, the extra income makes them prefer to help the NGO-run facility rather than take referrals at their own facilities. At another private circumcision facility, a staff member who asked to remain anonymous reported that government workers even ask for payments to refer men for circumcision when the issue arises during other routine clinic visits at government facilities.
It’s unclear how widespread such behavior is, but the use of ‘NGO branding’ as leverage for higher pay may inadvertently discourage men from undergoing it, either by raising its cost or by subtly conveying the idea that it is less of a priority than other services that are routinely available at all times.
Donor funding also may undermine the long-term goal of convincing men that circumcision is something they should want on their own. The case of a so-called ‘hard to reach group’ illustrates this issue. These are men above the age of 25 working as casual laborers.
Across the board, mobilisers as well as technical advisors say it has been very difficult to persuade this group to undergo medical circumcision. The men complain that they would lose income on the days spent recuperating, which would be especially difficult considering the nature of their work. They often flatly say that they will only undergo the procedure if they are paid for the days of work they would miss.
So far, it’s unclear how the public health system will deal with this difficult problem. There is evidence that providing reimbursement for men to get circumcised works. Health experts themselves are divided on the issue.
The biggest stumbling block to scaling up and sustaining voluntary medical male circumcision in Kenya might be money. Up to now, donors have paid 100 per cent of the costs related to advocating and performing voluntary medical male circumcision. For all that has been achieved, it has also enabled the government of Kenya to avoid having to decide where it believes circumcision belongs in the country’s overall priorities.
It can’t avoid the issue forever, though: donor support cannot and will not be sustained indefinitely.
The issue may not be as easy to resolve. Should the government take funds from malaria, immunisation and other programs, in the process stretching already thin budgets and less than motivated staff members for a voluntary procedure that the identified communities did not consider important a decade ago? And if spending on other programs can’t be cut, where will additional funds be found?
Thus, the government nearly achieved the ambitious goals it set for itself in 2008. It aimed to see 860,000 boys and men ages 15 to 49 years circumcised over the coming five years, and by 2013 had achieved more than 90 per cent of that goal. But how can Kenya keep its momentum and build on its initial successes? Planners recognise the new challenge; they call this new stage of circumcision advocacy the “sustainable phase.”
To put the circumcision effort on a more sustainable footing, policy-makers will have to look at what has worked so far, and figure out how to sustain it into the future.
That doesn’t automatically imply cutting expenditures to the bare bone. Research by Prof. Kawango Agot in Nyando District Kenya showed that compensating men for agreeing to undergo circumcision is effective though long-term benefits are yet to be analysed. Considering the success of the concept, policy makers need to consider innovative approaches that work without distracting men from the realization that medical circumcision is a decision they should make in their own interest.
Similarly, policy-makers need to explore whether they can achieve savings by using mobilizers in on-going programs, both aimed at circumcision and other health concerns.
One idea for the new phase would be to use them to refer clients for other programs such as immunization and antenatal care.
Other resources currently devoted to promoting circumcision also could be shared with other programs. For example, theaters could be used for both medical male circumcision and other surgical procedures. Similarly, why can’t community health workers who are already going out to raise awareness on immunization be trained as circumcision outreach workers too? And why can’t the health promotion messages in schools address the importance of medical male circumcision as well as other risk reduction practices?
Finally, it’s important to remember that getting circumcised actually is quite cost-effective – a one-time intervention that gives men life-long, though partial, risk reduction of acquiring HIV as well as other sexually transmitted infections. Recent studies demonstrate that, as part of a comprehensive HIV prevention package, medical male circumcision offers excellent value for money. They show, for instance, that reaching the point that 80 per cent of men 15 - 49 years old in all priority countries are circumcised – a rate that would require approximately 20 million new circumcisions in a period of time – would cost US$1.5 billion but result in net savings of US$16.5 billion by 2025 since 3.4 million fewer men would require treatment and care.
Some pillars of the second National strategy also present opportunities for increased Kenyan leadership of circumcision efforts. It calls for consideration of early infant male circumcision in light of an encouraging pilot study conducted in Kisumu County.
The should be consideration for devices: Geoffrey Omariba, who oversees medical male circumcision at Migori Referral Hospital under Family AIDS Care and Services (FACES), says men increasingly are inquiring about circumcision devices that make the procedure less painful.
Furthermore, experts are arguing that women should be encouraged to become more involved in promoting it. And Kenya’s policy of devolution suggests local governments could help pay for circumcisions too.
Dr Martin Serongo, Head of NASCOP, concludes: “The new devolved governance structure presents an opportunity to further decentralize coordination of VMMC implementation to counties, with improved chances of ownership and- sustainability.”
So there is hope. Not all that long ago, one time health cabinet secretary, James Macharia, offered Sh100,000 as a reward to persons who will report cases of Guinea worm disease. Of course this was in a bid to receive the WHO guinea-worm free country certification, but if the government can allocate funds for such a reward, surely we can allocate funds for voluntary medical male circumcision.