I once heard a speaker at a conference discuss a project involving the Turkana tribe of Northern Kenya and the Norwegian government’s agency for international aid. The Turkana lived in a mostly semi-arid part of the country and kept very large herds of cattle. Their marginal grassland eventually became degraded and anytime the rains failed, many animals would die, leaving the herdsmen destitute.
The project attempted to solve this problem, by giving incentives to Turkana families to move to the shores of Lake Turkana and then teaching the men how to fish, as an alternative to keeping livestock. Thousands of herdsmen did move and even joined the fishermen’s cooperative that the Norwegians had set up. The cooperative was soon distributing profits from the sales of smoked fish. But once the Turkana fishermen received their earnings, they went out and bought more cows, sheep and goats, so their herds grew even larger, compounding the problem the Norwegians had hoped to solve.
GOOD INTENTIONS ARE NOT ENOUGH
As the Turkana and the development partners learnt, most projects – no matter how well intentioned- don’t get really far without the local community buy-in.
Thanks in large part to massive donor funding, the effort to promote medical male circumcision Kenya stands today where the Turkana did when they moved to the shores of the lake. We are rightfully praised for our success, but success could turn to disappointment unless the country figures out how to adjust its strategies for the future.
The government set an ambitious goal of circumcising 860,000 boys and men ages 15 to 49 years between 2008 and 2013. By the end of the period, it had come very close: 792,931 male circumcisions had been performed, representing 92.2% of the programme’s numerical goal for male circumcisions performed. The effort also had achieved a respectable 71% of its coverage goal for the primary target group of men ages 15-49 years, according to the National AIDS and STI Control Programme (NASCOP).
Voluntary Medical Male Circumcision Procedures done in Nyanza 2008-2011
But as we move to a second phase meant to run between 2014 and 2019, Kenya’s is but an incomplete success story.
How can Kenya keep its momentum and build on its initial successes? Planners recognize the new challenge; they call this new stage of circumcision advocacy the “sustainable phase”. A good starting point for making that phase a success like the first phase would be to consider that reliance on donors and partners won’t continue forever.
MISUNDERSTOOD ROLE OF DONORS
The role of the donor community in developing countries is often misunderstood. In Kenya, for example, which has received substantial aid for the last fifty years, the temptation is to assume that rich countries will always help poor countries. Some might even say that they have a moral obligation to do so.
The reality is quite different. All donor and development partner projects are time limited and goal oriented; they have never been offered indefinitely and probably never will be – nor should they be if developing countries hope to move past the point of relying on financial aid to self supporting systems that exist in developed nations.
Consider the Marshall Plan of 1948, in which the United States gave economic support to help rebuild Western European economies after the end of World War II. The plan consisted of aid in the form of grants and loans. Germany, which up until the 1953 Debt agreement had to work on the assumption that all the Marshall plan aid was to be repaid, spent its funds very carefully. The cautious approach it took ensured that it was able to continue building on its own after making the final loan repayment in 1971.
When it comes to voluntary medical male circumcision in Kenya, what started as a randomized control trial yielded such great results that in 2007 the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended voluntary medical male circumcision (VMMC) as one component of a comprehensive HIV preventive strategy in regions with low male circumcision rates and a high prevalence of HIV infection and where heterosexual sex is the main mode of transmission.
To put the circumcision effort on a more sustainable controlled footing, policy-makers will have to look at what has worked so far, and figure out how to sustain it into the future. One thing that has worked is the use of mobilizers in the quarterly rapid results initiatives (RRIs). These outreach workers boosted the number of men circumcised.
THE CASE FOR CONDITIONAL CASH TRANSFERS
There is also need to develop communication and service delivery approaches to dispel misconceptions and increase circumcision among men 25 years and older, a group whose participation has been disappointing.
This might require novel strategies, one of which was tested in a randomized control trial run by Prof. Kawango Agot in Nyando District Kenya. The trial examined the effect of compensating men for agreeing to undergo circumcision. “This was inspired by the pioneering program in Mexico, Progresa, which offered cash to low-income households if they sent their children to school and vaccinated newborns,” Prof. Agot said. “And it proved to be effective so much so that it inspired many countries to begin conditional cash transfer (CCT) or conditional in-kind transfer programs”
The study demonstrated that incentives were effective in increasing uptake because participants offered compensation in the form of food vouchers were significantly more likely to become circumcised within 2 months than participants in the control group. There was also a significant increase in medical male circumcision among married and older participants, groups that have been hard to reach previously. However, evaluation of scaled-up implementation of the intervention is needed to determine whether it will help achieve higher circumcision coverage over longer periods of time.
Also read: Male cut: the incomplete success story
Nevertheless, 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.
Another issue that bears watching is the use of mobilizers. One idea for the new phase would be to use them to refer clients for other programs such immunization, 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?
Integrating circumcisions resources with other programs could help put circumcision on a sustainable footing by erasing the perception that it is an ‘NGO project.’ It might also help counter an unfortunate side-effect of the current emphasis on circumcision by helping to clarify that, for all its benefits, the procedure needs to be seen as part of a larger package of HIV-prevention strategies that includes condom use and HIV testing, among other strategies.
THE ISSUE OF “NET SAVINGS”
As to concerns that the country can’t afford to assume responsibility for promoting circumcision, advocates can stress 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% 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.
Getting by without donor support will require not only the central government, but also local communities to join in efforts to make circumcision more common.
That may not be as difficult a goal as it sounds, especially with Kenya’s new devolved system of government. Perhaps a leading example that there is a spirit of innovation at the local level is Migori County, where I spoke to Daniel Oneya Deputy County AIDS and STI Coordinator. The county has prepared a draft budget that includes funds for VMMC that supporters hope to present during the annual county budget-planning meeting. Whether the budget shall be considered, let alone approved, remains to be seen.
But if one is to look at the data, then there shouldn’t be any reason why VMMC should take a back seat.
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.
Also encouraging are good results from initial tests of new circumcision devices that make circumcision less painful. Geoffrey Omariba, who oversees medical male circumcision at Migori Referral Hospital under Family AIDS Care and Services (FACES), says men increasingly are inquiring about these devices.
Circumcision could also get increased support if women are encouraged to become more involved in promoting it, encouraging men to abstain from sex until complete healing and practicing safe sex, especially in the post-circumcision healing period.
Summing up, 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. The one time health cabinet secretary, James Macharia, offered Kshs. 100,000 (US$ 1000) 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.
Otherwise we would have a repeat of the Turkana “development project” failure.
I wonder: If the Turkana had understood all the aspects of their move to Lake Turkana and had been more engaged in figuring out their own solution, would the outcome have been better?
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