By Oscar Abello
President Barack Obama. Former Kenya Prime Minister Raila Odinga. Oscar-award winning actress Lupita Nyong’o. They’re not just of Kenyan heritage—all three are specifically of Luo heritage, the third largest ethnic group in Kenya, predominantly residing in the Nyanza province on the shores of Lake Victoria in Kenya’s western region.
The Luo standout in Kenya for another reason. They’re one of the few ethnic groups in the country that do not practice male circumcision as a rite of passage into adulthood for young boys.
Why does that matter? As NPR reported in 2012, “The rate of HIV among Luo men was 13 percent in 2009, the latest year for which figures are available. This is more than three times the rate among tribes that do circumcise.”
The World Health Organization (WHO) and UNAIDS began recommending voluntary medical male circumcision (VMMC) as an HIV prevention strategy in 2007, after studies in Kenya, Uganda and South Africa showed that medical male circumcision reduces the risk of sexual transmission of HIV from women to men by approximately 60 percent.
When Kenya’s Ministry of Health began offering free VMMC services as an HIV prevention strategy, Nyanza was a priority. In 2008, then-Prime Minister Odinga came out as a major advocate for VMMC, stirring up a huge debate in his own Luo community, where he’s still regarded as a community “kingpin”. Even with outspoken support from the top, however, the public sector can’t reach everyone on its own.
“Some people want to benefit from circumcision, but do not want to go to public sector [health centers] for various reasons—privacy, perception of better quality services—not to say that the quality of the public sector VMMC services is wanting in reality,” says Dr.Preston Izulla, senior manager for clinical services and quality assurance at Population Services Kenya (PS Kenya), PSI’s network member in the country. “It’s a perception issue.”
PS Kenya began working closely with Kenya’s Ministry of Health in 2011 to explore how to integrate VMMC services into a network of 310 private healthcare providers, operating as a social franchise under the shared brand Tunza, with shared quality assurance standards.
Together with the Ministry of Health, PS Kenya selected 10 Tunza social franchise clinics in Nyanza that met the Ministry of Health’s VMMC service delivery requirements. Each clinic had to have more than one room, and have at least two staff members (a surgeon and an assistant) who could be responsible for VMMC. The Ministry trained the provider teams, using its own curriculum, and in January 2012, the 10 Tunza clinics began offering VMMC services for a small fee.
Demand remains a major barrier for VMMCs. Demand creation campaigns can address many obstacles, from obvious barriers like fear of the pain, to not-so-obvious barriers like fearing a partner’s mistrust taking VMMC as a sign that a man intends to sleep around. The private sector is uniquely placed to overcome one barrier in particular – that some clients can’t or won’t seek services in the public sector. To reach the total market for the service, the private sector must be a viable distribution channel.
“One of the target groups we reach out to are men in their early to mid-20s, who are either formally employed or working in the informal sector and therefore have some disposable income, and often don’t have time for long lines at public clinics,” Izulla says. “That includes young men in Nyanza as well as Mombasa and Nairobi, where they are moving to find jobs and where they are seeking out new relationships.”
Given the mobility of this target population, Izulla mentioned plans to expand VMMC to five Tunza clinics in Mombasa and five in Nairobi in the next year.
Tunza’s network of community heath mobilizers continue to be an important asset in breaking through to the right populations. “They visit locations strategically – car repair shops, workplaces, other locations frequented by men – to have conversations about VMMC,” says Izulla. “But we need to re-define the appropriate message for mass communication to this group – 18-25 year olds with disposable income. That’s the next step of our intervention.”
In consultation with PSI’s global network of behavior change communication experts, Izulla and the local PS Kenya team determined that the current messaging around HIV prevention doesn’t resonate well with this group, nor with those in steady partnerships or marriages.
As demand for VMMC eventually increases, the Ministry of Health promises the supply will too. “The Ministry has the capacity to do [more private sector] trainings, and in fact a few weeks ago it released new guidelines for VMMC for adolescents (children 10-14 years old), and were already contacting our providers to come in for updated training,” Izulla says. “The Ministry has also been excellent in monitoring and supporting quality assurance. They are willing to scale up on training. The onus is on us to identify growth markets for VMMC.”
But can the private sector really find a market foothold in a service that has been pushed for free at public clinics for a few years now? The Tunza network’s experience with contraceptives, specifically long-acting reversible methods, points to yes.
Long-acting reversible contraceptive methods, such as IUDs and implants are usually given for free in the public sector, but challenges due to running out of stock or other infrastructural challenges have led many clients to seek out private sector providers, often on referral from overwhelmed public sector staff. Tunza social franchise providers stepped in, aided in part by vouchers for long-acting reversible contraceptives, and that, Izulla says, “Led to significant increase in uptake.”
“That’s just one example of how the Tunza network has grown into a platform in Kenya and managed to create demand for and increase access to life-saving goods and services exponentially because of the voucher system and close relationship with Ministry of Health,” Izulla says.
Now, PS Kenya and the Ministry of Health must continue to create demand and increase access to VMMC through private sector channels. To eliminate HIV for future generations, VMMC has many places to go, and the public sector alone can’t take it everywhere it needs to be.
Part of a special series on PSI’s path to one million voluntary medical male circumcision clients. Learn more.
Photo credit: What Took You So Long Foundation