OPINION:Medical Male Circumcision in Kenya: Prepared for disappearing donors?

OPINION:

Medical Male Circumcision in Kenya: Prepared for disappearing donors?
 

Kenya has earned the champion title in the scale-up of medical male circumcision for HIV prevention. But to keep its lead, the country needs to put a lot more skin in the game.

In the early days, the Kenyan government displayed palpable enthusiasm for the VMMC program at the national, provincial and district levels.Community and political endorsements were obtained by the end of 2008 and the program was ready to take off. And it did!Kenya led 13 other African countries in rolling out VMMC and was, for years, the to-go-to place for lessons learned on well-coordinated and successful VMMC rollout. We were proud to lead and others follow. Even other public health programs in Kenya learnt from VMMC.

Where Kenya has come from: 

VMMC for HIV prevention was launchedin Kenya by the Ministry of Health in 2008 following three landmark studies conducted in Kenya (Kisumu), Uganda (Rakai) and South Africa (Orange Farm). 

These studies demonstrated without a doubt that circumcising sexually active men reduces their risk of acquiring HIV from their female partners during sex. 

When the results of the studies were releasedby the researchers and endorsed by the World Health Organization and the Joint United Nations Programme on HIV/AIDS (WHO/UNAIDS)in 2007, Kenya moved quickly to developa VMMC scale-up plan in regions with high HIV burdens.Community engagement activities were carried out to obtain buy-in from various stakeholders  where the intervention was to be implemented first.

 A national target of 860,000circumcisions among men aged 15-49 years was set, with 2013 as the end date. It was anticipated that this would increase the prevalence of male circumcision from 46% to 80% in Nyanza Province and from 85%to 94% nationally.

So what’s the problem? 

 There is one glaring hitch - a hitch that has plagued the program to date: 100% of the funds are externally sourced.This means the VMMC program in Kenya was fully funded by the United States Government's President's Emergency Plan for AIDS Relief (PEPFAR) and a few other external collaborators, and mostly implemented by local andinternational partners.

 Kenya received $61,000,000 for its VMMC program between 2012 and 2015. That is 6 billion Kenya Shillings in four years.And that excludes supplemental funds from Global Fund, Bill& Melinda Gates Foundation, and other sources. Kenya had circumcised around790,000 adolescent boys and adult men by the end of 2013 against a projection of 860,000 circumcisions. 

According to the Kenya AIDS Indicator Survey of 2012/2013, the national circumcision prevalence increased from 85% to 91% (against a target of 95%) and from 46% to 66% in Nyanza Province (against a target of 80%). The target was revised in the second VMMC strategic plan (2014/15-2018/19) to 1,005,757. 

By the end of 2015, Kenya had circumcised over 1.2 million men, and averted an estimated 21,000-33,000 new HIV infections, according to mathematical modelling studies. The benefits of thesecircumcisions are expected to increase over time, and the models estimate that 60,000 to 180,000 new HIV infections will be averted by 2030.

Feeble support by those who would make a difference – health facility staff: 

Progress to dateis commendable,even with the increased national target of 1,005,757moving the goal post even further afield.

And with that, comes the question, "What Next?".Almost 10 years into the program Kenya still has not taken ownership of this successful program: funding still comes from foreign donors and all service provision is still done by partners despite thetrainingofsome 4,000 Ministry of Health (MOH) staff. 

Renovated and equipped circumcision theaters in hundreds of facilities under the MOH sit idly by unless partners are present to provide the services.While support remains solid at the MOH leadership level, staff and leadership at facility level continue to view VMMC as a foreign donor agenda.

National and county governments are equally disappointing: 

Lack of interest by county governments to allocate resources to VMMC is a total let-down for such a heretofore successful program. With limited funds availed for healthprograms in our counties, the county health leadership has no option but to allocate a negligible amount to HIV-related program, and zero to the VMMC programs.

This trend is worrying, because we are in a relay. PEPFAR and collaborators are holding the funding baton. Other partners are holding the service-provision baton. Both donors and implementing partners will soon want to hand over the batons to someone. But who is there to receive them?

What if donors pulled out today?

 I am not a prophet of doom but I am afraid that what I see does not look promising. As I write, the Kenyan government is being asked by donors to further integrate the VMMC program into government health systems and to begin to absorb the costs. 

The foreign support for this handover has largely been used to hold stakeholder meetings,upon meetings, upon meetings in Nyanza and Nairobi regions to plan, but with little to show for results. And, to my knowledge, no county in Kenya where VMMC programs are currently implemented has set aside any funds towards VMMC, yet we are supposedly in transition periodto self-sustainability.What kind of sustainability comes with zero domestic financing? 

Just a few days ago we were faced with the news that the United States Government has put on hold direct funding to the MOH, and although this does not affect essential services, it is a wake up call that total dependence on donor funding can, and does, leave us as a nation exposed.

Parting shot: 

VMMC is effective. VMMC is a one-off intervention. VMMC is inexpensive (approximately KShs5,000 per circumcision) and cost-saving over time. On the other hand, treatment for a person living with HIV is estimated atKShs. 25,000per year and this is five times more than cost of one circumcision. On that note, calculate the cost in a lifetime. My appeal is that national and county governments step into the funding and service provision shoes of PEPFAR and implementing partners.I will be happy the day a clientwalks into a government health facility and gets circumcised without donor support.I believe we can get there, but we must want to. Otherwise, we’ll lose our champion title, but, worse, we’ll lose against the real foe—HIV. 

By Godfrey OchiengOkumu

AVAC – Global Advocacyfor HIV Prevention - Fellow

gokumu@nigee.org