Country Experiences in the Scale-up of Male Circumcision in the Eastern and Southern African Region: Two Years and Counting

This 24-page report of a sub-regional consultation held in Windhoek, Namibia, in July 2009, summarises progress reports, lessons learned, and priorities for the next year from nine countries working to scale-up male circumcision for HIV prevention. The specific objectives of the meeting were to share country experiences and lessons learned in the roll out and scale-up of male circumcision; examine the facilitating and constraining factors to implementation; review tools and guidelines available to support implementation; identify inter-country, regional, and global support actions required to strengthen scale-up; and prepare action plans by country for the following 12 months. According to the report, all countries represented have made progress towards establishing the necessary conditions to increase the availability of male circumcision services for HIV prevention.

The report suggests that political commitment has been strong in some countries, including Kenya and Botswana, and the support of traditional leaders and elders has been pivotal in Kenya, Namibia, and Lesotho. Women's groups have also been actively involved in Zimbabwe. National and community consultations have taken place to gain support of key stakeholders and partnerships involving national and local governments, donors, and technical support agencies have been created to sustain and accelerate the progress.

Situation analyses have been completed or are underway in all countries. Some have either formally adopted national policy guidelines on male circumcision or have developed draft policies. Scale-up strategies have been developed with defined objectives and targets. According to the report, Botswana and Kenya have already launched national strategies, while Swaziland, Zambia, and Zimbabwe are developing implementation plans.

The report states that country teams identified some important facilitating factors and lessons learned. Among these are that high-level political support is critical to accelerating scale-up. The leadership of the World Health Organization and several United Nations (UN) agencies has been invaluable, and the tools developed by the UN team have provided clear guidance for country programming. The need to engage key stakeholders, particularly traditional leaders and women's groups, at an early stage is seen as critical to the pace of scale-up.

Countries have also faced challenges and constraints. Key constraints include: shortage of human resources for programming and service delivery; difficulties in accessing funds; challenges creating appropriate and effective communication messages - for example, that male circumcision is not a "magic bullet"; and delays in getting buy-in from 'gatekeepers' such as politicians and traditional leaders, which has been a time consuming process. Community engagement to influence behavioural change was also recognised as a challenge, as was addressing implications for women in rolling out male circumcision. For example, there may be a reduction in women's ability to negotiate condom use.

The report also includes a number of next steps for each country to work on over the following 12 months. These are divided by country and include: increasing human resources and funding; reviewing existing prevention communication strategies to identify ways to integrate male circumcision; expanding monitoring and evaluation of health management information; developing information packages for adolescent male circumcision; identifying a 'champion' for the cause within the Ministry of Health; engaging traditional circumcisers and traditional healers; investigating service delivery approaches; and developing implementation strategies.