Kenya MC Rapid Results Initiative
Process, Results, Challenges, Lessons Learnt
Presented by:
Kawango Agot
Impact R&D Organization; MC Consortium
Why rapid scale up of MC?
• Models show large benefits of MC in low circumcision, high HIV
prevalence communities, with one HIV infection averted for every
5-15 circumcisions performed over a 10 year time period.
• The impact and cost-effectiveness of MC programs will depend on
the HIV prevalence, the uptake of MC by adult men, and the speed
with which services are scaled up.
• In Nyanza Province, the current site of most MC services, it is
estimated that 80% MC uptake over 10 years could result in the
male HIV prevalence decreasing from 17% to 7%, and female
prevalence from 22% to 10%
• If scale-up could be achieved more rapidly, the impact over the
same period of time would be significantly greater.
Rapid Results Initiative (RRI)
• RRI is a strategy used by government ministries and departments
to tackle large scale change efforts through a series of small-scale,
result-producing and momentum building initiatives
• In Public Health in Kenya, RRI approach has typically been used to
accelerate nationwide uptake of services such as immunization,
HIV Testing and Counseling, etc.
• Strategy applied to MC in Nov/Dec 2009, on a pilot basis:
– About 40,000 were circumcised between Oct 2008 and Oct 2009
– RRI target: 30,000 circumcisions performed in 30 working days
Summary of process
• Set up a coordinating committee at provincial level; held several planning
meetings, including with district MOH leadership to set goals and
strategies; three sub-committees formed:
– Service delivery (oversee staff, supplies, disinfection, M&E, etc)
– Communication and Social Mobilization
– Logistics (transport, funds flow, etc)
• Identical coordinating structure replicated at district level
• Service providers organized in teams, with experienced team leaders and
district coordinators overseeing day-to-day activities
• Mostly, experienced and inexperienced staff worked together
• Weekly review meetings held to address challenges, make revisions
• Field supervision of service provision done daily; data forms reviewed in
the field weekly; forms sent to central data center for review and entry.
• Exercise launched and closed by Provincial Commissioner; media present
• Ministry of Education and other government ministries involved
MC TARGETS BY REGION AND TIMELINE
(TO REACH 80% AMONG CURRENTLY NON-CIRCUMCISED AND 94% NATIONALLY)
Service package
MC Service package
• Counseling for MC; PITC offered on opt-out basis
• Clinical examination
• Management of STI and other genito-urinary conditions
• Surgical excision of foreskin using forceps guided method
• Post operative care
• Follow up
MC Service provision team (4)
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RCO/Nurse: Surgeon
Nurse/RCO: Assistant Surgeon
MC Counselor, also trained on VCT/PITC
Hygiene/Infection Prevention Officer
Procession during the RRI launch
Banner at a health facility inviting MC clients
MC educ/consenting; PITC (Note: staff is female)
Provincial Director of Health at a MC site
Summary of RRI results
• 36,077 MCs performed in 30 working days.
• 28,672 (78%) done by two partners in seven districts:
– An average of 10.2 MCs (range 8-12) done per team daily
– 39% of men tested at MC venues; 17% tested as part of but
prior to RRI (56% total); 3% were HIV infected.
– 55% MCs done on ≥15 year-olds; 23% among 12-15 yearolds.
– AE rate was 1.9% (1.83% moderate, 0.05% severe); however,
of the 6,595 who returned for f/u visits, 8.4% had AEs.
– Follow-up rate at the MC venues was 23%.
Key challenges
• Obtaining parental consent for minors, especially 15-17
year-olds.
• Sustaining demand for services erratic, and marked
fluctuations interfered with staff and supplies allocation.
• Lower than expected rates of testing (56%) and sevenday follow-up (23%).
• Availability of MOH staff unpredictable at times, affecting
planning especially in mixed teams (MOH + non-MOH).
• National data tools not out at the time and all partners
did not use identical forms, hence limited ability to
compare all data across partners.
Key lessons learnt
• Effective in increasing MC service uptake and program roll out.
• Built momentum for increased public support for and
normalization of MC (there was high demand by parents in urban
centers for circumcision of young sons).
• The public ready for MC, esp. if services are taken close to them.
• MC services can be provided safely in diverse settings.
• RRI for MC is cost effective (US$ 39 during the RRI vs. US$ 86 in
the preceding 13 months, thus a 56% saving).
•
Social mobilization for stable client flow is the most important determinant
of efficiency.
• Engaging non-health depts, other NGOs and all sectors of
community could make MC a movement in Nyanza rather than
just a public health exercise.
Recommendations
• Expand MC services within and beyond the formal health
sector to address unmet demand
• Adopt RRI as a strategy for scaling up MC (for short periods to
reduce staff burnout)
• Conduct integrated RRI for MC and HTC for greater impact
• Re-engineer MC messaging to increase uptake by older,
sexually active men
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Invest more resources in social mobilization for MC uptake
• Reduce emphasis on post operative follow-up as a measure of
MC program success
• Put in place equipment, supplies and coordination strategies
prior to start-up; monitor quality of services/data frequently
Acknowledgements
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Nyanza Community and Political Leadership.
Ministry of Public Health and Sanitation
Ministry of Medical Services
MC Partners:
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Impact Research & Development Organization (CDC)
Nyanza Reproductive Health Society (CDC)
Family AIDS Care and Education Services (CDC)
APHIA II Nyanza, including Engenderhealth (USAID)
– Catholic Medical Missions Board (CDC)
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National & Nyanza Provincial Male Circumcision Taskforces
Family Health International
Nyanza Provincial Commissioner and Provincial Administration
PEPFAR (CDC, USAID)
Thank you!!
Ensure you visit: www.malecircumcision.org