Creating Demand for Male Circumcision 

Jhpiego has been working in Malawi since 1999. Its work has focused on a number of health interventions including the provision Voluntary Medical Male Circumcision (VMMC).. PacharoMunthali in this article follows up the Voluntary Medical Male Circumcision (VMMC) work that Jhpiego has been carrying out in Zomba. In the article he explores the successes registered so far. He strives to find out gaps that as a nation we need to address.  

 It’s morning. Precisely, it is three minutes after 9 hours. Since arriving at the health centre, apart from meeting the medical personnel and being briefed on the procedure that is followed, he uttered nothing. For ten minutes it seemed as if he would say nothing.

 He is Village Headman Mzazira II has been waiting outside Chipini Health Centre. It is a symbolic wait, at least he knows. It’s not just his wait. Once he gets circumcised he believes his subjects will follow suit. He is at Chipini Health Centre for his screening and Voluntary Medical Male Circumcision (VMMC) procedure.

 Chipini Health Centre is a Chingale -based health facility in Zomba district. The district with 2014 population estimates hovering above 600,000; the district has high HIV prevalence rate.  

HIV prevalence is around 15. That’s alarming. The District Medical Officer, Dr Vanessa Kandole early this year was quoted by Malawi News agency, describing the situation as “pathetic.”

"As a key component of prevention of HIV, Voluntary Male Medical Circumcision (VMMC) is important in Zomba as one way of reducing the prevalence rate which currently is on the higher side," Kandole had explained in the media.

Kandole has stated that VMMC campaigns have been conducted since 2013 in Zomba. As a result at least 18 thousand males have gotten the smart cut. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS); an estimated 5.8 million males had undergone VMMC by the end of 2013 in 14 priority countries in East and southern Africa.

The effort towards attain such cuts has been collaborative. Being led by Ministry of Health, Jhpiego has been one of the players. The presence of Jhpiego in areas around Chipini Health Centre has been one instance.

Today at Chipini Health Centre, male community members are waiting anxiously. In numbers, so far there is presence of eleven individuals – men and of course adolescent boys. All these mortals want to be subjected to the meticulous procedures of male circumcision. Voluntarily medically sound of course. All this is being done for a good reason – HIV prevention.

 When his turn comes, he will undergo counseling. After counseling he will go through the screening process. It is after screening that he will submit himself to the actual VMMC procedure. It’s a process.

 “You see this is symbolic. I am a village headman, and I want to lead by example,” Village headman Mzazira 2 says as goes inside the clinic.

 “I want my people to appreciate, and soberly understand that this is life,” he grins.

Chipini is just one area in which Jhpiego is carrying out its intervention. Jhpiego has been in Malawi since 1999. From 2010 to 2011 Jhpiego, under MCHIP, facilitated the development of national standard operating procedures for voluntary medical male circumcision (VMMC).  During that period Jhpiego implemented Malawi’s first pilot initiative on VMMC for HIV prevention in Mulanje, resulting in provision of male circumcision services to 4,348 men.

 In 2012, Jhpiego received additional funding through Maternal and child health integrated program to provide VMMC services to more than 8,000 males in Thyolo District. As Jhpiego expands its work the foot prints that it has marked are indelible. Since 2011 to date 115647 males have undergone voluntary medical male circumcision.

 Jhpiego has a number of advocacy approaches. One of them is through the use of chiefs. After conducting advocacy meetings with chiefs in the target districts, the Ministry of Health requested MCHIP to offer VMMC services in vulnerable and hard to reach health centres only to ensure the procedure is recognized as a medical intervention and is not confused with traditional rites of initiation.

“Our work especially on promotional activities have focused mainly on inter and intrapersonal communication at the local level. The approach has yielded enormous success,” says Samson Jali, Community Mobilisation Assistant.  

Jhpiego is working in a number of districts. The VMMC project called Sankhani has spread from Chikwawa, Zomba to Thyolo.

 Why choosing these districts?

“Ministry of Health and USAID after World Health Organization (WHO) recommendation identified some districts which were a priority due to high HIV prevalence. The three are among the priority districts,” says Lionel Chipeta, Communications and Demand Creation Manager.

As Chipeta shows the figures of the number of clients that have received smart cut, he reveals that they foster demand creation through interpersonal communication.

“Mostly we are using Interpersonal communication which triggers honest discussions with individuals and groups. We also have events like pool tournament, bawo tournament, football bonanzas which are simply crowd pullers and then we engage them into discussions using Community Mobilizers,” he adds.

Two main obstacles are apparent so far. In the three districts where implementation work is being carried out, Chipeta says, they “still haven’t registered a lot more of the older population.”  Those that are above 15 haven’t been forth comingas expected.  

“At national level, Malawi has done about 7% of the modelled targeted number while countries like Tanzania have reached about 90% of their target, Botswana is at 41% while Zambia is around 53%. As a nation, we is still very low in reaching our expected target to halt more HIV cases as desired.”Adds Chipeta.

“We still have people failing to comprehend and understand the science behind VMMC,” he adds.

So far, as they look forward to next year, Chipeta believes progress has been admirable. They only need to strengthen the approaches to reach out to more young adults, especially those between ages of 15-29. This group is at high risk as it is very sexually active.

Jhpiego’s approach has embraced the enormous involvement of community leaders such chiefs.  

“Chiefs are custodians of culture and they are in authority in the districts we are currently working. It is credible to involve them so that this intervention is not seen as an alien intervention. At all levels people have to understand the science behind VMMC and how it works,” Chipeta concludes.

 VMMC is a Ministry of health intervention. For its success, the Ministry is working with a number of partners. Jhpiego is one of them. Jhpiego is implementing partner with funding from Presidents Emergency Plan for AIDS Relief (PEPFAR) and United States Agency for International Development (USAID).