Academic journal article Applied Health Economics and Health Policy

Using the Economics of Certification to Improve the Safety and Quality of Male Circumcision in Developing Countries

Academic journal article Applied Health Economics and Health Policy

Using the Economics of Certification to Improve the Safety and Quality of Male Circumcision in Developing Countries

Article excerpt

Key points for decision makers

* Provider quality and safety remain prominent issues for male circumcision (MC) scale up for HIV reduction

* Innovative applications of certification can improve the situation

* Certification can accommodate the plethora of MC provider types and skill levels

1. Introduction

With millions infected and an annual incidence of roughly 2 million new infections, HIV remains a vexing public health issue.[1,2] Notwithstanding advances in treatment, many still believe that prevention holds the key to reining in the epidemic.[3] One burgeoning strategy is male circumcision (MC).[4] MC can reduce the rate of HIV transmission by up to 60% for heterosexual men, and is now a focal point for the global HIV agenda.[5-11] Despite being a medically simple and safe procedure,[5,7,12] empirical evidence and anecdotal narratives report complications in a fourth of some developing country MC cases, with up to 6% causing irreversible damage.[7,12] Additionally, there have been troubling reports of MC-associated mortalities, primarily concentrated among ritualistic practices.[12]

As the international health community expands circumcision campaigns, it has accepted that procedure safety will be a prominent goal but is also far from guaranteed.[5-7,12] Many developing countries are challenged by an insufficient supply of reputable and accessible providers[13] and may have a provider mix with widely varying and nontransparent skill levels. Additionally, increasing local demand for MC could simultaneously attract dubious providers attempting to profit from its growing popularity.[5,12] Therefore, men undergoing circumcision in these contexts may expose themselves to high and variable risks of complication.

There has been no consensus on how to address provider variability. Some find traditional healers without formal training acceptable for complementary care, while others demand "the provision of circumcision... maintain the highest achievable levels of safety".[6,7] While both perspectives focus on patient welfare, their endpoints are markedly different. The latter is perhaps too rigid to reflect realistic provider availability, and the former, although more accommodating to alternative providers, still leaves the issue of quality assurance unresolved.

Currently, private providers deliver substantial ambulatory and sexual health services in developing countries and are also a heterogeneous group.[14] Informal providers, often devoid of clinical training, are numerous in these contexts.[14] Furthermore, the international focus on areas where MC prevalence is low may have diverted attention from areas where MC prevalence is high but quality is not.[15] For example, a study in Bungoma, Kenya, where MC was already common, found that nearly half of the procedures were performed by traditional providers, with complication rates of up to 35.2%.[12] Even medical procedures still lead to adverse events 17% of the time, with virtually no perceptible difference in severity between the two settings.[12] The most common adverse events related to pain, excessive bleeding, infection and bodily lacerations; however, some events were still life-threatening.[12] Therefore, within a variety of developing countries, informal providers are prominent among patients' care options, with unclear and potentially harmful effects.

To date, several countries with established or burgeoning MC campaigns have either initiated provider training or outlined a strategy to do so.[16] Similarly, some countries legally stipulate which providers are allowed to perform MC-related tasks.[16] Although these measures intend to address MC adverse events, the former may face various expansion restraints at different times and settings, and the latter engenders regulatory challenges to be explored within the government regulation model. Thus, new policy prescriptions that can either operate independently from or synergistically with contemporary efforts are likely needed. …

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