Lessons From Botswana: Enhancing Trust in Medical Male Circumcision Programs
Executive Summary
In 2007, The World Health Organization and UNAIDS set forth recommendations on expanding medical male circumcision programs as a measure to reduce HIV transmission. These recommendations were adopted across multiple African countries, including Botswana, in an effort to combat the growing HIV crisis. Botswana’s circumcision program faced implementation barriers due to mistrust in political, economic, and cultural contexts. Future programs must learn from the experience in Botswana and actively engage with the community through needs assessments, internal reviews, and follow-up studies in order to effectively expand access to medical male circumcision.
Introduction
In 2007, The World Health Organization and The Joint United Nations Program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision in settings with high HIV prevalence and low prevalence of male circumcision (1). Based on these criteria, the WHO and UNAIDS identified a set of 15 countries across Eastern and Southern Africa to scale-up voluntary medical male circumcision (VMMC) programs (2). The success of these programs has been limited, with UNAIDS reporting that from 2011-2017 only three of the fifteen prioritized countries had achieved the goal of 80% prevalence of male circumcision (2). These programs have been fraught with political, economic, and cultural conflicts that have resulted in the lack of trust between international organizations and local communities. Botswana’s Safe Male Circumcision (SMC) program illustrates the impact of collective tension on the uptake and implementation of male circumcision programs.
Case Study
As one of the fifteen prioritized countries, Botswana committed to developing a voluntary medical male circumcision program across the country in 2010. The Botswana SMC program was established as a partnership with the Ministry of Health, African Comprehensive HIV/AIDS Partnership, and the U.S CDC (3). International donor organizations, PEPFAR, and the Bill and Melinda Gates Foundation all provided substantial financial support to help advance the program’s goals. The program’s implementation strategy was based on two key components: health system integration and sustainable implementation. The integration phase focused on incorporating SMC into the local health system through health education and safety trainings. During the implementation phase, marketing strategies developed by the WHO were used to encourage the public uptake of the SMC program (3). This implementation approach resulted in a divide between the local population and international organizations based on political, economic, and cultural differences.
One of the major political issues with the program was the lack of mutual trust between international and local leadership. A qualitative study assessing the barriers to implementation of Botswana’s SMC program found that Ministry of Health leadership did not feel trusted by international partners in their ability to coordinate the program. One of the Ministry of Health officials stated, “This is not the first time I hear this . . .will you be happy if I tell you how to structure and run your organization?” (3) This paternalistic approach to international assistance is a key issue and has been found to lead to dependency as one Ministry of Health official stated, “..while we benefit a lot from partners through MOVE. . ., at the end of the day they are creating a dependency syndrome.”(3) The lack of political autonomy in Botswana’s SMC program resulted in the erosion of trust between parties and created an environment of dependency.
Botswana’s SMC program struggled to achieve sustainability due to the lack of transparency of financial investments. Both international partners and the Ministry of Health felt there was not clear communication regarding their respective program budgets. One Ministry of Health official stated that, “DPs (Development Partners) do not tell us everything about their budgets. . .The Minister has to act like a parent and cover this even though we are not informed about everything concerning DPs budgets distribution.”(3) This lack of transparency has the ability to create redundancies in spending and reduce the ability of the Ministry of Health to sustainably implement the program. A development partner emphasized this concern when they shared that, “I really wish the government owned the program truly as their program, not outsource it as the implementation reveals now . . . The Government of Botswana has not budgeted to achieve this without donor funding.”(3) This concern became a reality when one of the major development partners ceased participation and funding of the program in 2015 (3). As a result, male circumcision rates dropped by over 50% across the country due to lack of access to clinics (4). The tension regarding financial transparency within the program created issues regarding ownership and degraded trust between the partners.
The expansion of Botswana’s SMC program neglected to account for traditional practices and values which resulted in distrust between traditional leaders and program coordinators. Many community members felt that the biomedical approach to circumcision oversexualized the practice through their marketing strategy. This emphasis on sex created tension with traditional leaders who felt that words like ‘penis’ should not be used in advertisements (3). Cultural differences also led to the lack of uptake of the SMC program across various communities. The Boteti community did not participate in the SMC program due to traditional differences and continued to carry-out their own practices (3). Cultural differences between international partners, government officials, and community members created an environment of distrust between the community and program leaders.
Recommendations
It is clear that the success of international programs is dependent on establishing trust between the local community and program administrators. This important relationship ensures that all parties can adequately communicate their perspectives and understand each other’s priorities. The Botswana SMC program serves as an instructive example of how distrust can lead to political, economic, and cultural conflicts. Future voluntary medical male circumcision programs should establish trust with the community through three key mechanisms: Needs assessments, internal reviews, and follow-up studies.
Implementation of a Needs Assessment prior to Program Implementation
A needs assessment should be conducted prior to any VMMC in order to better understand the priorities and perspectives of the local community. The assessment should focus on the views of community members, traditional leaders, and government officials. This comprehensive approach will ensure that the voices of all members of the population are considered when developing the program.
Active Engagement with Community Leaders and Formation of Clear Communication Channels
Throughout the implementation phase, program coordinators should actively engage with the community through internal reviews to measure the effectiveness of current strategies and identify any internal conflicts. This active engagement should incorporate both formal and informal dimensions to create an accessible environment for community members to voice concerns. It is essential that an internal review process exists throughout the program in order to address any new issues that arise.
Follow-up Review and Assessment of Program
Following the completion of the program, a follow-up study should be conducted to review the outcomes the VMMC program. This follow-up study should incorporate the perspectives of all stakeholders including community members, ministry of health officials, and international partners. Through a stronger understanding into the perspectives of all groups, future programs will be able to develop a more comprehensive and effective plan.
References
Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa. Accessed November 29, 2023. https://unaids-test.unaids.org/sites/default/files/unaids/contentassets/documents/unaidspublication/2011/JC2251_Action_Framework_circumcision_en.pdf.
Luseno, Winnie Kavulani, Stuart Rennie, and Adam Gilbertson, "A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa," International Journal of Impotence Research 35, no. 3 (2023): 269-278
Katisi, Masego, and Marguerite Daniel, "Exploring the Roots of Antagony in the Safe Male Circumcision Partnership in Botswana," PloS One 13, no. 9 (2018): e0200803.
Global AIDS monitoring 2019 - joint united nations programme on HIV/AIDS, accessed November 27, 2023, https://indicatorregistry.unaids.org/sites/default/files/2019-global-aids-monitoring_en_0.pdf.