In 2008, PSI started pumping $500,000 privately raised funds to support Zambian public health clinics performing adult male circumcisions.
It was a bold move, says Doug Call, Senior Regional Director of Southern Africa at PSI, despite support from local government and evidence from recent randomized controlled trials that showed a 60 percent reduced chance of HIV transmission for HIV-negative circumcised men.
“It was risky on a number of fronts,” Call remembers. “The randomized controlled trials were published but there was and continues to be a backlash against male circumcision. We didn’t know whether or not the donor environment in the U.S. would really get behind the idea to fund this.”
PSI also did not want to make an investment and have it fall apart, Call says, over a project that was culturally loaded.
By the end of 2008, PSI, through its partnership with the Zambian government, performed nearly 2,500 circumcisions. The next year, the program expanded to Zimbabwe — with more than $1 million in private funding for the start-up initiative — and by 2011, the project received its first funding award from the U.S. Agency for International Development and then by the Bill & Melinda Gates Foundation in 2010.
Now, PSI’s voluntary medical male circumcision program has performed the surgical operation on more than 400,000 teenage boys and adult men in Southern Africa. The United Nations Children’s Fund, the Gates Foundation, USAID and the U.K. Department for International Development are backing is Zimbabwe project with an approximate collective $57 million, and the Zambia initiative is receiving roughly $39 million from USAID, the Gates Foundation and the U.S. Department of Defense.
The programs continue to grow – in November 2012, a new phase in Zimbabwe expanded to circumcising male infants. Partners hope to soon roll out products that offer male adolescents and adults the chance to have the procedure done with a device that does not require the typical out-patient surgery, and painlessly cuts off circulation to foreskin over the course of several days.
“People were skeptical about whether we would be able to scale this up, but it was very innovative and we had the support of the government,” explained Dr. Karin Hatzold, the Zimbabwe-based Deputy Director of Programs at PSI/Zimbabwe. “That helped in attracting other donors.”
In today’s uncertain funding climate, investing a relatively small amount of privately raised money, time or effort into a fledgling global health project has become an increasingly popular way to get a project off the ground and catch the attention of a donor.
It’s about finding the value in what you already have, says Amanda Glassman, Director of Global Health Policy for the Center of Global Development, a Washington-based think tank.
“You start to say, ‘How can I do more with less and what is the code value for money?’” Glassman says. “There’s not one easy answer, but it’s more about identifying what the opportunities are to improve the amount of health we get for the money.”
Tracking results in terms of costs incurred and possibly saved can be key to leveraging an investment, says Glassman.
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In the case of Julia Bunting, finding a way to scale up the delivery of an expensive contraceptive implant in Southern Africa meant taking one small action in the form of a single phone call.
At the time, in 2011, Bunting led DFID’s AIDS and reproductive health team. But she was also the Chair of the global Reproductive Health Supplies Coalition.
The International Planned Parenthood Federation had contacted Bunting about worldwide access to contraceptive implants, which were then running in the markets at a largely unaffordable $22 to $25 a unit.
Bunting reached out to the pharmaceutical company Merck, explained the cost problem, and then engaged in a series of talks with the company over the next four months. In June 2011, Merck announced it would reduce the price of the implants, Implanon, and place them on a sliding scale – a decision that has since saved more than $15 million.
“My director was really kind of excited and asked me to explain the process and I said to him, ‘I phoned Frank,’” Bunting says of her contact at Merck.
Bunting’s colleagues lauded her direct approach as innovative. She disagrees.
“What else would you do? You pick up the phone and talk to the person who can solve the problem you are trying to solve.”
The United Nations Population Fund then opted for a similar, direct approach talking with the pharmaceutical company Bayer. This and subsequent public-private partnerships have saved upwards of $400 million on the distribution of contraceptive implants, Bunting says.
“It’s about reframing the issue and the investment and thinking outside of our small boxes,” says Lyndon Haviland, a global health consultant, when discussing ways to maximize global health investments. Haviland has worked in senior capacity for a variety of UN agencies and is now working for the GAVI Alliance, which is leveraging its child immunization campaign to achieve broader change — like stronger health systems and economies — thereby reaching a wider partnership base, as well.
While PSI’s VMMC program is targeted, the initiative presented many unknowns and prompted both speculative and creative thought processes.
“One concern early on was if you circumcise a young man,” remembers Call, from PSI, “will they think they are immunized or invulnerable to HIV, and will they then go around having higher risk behavior?”
PSI has used text messaging to stay in touch with patients following routine out-patient counseling sessions, reminding them to use condoms, reduce their number of sexual partners and wait until they are fully healed to resume sexual activity.
Another lingering question was if young adult men could be convinced to have a surgical procedure, perceived as painful, to make them less vulnerable to HIV, even if they might never contract or transmit HIV.
In Zimbabwe, PSI’s mass media campaigns are helping to change public opinion about circumcision, involving women and making the new male post-surgery “look” sexy, Hatzold says.
The more than 400,000 circumcisions performed in Southern and East Africa is still a drop in the bucket, considering the estimated 20 million sexually active HIV-negative men who are currently not circumcised and living in countries with high HIV-prevalence rates.
“We have a long way to go,” Call acknowledges.
Still, Paulin Basinga, a Senior Program Officer with the Gates Foundation’s HIV team, says that PSI’s VMMC program is on the right track.
“We normally don’t support programs for service delivery in countries because we want our funding to be catalytic,” Kasinga says.
Yet PSI’s service delivery work has been just that, significantly boosting the numbers of circumcised teenage boys and adult men in countries with high prevalence of HIV in a short period of time, eventually drawing a wide range of donor support. The program’s foundation in evidence and controlled trials were a pull for the Gates Foundation, Kasinga says.
“Our support with PSI through this program has been catalytic,” he says, “working closely with the governments and making sure we are implementing this plan, which has real potential for scale-up.”
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