Using the economics of certification to improve the safety and quality of male circumcision in developing countries

Michael R. Richards

Although male circumcision (MC) has been a widespread practice in some regions, while relatively new in others, it has recently ascended in popularity as a HIV-reduction intervention, particularly in areas with high rates of HIV but low rates of MC. However, the uptake and potential effectiveness of MC may be hampered by uneven levels of provider training and procedure skill within developing country settings. Indeed, this procedure that is otherwise considered simple and safe has witnessed complication rates as high as 25-35% in some areas, leaving some men with irreversible injuries. To improve the transparency of procedure quality for prospective patients, I borrow from a classic economics approach and advocate a new application in the form of provider certification. Building on some experience in the healthcare systems and economic rationale of high-income counties, I explore the potential for certifying providers of MC in low-income countries and compare and contrast three models of implementation: government agency, private certifiers and private MC device manufacturers. The hope is that increased transparency of provider quality through any or all three types of certifying programmes can better assist local men as they navigate this otherwise complex and unclear medical care market. As more resources are being devoted to MC scale up, I argue that certification should be considered for incorporation as a means of complementing both current and future efforts in order to enhance the effectiveness of MC campaigns. The two models based on privatized certification, as opposed to having the local government underwrite the intervention, may prove most useful when public or philanthropic funding is volatile or incomplete for a given location. The timing for MC campaign adoption and desired speed of scale up may vary across countries in ways that international assistance efforts cannot always immediately and flexibly adapt to. As such, the role of the diverse MC provider marketplace and accompanying quality-revelation mechanisms may take on different levels of importance and expediency across settings as individual countries move forward with their respective HIV prevention campaigns. The subsequent challenge is to creatively design solutions that are sustainable and applicable within diverse host-country environments and expectations. This is where I believe some economic insights are currently lacking in the MC dialogue. Although I believe the three certification models exhibit much potential for enhancing medical care delivery in developing countries, they are not without their challenges, and implementation would not necessarily be a simple process. Local levels of medical knowledge, public and private resource constraints and the integrity of local business transactions and government practices would likely influence the nature and success of a certification intervention. However, with sufficient model adaptability and partnerships across public and private sectors, I argue that many of these implementation issues could be proactively addressed. Creative and careful certification structures should ultimately improve the MC circumstances across a variety of developing countries.