Thirumurthy, H, Omanga, E, Rao, SO, Murray, K, Masters, S and Agot, K, 2016. Optimising the use of economic interventions to increase demand for voluntary medical male circumcision in Kenya, 3ie Impact Evaluation Report 47. New Delhi: International Initiative for Impact Evaluation (3ie)
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This study used a randomised trial design to test the effect of two distinct economic interventions: a fixed compensation and a lottery-based award to increase demand for male circumcision in Nyanza Province, Kenya.
Low uptake of male circumcision has been a major challenge to scaling-up voluntary medical male circumcision (VMMC) services and maximising its HIV-prevention impact in eastern and southern Africa. There is limited evidence on effective demand creation strategies for VMMC that address reported barriers to male circumcision. Building on insights from behavioural economics, this study assessed whether providing compensation for opportunity costs of time or lottery-based rewards can increase VMMC uptake among men in Nyanza Province, Kenya.
The main research question for this study is to assess the effect of two distinct economic interventions; a fixed compensation and lottery-based award, to increase demand for male circumcision in Nyanza Province, Kenya. Thus, the primary outcome of the study was the VMMC uptake within three months of enrolment.
Implementation of the intervention was conducted by the Impact Research and Development Organisation (IRDO), a Kenya-based NGO. The IRDO tested two distinct economic interventions that each have a compelling rationale based on prior economics, psychology and public health studies. The two distinct intervention arms were a fixed amount of compensation and a lottery-based award equivalent to the fixed compensation amount. The intervention issued prizes to those participants in the lottery-based rewards group whose cards revealed they had won something and food vouchers to men in the fixed compensation group if they underwent circumcision.
Theory of change
The rationale for the fixed compensation arm is that compensating men for out-of-pocket expenses and other financial costs associated with undergoing VMMC may help eliminate some of the barriers to VMMC uptake. Providing compensation to those who come for male circumcision will lower the price of the procedure and thereby result in increased demand. The rationale for using the lottery-based rewards rests on the theory of present-biased preferences, whereby individual behaviours are driven by immediate costs and benefits as opposed to future costs and benefits. The awards offer men the prospect of an immediate benefit from a behaviour otherwise associated with numerous costs.
The study used a randomised controlled trial design and was conducted over nine months within the Greater Nyando District in the Nyanza region of western Kenya. Out of the 30 sub-locations in the study, 7 sub-locations were randomly selected for enrolment of study participants. All males, who were between the ages 21-39 and self-reported to be uncircumcised, were eligible to be in the study. Eligible participants were randomised in a 1:1:1 ratio to the three study groups. Randomisation was performed using referral scratch cards that participants were allowed to hand select. Participants were told to bring their referral cards to VMMC clinics within three months if they chose to get circumcised and wished to receive the incentive corresponding to their study arm.
Among men above the age of 21 years, offering compensation for lost wages and transportation costs in the form of food vouchers – conditional on going for circumcision – were effective in increasing VMMC uptake within a period of three months. However, participants offered lottery-based rewards for VMMC uptake were not significantly more likely to become circumcised than participants in a control group. Moreover, the effect of providing fixed compensation was also significantly higher than the effect of the lottery-based rewards.
Cost efficiency analysis
The cost-effectiveness results indicate that the fixed compensation intervention was highly effective. In a population of 1,000 circumcised men, the study results show that there would be 71 additional circumcisions performed as a result of providing US$12.50 in compensation to clients at a total cost of US$1,599, indicating an incremental cost-effectiveness of $22.50 per person circumcised. On the other hand, the lottery-based rewards intervention was less cost-effective, at US$47.95 per additional person circumcised. Given evidence on the sizable HIV prevention benefits of male circumcision, it is warranted that demand creation interventions such as the one implemented in this study be considered by programmes and countries seeking to scale up VMMC.
Implications for policy and practice
The results indicate that offering compensation to VMMC clients is a strategy worth considering in order to achieve greater uptake of VMMC services among men above the age of 21 years in Kenya. Economic factors such as lost wages and opportunity costs of time are among the important barriers to VMMC uptake, particularly for men in the age groups that are likely to be employed in the formal or informal sector.
Implications for further research
Further testing of economic interventions in areas outside Kenya can be important to establish the generalisability of the results found in this study. To the extent that the economic barriers to VMMC uptake exist for at least some men, the results from this study ought to apply in other settings. However, it is possible that other barriers to VMMC uptake such as cultural factors are more prominent elsewhere, which would mean that providing compensation alone may not be as effective.