This analysis of four active NSV services currently operating in PNG provided an opportunity to consider the health systems implications of a national MC program without raising expectations that such a program was about to be introduced. The results suggests caution in implementing a future MC program, given obstacles in funding pathways, inconsistent support by government departments, difficulties with staff retention and erratic delivery of training programs With no current national MC program in PNG, and previous research indicating penile cutting as part of the cultural landscape, the underlying complexities in health service delivery in PNG uncovered in the analysis of the NSV suggests that focusing on strengthening the health system was of paramount importance before attempting to initiate and roll-out any new prevention technologies.
Health system readiness
According to mathematical modelling research, it is predicted that male circumcision will have a moderate impact on the PNG HIV epidemic overall with benefits reduced or eliminated by changes in sexual behavior . Therefore, health system readiness and good leadership is integral to the success of aligning MC as part of a comprehensive HIV strategy. Difficulties with management of the NSV program were described and due in part to competing responsibilities of key upper lever health official coordinators and frontline staff which impacted on planning, training and obtaining funding. If MC is introduced for HIV prevention in PNG, ensuring understanding of the program at multiple levels of government, particularly at provincial level, will be essential to future program success. Identification of key workers in provincial areas with clear and strong support from the NDoH will assist in maintaining momentum and support.
Effectively mobilising human resources has been a widely discussed topic in the implantation of a MC program in African countries [30–32]. This study demonstrated that sustained NSV services relied significantly on the motivation and support of frontline health workers, in particular, CHWs, whose ability to gain community support, promote awareness and provide successful services should not be over looked. Task-shifting to increase human resource capacity has been identified as a potential option in a number of African countries attempting to implement MC programs and has relevance to PNG[33, 34]. The introduction of MC for HIV prevention in PNG will require significant additional human resourcing and may benefit from considering how best to engage CHWs, who currently represent around 35% of frontline HW staff . In an already vulnerable health system, significant investment in equipment and negotiation of clinical space also needs consideration, a similar finding in other capacity studies in Africa [30, 32, 36–38].
Of particular concern for a future MC program, poor monitoring and recording of men who have undergone NSV, as well as identification and follow up of trained HWs, were recognised as problems in the current NSV program. Unevenness of NSV service provision appeared to exist across provinces and over time, however, a clear picture of the national program was difficult to obtain due to gaps in recorded statistics. The need for systematic monitoring and evaluation of MC services across government and NGO sectors is important, to observe gaps in workforce and other resources; to determine if priority targets are being met; and to identify changing demands or other issues within the program .
The challenges of implementing national MC programs in Africa have also centred around the ability to access sustained domestic and international funding with leadership and visible champions at all levels to mobilise essential for maximum effect [31, 32, 40]. Given the existing popular market for penile cutting in PNG, a sustainable population-based MC service may justify the introduction of a nominal user fee with a small user fee charged by one NGO for the NSV an observed possibility. However, sustainable funding of a targeted MC program may have to consider alternatives that would not exclude vulnerable, disadvantaged clients because of cost.
The role of NGOs in the roll out of MC programs in Africa has not been fully explored; however the potential benefit of an integrated approach needs further consideration. The success of NGO efforts in technical and financial support to strengthen service delivery in key provinces in PNG for NSV may be applied to a national MC program. For example, dilemmas were reported around access to appropriate transport particularly for rural outreach visits and concerns were raised around access to enough medicines and essential equipment. Partly out-sourcing a future MC program to the NGO sector in PNG could provide an opportunity for technical and financial assistance in managing key issues identified in the NSV study.
In Kenya, consistent political support and ongoing community consultation have allowed implementation challenges for MC to be addressed as they arise . The need to develop close relationships with communities is integral for program success across PNG and would need to be a focal point of implementing an invasive intervention such as MC. Promotion of NSV that was not followed up with an immediate service was shown to threaten community support for the program. Careful management of waiting lists and understanding the unique travel and access constraints present in much of PNG are required. Ensuring cooperation of services, particularly in urban centres, will assist in managing changes in demand, and corresponding waiting lists, as MC is rolled out.
Evidence of formal incentives for clients and HWs were observed and contributed to the promotion of the NSV service. However, difficulties with understanding motivations in clients were also reported by frontline HWs. As health workers were the only ones interviewed in this paper, minimal conclusive insight could be provided towards the community perceptions of NSV and the reasons for accessing the service. The impact of socio-cultural factors such as religion, traditional and contemporary understandings of family planning and the prevention of disease requires further exploration. The motivations for men accessing a MC program will need to be carefully monitored due to the potential for the program to result in reductions in condom usage, although such risk compensation has not been observed in other settings [41–45].
A dedicated men’s health service or clinic appeared to have the most success in promotion, access and uptake of NSV. With the minimum package for MC services as defined by WHO including voluntary counselling and testing (VCT); treatment and exclusion of STIs; and safe sex counselling (including provision and promotion of male and female condoms), a number of other opportunities arise for managing men’s sexual health in PNG . Promoting MC through male clinics as part of family health services and sexual health services, or establishing culturally relevant programs in individual provinces such as through mediated “Haus Man” (traditional male initiation) projects may be valuable options for future service delivery.
The research project involved qualitative research methods. However, as with the nature of qualitative research, data results are limited in their ability to be generalized to the wider population. The case study analysis of the NSV program in PNG utilised by the researchers has advantages, but also some limitations. Studying a case poses challenges since it involves more variables than data points. The case study approach was also constrained by factors impacting case selection including a limited number of known NSV services identified by the NDoH; available time; and access to the services. However, the case summaries presented provide a general picture of the situation at a particular point in time and an opportunity to better understand casual factors that enable or hinder similar health programs.