Driving Health System Strengthening Through Localized Implementation
As voluntary medical male circumcision (VMMC) has been demonstrated to safely and effectively reduce male HIV acquisition by up to 60%, the global health community has prioritized the scale-up of VMMC services in high HIV burden regions. However, despite significant investments and ambitious targets, VMMC expansion has fallen short in many countries. One key factor contributing to slower-than-anticipated progress may be the predominance of vertical (stand-alone) VMMC program models, which, while facilitating rapid initial scale-up, may not fully leverage existing healthcare infrastructure or promote long-term sustainability.
In contrast, an integrated VMMC approach that embeds services within the broader health system holds promise for strengthening local capacity, increasing community ownership, and ensuring program resilience beyond the intensive donor-supported scale-up phase. The experience of the ZAZIC consortium in Zimbabwe provides valuable insights into the benefits and challenges of implementing VMMC through an integrated, locally-led model.
Tailoring VMMC to Local Contexts
Beginning in 2013, the ZAZIC consortium – a partnership of three local Zimbabwean organizations – embarked on an ambitious effort to scale up integrated VMMC services in 21 districts, in close collaboration with the Ministry of Health and Child Care (MoHCC). This community-focused approach stood in contrast to the predominantly vertical VMMC programs that had been previously implemented in Zimbabwe’s urban centers.
ZAZIC’s model emphasized leveraging existing MoHCC healthcare workers, facilities, and supply chains to deliver VMMC as part of routine service delivery. Provincial and district health leadership played a central role in adapting the program to meet local needs, determining the optimal mix of staff (doctors, nurses, auxiliary personnel) and service delivery approaches (static sites, outreach, campaigns) based on community context.
“The VMMC program is part of the Ministry of Health program, so we make sure that everyone understands that it is part of hospital business,” explained one District Medical Officer. “This means that we have integrated circumcision to our health services.”
By embedding VMMC within the broader healthcare system, the ZAZIC model fostered local ownership and accountability. MoHCC staff felt a strong sense of program stewardship, with one Provincial Medical Director noting, “The ministry took the program on board, and we also have to take the program on board. We have to create demand for the program and also create awareness in the community to increase the uptake of the program.”
Navigating Challenges with Flexibility and Adaptability
The integrated nature of ZAZIC’s approach, while beneficial for long-term sustainability, presented some initial challenges during the rapid scale-up phase. The need to build partnerships, secure buy-in from local stakeholders, and adapt service delivery to diverse community contexts resulted in a somewhat slower pace of scale-up compared to vertical programs.
“Integration of the program is not a problem. We will do as we normally do with other programs,” remarked one key informant. However, they also acknowledged that “the VMMC thing is outreach based. We want it to become part of the day-to-day business of every facility.”
Decentralizing VMMC services to lower-level health facilities and further integrating it with other clinical services, such as HIV testing and sexually transmitted infection management, emerged as important strategies for improving client access and demonstrating the full integration of VMMC into routine care.
Staffing also posed an ongoing challenge, as healthcare worker attrition and mobility reduced the long-term impact of VMMC training efforts. “There is staff attrition, a lot of movements among health personnel,” noted one key informant. “You find that all trained doctors for VMMC…have gone, so we need to re-train other doctors.”
Adapting to Changing Priorities with Resilience
In 2015, a shift in PEPFAR’s global strategy required ZAZIC to rapidly consolidate its VMMC program from 21 to just 10 high-burden districts. This transition presented a significant shock to the integrated model, as productivity targets in the remaining districts increased dramatically.
Rather than faltering, ZAZIC demonstrated remarkable resilience and adaptability. The consortium rapidly implemented a “blended” approach, supplementing the existing MoHCC workforce with additional mobile and outreach teams to meet the heightened demand. ZAZIC also expanded VMMC training efforts, added more outreach sites, and intensified community-based demand creation activities to ensure continued service access.
Despite the challenges of this transition, ZAZIC’s productivity and safety indicators remained strong. In the 12 months following the consolidation, the program conducted 57,282 VMMCs, a 27.7% increase over the previous year. Importantly, the vast majority of these procedures (approximately 85%) were still performed by MoHCC staff, underscoring the program’s successful integration within the local health system.
Achieving Sustainable Impact Through Local Ownership
Over its first three years of implementation, ZAZIC safely performed 192,575 VMMCs, with reported moderate and severe adverse event rates consistently below the global standard of 2%. This level of productivity and safety is comparable to, or exceeds, the achievements of more vertically-implemented VMMC programs in the region.
Critically, ZAZIC’s approach appears to have fostered a high degree of local ownership and capacity building within the MoHCC. District and provincial health leaders took an active role in shaping the program, determining staffing and service delivery models to best meet community needs. The integration of VMMC data reporting into the national District Health Information System further solidified the program’s institutionalization within the broader healthcare infrastructure.
While the integrated model presented some initial challenges, such as slower scale-up and ongoing staffing issues, ZAZIC’s experience demonstrates the potential for this approach to drive sustainable, country-led VMMC services. By leveraging existing systems and building local capacity, the consortium was able to weather significant programmatic shifts and continue delivering high-quality, accessible VMMC services.
As the global health community continues to grapple with the complexities of VMMC scale-up, the ZAZIC experience offers valuable lessons. Integrating VMMC within the broader healthcare system, while adapting to local contexts and priorities, may be a more effective path to achieving lasting impact and health system strengthening.
Embracing Integrated, Localized Approaches for VMMC
The ZAZIC consortium’s experience in Zimbabwe underscores the potential benefits of implementing VMMC through an integrated, locally-led model. By embedding services within the existing healthcare infrastructure and empowering district and provincial health authorities to shape the program, ZAZIC was able to achieve robust productivity and safety outcomes, while also fostering a strong sense of local ownership and capacity building.
While the integrated approach presented some initial challenges, such as slower scale-up and ongoing staffing issues, ZAZIC’s ability to adapt and implement a “blended” model during a period of significant programmatic shift demonstrates the resilience and long-term sustainability of this approach.
As the global health community continues to invest in VMMC scale-up, the ZAZIC experience offers valuable insights. Integrating VMMC within broader healthcare systems, while tailoring implementation to local contexts and priorities, may be a more effective path to achieving lasting impact and strengthening health systems. By embracing integrated, localized approaches, programs can build upon existing infrastructure, foster community ownership, and ensure the resilience of VMMC services well beyond the intensive donor-supported scale-up phase.
