Interventions to Drive Uptake of Voluntary Medical Male Circumcision—A Collection of Impact Evaluation Evidence

In the last few decades, significant progress has been made in improving population health outcomes. This is largely attributable to the development of effective public-health tools—diagnostics, vaccines, other prevention technologies, and treatment regimens. Advances in delivery have enabled these technologies and interventions to reach end users in even the most remote areas. However, although uptake of services has followed, the pace has often been suboptimal. The global health field has come a long way in ensuring that services are available, but when it comes to motivating people to be better consumers of treatment and of preventive health services, there are relatively few proven interventions that promote uptake. Voluntary medical male circumcision (VMMC) is one program facing such a challenge in eliciting uptake of services among large numbers of men and boys. VMMC is being scaled up in 14 eastern and southern African countries as a key HIV prevention intervention. To date, more than 11.7 million circumcisions have been performed, against a target of 20 million by 2016. A large proportion who have received services are adolescents, but for the VMMC program to achieve its intended rapid impact on the HIV epidemic, a greater proportion of older, sexually active, and high-risk males must access services. The public health field needs new approaches and interventions to attract and motivate men to be circumcised. A systematic approach and framework to improve demand for VMMC has been recommended. The 4 components of this approach are (1) a greater emphasis on generating insights into the factors that drive or limit men’s motivation and ability to undergo VMMC, (2) developing an innovative and comprehensive portfolio of demand generation solutions based on these insights, (3) implementing a proven portfolio of interventions at scale and in a coordinated manner to achieve high levels of coverage, and (4) a robust measurement and evaluation agenda. A key component of this approach is thus to generate evidence on which interventions work and should be scaled up to drive greater efficiency and effectiveness within programs. Equally important is knowing which behavior change interventions are not effective. Only a few evaluations of VMMC demand generation interventions have been published to date, which highlights the need for greater evidence. The collection of impact evaluations in this supplement presents a rich and unique body of evidence on the effectiveness of various demand generation interventions for VMMC. It also provides an opportunity to analyze the science of evaluation in relation to demand generation interventions within the context of large-scale national programs. The approach taken to design and implement these interventions is interesting and worth highlighting. The International Initiative for Impact Evaluation (3ie), a grant-making nonprofit organization that promotes evidence-based policy making using impact evaluation, played a funding, convening, and technical support role. 3ie convened a group of evaluators, country stakeholders, and program implementers in a “matchmaking” workshop in April 2013. Teams were formed to work on intervention design, such that the interventions were field-driven and realistic, yet also included an evaluation component. The objective was to ensure rigorous assessment of impact and that effective interventions could be translated into large-scale programs and integrated into national VMMC policies and practices. The subsequent request for proposals produced 7 pilot interventions to increase the demand for VMMC with embedded qualitative and impact evaluations to determine whether and to what degree these interventions were effective. The program was designed to fund low-cost, rapid impact evaluations of the pilot interventions. Here, we synthesize and reflect on the approaches taken and the findings, in their relevance both to VMMC and to a broader array of large-scale global health programs.