An individual’s knowledge of the health benefits of voluntary medical male circumcision appears to be more important than financial status in regard to his or her willingness to pay for the procedure, according to a cross-sectional household survey in Kenya.1 Sixty-two percent of surveyed heads of household reported having a monthly household income considered sufficient to afford the cost of a circumcision; however, 60% of household heads reported not being willing to pay for the procedure, no matter the cost. Slightly more than half (53%) of household heads knew that circumcision reduces the risk of HIV transmission. Compared with household heads who believed that circumcision protects against HIV transmission, those who did not had lower odds of being willing to pay for the procedure (odds ratios, 0.3).
In 2008, a voluntary medical male circumcision program was launched in Kenya as part of a comprehensive national HIV prevention strategy. Although the procedure was offered free of charge, the program’s sustainability is questionable because of its heavy reliance on donor funding. To assess the feasibility of introducing a patient charge, the investigators conducted a random household survey in Kisumu County, which was selected because it has the lowest uptake of male circumcision and the highest prevalence of HIV in the country, and because the program rollout campaign was launched there. Heads of household—i.e., those considered to have the final say in the health care decisions for their household—were selected to answer questions about their social and demographic characteristics, how HIV is spread and whether male circumcision reduces the risk of HIV transmission. A household was considered able to afford a circumcision if the head reported having a total monthly household income of at least 1,000 Kenyan shillings (about US$10). Bivariate and multivariate analyses were used to assess correlates of willingness to pay for the procedure.
Analyses were based on responses from the heads of 384 households. Fifty-four percent were male, and 62% were 26–50 years old. More than two-thirds were married, and nearly all had at least some formal education. Some 62% of households had a total monthly income considered large enough to afford to pay for voluntary medical male circumcision; however, just 40% of household heads reported being willing to pay for the procedure. On cross-tabulation, 27% of households were both able and willing to pay for circumcision, 13% were willing but not able, 35% were able but not willing, and 25% were neither able nor willing.
Among the household heads willing to pay for a circumcision, 59% indicated that they would be willing to do so if it cost them 500 shillings or less; much smaller proportions showed willingness to pay if the procedure cost 1,000 or 2,000 shillings (29% and 20%, respectively). Overall, only about half of household heads (53%) knew that male circumcision reduces the risk of HIV transmission; of those, nearly all (91%) were willing to pay for the procedure.
In multivariate analyses, household heads’ knowledge of the role of male circumcision in reducing HIV transmission was the factor most strongly associated with willingness to pay for the procedure. Compared with their counterparts who knew of this benefit, household heads who believed the procedure did not provide such protection were less likely to be willing to pay for it (odds ratio, 0.3). In addition, widowed household heads were half as likely as their married counterparts to be willing to pay (0.5). Ability to pay was not associated with willingness.
"Knowledge about the role of male circumcision in prevention of HIV transmission is more important in determining the household [head’s] willingness to pay for [voluntary medical male circumcision] regardless of income levels," the investigators write. They note that their findings contrast with those of other studies conducted elsewhere in Africa and Asia that have found income or ability to pay to be positively associated with willingness to pay for community-based insurance, azithromycin as a trachoma-control measure and cataract surgery, and suggest that the large proportion of household heads who did not know of circumcision’s HIV preventive benefit could explain the difference.—S. London