The Cost of Voluntary Medical Male Circumcision in South Africa

Abstract

Given compelling evidence associating voluntary medical male circumcision (VMMC) with men’s reduced HIV acquisition through heterosexual intercourse, South Africa in 2010 began scaling up VMMC. To project the resources needed to complete 4.3 million circumcisions between 2010 and 2016, we (1) estimated the unit cost to provide VMMC; (2) assessed cost drivers and cost variances across eight provinces and VMMC service delivery modes; and (3) evaluated the costs associated with mobilize and motivate men and boys to access VMMC services. Cost data were systematically collected and analyzed using a provider’s perspective from 33 Government and PEPFAR-supported (U.S. President's Emergency Plan for AIDS Relief) urban, rural, and peri-urban VMMC facilities. The cost per circumcision performed in 2014 was US$132 (R1,431): higher in public hospitals (US$158 [R1,710]) than in health centers and clinics (US$121 [R1,309]). There was no substantial difference between the cost at fixed circumcision sites and fixed sites that also offer outreach services. Direct labor costs could be reduced by 17% with task shifting from doctors to professional nurses; this could have saved as much as $15 million (R163.20 million) in 2015, when the goal was 1.6 million circumcisions. About $14.2 million (R154 million) was spent on medical male circumcision demand creation in South Africa in 2014—primarily on personnel, including community mobilizers (36%), and on small and mass media promotions (35%). Calculating the unit cost of VMMC demand creation was daunting, because data on the denominator (number of people reached with demand creation messages or number of people seeking VMMC as a result of demand creation) were not available. Because there are no “dose-response” data on demand creation ($X in demand creation will result in an additional Z% increase in VMMC clients), research is needed to determine the appropriate amount and allocation of demand creation resources.

Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review

“…Eleven studies presented cost data [14,25,[36][37][38][39][40][41][42][43][44], three of which were related to articles included in the main effectiveness review. Studies were published between 2012 and 2018 and took place in Kenya [38,41], South Africa [39,42,43], Tanzania [44], Uganda [36,37,40], and Zimbabwe [14,25]. Descriptions of included cost studies and their outcomes are presented in Table 5.…”

“…Descriptions of included cost studies and their outcomes are presented in Table 5. Seven of the included studies assessed community-based interventions [14,36,[40][41][42][43][44], two assessed school-based interventions [25,39], and two assessed facility-based interventions [37,38]. Generally, cost studies showed that service delivery interventions may create economies of scale and efficiencies when implemented widely.…”

“…Though activities to enhance uptake increase total costs, linkage to VMMC services that use task-shifting/sharing providers, pre-established facilities (both fixed site VMMC clinics and other clinics temporarily repurposed for VMMC services), and integrated HIV, sexual, and reproductive health services may save costs. Five studies assessing community-based interventions compared costs between various service delivery modalities, including mobile vs fixed, outreach vs fixed, and horizontal vs diagonal [36,[40][41][42][43]. These studies had mixed results.…”

Voluntary Medical Male Circumcision for HIV Prevention: New Mathematical Models for Strategic Demand Creation Prioritizing Subpopulations by Age and Geography

“…The return on investment was highest if males are circumcised between the ages of 20 and 25 years, but this return on investment declined with age steeply thereafter. In addition, a costing exercise conducted by the Health Policy Project and the USAID- and PEPFAR-funded Project SOAR (Supporting Operational AIDS Research) that systematically collected cost data from 33 national government- and PEPFAR-supported urban, rural, and peri-urban VMMC facilities in eight of South Africa’s nine provinces [30] revealed that unit costs were significantly higher in public hospitals than in health centers and clinics. Direct costs could be reduced by 17% if South Africa encouraged task shifting from doctors to nurses.…”

Estimating Client Out-of-Pocket Costs for Accessing Voluntary Medical Male Circumcision in South Africa

“…VMMC demand creation—mobilizing and motivating men to accept and access VMMC services—is crucial to reach this ambitious target. In 2014, VMMC demand creation expenditures ($14.2 million) [13] represented about 26% of all resources that the President’s Emergency Plan for AIDS Relief (PEPFAR) spent on VMMC in South Africa [14]. Given this large investment, why is uptake low?…”