The Cost of Voluntary Medical Male Circumcision in South Africa

PLoS One. 2016 Oct 26;11(10):e0160207. doi: 10.1371/journal.pone.0160207. eCollection 2016.

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.

MeSH terms

  • Anti-Retroviral Agents / therapeutic use
  • Circumcision, Male / economics*
  • Cost-Benefit Analysis*
  • HIV Infections / drug therapy
  • HIV Infections / economics*
  • HIV Infections / prevention & control
  • Health Facilities / economics
  • Humans
  • Male
  • South Africa
  • Urbanization

Substances

  • Anti-Retroviral Agents

Grants and funding

This manuscript is made possible by the generous support of the American people through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) with the United States Agency for International Development (USAID) under the Cooperative Agreement Health Policy Project, Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010, Cooperative Agreement Project SOAR (Supporting Operational AIDS Research), number AID-OAA-14-00026, and Cooperative Agreement Strengthening High Impact Interventions for an AIDS-free Generation, number AID-OAA-A-14-00046. The Health Policy Project is implemented by Futures Group, in collaboration with Plan International United States of America, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The funder was involved in study design, decision to publish, and preparation of the manuscript. The findings and conclusions in this paper do not necessarily represent the views or positions of PEPFAR, USAID, the South African National Department of Health, or the United States Government.