Voluntary medical male circumcision service delivery in South Africa: The economic costs and potential opportunity for private sector involvement

PLoS One. 2018 Dec 17;13(12):e0208698. doi: 10.1371/journal.pone.0208698. eCollection 2018.

Abstract

Background: In 2010, the South African Government initiated a voluntary medical male circumcision (VMMC) program as a part of the country's HIV prevention strategy based on compelling evidence that VMMC reduces men's risk of becoming HIV infected by approximately 60%. A previous VMMC costing study at Government and PEPFAR-supported facilities noted that the lack of sufficient data from the private sector represented a gap in knowledge concerning the overall cost of scaling up VMMC services. This study, conducted in mid-2016, focused on surgical circumcision and aims to address this limitation.

Methods: VMMC service delivery cost data were collected at 13 private facilities in three provinces in South Africa: Gauteng, KwaZulu-Natal, and Mpumalanga. Unit costs were calculated using a bottom-up approach by cost components, and then disaggregated by facility type and urbanization level. VMMC demand creation, and higher-level management and program support costs were not collected. The unit cost of VMMC service delivery at private facilities in South Africa was calculated as a weighted average of the unit costs at the 13 facilities.

Key findings: At the average annual exchange rate of R10.83 = $1, the unit cost including training and cost of continuous quality improvement (CQI) to provide VMMC at private facilities was $137. The largest cost components were consumables (40%) and direct labor (35%). Eleven out of the 13 surveyed private sector facilities were fixed sites (with a unit cost of $142), while one was a fixed site with outreach services (with a unit cost of $156), and the last one provided services at a combination of fixed, outreach and mobile sites (with a unit cost per circumcision performed of $123). The unit cost was not substantially different based on the level of urbanization: $141, $129, and $143 at urban, peri-urban, and rural facilities, respectively.

Conclusions: The private sector VMMC unit cost ($137) did not differ substantially from that at government and PEPFAR-supported facilities ($132 based on results from a similar study conducted in 2014 in South Africa at 33 sites across eight of the countries nine provinces). The two largest cost drivers, consumables and direct labor, were comparable across the two studies (75% in private facilities and 67% in public/PEPFAR-supported facilities). Results from this study provide VMMC unit cost data that had been missing and makes an important contribution to a better understanding of the costs of VMMC service delivery, enabling VMMC programs to make informed decisions regarding funding levels and scale-up strategies for VMMC in South Africa.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Circumcision, Male / economics*
  • Cost-Benefit Analysis
  • Delivery of Health Care / economics*
  • Elective Surgical Procedures / economics*
  • HIV Infections / economics
  • HIV Infections / prevention & control
  • Health Care Costs
  • Humans
  • Male
  • Private Sector
  • Quality Improvement / economics
  • Rural Population
  • South Africa
  • Urban Population
  • Voluntary Programs

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 U.S. Agency for International Development (USAID) under the Cooperative Agreement Project SOAR (Supporting Operational AIDS Research), number AID-OAA-A-1400060. Carl Schütte is employed by Strategic Development Consultants. Strategic Development Consultants provided support in the form of salary for author CS and research materials but did not have any additional role in the study design data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. Michel Tchuenche and Steven Forsythe are employed by Avenir Health. Lahla Ngubeni was contracted by Avenir Health. Avenir Health provided support in the form of salaries for authors MT, LN and SF but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. The information provided does not necessarily reflect the views of USAID or the United States Government, and the contents of this article are the sole responsibility of Projects SOAR, the Population Council, and the authors.