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Background: Voluntary medical male circumcision (VMMC) is recommended by WHO as a key component of HIV prevention. VMMC programs have substantially contributed to avert new infections, but while coverage scales up, critical challenges arise such as technology adoption and availability of resources hindering the achievement of their goals. The objective of this study was to estimate average costs and to analyze the determinants of efficiency of VMMC in Kenya, Rwanda, South Africa and Zambia for 2013, as part of the ORPHEA project.
Methods: ORPHEA is a cross-sectional observational study with data collected in Kenya, Rwanda, South Africa, and Zambia between 2011 and 2013. The analytical sample comprise of 82 facilities: 25 facilities in Kenya, 20 facilities in Rwanda, 23 facilities in South Africa, and 14 facilities in Zambia. Micro-costing methods were applied to determine relevant costs (personnel, supplies, utilities, equipment and property) and output data. Information on self-reported time allocation was used to estimate staff costs and national prices of surgical kits and HIV tests were used in the calculations.
Results: Average cost per VMMC was US$ 29 in Rwanda, US$ 51 in Zambia, US$ 32 in Kenya, and US$ 106 in South Africa. Considerable variation in the average cost within countries was found; staff costs dominated in South Africa and Zambia (55 and 59% respectively), and circumcision kits costs in Kenya and Rwanda (46%). In all countries, except for Rwanda, we found that unit cost per VMMC decreased with the number of MC clients: from 31 to 48% of average reduction by doubling the number of clients. In general, there were also variations by type of facility, with lower average cost per MC clients found in health centers (both public and private) as compared to hospitals.
Conclusions: There were important differences in the average cost per VMMC across facilities in the four countries studied that provide opportunities for increase the levels of efficiency in the provision of VMMC. Additionally, it is important to expand the volume of VMMC services by means of sustained demand generation, while acceptable levels of quality are maintained.