Spending and procedural data on voluntary medical male circumcision

Introduction: Voluntary male medical circumcision (VMMC) reduces HIV
acquisition by up to 60%.  Kenya has successfully scaled up VMMC
to an estimated 91% of eligible men and boys in certain regions. Given
that funding toward VMMC is expected to decline in the coming years, it is
important to identify what models of care are most appropriate and
efficient as new cohorts of men become eligible for VMMC. To this end, we
compared the costs of facility-based VMMC and one within a rapid results
initiative (RRI), a public health service scheduled during school holidays
to perform many procedures over a short period.   Methods: We
employed activity-based micro-costing to estimate the costs, from the
implementer perspective, of facility-based VMMC and RRI-based VMMC
conducted between October 2017 and September 2018 at 41 sites in Kisumu
County, Kenya supported by the Family AIDS Care & Education
Services (FACES). We conducted site visits and reviewed financial ledger
and programmatic data to identify and quantify resources consumed and the
number of VMMC procedures performed during routine care and RRIs. Ledger
data were used to estimate fixed costs, recurring costs, and cost per
circumcision (CPC) in United States dollar (USD). A sensitivity analysis
was done to estimate CPC where we allocated 6 months of the ledger to
facility-based and 6 months to RRI.   Results: Overall, FACES
spent $3,092,891 toward VMMC services and performed 42,139 procedures
during the funding year. This included $2,644,910 in stable programmatic
costs, $139,786  procedure costs, and $308,195 for RRI-specific
activities. Over the year, 49% (n=20,625) of procedures were performed as
part of routine care and 51% (n=21,514) were performed during the RRIs.
Procedures conducted during facility-based cost $99.35 per circumcision,
those conducted during the RRIs cost $48.51 per circumcision, and
according to our sensitivity analysis, CPC for facility-based ranges from
$99.35 to $287.24 and for RRI costs ranged from $29.81 to $48.51.
  Conclusion: The cost of VMMC during the RRI was substantially
lower than unit costs reported in previous costing studies. We conclude
that circumcision campaigns, such as the RRI, offer an efficient and
sustainable approach to VMMC.