How Much Does It Cost to Improve Access to Voluntary Medical Male Circumcision among High-Risk, Low-Income Communities in Uganda?

Background
The Ugandan Ministry of Health has endorsed voluntary medical male circumcision as an HIV prevention strategy and has set ambitious goals (e.g., 4.2 million circumcisions by 2015). Innovative strategies to improve access for hard to reach, high risk, and poor populations are essential for reaching such goals. In 2009, the Makerere University Walter Reed Project began the first facility-based VMMC program in Uganda in a non-research setting. In addition, a mobile clinic began providing VMMC services to more remote, rural locations in 2011. The primary objective of this study was to estimate the average cost of performing VMMCs in the mobile clinic compared to those performed in health facilities (fixed sites). The difference between such costs is the cost of improving access to VMMC.
Methods
A micro-costing approach was used to estimate costs from the service provider’s perspective of a circumcision. Supply chain and higher-level program support costs are not included.
Results
The average cost (US$2012) of resources used per circumcision was $61 in the mobile program ($72 for more remote locations) compared to $34 at the fixed site. Costs for community mobilization, HIV testing, the initial medical exam, and staff for performing VMMC operations were similar for both programs. The cost of disposable surgical kits, the additional upfront cost for the mobile clinic, and additional costs for staff drive the differences in costs between the two programs. Cost estimates are relatively insensitive to patient flow over time.
Conclusion
The MUWRP VMMC program improves access for hard to reach, relatively poor, and high-risk rural populations for a cost of $27-$38 per VMMC. Costs to patients to access services are almost certainly less in the mobile program, by reducing out-of-pocket travel expenses and lost time and associated income, all of which have been shown to be barriers for accessing treatment.

研究背景
乌干达卫生部已将自愿医疗男性包皮环切术（Voluntary Medical Male Circumcision, VMMC）列为艾滋病（HIV）预防策略，并设定了宏伟目标，例如截至2015年完成420万例包皮环切手术。针对难以覆盖的高风险贫困人群优化可及性的创新策略，是达成此类目标的关键。2009年，马克雷雷大学沃尔特·里德项目（Makerere University Walter Reed Project, MUWRP）在乌干达非研究场景下启动了首个基于医疗机构的VMMC项目；2011年，该项目又开设了流动诊所，为更偏远的农村地区提供VMMC服务。本研究的核心目标是估算流动诊所与固定医疗机构开展VMMC的平均成本，二者的成本差值即为提升VMMC可及性所需的额外投入。
研究方法
本研究从服务提供者的视角，采用微观成本法（micro-costing）估算包皮环切术的成本，未纳入供应链及更高层级的项目支持成本。
研究结果
以2012年美元计价，每例手术的平均资源成本为：流动项目61美元（偏远地区为72美元），固定医疗机构为34美元。两项项目在社区动员、HIV检测、初始体检以及手术医护人员的成本上较为相近。成本差异主要源于一次性手术器械包的费用、流动诊所额外的前期投入以及额外的医护人员开支。成本估算结果随时间推移的患者流量变化相对不敏感。
研究结论
MUWRP的VMMC项目提升了难以覆盖、相对贫困的高风险农村人群的VMMC可及性，每例手术的成本为27至38美元。流动诊所模式下患者的就医成本无疑更低，这得益于患者无需承担高额自付交通费用、减少了误工时间及相关收入损失，而上述因素均被证实为阻碍人群获取医疗服务的障碍。