The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda

Abstract

BackgroundUganda is working to increase voluntary medical male circumcision (VMMC) to prevent HIV infection. To support VMMC quality improvement, this study compared three methods of disseminating information to facilities on how to improve VMMC quality: M—providing a written manual; MH—providing the manual plus a handover meeting in which clinicians shared advice on implementing key changes and participated in group discussion; and MHC—manual, handover meeting, and three site visits to the facility in which a coach provided individualized guidance and mentoring on improvement. We determined the different effects these had on compliance with indicators of quality of care.MethodsThis controlled pre-post intervention study randomized health facility groups to receive M, MH, or MHC. Observations of VMMCs performance determined compliance with quality indicators. Intervention costs per patient receiving VMMC were used in a decision-tree cost-effectiveness model to calculate the incremental cost per additional patient treated to compliance with indicators of informed consent, history taking, anesthesia administration, and post-operative instructions.ResultsThe most intensive method (MHC) cost $28.83 per patient and produced the biggest gains in history taking (35% improvement), anesthesia administration (20% improvement), and post-operative instructions (37% improvement). The least intensive method (M; $1.13 per patient) was most efficient because it produced small gains for a very low cost. The handover meeting (MH) was the most expensive among the three interventions but did not have a corresponding positive effect on quality.ConclusionHealth workers in facilities that received the VMMC improvement manual and participated in the handover meeting and coaching visits showed more improvement in VMMC quality indicators than those in the other two intervention groups. Providing the manual alone cost the least but was also the least effective in achieving improvements. The MHC intervention is recommended for broader implementation to improve VMMC quality in Uganda.

Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review

“…Eleven studies presented cost data [14,25,[36][37][38][39][40][41][42][43][44], three of which were related to articles included in the main effectiveness review. Studies were published between 2012 and 2018 and took place in Kenya [38,41], South Africa [39,42,43], Tanzania [44], Uganda [36,37,40], and Zimbabwe [14,25]. Descriptions of included cost studies and their outcomes are presented in Table 5.…”

“…Descriptions of included cost studies and their outcomes are presented in Table 5. Seven of the included studies assessed community-based interventions [14,36,[40][41][42][43][44], two assessed school-based interventions [25,39], and two assessed facility-based interventions [37,38]. Generally, cost studies showed that service delivery interventions may create economies of scale and efficiencies when implemented widely.…”

“…Finally, one study assessed cost effectiveness of three facility-based quality improvement strategies, which increased in intensity from providing a VMMC training manual to providing a training package including a manual, handover meeting, and individualized guidance and mentoring [37]. Quality was measured in terms of compliance to VMMC quality of care indices for four domains: informed consent, history-taking, anesthesia administration, and post- Uganda "Make the Cut" with added home visits, a video, closer coordination with schools, and accommodation of exams and holidays…”

Coaching Intensity, Adherence to Essential Birth Practices, and Health Outcomes in the BetterBirth Trial in Uttar Pradesh, India

“…14 To improve performance, coaches use multiple approaches, including modeling desired behaviors, providing supportive supervision, providing auditing and feedback, and promoting problem solving. 15 These strategies are effective at improving quality of care in low-and middle-income countries across a variety of clinical areas, 16,17 including Integrated Management of Childhood Illness, 18,19 drug management and prescription practices, 20,21 primary care, 22 malaria case management, 23 voluntary male circumcision, 24 and reproductive health. 25,26 Although some studies have reported associations between increased intensity of coachingrelated activities and improved quality of care, [21][22][23] the optimal coaching intensity needed to promote and sustain behavior change is unknown.…”

Scoping review of costs of implementation strategies in community, public health and healthcare settings

“…Expressed in terms of year 2020 US dollars, the estimates of the total costs of the D&I strategies ranged from $7288 27 to $3.0 million 28 for multicomponent strategies, excluding studies with incomplete cost information for all identified strategies [29][30][31] and studies that were designed to compare the effect of different strategies. [32][33][34][35][36][37][38] In contrast, the range was $212 39 -$4.4 million 40 for discrete D&I strategies (online supplemental table S4). No association was observed between the number of strategies used and the total cost, given the broad range of the D&I strategies and associated costs.…”