The cost of demand creation activities and voluntary medical male circumcision targeting school-going adolescents in KwaZulu-Natal, South Africa

Abstract

BackgroundVoluntary medical male circumcision is an integral part of the South African government’s response to the HIV and AIDS epidemic. However, there remains a limited body of economic analysis on the cost of VMMC programming, and the demand creation activities used to mobilize males, especially among adolescent boys in school. This study addresses this gap by presenting the costs of a VMMC program which adopted two demand creation strategies targeting school-going males in South Africa.MethodsCost data was collected from a VMMC program in the KwaZulu-Natal province of South Africa. A retrospective, micro-costing ingredient approach was applied to identify, measure and value resources of two demand creation strategies targeting young males.ResultsThe program circumcised 4987 young males between May 2011 and February 2013, at a cost of $127.68 per circumcision. Demand creation activities accounted for 32% of the total cost, HCT contributing 10% with the medical circumcision procedure accounting for 58% of the total cost. Using the first demand creation strategy, 2168 circumcisions were performed at a cost of $149.57 per circumcision. Following this first strategy, a second demand creation strategy was adopted which saw the cost fall to $110.85 per circumcision. More young males were recruited following the second strategy with clinic services more efficiently utilized. Whilst the cost per circumcision of demand activities rose slightly between the first ($39.94) and second ($41.65) strategy, there was a substantial reduction in the cost of the circumcision procedure; $90.01 under the first strategy falling to $60.60 following the adoption of the second demand creation strategy.ConclusionEnsuring the optimal use of clinic facilities was the primary driver in reducing the cost per circumcision. This VMMC program has illustrated the value of evaluating progress and instituting changes to attain better cost efficiencies. This adjustment resulted in a substantial reduction in the cost per circumcision.

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.…”

“…Overall, age prioritization interventions increased demand generation costs but resulted in sufficient demand to decrease overall VMMC unit costs and lower costs per HIV infection averted [14,25,39]. For example, one study assessing the cost of demand creation strategies targeting school-going adolescents in South Africa found that expanding in-school recruitment and adding peer recruiters while reducing VMMC clinic days increased overall demand creation unit costs but reduced VMMC procedure costs, thus reducing overall VMMC unit cost through increased recruitment and clinic efficiencies [39].…”

Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya

“…Estimates from the sensitivity analyses indicate that the VMMC intervention is highly cost-effective when administered to street-connected youth, even at a cost of $108 per individual, and these estimates are in line with previous findings from the literature [ 20 , 23 , 32 ]. While differentiated approaches have shown encouraging results for developing VMMC programs that target adolescents [ 29 – 31 ], they often incur greater costs to reach this age group and are limited to the local context [ 47 ]. Findings from this pilot intervention are consistent with studies modelling age-specific VMMC programs in Sub-Saharan Africa [ 23 – 25 ] and may support, from a cost-effectiveness perspective, spending more on the differentiated approaches needed to reach these populations.…”

“…The strategies Kenya has used to achieve the national target of circumcising 80% of the country’s adult males [ 27 ] have routinely overlooked SCY who do not access health services through traditional channels [ 27 , 28 ]. Programs which employ innovative and locally-tailored approaches to youth and hard-to-reach populations have shown higher circumcision rates, more efficient resource utilization and increased cost-savings [ 29 – 32 ].…”