Applying the WHO MOVE Guidance for Male Medical Circumcision – Cost of Facility-based Provision in a Test Case for South

1. Applying the WHO MOVE Guidance for Male Medical Circumcision – Cost of Facility-based Provision in a Test Case for South Africa SHIPP Sexual HIV Prevention Programme Health Policy Initiative TO2 Partners

2. Acknowledgments • Data for this analysis came from a variety of sources and represents the work of many individuals. • Some data from prior HPI TO1 MMC costing in South Africa • Ozayr Mohamed, Steven Forsythe • Bophelo Pele Project, Orange Farm, Gauteng • CHAPS

3. Background (1): VMMC in South Africa • Government & partners committed to scale-up of voluntary medical male circumcision (VMMC). • Traditional MC occurs for certain groups • But initiation may or may not involve complete circumcision* • Unmet need for voluntary medical male circumcision (VMMC) • Additional 4.33 mn. MMCs in 2011-15 (~80% coverage) • PEPFAR reported VMMC in 2010: 131,117 • NDOH target for 2011-12: 500,000 VMMCs • Allocation: R160 million (about US$20 million) • How to achieve the scale-up? * Data from Bophelo Pele, Orange Farm

4. Background (2): Origin of this work • March 2011: NDOH was considering various scale-up plans: • Mobile clinics and/or transitory “park homes” • Scale-up of VMMC provision via existing public health facilities: clinics, CHCs, district hospitals; and using MOVE • Mixed models • NDOH request to HPI TO2: look again at unit costs with a model of their choosing, apply scenarios • This should focus on the unit cost of 2: fixed facilities • Build on previous unit cost work by HPI at 20 South African facilities in 2010

5. PREVIOUS Cost estimates

6. Costs recently used in a 13 country study Njeuhmeli et al. PLOS 2011 Direct costs: $69.71 Indirect costs: $10.42 $80.13 (+/- 20%: $64.1-$96.16) Source: Zimbabwe 2010 data (plus Swaziland)

7. Costs from HPI work in 2010 in South Africa Mohamed et al. 2010 • 20 sites visited and retrospective data collected (2008-09) • Costing using an ingredients-based approach • Cost of provision “as-is” • Cost of provision using the MOVE model • For B. “MOVE” unit costs: • Costs with disposable MC consumables kits; • task sharing; 1 doctor + 1 surgical nurse + 4 nursing assistants • variation in costs as cost of disposable MC kits is varied • Included indirect costs: avg. in public facilities = 24% of total

8. South Africa facility-based costing, 2010 Mohamed et al. (HPI 2010) – unit cost without complications “As-is” costs

9. South Africa facility-based costing, 2010 Mohamed et al. (HPI 2010) – unit cost without complications MOVE-based costs

10. TEST CASE: Cost estimate

11. Proposed test case of scale-up plan • Prepare facilities to apply MOVE • Facilities will procure MMC commodities and equipment • Procurement will be from each facility’s existing suppliers • These costs will be funded though CCMT Conditional Grants to provinces

12. Preparing the analysis -1 NDOH guidance for the costing exercise: • Surgical technique: forceps-guided MMC (FGMC) • Use disposable standard consumables kit for FGMC, with reusable instruments. Add infection prevention, waste management, and emergency commodities. • Apply WHO MOVE staffing model with task sharing • Apply current SA commodity and equipment prices, as known • Focus on direct costs to be covered by additional funds

13. Preparing the analysis -2 Not yet known/estimated at this stage: • Actual mix of facilities that will provide MMC from clinic, CHC, DH • Facility readiness for MMC: basic commodity availability, equipment, infrastructure, staff complement, staff training • Magnitude of demand for MMC at public health facilities • Demand creation and IEC in catchment areas of facilities • Possible changes to prices, esp. if pooled procurement • Other constraints on scale-up

14. What was costed – 1 (MOVE elements) Not costed: HTC (only pre-procedure MMC counseling)

15. What was costed - 2 No indirect costs Key points: • Salary data same as 2010 study • Follow-up visits at +2, +7 days • 1 week MMC training for staff (except clerks); differing costs • Haemostasis by diathermy • Autoclave (differing volume) for sterilization of reusable instruments • Emergency (haemorrhage or sepsis) cases are 2%

16. Analysis setup - 1 Two possible site layouts and staffing models, based on MOVE:

17. MOVE –based 8-bays site design Source: WHO MOVE 2010

18. Analysis setup - rationale Primary cause for using two types of sites: Demand • without demand creation, volume likely low <20 MMCs per day/team • 4-bay designs suitable when demand >30 MMCs per day per team • Pre-procuring commodities and staffing up at the 8-bays design without demand creation may lead to cost inefficiencies • Designs started as 4-bay sites can be expanded with additional site preparation when demand creation picks up • Many facilities already require renovations to accommodate even a 4-bay design* * Site assessment essential – SA mapping ongoing

19. Sources for cost data • Bophelo Pele Male Circumcision Project, Orange Farm, Gauteng implemented by CHAPS – March 2011 • Cost data collection for MMC by HPI project in early 2010 • Cost enquiries for autoclaves and diathermy machines – March 2011 • Other inputs from key contacts – March 2011 • Rand/$ = 6.88 • Kit 1 price = R103 ($15 ) per MMC Consumable pack

20. ANALYSIS RESULTS

21. Unit direct costs per client: 4-bay site design At 15 clients per day per site Unit direct costs, 4-bay design Standard client (no complications) Rand 248 / $36.1 With complications(2% or less): Rand 2,030.6 / $306.6

22. Unit direct costs per client: 8-bay site design At 30 clients per day per site Unit direct costs, 8-bay site Standard client (no complications) Rand 316.4 / $46 With complications (2% or less: Rand 2,109.4 / $306.6

23. Increasing returns to scale – but this tapers off

24. FOR FURTHER CONSIDERATION

25. Also calculated • Monthly and first year direct cost per SA province • Latter is inclusive of total site preparation costs • Estimate of numbers of full-time equivalent staff needed to staff sites Above calculations at province level based on: • Number of facilities to initiate the service • Proportion of 4-bay and 8-bay sites • Proportion of facilities needing VMMC site preparation

26. For further consideration • Demand creation should be costed (estimates available) • Task-shifting could reduce personnel costs, especially in the 8-bay design • Requires policy change and extra up-front training costs for surgical nurses • Weekend clinic? Labor cost calculation assumed that facilities are open for 22 days/month only; 48 weeks/year • Keeping facilities open on Saturday to catch working men, but might require paying some staff overtime

27. THANK YOU Acknowledgements Eurica Palmer, Farley Cleghorn, Zuzelle Pretorius (HPI TO2, Futures Group)Shaidah Asmall – NDOH, former HPI TO2 Dr N Dlamini – NDOHDr Loy - NDOH

28. BACKUPs

29. Purpose of this analysis • Provide a cost range for financial planning at NDOH • Provide a flexible costing tool for NDOH use in budgeting Facility based Medical Male Circumcision Costing tool (FMMCC,v.1) • Provide a consistent procurement list and staffing model for province and facility-level planning • Provide a unit cost for benchmarking against other MMC rollouts across Africa, and southern Africa in particular Specifically, the costing tool will: • Guide NDOH on cost implications for MMC • incorporate the effect of price changes – e.g., due to pooled procurement and other factors on national and province-level costs

30. WHO MOVE Guidance – Part B (Kits and Modules) There are three variations in the kits, given the surgical method: Both Kit 1 and 2 require an autoclave

31. WHO MOVE Guidance – Part A • WHO Model for Optimizing Volume and Efficiency for MC (2010) • Three recommended surgical MC methods (procedure time): • Forceps-guided (19 minutes 20 seconds) • Dorsal slit (21 minutes 45 seconds) • Sleeve resection (27 minutes) • Recommended use of the following techniques/concepts: • Hemostasis by diathermy machine • Task Sharing and/or Task Shifting • Bundling of surgical items; use pre-assembled surgical kits • Theater layout for fast patient turnover • Client scheduling (appointments) • Staff ratios • 1 physician/surgeon per 4 clients (1 surgeon per 4 surgical bays*) • 4 preparation/surgical assistants (e.g., nurse assistants) per surgeon • 1 anesthesia/suture provider (e.g., surgical nurse) per surgeon • 1-2 counselors per team + 1 site manager (if high volume site)