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

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

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 (~80% coverage) PEPFAR reported VMMC in 2010: 131,117 –NDOH target for : 500,000 VMMCs Allocation: R160 million (about US$20 million) –How to achieve the scale-up? * Data from Bophelo Pele, Orange Farm

Background (2): Origin of this work March 2011: NDOH was considering various scale-up plans: 1.Mobile clinics and/or transitory “park homes” 2.Scale-up of VMMC provision via existing public health facilities: clinics, CHCs, district hospitals; and using MOVE 3.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

PREVIOUS COST ESTIMATES

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

Costs from HPI work in 2010 in South Africa Mohamed et al sites visited and retrospective data collected ( ) Costing using an ingredients-based approach A.Cost of provision “as-is” B.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

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

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

TEST CASE: COST ESTIMATE

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

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 Preparing the analysis -1

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 Preparing the analysis -2

What was costed – 1 (MOVE elements) Kit 1: Standard consumables pack (disposable) + Reusable instruments for forceps-guided method AND Module 1: Supplies needed for infection prevention & waste management and Module 2: Essential operating theater equipment for MMC and Module 3: Essential emergency case management equipment and commodities. Not costed: HTC (only pre-procedure MMC counseling)

What was costed - 2 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% No indirect costs

Analysis setup - 1 Two possible site layouts and staffing models, based on MOVE: Site Layout 1 – Four (4) bays Staffing: 1 physician/surgeon 1 surgical nurse 4 assistants 2 counsellors 1 clerk/receptionist Site Layout 2 – Eight (8) bays Staffing: 2 physicians/surgeons 2 surgical nurses 8 assistants 2 counsellors 1 receptionist 1 site manager 1 data assistant/clerk 1 autoclave o perator

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

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

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

ANALYSIS RESULTS

Unit direct costs per client: 4-bay site design 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 At 15 clients per day per site

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

Increasing returns to scale – but this tapers off

FOR FURTHER CONSIDERATION

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

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

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

BACKUPS

1.Provide a cost range for financial planning at NDOH 2.Provide a flexible costing tool for NDOH use in budgeting Facility based Medical Male Circumcision Costing tool (FMMCC,v.1) 3.Provide a consistent procurement list and staffing model for province and facility-level planning 4.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 Purpose of this analysis

There are three variations in the kits, given the surgical method: WHO MOVE Guidance – Part B (Kits and Modules) Both Kit 1 and 2 require an autoclave Kit 1: Standard consumables pack (disposable) + reusable instruments for forceps-guided method Or Kit 2: Standard consumables pack (disposable) + reusable instruments for sleeve resection and dorsal slit methods or Kit 3: standard consumables pack (disposable) + disposable instruments for the forceps-guided method Both Kit 1 and 2 require an autoclave

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) WHO MOVE Guidance – Part A