The voluntary medical male circumcision Site Capacity and Productivity Assessment Tool (SCPT): An innovative visual management tool to optimize site service delivery.

Given constrained funding for HIV, achieving global goals on VMMC scale-up requires that providers improve service delivery operations and use labor and capital inputs as efficiently as possible to produce as many quality VMMCs as feasible. The Voluntary Medical Male Circumcision Site Capacity and Productivity Assessment Tool (SCPT) is an electronic visual management tool developed to help VMMC service providers to understand and improve their site's performance. The SCPT allows VMMC providers to: 1) track the most important human resources and capital inputs to VMMC service delivery, 2) strategically plan site capacity and targets, and 3) monitor key site-level VMMC service delivery performance indicators. To illustrate a real-world application of the SCPT, we present selected data from two provinces in Mozambique-Manica and Tete, where the SCPT was piloted We looked at the data prior to the introduction of SCPT (October 2014 to August 2016), and during the period when the tool began to be utilized (September 2016 to September 2017). The tool was implemented as part of a broader VMMC site optimization strategy that VMMC implementers in Mozambique put in place to maximize programmatic impact. Routine program data for Manica and Tete from October 2014 to September 2017 showcase the turnaround of the VMMC program that accompanied the implementation of the SCPT together with the other components of the VMMC site optimizatio strategy. From October 2016, there was a dramatic increase in the number of VMMCs performed. The number of fixed service delivery sites providing VMMC services was expanded, and each fixed site extended service delivery by performing VMMCs in outreach sites. Alignment between site targets and the number of VMMCs performed improved from October 2016. Utilization rates stabilized between October 2016 and September 2017, with VMMCs performed closely tracking VMMC site capacity in most sites. The SCPT is designed to address the need for site level data for programmatic decision-making during site planning, implementation, monitoring and evaluation. Deployment of the SCPT can help VMMC providers monitor the performance of VMMC service delivery sites and improve their performance. We recommend use of the customized version of this tool and model to the need of other programs.

Estimating the Cost of the Design, Production, and Dissemination of Social Media Videos for Social and Behavioral Change: Evidence From Merci Mon Héros in Niger and Côte d'Ivoire.

Merci Mon Héros (MMH) is a youth-led multi-media campaign in Francophone West Africa seeking to improve reproductive health and family planning outcomes using radio, television, social media, and community events. One component to this project is the development of a series of youth-driven videos created to encourage both youth and adults to break taboos by talking to each other about reproductive health and family planning. A costing study was conducted to capture costs associated with the design, production, and dissemination of 11 MMH videos (in French) on social media in Côte d'Ivoire and Niger. The total costs to design, produce and disseminate 11 of the campaign videos for MMH in both Côte d'Ivoire and Niger were $44,981. Unit costs were calculated using three different denominators, resulting in average unit costs of $0.16 per reach, $1.29 per engagement, and $4.27 per video view. These findings can be useful for future studies of SBC interventions using social media for framing the analysis and selecting the appropriate metrics for the denominator, as well as for budgeting and planning SBC programs using social media.

Estimating male circumcision coverage in 15 priority countries in sub-Saharan Africa.

INTRODUCTION: Given the importance of voluntary medical male circumcision (VMMC) in reducing HIV incidence, access to and use of quality data for programme planning and management are essential. Unfortunately, such data are currently not standardized for reliable and consistent programme use in priority countries. To redress this, the UNAIDS Reference Group (RG) on Estimates, Modelling, and Projection worked with partner Avenir Health to use the Decision Makers Program Planning Toolkit (DMPPT) 2 Online to provide estimates of VMMC coverage and to support countries to set age- and geographic-specific targets. This article describes the methods and tools used for assembling, reviewing and validating VMMC programme data as part of the 2021 Estimates process. DISCUSSION: The approach outlined for integrating VMMC data using the DMPPT2 Online required significant country engagement as well as upgrades to the DMPPT2 Online. The process brought together local-level VMMC stakeholders, for example Ministries of Health, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the US President's Emergency Plan for AIDS Relief, the World Health Organization (WHO), VMMC implementers and so on, to review, amend and agree on historical and more recent VMMC data. The DMPPT2 Online was upgraded to align with the Spectrum and Naomi models used in the Annual HIV Estimates process. In addition, new and revised inputs were incorporated to enhance accuracy of modelled outputs. The process was successful in mobilizing stakeholders behind efforts to integrate VMMC into the annual HIV Estimates process and generating comprehensive, country-owned and validated VMMC data that will enhance programme monitoring and planning. CONCLUSIONS: VMMC programme data from most of the priority countries were successfully reviewed, updated, validated and incorporated into the annual HIV Estimates process in 2020. It is important to ensure that these data continue to be used for programme planning and management. Current and future data issues will need to be addressed, and countries will need ongoing support to do so. The integration of the DMPPT2 Online into the annual HIV Estimates process is a positive step forward in terms of streamlining country-owned planning and analytical practices for the HIV response.

Moving away from the "unit cost". Predicting country-specific average cost curves of VMMC services accounting for variations in service delivery platforms in sub-Saharan Africa.

BACKGROUND: One critical element to optimize funding decisions involves the cost and efficiency implications of implementing alternative program components and configurations. Program planners, policy makers and funders alike are in need of relevant, strategic data and analyses to help them plan and implement effective and efficient programs. Contrary to widely accepted conceptions in both policy and academic arenas, average costs per service (so-called "unit costs") vary considerably across implementation settings and facilities. The objective of this work is twofold: 1) to estimate the variation of VMMC unit costs across service delivery platforms (SDP) in Sub-Saharan countries, and 2) to develop and validate a strategy to extrapolate unit costs to settings for which no data exists. METHODS: We identified high-quality VMMC cost studies through a literature review. Authors were contacted to request the facility-level datasets (primary data) underlying their results. We standardized the disparate datasets into an aggregated database which included 228 facilities in eight countries. We estimated multivariate models to assess the correlation between VMMC unit costs and scale, while simultaneously accounting for the influence of the SDP (which we defined as all possible combinations of type of facility, ownership, urbanicity, and country), on the unit cost variation. We defined SDP as any combination of such four characteristics. Finally, we extrapolated VMMC unit costs for all SDPs in 13 countries, including those not contained in our dataset. RESULTS: The average unit cost was 73 USD (IQR: 28.3, 100.7). South Africa showed the highest within-country cost variation, as well as the highest mean unit cost (135 USD). Uganda and Namibia had minimal within-country cost variation, and Uganda had the lowest mean VMMC unit cost (22 USD). Our results showed evidence consistent with economies of scale. Private ownership and Hospitals were significant determinants of higher unit costs. By identifying key cost drivers, including country- and facility-level characteristics, as well as the effects of scale we developed econometric models to estimate unit cost curves for VMMC services in a variety of clinical and geographical settings. CONCLUSION: While our study did not produce new empirical data, our results did increase by a tenfold the availability of unit costs estimates for 128 SDPs in 14 priority countries for VMMC. It is to our knowledge, the most comprehensive analysis of VMMC unit costs to date. Furthermore, we provide a proof of concept of the ability to generate predictive cost estimates for settings where empirical data does not exist.

Meta-analysis of average costs of HIV testing and counselling and voluntary medical male circumcision across thirteen countries.

Objective: Explore facility-level average costs per client of HIV testing and counselling (HTC) and voluntary medical male circumcision (VMMC) services in 13 countries.Methods: Through a literature search we identified studies that reported facility-level costs of HTC or VMMC programmes. We requested the primary data from authors and standardised the disparate data sources to make them comparable. We then conducted descriptive statistics and a meta-analysis to assess the cost variation among facilities. All costs were converted to 2017 US dollars ($).Results: We gathered data from 14 studies across 13 countries and 772 facilities (552 HTC, 220 VMMC). The weighted average unit cost per client served was $15 (95% CI 12, 18) for HTC and $59 (95% CI 45, 74) for VMMC. On average, 38% of the mean unit cost for HTC corresponded to recurrent costs, 56% to personnel costs, and 6% to capital costs. For VMMC, 41% of the average unit cost corresponded to recurrent costs, 55% to personnel costs, and 4% to capital costs. We observed unit cost variation within and between countries, and lower costs in higher scale categories in all interventions.

Using mathematical modeling to inform health policy: A case study from voluntary medical male circumcision scale-up in eastern and southern Africa and proposed framework for success.

BACKGROUND: Modeling contributes to health program planning by allowing users to estimate future outcomes that are otherwise difficult to evaluate. However, modeling results are often not easily translated into practical policies. This paper examines the barriers and enabling factors that can allow models to better inform health decision-making. DESCRIPTION: The Decision Makers' Program Planning Tool (DMPPT) and its successor, DMPPT 2, are illustrative examples of modeling tools that have been used to inform health policy. Their use underpinned Voluntary Medical Male Circumcision (VMMC) scale-up for HIV prevention in southern and eastern Africa. Both examine the impact and cost-effectiveness of VMMC scale-up, with DMPPT used initially in global advocacy and DMPPT 2 then providing VMMC coverage estimates by client age and subnational region for use in country-specific program planning. Their application involved three essential steps: identifying and engaging a wide array of stakeholders from the outset, reaching consensus on key assumptions and analysis plans, and convening data validation meetings with critical stakeholders. The subsequent DMPPT 2 Online is a user-friendly tool for in-country modeling analyses and continuous program planning and monitoring. LESSONS LEARNED: Through three iterations of the DMPPT applied to VMMC, a comprehensive framework with six steps was identified: (1) identify a champion, (2) engage stakeholders early and often, (3) encourage consensus, (4) customize analyses, (5), build capacity, and (6) establish a plan for sustainability. This framework could be successfully adapted to other HIV prevention programs to translate modeling results to policy and programming. CONCLUSIONS: Models can be used to mobilize support, strategically plan, and monitor key programmatic elements, but they can also help inform policy environments in which programs are conceptualized and implemented to achieve results. The ways in which modeling has informed VMMC programs and policy may be applicable to an array of other health interventions.

Voluntary medical male circumcision service delivery in South Africa: The economic costs and potential opportunity for private sector involvement.

BACKGROUND: In 2010, the South African Government initiated a voluntary medical male circumcision (VMMC) program as a part of the country's HIV prevention strategy based on compelling evidence that VMMC reduces men's risk of becoming HIV infected by approximately 60%. A previous VMMC costing study at Government and PEPFAR-supported facilities noted that the lack of sufficient data from the private sector represented a gap in knowledge concerning the overall cost of scaling up VMMC services. This study, conducted in mid-2016, focused on surgical circumcision and aims to address this limitation. METHODS: VMMC service delivery cost data were collected at 13 private facilities in three provinces in South Africa: Gauteng, KwaZulu-Natal, and Mpumalanga. Unit costs were calculated using a bottom-up approach by cost components, and then disaggregated by facility type and urbanization level. VMMC demand creation, and higher-level management and program support costs were not collected. The unit cost of VMMC service delivery at private facilities in South Africa was calculated as a weighted average of the unit costs at the 13 facilities. KEY FINDINGS: At the average annual exchange rate of R10.83 = $1, the unit cost including training and cost of continuous quality improvement (CQI) to provide VMMC at private facilities was $137. The largest cost components were consumables (40%) and direct labor (35%). Eleven out of the 13 surveyed private sector facilities were fixed sites (with a unit cost of $142), while one was a fixed site with outreach services (with a unit cost of $156), and the last one provided services at a combination of fixed, outreach and mobile sites (with a unit cost per circumcision performed of $123). The unit cost was not substantially different based on the level of urbanization: $141, $129, and $143 at urban, peri-urban, and rural facilities, respectively. CONCLUSIONS: The private sector VMMC unit cost ($137) did not differ substantially from that at government and PEPFAR-supported facilities ($132 based on results from a similar study conducted in 2014 in South Africa at 33 sites across eight of the countries nine provinces). The two largest cost drivers, consumables and direct labor, were comparable across the two studies (75% in private facilities and 67% in public/PEPFAR-supported facilities). Results from this study provide VMMC unit cost data that had been missing and makes an important contribution to a better understanding of the costs of VMMC service delivery, enabling VMMC programs to make informed decisions regarding funding levels and scale-up strategies for VMMC in South Africa.

Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries.

Background: The new World Health Organization and Joint United Nations Programme on HIV/AIDS strategic framework for voluntary medical male circumcision (VMMC) aims to increase VMMC coverage among males aged 10-29 years in priority settings to 90% by 2021. We use mathematical modeling to assess the likelihood that selected countries will achieve this objective, given their historical VMMC progress and current implementation options. Methods: We use the Decision Makers' Program Planning Toolkit, version 2, to examine 4 ambitious but feasible scenarios for scaling up VMMC coverage from 2017 through 2021, inclusive in Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, and Zimbabwe. Results: Tanzania is the only country that would reach the goal of 90% VMMC coverage in 10- to 29-year-olds by the end of 2021 in the scenarios assessed, and this was true in 3 of the scenarios studied. Mozambique, South Africa, and Lesotho would come close to reaching the objective only in the most ambitious scenario examined. Conclusions: Major changes in VMMC implementation in most countries will be required to increase the proportion of circumcised 10- to 29-year-olds to 90% by the end of 2021. Scaling up VMMC coverage in males aged 10-29 years will require significantly increasing the number of circumcisions provided to 10- to 14-year-olds and 15- to 29-year-olds.

Correction: The Cost of Voluntary Medical Male Circumcision in South Africa.

[This corrects the article DOI: 10.1371/journal.pone.0160207.].

Correction: Estimating Client Out-of-Pocket Costs for Accessing Voluntary Medical Male Circumcision in South Africa.

[This corrects the article DOI: 10.1371/journal.pone.0164147.].

The Cost of Voluntary Medical Male Circumcision in South Africa.

Given compelling evidence associating voluntary medical male circumcision (VMMC) with men's reduced HIV acquisition through heterosexual intercourse, South Africa in 2010 began scaling up VMMC. To project the resources needed to complete 4.3 million circumcisions between 2010 and 2016, we (1) estimated the unit cost to provide VMMC; (2) assessed cost drivers and cost variances across eight provinces and VMMC service delivery modes; and (3) evaluated the costs associated with mobilize and motivate men and boys to access VMMC services. Cost data were systematically collected and analyzed using a provider's perspective from 33 Government and PEPFAR-supported (U.S. President's Emergency Plan for AIDS Relief) urban, rural, and peri-urban VMMC facilities. The cost per circumcision performed in 2014 was US$132 (R1,431): higher in public hospitals (US$158 [R1,710]) than in health centers and clinics (US$121 [R1,309]). There was no substantial difference between the cost at fixed circumcision sites and fixed sites that also offer outreach services. Direct labor costs could be reduced by 17% with task shifting from doctors to professional nurses; this could have saved as much as $15 million (R163.20 million) in 2015, when the goal was 1.6 million circumcisions. About $14.2 million (R154 million) was spent on medical male circumcision demand creation in South Africa in 2014-primarily on personnel, including community mobilizers (36%), and on small and mass media promotions (35%). Calculating the unit cost of VMMC demand creation was daunting, because data on the denominator (number of people reached with demand creation messages or number of people seeking VMMC as a result of demand creation) were not available. Because there are no "dose-response" data on demand creation ($X in demand creation will result in an additional Z% increase in VMMC clients), research is needed to determine the appropriate amount and allocation of demand creation resources.

Estimating Client Out-of-Pocket Costs for Accessing Voluntary Medical Male Circumcision in South Africa.

In 2010, South Africa launched a countrywide effort to scale up its voluntary medical male circumcision (VMMC) program on the basis of compelling evidence that circumcision reduces men's risk of acquiring HIV through heterosexual intercourse. Even though VMMC is free there, clients can incur indirect out-of-pocket costs (for example transportation cost or foregone income). Because these costs can be barriers to increasing the uptake of VMMC services, we assessed them from a client perspective, to inform VMMC demand creation policies. Costs (calculated using a bottom-up approach) and demographic data were systematically collected through 190 interviews conducted in 2015 with VMMC clients or (for minors) their caregivers at 25 VMMC facilities supported by the government and the President's Emergency Plan for AIDS Relief in eight of South Africa's nine provinces. The average age of VMMC clients was 22 years and nearly 92% were under 35 years of age. The largest reported out-of-pocket expenditure was transportation, at an average of US$9.20 (R 100). Only eight clients (4%) reported lost days of work. Indirect expenditures were childcare costs (one client) and miscellaneous items such as food or medicine (20 clients). Given competing household expense priorities, spending US$9.20 (R100) per person on transportation to access VMMC services could be a significant burden on clients and households, and a barrier to South Africa's efforts to create demand for VMMC. Thus, we recommend a more focused analysis of clients' transportation costs to access VMMC services.