Assessing the Costs of Multiple Program Approaches and Service Delivery Modes for Adult Male Circumcision in Nyanza Province, Kenya

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Assessing the Costs of Multiple Program Approaches and Service Delivery Modes for Adult Male Circumcision in Nyanza Province, Kenya By Elliot Marseille, James G. Kahn, Sharone Beatty, and Paul Perchal
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Assessing the Costs of Multiple Program Approaches and Service Delivery Modes for Adult Male Circumcision in Nyanza Province, Kenya By Elliot Marseille, James G. Kahn, Sharone Beatty, and Paul Perchal 2011 EngenderHealth. 440 Ninth Avenue New York, NY U.S.A. Telephone: Fax: This publication was prepared under a subagreement funded by FHI under Grant No , funded by the Bill & Melinda Gates Foundation. The content of this publication does not necessarily reflect the views, analysis, or policies of FHI or the Bill & Melinda Gates Foundation, nor does any mention of trade names, commercial products, or organizations imply endorsement by FHI or the Bill & Melinda Gates Foundation. Suggested citation: Marseille, E., Kahn, J. G., Beatty, S., and Perchal, P Assessing the costs of multiple program approaches and service delivery modes for adult male circumcision in Nyanza Province, Kenya. New York: EngenderHealth. Photo credits: Cover and pp. 11, 23, 45, and 47, Multy Media Agencies; p. 41, S. Odiwuor contents 4 Acknowledgments 5 Acronyms & Abbreviations 6 Executive Summary 12 Background 16 Objectives & Methodology 24 Findings Current Cost per MC Delivered, by Program Approach and Service Delivery Mode Program Components that Decrease the Unit Cost While Maintaining Quality Differences in HIV Cases Averted and Potential Savings in HIV Treatment Costs 42 Discussion Cost Differences between Program Approaches Unit Costs by Service Delivery Modes Strategies for Increasing Efficiency Study Limitations 46 Conclusion and Recommendations 49 References ACKNOWLEDGMENTS EngenderHealth would like to thank the following people for their contributions to this report: Dr. Elliot Marseille, Dr. James Kahn, and Paul Perchal, for analyzing the data and writing the report; Sharone Beatty, George Odingo, Everlyne Nyagaya, Emma Llewellyn, and Walter Obiero, for leading data collection in Kenya; the date collection teams; the Male Circumcision Consortium, the AIDS, Population, and Health Integrated Assistance-II (APHIA-II) Nyanza Project, the Nyanza Reproductive Health Society (NRHS), the Kenya Ministry of Public Health and Sanitation, the Kenya Ministry of Medical Services, and the Nyanza Provincial Health Management and District Health Management teams, for their ongoing collaboration and support; Robert Bailey, Naomi Bock, Emmanuel Njeuhmeli, Jackson Kioko, Nicholas Muraguri, Peter Cheratich, John Bratt, and Barbara Janowitz, for reviewing earlier drafts; Michael Klitsch, for editing the manuscript and managing the publication process; and Lerner Design Group, for designing and formatting this report. EngenderHealth also thanks those who enthusiastically gave their time to participate in the time and motion observations and interview. We would also like to acknowledge the technical assistance provided by the APHIA-II Nyanza Project and the NRHS at the study sites, with the generous support of the American people through funding from the U.S. Agency for International Development (USAID) and the U.S. Centers for Disease Control and Prevention (CDC) through the President s Emergency Plan for AIDS Relief (PEPFAR). FHI, EngenderHealth, and the University of Illinois at Chicago, working with the Nyanza Reproductive Health Society, are partners in the Male Circumcision Consortium, which is funded by a grant to FHI from the Bill & Melinda Gates Foundation. 4 EngenderHealth Assessing the Costs for Adult Male Circumcision in Kenya ACRONYMS & ABBREVIATIONS AIDS APHIA CDC GOK HCT HIA HIV KEPH MC MCC MOH NASCOP NGO NRHS PANCEA RRI STI T&M UNAIDS UNDP VMMC WHO acquired immunodeficiency syndrome AIDS, Population, and Health Integrated Assistance US. Centers for Disease Control and Prevention Government of Kenya HIV counseling and testing HIV infection averted human immunodeficiency virus Kenya Essential Package for Health male circumcision Male Circumcision Consortium Ministry of Health National AIDS and STD Control Program nongovernmental organization Nyanza Reproductive Health Society Prevent AIDS Network for Cost-Effectiveness Analysis Rapid Results Initiative sexually transmitted infection time and motion Joint United Nations Programme on HIV/AIDS United Nations Development Programme voluntary medical male circumcision World Health Organization Assessing the Costs for Adult Male Circumcision in Kenya EngenderHealth 5 Executive Summary It is well established that adult male circumcision (MC) is an effective and cost-effective method of preventing female-to-male transmission of HIV. MC has been accepted by the global health community as an important new strategy for confronting the HIV epidemic. The World Health Organization (WHO) estimates that as many as 2 million new infections in Sub-Saharan Africa can be averted in the next 10 years with careful, intentional scale-up of safe, high-quality MC services. Kenya has formally adopted MC as part of its response to the epidemic, and the Kenya Ministry of Health (MOH) released the Kenya National Strategy for Voluntary Medical Male Circumcision (GOK, 2009). The strategy emphasizes a decentralized approach to MC implementation, including availability of MC at community-level sites through to district hospitals. In Nyanza Province, MC services are currently being provided at fixed or base health facilities and via outreach and mobile services. The national strategy states that voluntary medical male circumcision (VMMC) services may be delivered through either community- or facility-based systems (GOK, 2009, p. 15). It recommends that at all times, community services should have functional linkages with the adjacent health facility to ensure commodity supply, reporting, and quality assurance. Community VMMC services (otherwise known as mobile outreach) may be delivered through health facilities, schools, churches, or tented camps (GOK, 2009, p. 15). Given the system constraints, facility-based MCs are not expected to meet the strategic targets for VMMC in the short term (GOK, 2009, p. 15). A large variety of strategies support mobile outreach: hospitals or health institutions, professional boards, private companies, nongovernmental organizations (NGOs), or governmental bodies. The categories of health professional involved vary from one strategy to another, and ways of mobilizing health professionals to increase access to MC services can also differ (deploying existing MOH staff, hiring additional full-time or part-time staff, etc.). In this study, outreach refers to when a health center or dispensary receives supplemental inputs (e.g., trained MC surgeons/surgical assistants, equipment such as an autoclave, surgical instruments, etc.) from an adjacent district or subdistrict hospital to provide MCs that meet standard surgery requirements during prescheduled MC days. The receiving facility contributes minimal or no inputs (local technical support, supplies) other than providing a space for surgeries. Mobile refers to when a fully contained MC surgical unit (e.g., trained MC surgeons/ surgical assistants, equipment, surgical instruments, supplies, tents, vehicle) is able to stage MC operations that meet standard MC surgery requirements at any location (e.g., a school, community center, field, etc.), with the receiving location providing the space only. For all three service delivery modes (base, outreach, mobile), limited availability of physicians and other senior health worker cadres (clinical officers and nurses) and other potential sources of high costs (e.g., equipment, vehicles, etc.) are barriers to scale-up of MC services. The financial resources necessary to respond to emerging and projected demand cannot be absorbed by the national budget, nor can any single donor provide the support necessary to train all clinical staff, equip surgical theaters, and secure and regularize the required commodity flows. A number of 6 EngenderHealth Assessing the Costs for Adult Male Circumcision in Kenya international and local NGOs, with financing from donors, have supported the roll-out of the national MC program in Nyanza through a combination of horizontal and vertical program approaches. These organizations include EngenderHealth, through the AIDS, Population, and Health Integrated Assistance Project II (APHIA II) (funded by the U.S. Agency for International Development [USAID]) 1 and the Nyanza Reproductive Health Society (NRHS) (funded by the U.S. Centers for Disease Control and Prevention [CDC]). APHIA II supported the MOH from October 2008 to October 2010 to implement MC services based on a horizontal program approach. NRHS has supported the MOH since October 2008 to implement MC services following a combination of horizontal and vertical program approaches. The opportunity to change the course of the epidemic in one of the world s most-affected countries requires that the response be as thoughtfully planned and evidence-based as possible. Until recently, the potential savings of various MC service delivery modes have not been systematically quantified in Kenya and other countries. While research is examining the expected impact of scaling up safe MC services, including costs, the number of infections that could be averted, and the cost savings, a better understanding is still needed of the unit costs of various adult MC service delivery modes, their determinants and trends, and the potential for enhanced efficiency. The current study, which was conducted from May 2010 to April 2011, compares the costs of various approaches and modes for delivering MC services using the forceps-guided method in Nyanza Province, Kenya, and aims to assist the Government of Kenya (GOK) in scaling up a national MC program by addressing three questions that can inform the choice of MC program approaches and service delivery modes in Nyanza Province: 1. what are the current costs per MC by program approach and service delivery mode? Program approaches and modes assessed are: a. Horizontal versus diagonal (combination of horizontal and vertical) approaches b. Fully MC-capable health facilities (fixed/base facilities) versus outreach services, versus mobile services 2. How do unit costs vary over the study period (i.e., from start-up to full implementation)? 3. what is the composition of the unit costs for each program approach and service delivery mode? 4. What do the cost findings suggest for strategies to increase efficiency? What would be the potential impact of these strategies on program costs, HIV infections averted, and cost per infection averted? The second study question regarding trends in unit costs over the study period was not possible to analyze, due to difficulty in obtaining reliable allocations of the portion of time that MOH staff allocated to MCs over time. The key results related to each of these questions are summarized below, followed by our recommendations. What are the current costs per MC, by service delivery approach and mode? During the period November 2008 to April 2010, a total of 62,705 MCs were delivered, 90.1% through the NRHS diagonal approach and 9.9% through the APHIA-II horizontal approach. 2 Overall, community-based services dominated the caseload, with 68.6% of MCs delivered at either mobile or outreach sites; the balance were provided at base facilities. This number is dominated by the large 1 APHIA II Nyanza worked with Kenya s Ministry of Health, and with faith- and community-based organizations and other agencies to reduce the risk of HIV transmission and the fertility rate in Nyanza Province. EngenderHealth led the consortium of partners that implemented the project, which included the Academy for Educational Development, the Christian Health Association of Kenya, the Inter Diocesan Christian Community Services, and PATH. 2 A diagonal program approach is one that combines aspects of both horizontal and vertical program approaches. Assessing the Costs for Adult Male Circumcision in Kenya EngenderHealth 7 Executive Summary number of cases performed with NRHS support. APHIA II delivered 53.5% of its MCs at outreach or mobile sites, while NRHS provided 70.3% of its MCs at outreach or mobile sites. Using microcosting methods that identify and value each of the resources required to deliver MC services, we analyzed unit costs distributed across service delivery modes, as shown in the figure below. Overall costs were $38.62 and $44.62 for APHIA II and NRHS, respectively. Outreach services were similar, and mobile services were 37% lower at the APHIA II sites than at the combined NRHS outreach/ mobile sites. How to decrease cost while maintaining quality? We conducted a time and motion (T&M) study of 246 MC procedures performed using the forceps-guided method at base hospitals, at outreach sites, and at temporary sites served by mobile surgical teams; 130 procedures were supported by APHIA-II and 116 by NRHS. The resulting information, combined with cost data collected by a trained data collection team with support from EngenderHealth and the authors of this report, allowed us to describe variations in cost by: w Variations in staffing patterns, w Number of MCs performed per surgery-day w The time required for specific steps of the MC procedure w Waiting time prior to the first surgery of the day We found extensive use of nonphysicians on the surgical teams for both approaches, with a team consisting of an average of 4.2 and 3.9 members for APHIA II and NRHSsupported procedures, respectively. PER-CLIENT COST OF MC PROVISION, BY SERVICE DELIVERY MODE $50 $40 $30 $20 $10 Personnel direct services HQ and hospital admin. support Supplies medical Mobilizers + other demand gen. Transportation Training Facility rents & renovations Capital equipment 0 Base Outreach Mobile Total Base Out/Mob Total Facility services; indirect costs APHIA-II NRHS 8 EngenderHealth Assessing the Costs for Adult Male Circumcision in Kenya As the figure below illustrates, the number of procedures performed per surgery-day was lowest at the APHIA II supported base facilities (3.2) and highest at the outreach/ mobile sites (7.2). Through the T&M data collection exercise, we were able to obtain detailed information on the amount of staff time required by the MC operation. The table below shows that the average procedure time per MC varied from 22 to 31 minutes, and the total time (including postoperative time) varied from 23 to 33 minutes. The amount of down time prior to the beginning of surgical activity on each scheduled surgery day was significant and averaged 1.6, 2.7, and 1.7 hours, respectively, for base, outreach, and mobile sites. NO. OF MC PROCEDURES PER SURGERY-DAY 8 7 MC procedures per surgery-day n Base (n=12) n Mobile; combined mob./out. for NRHS (n=36) n Outreach (n=20) 1 0 Total APHIA II NRHS Time in Minutes Per MC Base (n=63) Outreach (n=43) Mobile (Combined Mobile/Outreach for NRHS) (n=139) Total Surgeon time Procedure time Total time per case Surgeon time as % of total 53% 48% 49% 49% Assessing the Costs for Adult Male Circumcision in Kenya EngenderHealth 9 Executive Summary How might efficiency strategies affect cost and impact on the HIV epidemic? The unit cost of MCs using the forceps-guided method ranged from $29 to $46 per procedure (see table below). The number of MCs that can be performed with a budget of $1 million (calculated by dividing $1 million by the unit cost of the procedure) ranges from 21,643 to 34,103. We estimate that in a setting like Nyanza Province, with an HIV prevalence of around 20% (17% among men, 26% among women), 10 MCs avert about 2.5 HIV infections over 20 years; thus, 0.25 HIV infections are averted per MC. This estimate includes indirectly averted infections (e.g., in female sex partners) and is discounted to the present, per normal practice. The resulting estimate of HIV infections averted (HIAs) per $1 million ranges from 6,172 to 8,526, depending on the mode of MC provision. The cost per HIV infection averted ranges from $ to $ All of these values are far below the lifetime medical cost of HIV disease, estimated at $6,000 in East Africa. Thus, each of the MC delivery models results in substantial net savings. Using this model, and drawing on the findings from the cost analysis, we identified five possible strategies that could enhance program efficiency (defined as cost per HIA). We found that scheduling and administrative efficiencies, if feasible to implement, would yield up to a 20% drop in cost per MC, with operational efficiency (reducing start-up time on MC days) offering smaller savings. Two technical innovations (use of electrocautery and MC devices) appear to increase costs, given the cost structure of the MC programs we studied. Demand generation could efficiently increase demand for services and could potentially reduce unit costs, by distributing fixed costs over more MCs. Conclusions and Recommendations The most important overall finding of this study is that the cost differences between program approaches to MC scale-up using the forceps-guided method are not dramatic and are unlikely to be accounted for by the relative virtues and drawbacks of the more horizontal APHIA II approach and the more diagonal NRHS approach. In the Nyanza context, both approaches provide MC services well within the range of other published unit costs in other African settings. Differences in unit cost between APHIA II and NRHS-supported MC services are modest (less than onethird), not consistently in the same direction, and to a large extent explained by differences in compensation levels. This compares with more than 10-fold variations in unit costs for other prevention strategies, previously reported by the Prevent AIDS Network for Cost-Effectiveness Analysis (PANCEA) project and other studies (Dandona et al., 2008; Marseille et al., 2007; Stover & Forsythe, 2010). COST PER MC PROCEDURE AND COST-EFFECTIVENESS APHIA NRHS Base Outreach Mobile Base Outreach/ mobile Cost per MC $38.33 $40.51 $29.32 $39.58 $46.20 MCs per budget 26,092 24,687 34,103 25,266 21,643 HIA per $1 million 6,523 6,172 8,526 6,316 5,411 Cost-effectiveness: Cost per HIA $ $ $ $ $ EngenderHealth Assessing the Costs for Adult Male Circumcision in Kenya However, 90% of the MCs performed during the study were conducted using the NRHS approach, versus about 10% by means of the APHIA II approach. This disparity may be attributable to the ability of the NRHS to deploy its own dedicated MC teams to provide MCs 100% of the time; in contrast, the APHIA II approach used existing MOH staff, which provide MCs only 12 38% of the time. The larger NRHS service volume to date may suggest that the diagonal NRHS approach can be scaled up more quickly in the short term, though with possibly larger future impediments to full integration with the MOH s services. Both MC program approaches that we assessed rely largely on external financial support. It is therefore plausible that either, with additional funding, could attain higher service volumes, either through intensified efforts in existing service areas or through expansion of activities to new, underserved areas. Overall, community-based services dominated the caseload in either approach, with 68.6% of MCs delivered at either mobile or outreach sites. This indicates that access to MCs for rural and remote populations can be improved through either approach, utilizing outreach and mobile modes of service delivery. suggests that increased demand will not increase efficiency in itself. Proactive efforts will be required to do so. The study findings lend support to the following recommendations: u As additional resources are mobilized, expand access to MC services through a combination of both horizontal and diagonal MC program approaches both are costeffective, and neither has a marked advantage over the other. u Continue the use of multiple MC service delivery modes: base, outreach, and mobile. The presence of all three modes increases access to MC services, and the three have similar unit
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