Bollinger, L., Adesina, A., Forsythe, S., et al. PLOS ONE (May 2014), 9(4): e84701, doi: 10.1371/journal.pone.0084701.
This modeling study estimated potential gains in efficiency as voluntary medical male circumcision (VMMC) programs scale up. The authors examined the primary cost drivers associated with providing VMMC in sub-Saharan Africa for different dimensions of VMMC service, such as the type of facility and service provider. The analysis used actual cost data from urban and rural facilities in Kenya, Namibia, South Africa, Tanzania, Uganda, and Zambia. The two highest components of costs across all countries were direct personnel (36%) and consumables (28%), with considerable variation by country. Training, capital costs, maintenance and utilities, support staff, and management and supervision accounted for the other costs. The model showed that economies of scale (EOS) declined as VMMC volume increased. According to this analysis, efficiency could be improved. The decline in EOS as VMMC volume increased suggested that programs were still at the phase where adding new sites led to additional start-up costs, rather than savings due to EOS. The authors noted that personnel costs represent a substantial proportion of overall costs, so task sharing would be central to improving efficiency. They also anticipated that consumables would likely become more efficient as prices and distribution costs decline. The authors recommended conducting additional analyses with country-specific data that also include the considerable investment in demand creation for VMMC.