title: Cost drivers for voluntary medical male circumcision using primary source data from sub-Saharan Africa.
abstract: BACKGROUND
  As voluntary medical male circumcision (VMMC) programs scale up, there is a pressing need for information about the important cost drivers, and potential efficiency gains. We examine those cost drivers here, and estimate the potential efficiency gains through an econometric model.
  
  
  RESULTS
  We examined the main cost drivers (i.e., personnel and consumables) associated with providing VMMC in sub-Saharan Africa along a number of dimensions, including facility type and service provider. Primary source facility level data from Kenya, Namibia, South Africa, Tanzania, Uganda, and Zambia were utilized throughout. We estimated the efficiency gains by econometrically estimating a cost function in order to calculate the impact of scale and other relevant factors. Personnel and consumables were estimated at 36% and 28%, respectively, of total costs across countries. Economies of scale (EOS) is estimated to be eight at the median volume of VMMCs performed, and EOS falls from 23 at the 25th percentile volume of VMMCs performed to 5.1 at the 75th percentile.
  
  
  CONCLUSIONS
  The analysis suggests that there is significant room for efficiency improvement as indicated by declining EOS as VMMC volume increases. The scale of the fall in EOS as VMMC volume increases suggests that we are still at the ascension phase of the scale-up of VMMC, where continuing to add new sites results in additional start-up costs as well. A key aspect of improving efficiency is task sharing VMMC procedures, due to the large percentage of overall costs associated with personnel costs. In addition, efficiency improvements in consumables are likely to occur over time as prices and distribution costs decrease.
authors.affiliation: Health Policy Initiative Costing Task Order, Washington, District of Columbia, United States of America; Health Policy Project, Washington, District of Columbia, United States of America; Futures Institute, Glastonbury, Connecticut, United States of America.
authors.forename: Lori
authors.initials: L
authors.lastname: Bollinger
authors.affiliation: Health Policy Initiative Costing Task Order, Washington, District of Columbia, United States of America; Health Policy Project, Washington, District of Columbia, United States of America; Futures Institute, Glastonbury, Connecticut, United States of America.
authors.forename: Adebiyi
authors.initials: A
authors.lastname: Adesina
authors.affiliation: Health Policy Initiative Costing Task Order, Washington, District of Columbia, United States of America; Health Policy Project, Washington, District of Columbia, United States of America; Futures Institute, Glastonbury, Connecticut, United States of America.
authors.forename: Steven
authors.initials: S
authors.lastname: Forsythe
authors.affiliation: Health Policy Initiative Costing Task Order, Washington, District of Columbia, United States of America; Health Policy Project, Washington, District of Columbia, United States of America; Futures Group, Washington, District of Columbia, United States of America; United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Ramona
authors.initials: R
authors.lastname: Godbole
authors.affiliation: United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Elan
authors.initials: E
authors.lastname: Reuben
authors.affiliation: United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D017954:Africa South of the Sahara; D002944:Circumcision, Male / Q000191:economics*; D003362:Cost-Benefit Analysis; D006801:Humans; D008297:Male