Cost Estimation of Early Infant Male Circumcision in Zimbabwe
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KARIN HATZOLD , MD, MPH
Population Services International
Collin Mangenah, CeSSHAR Zimbabwe
Harsha Thirumurthy, UNC
8
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International AIDS Economics Network
Pre-Conference Meeting
July 19, 2014
Melbourne, Australia
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EIMC is cheaper,
quicker, simpler &
has complete healing in less than 7
days with low rate of AEs
Zimbabwe plans to offer EIMC for HIV
prevention alongside adult and
adolescent VMMC
Currently EIMC devices prequalified
by WHO
New device -
AccuCirc
–
pre-packaged, disposable, potentially
usable by midwives
AccuCirc previously evaluated in
Botswana, (single-arm study with 151
male infants)
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AccuCirc vs Mogen Clamp
Doctor delivered
n = 150
Ratio=2:1
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Relative safety
Relative acceptability
Relative cost
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AccuCirc only
Nurse mid-wife delivered
n=500
No randomisation
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Safety
Acceptability
Cost
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What is the unit cost of EIMC in Zimbabwe?
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AccuCirc
–
Mogen Clamp
What are the key cost drivers for EIMC in Zimbabwe?
Role of various components:
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Device and Commodities price
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Personnel salaries
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Facility capacity utilization
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Nurse mid-wives procedure time
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150 eligible male infants
enrolled
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100 Accucirc, 50 Mogen clamp
2 moderate (and quickly
resolved) adverse events in the
AccuCirc arm (95% CI 0.004-
0.077) and 0 in the Mogen
clamp arm (95% CI 0.0-0.089)
Nearly all parents (99.5%)
reported great satisfaction with
the outcome
All parents, regardless of arm
said they would recommend
EIMC to other parents, and
would circumcise their next
newborn son
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Unit costs
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Direct (personnel, drugs, supplies, training & environmental
costs ) + indirect (capital & overheads)
Time and motion to calculate labor costs
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Stopwatch & video camera captured time spent on each task
One way sensitivity analysis
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D
evice price, Salaries, Site Capacity Utilization, Procedure
time
Analysis excludes
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Costs to clients (transport, caregiver costs)
–
Demand creation costs
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Personnel 100% dedicated to EIMC
Personnel Salaries based on PSI/Z & CeSHHAR scales
Costs collected under pilot field study environment
Use of MoHCC perspective excludes
costs to clients, care
giving costs
Analysis based on 3024 annual procedures based on site
capacity (12 procedures/day x 252 working days)
Doctors trained by international consultants; nurses / mid-
wives trained by local master trainers
AccuCirc device price = $10 (Clinical Innovations)
All costs in 2013 US$
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Cost Comparison of Comparative Trial and Field study**
All costs in 2013 US$
** Based on 400 EIMCs delivered by nurse/midwife
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Total cost of EIMC procedure
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$38.25 by midwives vs $51.62 by doctors
Would improvements by nurse mid-wives in
time taken to perform a procedure impact
the cost?
Improvement in time taken by nurse mid-
wives on EIMC procedure leads to further
reductions in the cost of an EIMC but by a
small amount.
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EIMC using AccuCirc is cheaper compared to Mogen
Clamp ($51.62 vs $58.13)
Nurse-delivered EIMC is considerably cheaper than by
doctors ($38.25 vs $51.62)
Key cost drivers are device price, personnel costs, & site
capacity utilization
Sensitivity analysis confirms device price, personnel
costs & site
capacity utilization
as key cost drivers
Improvements in time taken to perform EIMC does not
lead to substantial cost reductions ($38.25 vs $ 37.44)
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Device price is a large portion of AccuCirc costs;
Need to negotiate price reduction
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Site capacity utilization is an important cost driver;
Ensuring demand for EIMC is therefore critical
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Cost substantially reduced if EIMC is performed by
nurse mid-wives instead of doctors (this is also likely
to make procedure more widely available)
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Centre for Sexual Health & HIV/AIDS
Research (CeSHHAR) Zimbabwe, Harare,
Zimbabwe
Centre for Sexual Health & HIV Research,
University College London, London, UK
Ministry of Health and Child Care, Harare,
Zimbabwe
Population Services International-Zimbabwe,
Harare, Zimbabwe
University of Zimbabwe, Harare, Zimbabwe
London School of Hygiene & Tropical
Medicine, London, UK
UNC Gillings School of Global Public Health,
NC, USA
Bill & Melinda Gates Foundation, USA
City Health Department, Harare, Zimbabwe
EIMC Study team
Gerald Gwinji, MoH Zimbabwe
Getrude Ncube, MoH Zimbabwe
Owen Mugurungi, MoH Zimbabwe
Cynthia Chasokela, MoH Zimbabwe
Margaret Nyandoro , MoH Zimbabwe
Nontando Mothobi, MoH Zimbabwe
Ismail Ticklay, University of Zimbabwe
Karin Hatzold, Population Services International
Christopher Samkange, University of Zimbabwe
Collin Mangenah, CeSSHAR;
Frances Cowan, CeSHHAR; University College
London
Judith Sherman, UNICEF Zimbabwe
Webster Mavhu, CeSHHAR; University College
London
Helen Weiss, London School of Hygiene & Tropical
Medicine
Harsha Thirumurthy, University of North Carolina at
Chapel Hill
Andrea Biddle, University of North Carolina at
Chapel Hill
Good Afternoon Everyone, I will be presenting data on costing of early infant male circumcision, results from a comparative trial of two devices, the Mogen clamp and the AccuCirc device. I would like to acknowledge my two colleagues, Collin Mangenah from Cesshar Zimbabwe and Harsha Thirumurthy from University of North Carolina, who conducted this costing study.
Harsha Thirumurthy, University of North Carolina at Chapel Hill
Collin Mangenah, Centre for Sexual Health HIV AIDS Research Zimbabwe
Study on the cost of early infant male circumcision in Zimbabwe using AccuCirc and Mogen Clamp devices, with a focus on safety, acceptability, and cost drivers for the procedure. The research includes comparative trials, costing methods, and results related to personnel, device prices, and procedure times.
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Estimating the costs of early infant male circumcision in Zimbabwe: results from a comparative trial of AccuCirc and Mogen Clamp KARIN HATZOLD , MD, MPH Population Services International Collin Mangenah, CeSSHAR Zimbabwe Harsha Thirumurthy, UNC 8th International AIDS Economics Network Pre-Conference Meeting July 19, 2014 Melbourne, Australia
Study Background EIMC is cheaper, quicker, simpler & has complete healing in less than 7 days with low rate of AEs Zimbabwe plans to offer EIMC for HIV prevention alongside adult and adolescent VMMC Currently EIMC devices prequalified by WHO New device - AccuCirc pre-packaged, disposable, potentially usable by midwives AccuCirc previously evaluated in Botswana, (single-arm study with 151 male infants)
Prequalification studies in Zimbabwe Comparative trial AccuCirc vs Mogen Clamp Doctor delivered n = 150 Ratio=2:1 Field trial AccuCirc only Nurse mid-wife delivered n=500 No randomisation Primary outcomes Relative safety Relative acceptability Relative cost Primary outcomes Safety Acceptability Cost
Costing research questions What is the unit cost of EIMC in Zimbabwe? AccuCirc Mogen Clamp What are the key cost drivers for EIMC in Zimbabwe? Role of various components: Device and Commodities price Personnel salaries Facility capacity utilization Nurse mid-wives procedure time
EIMC comparative trial: safety and acceptability results 150 eligible male infants enrolled 100 Accucirc, 50 Mogen clamp 2 moderate (and quickly resolved) adverse events in the AccuCirc arm (95% CI 0.004- 0.077) and 0 in the Mogen clamp arm (95% CI 0.0-0.089) Nearly all parents (99.5%) reported great satisfaction with the outcome All parents, regardless of arm said they would recommend EIMC to other parents, and would circumcise their next newborn son
EIMC Costing Methods Unit costs Direct (personnel, drugs, supplies, training & environmental costs ) + indirect (capital & overheads) Time and motion to calculate labor costs Stopwatch & video camera captured time spent on each task One way sensitivity analysis Device price, Salaries, Site Capacity Utilization, Procedure time Analysis excludes Costs to clients (transport, caregiver costs) Demand creation costs
Key assumptions Personnel 100% dedicated to EIMC Personnel Salaries based on PSI/Z & CeSHHAR scales Costs collected under pilot field study environment Use of MoHCC perspective excludes costs to clients, care giving costs Analysis based on 3024 annual procedures based on site capacity (12 procedures/day x 252 working days) Doctors trained by international consultants; nurses / mid- wives trained by local master trainers AccuCirc device price = $10 (Clinical Innovations)
Comparative trial costing results AccuCirc Cost($)/ EIMC Mogen Clamp Cost($)/EIMC Cost Category - direct Consumable supplies Non-consumable supplies Device cost Personnel costs Training costs Environmental costs Subtotal Cost Category - indirect Capital equipment costs Support personnel costs Subtotal TOTAL UNIT COST OF EIMC $15.01 $0.27 $10.00 $17.13 $1.88 $1.80 $46.09 $32.05 $0.10 $0.21 $17.13 $1.88 $1.20 $52.57 $0.06 $5.50 $5.56 $58.13 $0.04 $5.50 $5.54 $51.62 All costs in 2013 US$
Cost Comparison of Comparative Trial and Field study** Doctor Nurse / mid-wife Cost($)/EIMC Cost Category - direct Cost($)/ EIMC Consumable supplies Non-consumable Device cost Personnel costs Training costs Environmental costs Subtotal Cost Category - indirect Capital equipment costs Support personnel costs Subtotal TOTAL UNIT COST OF EIMC $15.01 $0.27 $10.00 $17.13 $1.88 $1.80 $46.09 $15.01 $0.27 $10.00 $4.68 $0.95 $1.80 $32.71 $0.04 $5.50 $5.54 $38.25 $0.04 $5.50 $5.54 $51.62 All costs in 2013 US$ ** Based on 400 EIMCs delivered by nurse/midwife
One way sensitivity analysis Site Procedure duration Personnel Salaries Percent change 30% AccuCirc Price $41.24 capacity utilization $36.74 $39.65 $39.45 20% $40.24 $39.18 $37.16 $39.05 10% $39.24 $38.25 $38.71 $38.25 $37.65 $38.25 $38.65 $38.25 Base case -10% $37.24 $37.78 $38.96 $37.84 -20% $36.24 $37.31 $39.86 $37.44
Field study cost results contd Total cost of EIMC procedure $38.25 by midwives vs $51.62 by doctors Would improvements by nurse mid-wives in time taken to perform a procedure impact the cost? Improvement in time taken by nurse mid- wives on EIMC procedure leads to further reductions in the cost of an EIMC but by a small amount.
Conclusions EIMC using AccuCirc is cheaper compared to Mogen Clamp ($51.62 vs $58.13) Nurse-delivered EIMC is considerably cheaper than by doctors ($38.25 vs $51.62) Key cost drivers are device price, personnel costs, & site capacity utilization Sensitivity analysis confirms device price, personnel costs & site capacity utilization as key cost drivers Improvements in time taken to perform EIMC does not lead to substantial cost reductions ($38.25 vs $ 37.44)
Recommendations Device price is a large portion of AccuCirc costs; Need to negotiate price reduction Site capacity utilization is an important cost driver; Ensuring demand for EIMC is therefore critical Cost substantially reduced if EIMC is performed by nurse mid-wives instead of doctors (this is also likely to make procedure more widely available)
Acknowledgements Centre for Sexual Health & HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe Centre for Sexual Health & HIV Research, University College London, London, UK Ministry of Health and Child Care, Harare, Zimbabwe Population Services International-Zimbabwe, Harare, Zimbabwe University of Zimbabwe, Harare, Zimbabwe London School of Hygiene & Tropical Medicine, London, UK UNC Gillings School of Global Public Health, NC, USA Bill & Melinda Gates Foundation, USA City Health Department, Harare, Zimbabwe EIMC Study team Gerald Gwinji, MoH Zimbabwe Getrude Ncube, MoH Zimbabwe Owen Mugurungi, MoH Zimbabwe Cynthia Chasokela, MoH Zimbabwe Margaret Nyandoro , MoH Zimbabwe Nontando Mothobi, MoH Zimbabwe Ismail Ticklay, University of Zimbabwe Karin Hatzold, Population Services International Christopher Samkange, University of Zimbabwe Collin Mangenah, CeSSHAR; Frances Cowan, CeSHHAR; University College London Judith Sherman, UNICEF Zimbabwe Webster Mavhu, CeSHHAR; University College London Helen Weiss, London School of Hygiene & Tropical Medicine Harsha Thirumurthy, University of North Carolina at Chapel Hill Andrea Biddle, University of North Carolina at Chapel Hill
