Transcript Document

Applying the WHO MOVE Guidance for Male
Medical Circumcision – Cost of Facility-based
Provision in a Test Case for South Africa
Health Policy Initiative TO2
Partners
Sexual HIV Prevention Programme
Acknowledgments
• Data for this analysis came from a variety of sources
and represents the work of many individuals.
– Some data from prior HPI TO1 MMC costing in South Africa
• Ozayr Mohamed, Steven Forsythe
– Bophelo Pele Project, Orange Farm, Gauteng
– CHAPS
Background (1): VMMC in South Africa
• Government & partners committed to scale-up of
voluntary medical male circumcision (VMMC).
– Traditional MC occurs for certain groups
• But initiation may or may not involve complete circumcision*
– Unmet need for voluntary medical male circumcision (VMMC)
• Additional 4.33 mn. MMCs in 2011-15 (~80% coverage)
• PEPFAR reported VMMC in 2010: 131,117
– NDOH target for 2011-12: 500,000 VMMCs
• Allocation: R160 million (about US$20 million)
– How to achieve the scale-up?
* Data from Bophelo Pele, Orange Farm
Background (2): Origin of this work
• March 2011: NDOH was considering various scale-up plans:
1. Mobile clinics and/or transitory “park homes”
2. Scale-up of VMMC provision via existing public health
facilities: clinics, CHCs, district hospitals; and using MOVE
3. Mixed models
• NDOH request to HPI TO2: look again at unit costs with a
model of their choosing, apply scenarios
• This should focus on the unit cost of 2: fixed facilities
• Build on previous unit cost work by HPI at 20 South African
facilities in 2010
PREVIOUS COST ESTIMATES
Costs recently used in a 13 country study
Njeuhmeli et al. PLOS 2011
Direct costs: $69.71
$80.13
Indirect costs: $10.42
(+/- 20%: $64.1-$96.16)
Source: Zimbabwe 2010 data (plus Swaziland)
Costs from HPI work in 2010 in South Africa
Mohamed et al. 2010
• 20 sites visited and retrospective data collected (2008-09)
• Costing using an ingredients-based approach
A. Cost of provision “as-is”
B. Cost of provision using the MOVE model
• For B. “MOVE” unit costs:
• Costs with disposable MC consumables kits;
• task sharing; 1 doctor + 1 surgical nurse + 4 nursing
assistants
• variation in costs as cost of disposable MC kits is varied
• Included indirect costs: avg. in public facilities = 24% of total
South Africa facility-based costing, 2010
Mohamed et al. (HPI 2010) – unit cost without complications
“As-is” costs
South Africa facility-based costing, 2010
Mohamed et al. (HPI 2010) – unit cost without complications
MOVE-based costs
TEST CASE: COST ESTIMATE
Proposed test case of scale-up plan
• Prepare facilities to apply MOVE
• Facilities will procure MMC commodities and
equipment
• Procurement will be from each facility’s existing
suppliers
• These costs will be funded though CCMT
Conditional Grants to provinces
Preparing the analysis -1
NDOH guidance for the costing exercise:
• Surgical technique: forceps-guided MMC (FGMC)
• Use disposable standard consumables kit for FGMC, with
reusable instruments. Add infection prevention, waste
management, and emergency commodities.
• Apply WHO MOVE staffing model with task sharing
• Apply current SA commodity and equipment prices, as
known
• Focus on direct costs to be covered by additional funds
Preparing the analysis -2
Not yet known/estimated at this stage:
• Actual mix of facilities that will provide MMC from clinic, CHC, DH
• Facility readiness for MMC: basic commodity availability,
equipment, infrastructure, staff complement, staff training
• Magnitude of demand for MMC at public health facilities
• Demand creation and IEC in catchment areas of facilities
• Possible changes to prices, esp. if pooled procurement
• Other constraints on scale-up
What was costed – 1 (MOVE elements)
Kit 1: Standard consumables pack (disposable) + Reusable
instruments for forceps-guided method
AND
Module 1: Supplies needed for infection prevention & waste
management
and
Module 2: Essential operating theater equipment for MMC
and
Module 3: Essential emergency case management equipment and
commodities.
Not costed: HTC (only pre-procedure MMC counseling)
What was costed - 2
Key points:
• Salary data same as 2010 study
• Follow-up visits at +2, +7 days
• 1 week MMC training for staff (except clerks); differing
costs
• Haemostasis by diathermy
• Autoclave (differing volume) for sterilization of reusable
instruments
• Emergency (haemorrhage or sepsis) cases are 2%
No indirect costs
Analysis setup - 1
Two possible site layouts and staffing models, based on MOVE:
Site Layout 1 – Four (4) bays
Staffing:
1 physician/surgeon
4 assistants
1 clerk/receptionist
1 surgical nurse
2 counsellors
Site Layout 2 – Eight (8) bays
Staffing:
2 physicians/surgeons
8 assistants
1 receptionist
1 data assistant/clerk
2 surgical nurses
2 counsellors
1 site manager
1 autoclave operator
MOVE –based 8-bays site design
Source: WHO MOVE 2010
Analysis setup - rationale
Primary cause for using two types of sites: Demand
a)without demand creation, volume likely low <20 MMCs per day/team
b) 4-bay designs suitable when demand >30 MMCs per day per team
c) Pre-procuring commodities and staffing up at the 8-bays design
without demand creation may lead to cost inefficiencies
d) Designs started as 4-bay sites can be expanded with additional
site preparation when demand creation picks up
e) Many facilities already require renovations to accommodate even
a 4-bay design*
* Site assessment essential – SA mapping ongoing
Sources for cost data
• Bophelo Pele Male Circumcision Project, Orange Farm, Gauteng
implemented by CHAPS – March 2011
• Cost data collection for MMC by HPI project in early 2010
• Cost enquiries for autoclaves and diathermy machines – March
2011
• Other inputs from key contacts – March 2011
• Rand/$ = 6.88
• Kit 1 price = R103 ($15 ) per MMC Consumable pack
ANALYSIS RESULTS
Unit direct costs per client: 4-bay site design
At 15 clients
per day per site
Unit direct costs, 4bay design
Standard client (no
complications)
Rand 248 / $36.1
With complications (2% or
less):
Rand 2,030.6 / $306.6
Unit direct costs per client: 8-bay site design
At 30 clients per
day per site
Unit direct costs, 8-bay
site
Standard client (no
complications)
Rand 316.4 / $46
With complications (2% or
less:
Rand 2,109.4 / $306.6
Increasing returns to scale – but this tapers off
FOR FURTHER CONSIDERATION
Also calculated
• Monthly and first year direct cost per SA province
– Latter is inclusive of total site preparation costs
• Estimate of numbers of full-time equivalent staff
needed to staff sites
Above calculations at province level based on:
– Number of facilities to initiate the service
– Proportion of 4-bay and 8-bay sites
– Proportion of facilities needing VMMC site preparation
For further consideration
• Demand creation should be costed (estimates available)
• Task-shifting could reduce personnel costs, especially
in the 8-bay design
– Requires policy change and extra up-front training costs for surgical
nurses
• Weekend clinic? Labor cost calculation assumed that
facilities are open for 22 days/month only; 48 weeks/year
– Keeping facilities open on Saturday to catch working men, but might
require paying some staff overtime
THANK YOU
Acknowledgements
Eurica Palmer, Farley Cleghorn, Zuzelle Pretorius (HPI TO2, Futures Group)
Shaidah Asmall – NDOH, former HPI TO2
Dr N Dlamini – NDOH
Dr Loy - NDOH
BACKUPS
Purpose of this analysis
1. Provide a cost range for financial planning at NDOH
2. Provide a flexible costing tool for NDOH use in budgeting
Facility based Medical Male Circumcision Costing tool (FMMCC,v.1)
3. Provide a consistent procurement list and staffing model for
province and facility-level planning
4. Provide a unit cost for benchmarking against other MMC
rollouts across Africa, and southern Africa in particular
Specifically, the costing tool will:
•
Guide NDOH on cost implications for MMC
•
incorporate the effect of price changes – e.g., due to pooled
procurement and other factors on national and province-level costs
WHO MOVE Guidance – Part B (Kits and Modules)
There are three variations in the kits, given the surgical
method:
Kit 1: Standard consumables pack (disposable) + reusable instruments
for forceps-guided method
Or
Kit 2: Standard consumables pack (disposable) + reusable instruments for
sleeve resection and dorsal slit methods
Both Kit 1 and 2 require an autoclave
or
Kit 3: standard consumables pack (disposable) + disposable instruments
for the forceps-guided method
Both Kit 1 and 2 require an autoclave
WHO MOVE Guidance – Part A
• WHO Model for Optimizing Volume and Efficiency for MC (2010)
• Three recommended surgical MC methods (procedure time):
– Forceps-guided (19 minutes 20 seconds)
– Dorsal slit (21 minutes 45 seconds)
– Sleeve resection (27 minutes)
• Recommended use of the following techniques/concepts:
–
–
–
–
–
Hemostasis by diathermy machine
Task Sharing and/or Task Shifting
Bundling of surgical items; use pre-assembled surgical kits
Theater layout for fast patient turnover
Client scheduling (appointments)
• Staff ratios
– 1 physician/surgeon per 4 clients (1 surgeon per 4 surgical bays*)
– 4 preparation/surgical assistants (e.g., nurse assistants) per surgeon
– 1 anesthesia/suture provider (e.g., surgical nurse) per surgeon
– 1-2 counselors per team + 1 site manager (if high volume site)