Estimating the costs of early infant male circumcision in Z - PowerPoint Presentation

Slide1

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 InternationalCollin Mangenah, CeSSHAR Zimbabwe Harsha Thirumurthy, UNC 8th International AIDS Economics NetworkPre-Conference MeetingJuly 19, 2014Melbourne, AustraliaSlide2

Study BackgroundEIMC is cheaper, quicker, simpler & has complete healing in less than 7

days with low rate of AEsZimbabwe plans to offer EIMC for HIV prevention alongside adult and adolescent VMMCCurrently EIMC devices prequalified by WHO

New device - AccuCirc pre-packaged, disposable, potentially usable by midwivesAccuCirc previously evaluated in Botswana, (single-arm study with 151 male infants)Slide3

Prequalification studies in Zimbabwe

Comparative trial AccuCirc vs Mogen Clamp

Doctor deliveredn = 150Ratio=2:1Primary outcomesRelative safetyRelative acceptabilityRelative costField trialAccuCirc onlyNurse mid-wife deliveredn=500No randomisationPrimary outcomesSafetyAcceptabilityCostSlide4

Costing research questionsWhat is the unit cost of EIMC in Zimbabwe?AccuCirc

Mogen ClampWhat are the key cost drivers for EIMC in Zimbabwe? Role of various components:Device and Commodities price

Personnel salariesFacility capacity utilizationNurse mid-wives procedure timeSlide5

EIMC comparative trial: safety and acceptability results150 eligible male infants enrolled

100 Accucirc, 50 Mogen clamp2 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 outcomeAll parents, regardless of arm said they would recommend EIMC to other parents, and would circumcise their next newborn sonSlide6

EIMC Costing MethodsUnit costsDirect (personnel, drugs, supplies, training & environmental costs ) + indirect (capital & overheads)

Time and motion to calculate labor costsStopwatch & video camera captured time spent on each taskOne way sensitivity analysisDevice price, Salaries, Site

Capacity Utilization, Procedure time Analysis excludes Costs to clients (transport, caregiver costs)Demand creation costsSlide7

Key assumptionsPersonnel 100% dedicated to EIMCPersonnel Salaries based on PSI/Z & CeSHHAR

scalesCosts collected under pilot field study environmentUse 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 trainersAccuCirc device price = $10 (Clinical Innovations)Slide8

Cost Category - direct

AccuCirc

Cost($)/ EIMCMogen ClampCost($)/EIMCConsumable supplies$15.01 $32.05 Non-consumable supplies$0.27 $0.10

Device cost

$10.00

$0.21

Personnel costs$17.13

$17.13 Training costs$1.88 $1.88

Environmental costs

$1.80

$1.20

Subtotal

$46.09

$52.57

Cost Category - indirect

Capital equipment costs

$0.04

$0.06

Support personnel costs

$5.50

$5.50

Subtotal

$5.54

$5.56

TOTAL UNIT COST OF EIMC

$

51.62

$58.13

All costs in 2013 US$

Comparative trial costing resultsSlide9

Cost Category - direct

Doctor

Cost($)/ EIMCNurse / mid-wife Cost($)/EIMCConsumable supplies$15.01 $15.01 Non-consumable$0.27 $0.27

Device cost$10.00

$10.00

Personnel costs

$17.13 $4.68

Training costs$1.88 $0.95

Environmental costs

$1.80

$

1.80

Subtotal

$46.09

$32.71

Cost Category - indirect

Capital equipment costs

$0.04

$0.0

4

Support personnel costs

$5.50

$5.50

Subtotal

$5.54

$

5.54

TOTAL UNIT COST OF EIMC

$

51.62

$38.25

Cost Comparison of Comparative Trial and

F

ield study**

All costs in 2013 US$

** Based

on 400 EIMCs delivered by

nurse/midwifeSlide10

One way sensitivity analysis

P

ercent changeAccuCirc PricePersonnel Salaries

Site

capacity utilization

Procedure duration

30%

$41.24

$39.65

$36.74

$39.45

20%

$40.24

$39.18

$37.16

$39.05

10%

$39.24

$38.71

$37.65

$38.65

Base case

$38.25

$38.25

$38.25

$38.25

-10%

$37.24

$37.78

$38.96

$37.84

-20%

$36.24

$37.31

$39.86

$37.44Slide11

Field study cost results cont’dTotal 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.Slide12

ConclusionsEIMC 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 driversImprovements in time taken to perform EIMC does not lead to substantial cost reductions ($38.25 vs $ 37.44)Slide13

RecommendationsDevice 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)Slide14

AcknowledgementsCentre

for Sexual Health & HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, ZimbabweCentre for Sexual Health & HIV Research, University College London, London, UK

Ministry of Health and Child Care, Harare, ZimbabwePopulation Services International-Zimbabwe, Harare, ZimbabweUniversity of Zimbabwe, Harare, ZimbabweLondon School of Hygiene & Tropical Medicine, London, UKUNC Gillings School of Global Public Health, NC, USABill & Melinda Gates Foundation, USACity Health Department, Harare, Zimbabwe EIMC Study teamGerald Gwinji, MoH ZimbabweGetrude Ncube, MoH ZimbabweOwen Mugurungi, MoH ZimbabweCynthia Chasokela, MoH ZimbabweMargaret Nyandoro , MoH ZimbabweNontando Mothobi, MoH Zimbabwe

Ismail Ticklay, University of ZimbabweKarin Hatzold, Population Services InternationalChristopher Samkange, University of ZimbabweCollin Mangenah, CeSSHAR

; Frances Cowan, CeSHHAR; University College London

Judith Sherman, UNICEF ZimbabweWebster Mavhu, CeSHHAR; University College London

Helen Weiss, London School of Hygiene & Tropical MedicineHarsha Thirumurthy, University of North Carolina at Chapel HillAndrea Biddle, University of North Carolina at Chapel Hill