Cost Analysis of Integrating the PrePex Medical Device
into a Voluntary Medical Male Circumcision Program in
Zimbabwe
Emmanuel Njeuhmeli1., Katharine Kripke2*., Karin Hatzold3, Jason Reed4, Dianna Edgil1,
Juan Jaramillo5, Delivette Castor1, Steven Forsythe2, Sinokuthemba Xaba6, Owen Mugurungi6
1 United States Agency for International Development, Washington, DC, United States of America, 2 Health Policy Initiative, Futures Institute, Washington, DC, United
States of America, 3 Population Services International, Harare, Zimbabwe, 4 Office of the U.S. Global AIDS Coordinator, Washington, DC, United States of America, 5 The
Partnership for Supply Chain Management System, Arlington, Virginia, United States of America, 6 Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
Abstract
Background: Fourteen African countries are scaling up voluntary medical male circumcision (VMMC) for HIV prevention.
Several devices that might offer alternatives to the three WHO-approved surgical VMMC procedures have been evaluated
for use in adults. One such device is PrePex, which was prequalified by the WHO in May 2013. We utilized data from one of
the PrePex field studies undertaken in Zimbabwe to identify cost considerations for introducing PrePex into the existing
surgical circumcision program.
Methods and Findings: We evaluated the cost drivers and overall unit cost of VMMC at a site providing surgical VMMC as a
routine service (‘‘routine surgery site’’) and at a site that had added PrePex VMMC procedures to routine surgical VMMC as
part of a research study (‘‘mixed study site’’). We examined the main cost drivers and modeled hypothetical scenarios with
varying ratios of surgical to PrePex circumcisions, different levels of site utilization, and a range of device prices. The unit
costs per VMMC for the routine surgery and mixed study sites were $56 and $61, respectively. The two greatest contributors
to unit price at both sites were consumables and staff. In the hypothetical scenarios, the unit cost increased as site
utilization decreased, as the ratio of PrePex to surgical VMMC increased, and as device price increased.
Conclusions: VMMC unit costs for routine surgery and mixed study sites were similar. Low service utilization was projected
to result in the greatest increases in unit price. Countries that wish to incorporate PrePex into their circumcision programs
should plan to maximize staff utilization and ensure that sites function at maximum capacity to achieve the lowest unit cost.
Further costing studies will be necessary once routine implementation of PrePex-based circumcision is established.
Citation: Njeuhmeli E, Kripke K, Hatzold K, Reed J, Edgil D, et al. (2014) Cost Analysis of Integrating the PrePex Medical Device into a Voluntary Medical Male
Circumcision Program in Zimbabwe. PLoS ONE 9(5): e82533. doi:10.1371/journal.pone.0082533
Editor: Nathan Ford, World Health Organization, Switzerland
Received July 28, 2013; Accepted October 23, 2013; Published May 6, 2014
This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for
any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Funding: Funding support for this work was provided by PEPFAR (President’s Emergency Plan for AIDS Relief) through the USAID | Health Policy Initiative Costing
Task Order, contract number GPO-I-00-05-00040-00, beginning July 1, 2010. The Costing Task Order is implemented by Futures Group, in collaboration with the
Futures Institute and the Centre for Development and Population Activities. The funder played a significant technical role in study design, analysis, decision to
publish, and preparation of the manuscript. The views expressed in this manuscript do not represent the opinion of USAID or the U.S. Government.
Competing Interests: The authors have declared that no competing interest exist.
* E-mail: kkripke@futuresinstitute.org
. These authors contributed equally to this work.
adult VMMC devices are currently being assessed for safety,
effectiveness, cost, and client and provider acceptability [8,9].
Devices could potentially simplify the procedure, enabling nonphysician providers to conduct the surgery in a wider array of
settings. The availability of devices might also offer an alternative
mode of VMMC for men who have fears related to conventional
surgery.
One adult VMMC device, PrePex, developed by Circ MedTech
(Herzelia, Israel), works by compressing the foreskin between a
fitted ring and elastic band, leading to distal tissue necrosis. In
most cases, PrePex does not require the use of injected anesthesia
and does not require suturing. Clients who undergo VMMC using
the PrePex device are required to wear the device for seven days
and then return to the clinic for removal on the seventh day. In a
Introduction
In 2005–2007, three randomized controlled clinical trials
demonstrated that voluntary medical male circumcision (VMMC)
reduced male acquisition of HIV through heterosexual intercourse
by approximately 60% [1–3]. Since then mathematical modeling
studies have suggested that scaling up VMMC in 13 Eastern and
Southern African countries to 80% coverage over five years and
maintaining that coverage through 2025 could avert 3.4 million
HIV infections over that time period and save approximately
$16.5 billion in the cost of HIV treatment and care [4].
Despite the promise of VMMC to substantially impact the HIV
epidemic in these settings, scale-up of VMMC programs has been
challenged by issues related to demand creation and service
availability in remote and resource-constrained areas [5–7]. New
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Cost of Integrating PrePex into VMMC
Figure 1. Key characteristics of the different implementation models. The routine surgery site and the hypothetical mixed site employed 1
medical doctor, 6 nurses, 3 theatre assistants, and 1 receptionist in a 4-bed facility, and the mixed study site employed 1 medical doctor, 8 nurses, 3
theatre assistants, and 1 receptionist in a 6-bed facility.
doi:10.1371/journal.pone.0082533.g001
Rwanda field study, the PrePex procedure took 4.3 minutes for
device application (including preparation) and 3.8 minutes for
device removal seven days later [10], compared with 23–
30 minutes for conventional surgery (from scrubbing the patient
in preparation for the operation to cleaning the wound after
suturing) in a multi-country study [11].
A series of three studies (safety case study, comparative study,
and field study) of the PrePex device was first completed in
Rwanda [10,12,13]. This same series of studies was subsequently
completed independently in Zimbabwe. The information generated from these six studies informed the WHO decision in May
2013 to add PrePex to its prequalification list [14,15].
Claims have been advanced that the PrePex procedure would
result in significantly decreased unit costs per VMMC compared
with conventional surgery; this has not been borne out in analyses
published to date. Using hypothetical costing information from
Kenya, Obiero and colleagues derived a unit cost of $44.54–
$49.02 for PrePex, not including the device cost, and $54.52–
$55.29 for forceps-guided surgical VMMC [16]. Duffy and
colleagues collected costs of PrePex-based and surgical VMMC
at a high-volume urban hospital in Uganda and found a unit cost
of $30.55 for PrePex-based and $22.65 for surgical VMMC, using
a PrePex device price of $20 and excluding demand creation costs
[17].
Countries in Eastern and Southern Africa have already begun
scaling up VMMC using conventional surgical approaches.
Because of age and other exclusions (PrePex is only qualified for
use with men over the age of 18), programs that wish to introduce
PrePex will need to continue to make conventional surgery
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available. Therefore, we sought to examine potential cost
implications of integrating the PrePex device into an existing
VMMC program. Instead of estimating a unit cost specifically for
PrePex-based VMMC vs. surgical VMMC, as others have [16,17],
we examined the site-level unit cost of VMMC at a highthroughput public facility providing only routine surgical VMMC
(‘‘routine surgery site’’) and at a similar facility in which staff and
equipment were added to also conduct PrePex-based circumcisions for a research study (‘‘mixed study site’’). We used data
collected during routine surgical implementation in Zimbabwe
and as part of the Zimbabwe PrePex field study, respectively.
Because of the differing staffing pattern and equipment used at
each site, the unit costs of the two sites are not comparable.
Therefore, to enable comparison of the unit costs, we also created
a hypothetical mixed site scenario that retained the same staffing
pattern and number of beds as the routine surgery site.
This study poses several questions: (1) What are the major
drivers of unit costs in each type of site (routine surgery and the
two different mixed sites)? (2) How would the unit cost at a mixed
site change with varying ratios of surgical to PrePex-based
circumcisions? (3) How would unit costs change with varying
levels of site utilization? (4) What impact would different device
prices have on the unit cost?
Methods
Implementation models
Three implementation models were evaluated (Figure 1): a
routine surgery site based on the configuration (staffing, equipment) of the Bulawayo VMMC Centre, a mixed study site based
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Cost of Integrating PrePex into VMMC
described below when calculating the unit cost at the mixed study
site.
on the configuration of the Harare PrePex Field Study Site, and a
hypothetical mixed site with a configuration comparable to that of
the routine surgery site. The Bulawayo and Harare sites are
dedicated VMMC sites, where efficiencies such as task sharing, use
of VMMC kits with disposable surgical instruments for the
conventional surgery, and use of multiple surgical beds for each
surgeon are being implemented.
The routine surgery site had a four-bed capacity and employed
one medical doctor, six nurses, three theatre assistants, and one
receptionist. The doctors had overall responsibility for the surgical
procedure, provided local anesthesia, removed the foreskin,
stopped bleeding either using sutures or electrocauterization, and
attended to post-operative complications and treatment of adverse
events involving wound revisions or severe infections with
abscesses. The nurses conducted group education sessions,
conducted pre-operative examination and counseling, conducted
HIV testing and counseling, assisted with circumcisions, conducted post-operative examination and counseling, and conducted
post-operative review of the client on day 2,day 7 and day 42 postsurgery. The theatre assistant was responsible for cleaning the
operation room, cleaning instruments after the operation, preparing instruments and operation room in case of adverse events, and
cleaning the waiting area, counseling and examination rooms. The
receptionist was responsible for taking clients’ personal details,
explaining the procedure, and booking the client for operation and
follow-up review.
The mixed study site had a six-bed capacity and employed one
medical doctor, eight nurses (an additional two nurses and two
beds to conduct PrePex circumcisions), three theatre assistants,
and one receptionist. In addition to the responsibilities outlined
above for the surgery site, the doctor supervised the nurses
conducting PrePex circumcisions, handled device-related complications, and conducted surgery in case of displacement of the
device. The nurses conducted the PrePex procedure: fitting the
PrePex device size, placing the device, removing the dried
foreskin, inner ring, and elastic band on day 7, dressing the
wound, and conducting post-operative review of the client after
removal of the device on day 7 and day 42. The theatre assistant
sterilized instruments used for removal of the foreskin and device.
All staff at the mixed site were qualified to conduct both types of
circumcisions based on client demand.
The hypothetical mixed site had a four-bed capacity and
employed the same staff as the routine surgery site.
Data on service delivery were collected between May 8 and July
9, 2012, at the Harare site for the mixed study site model and at
the Bulawayo site for the routine surgery site model. For PrePexbased circumcisions, clients who presented for placements were
counted as PrePex VMMCs conducted. All devices were removed
at day 7. The median number of daily circumcisions per site
during this period was used in all of the unit cost calculations
except the analysis that examined different levels of site capacity
utilization, which used the observed minimum, first quartile,
median, third quartile, maximum, and theoretical maximum
(explained in the Results section) numbers of clients per day. The
population to be circumcised included males ages 10 to 49 years;
those under 18 years of age, those declining to participate in the
study, and those with exclusions such as HIV infection, cracked
foreskin, phimosis, short or tight frenulum, or preputial adhesions
were not eligible to be circumcised using PrePex and were offered
conventional surgery. Those with active genital infections were
treated and asked to come back for circumcision at a later date. In
the mixed study sites during the period of data collection, 84% of
the circumcisions were conducted using conventional surgery and
16% were conducted using PrePex. This ratio was applied as
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Cost Model
All analyses were performed using Microsoft Excel 2010
(Microsoft Corporation, Redmond, WA). All costs are presented
in USD.
Unit costs per circumcision (regardless of site type) comprised
seven cost categories: consumables, device, supply chain management, staff, durable equipment, training, and waste management.
Indirect costs, costs for demand creation, and costs for complications were not included in this analysis. Unit costs represent costs
to the service provider and do not include costs to clients, such as
transport to and from the intervention sites. The VMMC unit cost
for the mixed sites is the average unit cost of all circumcisions
provided, including both conventional surgical VMMCs and
PrePex-based VMMCs; we did not disaggregate unit costs by
modality. Site-level unit costs were derived by calculating the per
circumcision cost for each of the seven cost categories and then
adding the costs of all the categories:
Unit cost~ cs ps zcp pp zdpp z 31:4%cs ps z31:4%(cp zd)pp
|fflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflffl{zfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflfflffl}
|fflfflfflfflfflffl {zfflfflfflfflfflffl}
consumable cost
supply chain management cost
z(szezt)=mzw
where cs is the per circumcision cost of consumables for
conventional surgical circumcisions
ps is the percentage of conventional surgical circumcisions at
the site (for the routine surgery site, ps = 100%)
cp is the per circumcision cost of consumables for PrePex-based
circumcisions
pp is the percentage of PrePex-based circumcisions at the site
(for the routine surgery site, pp = zero)
d is the device price
31.4% of the cost of consumables (including device) constitutes
the supply chain cost [18]
s is the annual staff cost at that type of site
e is the annual durable equipment cost at that type of site
t is the annual training cost at that type of site
m is the median number of circumcisions performed per day at
that type of site, multiplied by 220 working days per year
w is the cost of waste management per circumcision
Details about each cost category follow.
Consumables. Lists of required consumables for both
surgical VMMC using the forceps-guided technique and PrePexbased circumcisions were provided by the Zimbabwe PrePex Field
Study team, as defined in the study protocol. Consumables prices
were provided by the PEPFAR funded through USAID Partnership for Supply Chain Management System (SCMS) project and
are available in Table S1 and Table S2. For conventional surgical
VMMC, the study utilized pre-sterilized, disposable commodities
bundled into kits (market price sourced by SCMS as of February
15, 2013), while a combination of disposable and reusable
commodities was used for the PrePex procedure. The commodity
costs for the PrePex procedure were derived from average SCMS
pricing from procurements in 2009–2012, with data compiled on
January 10, 2013, or from a quotation obtained from Circ
MedTech on December 19, 2012, as indicated in Table S2. The
actual PrePex device is disposable/single-use. Each reusable
commodity cost was divided across 150 procedures to derive the
unit cost, based upon experience in the field study.
Device. The baseline PrePex device cost applied was USD
$20 per unit based on a quotation from Circ MedTech to SCMS
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Cost of Integrating PrePex into VMMC
on December 19, 2012. This is not the price that was used in the
series of clinical studies in Zimbabwe, but it was the price quoted
by the manufacturer for pilot implementation studies in several
countries.
Supply chain management. Based on a study of the existing
supply chain management system in Zimbabwe conducted by the
USAID DELIVER Project in 2010, supply chain costs per
circumcision were calculated by multiplying the costs of consumables (including device) by 31.4%, comprising 11.4% for
procurement costs plus 20% for logistics expenses [18].
Staff salaries. Current (2012) salaries of public-sector staff
involved in the VMMC program in Zimbabwe were used: medical
doctor, $2,200 per month; nurse, $700 per month; theatre
assistant, $150 per month; receptionist, $250 per month. These
salary costs are uniform for all sites where public-sector cadres are
used. Monthly salaries were multiplied by twelve to produce an
annual salary and then divided by the number of circumcisions per
year to produce per circumcision staff costs.
Durable equipment. The list of durable equipment utilized
by each type of site was provided by the Zimbabwe PrePex Field
Study team. Costs for each item were derived from average SCMS
pricing from procurements in 2009–2012, with data compiled on
January 10, 2013, and listed in Table S3. Equipment costs were
allocated uniformly over three years based on estimated life span.
Training. All nurses and doctors in the routine surgery and
mixed sites received the same initial competency-based team
training. Staff turnover was approximately 50% per year, so on
average an entirely new cohort of staff would need to be retrained
every 3.6 years. Therefore, training costs were allocated uniformly
over 3.6 years.
At the routine surgery site, the training cost in 2012 was USD
$884 per trainee for a 6-day course that included 2.5 days of
theory and 3.5 days of applied work. For the mixed sites, the
training cost was USD $1,252 per trainee for an 8.5-day course
that included an additional 2.5 days for applied training with
PrePex. All nurses and doctors at the mixed site were trained in
both surgical and PrePex-based circumcision.
Waste management. At the routine surgery site, according
to 2012 site records, the cost of waste management of USD $1.00
per kg of waste was based on current program generation of 25 kg
of waste per week, resulting from 130 circumcisions per week. The
same unit cost for waste management per VMMC was applied to
the mixed sites.
years old, and 5.6% were ineligible for physiological reasons such
as phimosis or tight foreskin. Since acceptability of the PrePex
device in Zimbabwe outside the study environment is currently
unknown, we looked at the effect on the unit cost of varying the
ratio of conventional surgical circumcisions to PrePex-based
circumcisions. The maximum percentage of PrePex-based circumcisions with 100% acceptability would be 68%, given age and
physiological exclusions. We kept the staffing and the total number
of circumcisions per day constant in this analysis: although in
theory both the staffing and the total number of circumcisions per
day might change with different ratios of the different types of
circumcisions, we did not have robust data upon which to base
changes in these variables for this analysis. The unit cost in this
analysis ranged from $60 per circumcision when 100% of
circumcisions were performed using conventional surgery to $63
per circumcision when 68% of circumcisions were performed
using PrePex (Table 2).
Utilization of site capacity
Generating, maintaining, and predicting fluctuations in demand
for VMMC over time can be challenging. In some countries
scaling up VMMC, sites have been fully staffed and equipped, only
to experience suboptimal utilization during some periods. We
examined the impact of different levels of site utilization on the
unit cost. In these analyses the daily costs for staffing, durable
equipment, and training were held constant, while consumables,
device, supply chain management, and waste management costs
varied by number of circumcisions. The distribution of numbers of
circumcisions per day was based on site utilization data from the
routine surgery and mixed study sites between May 8 and July 9,
2012. Because the sites were not operating at full capacity, a
theoretical maximum number of circumcisions per day was
estimated based on the complement of staff and equipment at
each type of site in an eight-hour day if demand for circumcisions
met or exceeded supply. The median number of VMMC
procedures per day was 26 at both the routine surgery site and
the mixed study site. The theoretical maximum number of daily
VMMCs was 80 at the routine surgery site and 120 at the mixed
study site. VMMC unit cost was highly sensitive to the level of site
utilization in both types of sites, ranging at the mixed study site
from $45 at the theoretical maximum utilization to $98 when the
site performed only nine VMMCs per day (the minimum observed
during the two-month period at this site). Similarly, at the routine
surgery site, the unit cost ranged from $45 at theoretical maximum
site utilization to $122 when only five VMMCs (the minimum
observed during the two-month period at this site) were performed
per day (Table 3).
Results
Key cost drivers
The unit cost per VMMC for the routine surgery site was
$55.83, for the mixed study site it was $60.58, and for the
hypothetical mixed site it was $57.45 (Table 1). The two largest
Impact of device price
contributors to the unit cost were consumables and staff. At the
routine surgery site, consumables ($30.36) and staff ($14.90)
contributed a combined 81% to the unit cost; in the mixed study
site, consumables ($30.87), including device, and staff ($17.83)
contributed a combined 80% to the unit cost; in the hypothetical
mixed site, consumables ($30.87), including device, and staff
($14.90) contributed a combined 80% to the unit cost. Training,
durable equipment, and waste management contributed negligibly
to the unit costs at all three sites.
The price of the PrePex device outside of small procurements
for research studies has not been negotiated. Because only 16% of
circumcisions used PrePex at the mixed sites, we modeled the
variations in unit cost as a function of a variety of PrePex device
prices using a fictional scenario in which 68% of the circumcisions
were performed using PrePex (the maximum possible in this
population given age and physiological exclusions), in order to see
the maximum possible impact of variations in device price. Under
these assumptions, the unit cost ranged from $50 at a device price
of $2.00 (device 3% of the unit cost) to $63 at a device price of $20
(device 22% of unit cost) (Table 4). Therefore, the unit cost is
sensitive to variations in the device price.
Impact of ratio of conventional surgical to PrePex-based
circumcisions at mixed site
At the mixed study site between May 8 and July 9, 2012, 28% of
the clients were ineligible for PrePex due to being less than 18
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Cost of Integrating PrePex into VMMC
Table 1. Cost drivers for unit cost of different implementation models.
Routine surgery site
Mixed study site*
Hypothetical mixed site*
Cost category
cost per circumcision
% of unit
cost
Cost per circumcision
% of unit
cost
Cost per circumcision
% of unit
cost
Staff
$14.90
27%
$17.83
29%
$14.90
26%
Training
$0.30
0.5%
$0.58
1.0%
$0.45
0.8%
Consumables
$30.36
54%
$27.62
46%
$27.62
48%
Device
$0.00
0%
$3.25
5%
$3.25
6%
Durable equipment
$0.55
1.0%
$1.42
2.3%
$1.35
2.4%
Supply chain management
$9.53
17%
$9.69
16%
$9.69
17%
Waste management
$0.19
0.3%
$0.19
0.3%
$0.19
0.3%
Total unit cost/circumcision
$55.83
$60.58
$57.45
*84% surgery+16% PrePex.
doi:10.1371/journal.pone.0082533.t001
of underutilization would be even greater if overhead costs had
been included in the analysis. This result highlights the importance
of optimal demand creation and a balanced relationship between
service supply (availability) and demand for VMMC services,
regardless of the circumcision method used.
Further research examining alternative service delivery models
in different settings and country contexts might find unit costs that
are different from those presented in this study. For example, if
implementation is carried out in a site dedicated entirely to
VMMC, rather than co-located or integrated within a public
health care facility, increased costs for waste transportation and
disposal and supply chain management might be expected with
either the routine surgery or mixed site model. If circumcisions are
outsourced to the private sector, staff salaries, facility rental or
construction, and profit may increase or decrease the unit costs.
The use of temporary or locum staff to adjust capacity to
accommodate fluctuations in demand could change the cost
structure. Different implementation models—for example, those
involving mobile teams and outreach campaigns—might include
additional or higher costs for expenses such as transportation. If a
new supply chain management system needs to be created or the
existing one strengthened, supply chain management costs would
Discussion
In this analysis we sought to examine the impact on VMMC
unit costs of introducing PrePex into an existing routine surgical
VMMC program in Zimbabwe. Introduction of PrePex at the
study site did not have a large impact on the overall unit cost. The
key cost drivers for both the routine surgery and the mixed sites
were consumables and staff salary costs, suggesting areas of focus
for lowering the price per VMMC. At the mixed study site, the
unit cost only increased by $3 when the ratio of surgical and
PrePex-based circumcisions was hypothetically varied from 100%
surgery to 32% surgery and 68% PrePex. Unit costs were highly
sensitive to potential variations in the device price when 68% of
the circumcisions were performed using the device; therefore, a
responsibly low public-sector price could result in cost savings and
avail VMMC services to more people in need, if acceptability of
PrePex turns out to be high.
The largest impact on the unit cost was underutilization of site
capacity. At the mixed study site, the minimum observed daily
service utilization resulted in unit costs twice those of maximum
observed service utilization. Similar cost increases were seen from
underutilization at the routine surgery sites. The negative impact
Table 2. Effect of proportion of conventional surgical versus PrePex-based circumcisions on unit cost at the mixed study site.
% conventional surgical circumcisions
% PrePex-based circumcisions
Unit cost
100%
0%
$60*
95%
5%
$60
90%
10%
$60
80%
20%
$61
70%
30%
$61
60%
40%
$62
50%
50%
$62
40%
60%
$62
32%
68%
$63
* This number is different from the unit cost at the routine surgery site because additional equipment and staff were added at the mixed study site, but there was no
increase in the number of circumcisions conducted per day.
doi:10.1371/journal.pone.0082533.t002
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Cost of Integrating PrePex into VMMC
Table 3. Effect of site capacity utilization on unit cost at
routine surgery site and mixed study site.
Minimum
First quartile
Median
Routine surgery site1
Mixed study site2
# circ/day
Unit cost
# circ/day
Unit cost
5
$122
9
$98
15
26
$67
$56
17
26
Table 4. Sensitivity analysis of device price on unit cost at
mixed study site with 68% of circumcisions conducted using
the PrePex device.
$71
$61
Third quartile
31
$53
33
$56
Actual maximum
56
$47
58
$50
Theoretical maximum
80
$45
120
$45
Unit cost
Device % of unit cost
$2
$50
3%
6%
$5
$52
$10
$56
12%
$15
$59
17%
$20
$63
22%
doi:10.1371/journal.pone.0082533.t004
demand creation, this question merits further research. At this
time, little is known about the acceptability of the PrePex device
outside of research settings, either in Zimbabwe or in other
cultural contexts. Costs of supervision, community engagement,
and program management were not included in this analysis.
These costs should be collected as the introduction of PrePex is
rolled out on a larger scale in a number of different settings.
This study provides new data on the cost of introducing the
PrePex device into an existing surgery-based VMMC program
and highlights the importance of controlling consumable and staff
costs and ensuring high levels of site utilization through effective
demand creation strategies. We found no evidence in these
analyses that introducing the PrePex device would result in
increased efficiency of the VMMC program in terms of reducing
the unit cost. To assist countries that wish to incorporate PrePex
into their VMMC scale-up plans, it will be necessary to collect a
broader diversity of actual cost data from different implementation
models, across different countries.
1
4 beds, 7 medical staff.
6 beds, 9 medical staff.
doi:10.1371/journal.pone.0082533.t003
2
likely be higher, at least temporarily. If commodity transportation
requires air freight rather than ocean freight, procurement costs
will be higher. The teams in Zimbabwe were highly experienced
and efficient, so they could conduct many circumcisions per day.
Newly trained teams usually need more time to conduct each
circumcision, reducing productivity and driving up unit costs.
It is also reasonable to speculate that unit costs could decrease as
a result of PrePex availability. At the point that they are no longer
experimental, PrePex circumcisions provided as a routine service
could be reduced in cost due to potential reductions in
consumables and supply chain costs and higher service utilization.
A responsible public-sector price for the PrePex device when
purchased in large volumes, which reflects the costs of materials
and production plus a reasonable mark-up for profit, should
reduce the overall consumables cost. Because supply chain costs
are related to consumables costs, by extension they might also
decrease.
In Zimbabwe, nurses are not allowed to perform certain aspects
of the surgical male circumcision procedure, but the PrePex Field
Study demonstrated that nurses are able to conduct the entire
PrePex VMMC procedure. Different staffing patterns can affect
the overall unit cost. For countries without task shifting, instituting
a task-shifting policy is one way to significantly decrease staff costs
and therefore decrease unit costs of VMMC.
This study has several limitations. The per-VMMC unit costs
provided did not include all cost components, and they were based
on limited data using a single service delivery model. PrePex
procedures were performed as part of a study, and thus the costs of
those procedures do not reflect routine service delivery conditions
(for example, in Zimbabwe the mixed sites employed more staff
than those sites offering routine circumcision, but did not observe
an increase in the total number of circumcisions. In routine service
delivery, it is doubtful that such additional staff would be hired
without any increase in uptake). Conventional surgical circumcisions, on the other hand, were provided as a routine service, in a
model perfected over years. Actual unit costs should be
determined by careful costing studies in a large number of sites
once routine implementation of both circumcision methods is well
under way. The unit costs did not include indirect costs or costs for
demand creation, each of which might contribute significantly to
the unit cost. Other groups have attempted to derive unit costs for
demand creation for VMMC in other settings, but they have
found too much variation in implementation and costs to be able
to produce a standard unit cost [19]. Because of the importance of
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Device price
Supporting Information
Table S1 Itemized consumables costs for forcepsguided routine surgical circumcisions.
(DOCX)
Table S2 Itemized consumables costs for PrePex-based
circumcisions.
(DOCX)
Table S3 Durable equipment costs for the routine
surgery site, mixed study site, and hypothetical mixed
site.
(DOCX)
Acknowledgments
The authors gratefully acknowledge the Zimbabwe Ministry of Health,
including the PrePex Field Study team, for providing the data. We thank
Renee Ridzon and Geoff Garnett from the Bill and Melinda Gates
Foundation, Julia Samuelson from the World Health Organization, Tim
Farley, Kevin Duffy, Moses Galukande, Tigistu Adamu, Kelly Curran,
Hally Mahler, Robert Bailey, and Walter Obiero for their critical feedback,
helpful discussion, and information sharing. Finally, the authors would like
to thank the publications staff at MCHIP for their assistance with copy
editing and formatting.
Author Contributions
Conceived and designed the experiments: EN KK KH JR DE JJ DC SF.
Performed the experiments: KK. Analyzed the data: KK. Contributed
reagents/materials/analysis tools: KH SX OM. Wrote the paper: EN KK
KH JR DE JJ DC SF SX OM.
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Cost of Integrating PrePex into VMMC
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