Task-shifting reduces costs for early infant male circumcision

Comparative cost of early infant male circumcision by nurse-midwives and doctors in Zimbabwe.

Mangenah C, Mavhu W, Hatzold K, Biddle AK, Ncube G, Mugurungi O, Ticklay I, Cowan FM, Thirumurthy H. Glob Health Sci Pract. 2016 Jul 13;4 Suppl 1:S68-75. doi: 10.9745/GHSP-D-15-00201. Published online 2016 Jul 2.

Background: The 14 countries that are scaling up voluntary male medical circumcision (VMMC) for HIV prevention are also considering early infant male circumcision (EIMC) to ensure longer-term reductions in HIV incidence. The cost of implementing EIMC is an important factor in scale-up decisions. We conducted a comparative cost analysis of EIMC performed by nurse-midwives and doctors using the AccuCirc device in Zimbabwe.

Methods: Between August 2013 and July 2014, nurse-midwives performed EIMC on 500 male infants using AccuCirc in a field trial. We analyzed the overall unit cost and identified key cost drivers of EIMC performed by nurse-midwives and compared these with costing data previously collected during a randomized noninferiority comparison trial of 2 devices (AccuCirc and the Mogen clamp) in which doctors performed EIMC. We assessed direct costs (consumable and nonconsumable supplies, device, personnel, associated staff training, and waste management costs) and indirect costs (capital and support personnel costs). We performed one-way sensitivity analyses to assess cost changes when we varied key component costs.

Results: The unit costs of EIMC performed by nurse-midwives and doctors in vertical programs were US$38.87 and US$49.77, respectively. Key cost drivers of EIMC were consumable supplies, personnel costs, and the device price. In this cost analysis, major cost drivers that explained the differences between EIMC performed by nurse-midwives and doctors were personnel and training costs, both of which were lower for nurse-midwives.

Conclusions: EIMC unit costs were lower when performed by nurse-midwives compared with doctors. To minimize costs, countries planning to scale up EIMC should consider using nurse-midwives, who are in greater supply than doctors and are the main providers at the primary health care level, where most infants are born.

Abstract  Full-text [free] access 

Editor’s notes: The evidence behind the efficacy for male circumcision in HIV prevention has been proven beyond a reasonable doubt, and 14 countries with a high HIV prevalence are currently scaling up voluntary medical male circumcision. To improve future HIV prevention, WHO and UNICEF also recommend that early infant male circumcision be performed within the first 60 days of life in countries with a high HIV prevalence. In countries such as Zimbabwe, an acute shortage of human resources for health has the potential to hinder scale-up of early infant male circumcision.  However, with new devices such as the AccuCirc® , early infant male circumcision can be performed without advanced surgical skills – raising the potential for task shifting as a way to alleviate pressure on human resources.  

This study compares the unit cost of early infant male circumcision using the AccuCirc® , as performed by doctors and by nurse-midwives. Nurse-midwives on average took a longer time to complete a circumcision (average 18 minutes) as compared to doctors (average 16 minutes).  However, the reductions in salary costs offset this increased time, reducing the unit cost of early infant male circumcision overall. Integrating early infant male circumcision into a public health facility (as compared to a vertical programme) would further reduce the costs. 

This study suggests that countries seeking to scale up early infant male circumcision should consider task shifting as a way to reduce costs. Task shifting does pose the risk of increasing workload for lower-level personnel; more nurse-midwives will need to be trained to cope with additional responsibilities to avoid over-burdening existing personnel. However, this is a promising solution to enable scale-up of early infant male circumcision quickly and affordably in settings such as Zimbabwe.

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