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Randomized Controlled Trial
. 2023 Nov 16;18(11):e0294449.
doi: 10.1371/journal.pone.0294449. eCollection 2023.

Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa

Yanfang Su  1 , Rachel Mukora  2 , Felex Ndebele  2 , Jacqueline Pienaar  2   3 , Calsile Khumalo  2 , Xinpeng Xu  4 , Hannock Tweya  1   5 , Maria Sardini  3 , Sarah Day  3   6 , Kenneth Sherr  1 , Geoffrey Setswe  2   7 , Caryl Feldacker  1   5
Affiliations
Randomized Controlled Trial

Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa

Yanfang Su et al. PLoS One. .

Abstract

Introduction: Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa. However, with demonstrated VMMC safety, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications, annually. Embedded into a randomized controlled trial (RCT) to test safety of two-way, text-based (2wT) follow-up as compared to routine in-person visits among adult clients, the objective of this study was to compare 2wT and routine post-VMMC care costs in rural and urban South African settings.

Methods: Activity-based costing (ABC) estimated the costs of post-VMMC care, including counselling, follow-ups, and tracing in $US dollars. Transportation for VMMC and follow-up was provided for rural clients in outreach settings but not for urban clients in static sites. Data were collected from National Department of Health VMMC forms, RCT databases, and time-and-motion surveys. Sensitivity analysis presents different follow-up scenarios. We hypothesized that 2wT would save per-client costs overall, with higher savings in rural settings.

Results: VMMC program costs were estimated from 1,084 RCT clients: 537 in routine care and 547 in 2wT. On average, 2wT saved $3.56 per client as compared to routine care. By location, 2wT saved $7.73 per rural client and increased urban costs by $0.59 per client. 2wT would save $2.16 and $7.02 in follow-up program costs if men attended one or two post-VMMC visits, respectively.

Conclusion: Quality 2wT follow-up care reduces overall post-VMMC care costs by supporting most men to heal at home while triaging clients with potential complications to timely, in-person care. 2wT saves more in rural areas where 2wT offsets transportation costs. Minimal additional 2wT costs in urban areas reflect high care quality and client engagement, a worthy investment for improved VMMC service delivery. 2wT scale-up in South Africa could significantly reduce overall VMMC costs while maintaining service quality.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Costs in USD for routine care and 2wT per client (USD).
Fig 2
Fig 2. Cost changes by implementing 2WT compared to the routine, rural vs. urban (USD).
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