The provision of VMMC services at the facilities in this study was supported by the United States Agency for International Development (USAID) under the PEPFAR programme ¹⁸ . These services were provided in collaboration with the Ministry of Health at the national and county levels, in accordance with the National Strategy for Voluntary Male Medical Circumcision. The implementing partners identified Ministry of Health facilities where VMMC services were integrated into the routine primary health care services provided at these facilities. The integrated VMMC services were designed to provide a package of services, including education on the benefits of VMMC, risk reduction counselling, condom promotion, HIV testing services, and information on the VMMC procedures and follow- up. VMMC services were provided by staff comprising a clinical officer, a surgical assistant, a counsellor, and an infection prevention officer.

We conducted this study in 2019, using data collected from 2017–2018. The study employed an ingredient costing approach to estimate the unit cost of providing VMMC to one client at each site. All of the inputs were listed and their contribution to the overall cost was then quantified. Unit costs were adjusted for costs associated with complications. Our analysis adopted the health provider perspective.

Five facilities were purposively selected to participate in the costing study, representing urban and rural locations. Rachuonyo Health Centre and Kendu Health Centre were in Homabay county, and Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH), Chemelil Sugar Health Centre and Mashambani Health Centre were in Kisumu county. The facilities included in the study consisted of 4 public health facilities and one private health facility: JOOTRH is a teaching and referral hospital located in an urban area; Mashambani Health Centre and Chemelil Sugar Health Centre are two rural health centres; and Rachuonyo Health Centre and Kendu Bay Health Centre are two sub-county hospitals located in urban settings. Chemelil Sugar Health Centre is the only private health facility, while the other four are public health facilities.

Data collection tools used in this study were adapted from other costing studies used to estimate VMMC costs in Kenya and Tanzania in 2010 and 2014 ^{19, 20} . These tools were then reviewed to suit the needs of the current study. Cost data from facilities were collected retrospectively to cover 12-months of steady resource utilisation by the project, from July 2017 to June 2018. Before the start of data collection, staff from the VMMC Technical Support Unit (TSU), which is embedded within NASCOP, sensitised the implementing partners and service providers in the selected study sites. Data collectors were then trained on the tools and data collection procedures. Semi-structured data collection tools (questionnaires) were used to collect cost data from health managers or representatives, and other personnel who were directly involved in performing surgical and device procedures at the health facilities. Staff costs and other relevant information were obtained from the personnel registers or staff rosters, where applicable. In addition, information on the time taken by each staff member on any VMMC-related activity was obtained by conducting individual interviews with the staff. Staff were categorised as either direct or indirect staff: direct staff included members of the surgical team, such as clinical officers, nurses, counsellors, laboratory technicians, nurse assistants and hygiene officers. Support staff were considered as indirect staff members. The cost and quantity of each type of medicine and consumable used were obtained from the health facility pharmacy. For price information which was not available at the facility, reference was made to the most recent Kenya Medical Supplies Agency (KEMSA) price list. Cost data on capital items such as furniture, computers and equipment were obtained by reviewing the facility inventory and asset registers for each department involved in VMMC programme-related activities. Costs for office supplies and utilities were collected by reviewing the facility accounting records. Data on general services utilisation were obtained from inpatient and outpatient registers. Data collected included the number of inpatient admissions, the number of outpatients, and the number of VMMC procedures delivered using surgical and device procedures.

Data from each site was entered into an MS Excel spreadsheet, cleaned, and underwent preliminary analysis. All entered data were checked and validated, and in cases where inconsistencies were detected, additional clarification was sought from the key informants. The cost items were categorised into capital and recurrent resource costs. The total cost of programme implementation at each site was calculated by summing up the total cost of capital and recurrent cost items. The cost per VMMC procedure was determined by dividing the total cost by the number of VMMC clients per facility. The unit costs for VMMC procedures with and without complications were then estimated separately, using an Excel costing framework. The research team initially estimated the unit cost for normal VMMC procedures using both the surgical and device methods, and then adjusted them for the cost of procedures associated with mild and moderate complications. VMMC services were integrated into existing services in both public and private health facilities, at all sites, so the costs of infrastructure development were not included in our estimates. A step-down procedure was used to allocate costs to various cost centres. Overhead costs such as equipment repairs, utilities, transport, maintenance and support costs (e.g. management and field supervision) were allocated to different cost centres based on the ratio of VMMC outpatient visits (work load) to total facility outpatient visits. The contribution of staff to VMMC activities was estimated based on time that each staff member spent on VMMC-related work at the facility and programme level. The unit costs for procedures with mild and moderate complications were estimated separately for routine surgical procedures and device methods, for adolescents aged 10–14 years, adolescents and adults above 14 years of age, and infants aged 0–60 days, and for public and private health facilities.

Table 1 summarises the number of VMMC procedures performed by facility, procedure and age category, during the 2017–2018 study period. A total of 5,385 VMMCs were performed at all five sites. Eighty-five percent of VMMCs were performed in public facilities, while 15% were performed in the one private facility included in the study. The majority of VMMC procedures (61%) were performed among adolescents aged 10–14 years, all using the surgical forceps guided method. Twenty-nine percent of VMMCs were performed among adolescents and adults over 14 years, with 93% using the surgical method, and only 7% using a Mogen clamp device. JOOTRH delivered the highest number of VMMCs for those in the 10–14-year age category, while Chemelil delivered the highest number for those over 14 years of age. JOOTRH was the only facility that provided infant circumcision, using the device method.

Table 2 shows the unit cost for the delivery of non-complicated VMMC procedures by facility, procedure and age. Overall, the unit cost of delivering non-complicated VMMC procedures to infants aged 0–60 days was $14.05 (by device), to boys aged 10–14 years it was USD $19.35 (range $13.99-$22.54) by surgery, and to adolescents and adults over 14 years was $19.34 (range $13.84-$22.85) by surgery and was $20.5 by device. Devices were only used in JOOTRH because it has the capacity and the trained staff to use devices. There was no marked difference in the unit cost for the provision of procedures between boys aged 10–14 years, and adolescents and adults aged 14 years and above through the surgery method.

The main cost drivers for delivering non-complicated VMMC to boys aged 10–14 years, and to adolescents and adults aged over 14 years, across all study sites, were direct staff costs, medical and non-medical supplies, and utilities and overhead costs. Direct costs accounted for more than 60% of the total delivery costs per non-complicated VMMC, with the lowest cost at $6.75 in Rachuonyo and the highest cost at $15.5 in Chemelil health centre. There was no marked variation in the unit cost for delivering non-complicated VMMC between the 10–14 year and over 14-year age categories (see Table 4 Extended data).

For the delivery of VMMC services using the device method, the main cost drivers were consumable and drug supplies, utilities and overheads, and direct staff costs, with direct and indirect costs accounting for about 57% and 43% of the delivery costs respectively. Utility and overhead costs contributed nearly 36% of the total delivery cost. Among infants, the costs were higher due to the small number of VMMCs performed over a large fixed cost outlay, and in only one health facility (JOOTRH) (Table 5 Extended data).

The overall unit cost for delivering VMMC services with moderate and mild complications to infants was $17.88 and $18.78 respectively. The unit costs for delivering VMMC services with moderate and mild complications to adolescents aged 10–14 years across all the sites were $23.33 and $22.18, respectively. The unit costs for delivering VMMC services using the surgical method with moderate and mild complications to adolescents and adults above 14 years across all the sites were $25.31 and $22.31 respectively and with a device were $23.32 and $23.25 respectively. The cost per VMMC with moderate and mild complications for adolescents aged 10–14 years was lowest in Rachuonyo Sub-county hospital and highest in Chemelil sugar health centre (See Table 3).

The main cost drivers for the delivery of VMMC with complications (both moderate and mild) across the five sites were the drug consumables and supplies, utilities and overheads, and direct staff costs. (see Table 6 Extended data). It was slightly more expensive to deliver VMMC with moderate complications compared to VMMC with mild complications for adolescents and adults 14years and above. The direct costs of delivering VMMC with moderate complications were $24.4 higher than delivering VMMC with mild complications.