The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda

PLoS One. 2018 Apr 19;13(4):e0195691. doi: 10.1371/journal.pone.0195691. eCollection 2018.


Background: Uganda is working to increase voluntary medical male circumcision (VMMC) to prevent HIV infection. To support VMMC quality improvement, this study compared three methods of disseminating information to facilities on how to improve VMMC quality: M-providing a written manual; MH-providing the manual plus a handover meeting in which clinicians shared advice on implementing key changes and participated in group discussion; and MHC-manual, handover meeting, and three site visits to the facility in which a coach provided individualized guidance and mentoring on improvement. We determined the different effects these had on compliance with indicators of quality of care.

Methods: This controlled pre-post intervention study randomized health facility groups to receive M, MH, or MHC. Observations of VMMCs performance determined compliance with quality indicators. Intervention costs per patient receiving VMMC were used in a decision-tree cost-effectiveness model to calculate the incremental cost per additional patient treated to compliance with indicators of informed consent, history taking, anesthesia administration, and post-operative instructions.

Results: The most intensive method (MHC) cost $28.83 per patient and produced the biggest gains in history taking (35% improvement), anesthesia administration (20% improvement), and post-operative instructions (37% improvement). The least intensive method (M; $1.13 per patient) was most efficient because it produced small gains for a very low cost. The handover meeting (MH) was the most expensive among the three interventions but did not have a corresponding positive effect on quality.

Conclusion: Health workers in facilities that received the VMMC improvement manual and participated in the handover meeting and coaching visits showed more improvement in VMMC quality indicators than those in the other two intervention groups. Providing the manual alone cost the least but was also the least effective in achieving improvements. The MHC intervention is recommended for broader implementation to improve VMMC quality in Uganda.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Circumcision, Male / economics
  • Circumcision, Male / education*
  • Cost-Benefit Analysis
  • Decision Trees
  • HIV Infections / prevention & control
  • Health Education / economics*
  • Health Education / methods*
  • Health Personnel / economics
  • Health Personnel / education*
  • Humans
  • Information Dissemination / methods*
  • Male
  • Manuals as Topic
  • Mentoring
  • Patient Compliance
  • Quality Improvement
  • Uganda

Grant support

Support for this study was provided by the American people through the United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems Project, managed by University Research Co., LLC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. Funding for the VMMC quality improvement intervention was provided by the U.S. President’s Emergency Plan for AIDS Relief through USAID.