Estimating Client Out-of-Pocket Costs for Accessing Voluntary Medical Male Circumcision in South Africa

In 2010, South Africa launched a countrywide effort to scale up its voluntary medical male circumcision (VMMC) program on the basis of compelling evidence that circumcision reduces men's risk of acquiring HIV through heterosexual intercourse. Even though VMMC is free there, clients can incur indirect out-of-pocket costs (for example transportation cost or foregone income). Because these costs can be barriers to increasing the uptake of VMMC services, we assessed them from a client perspective, to inform VMMC demand creation policies. Costs (calculated using a bottom-up approach) and demographic data were systematically collected through 190 interviews conducted in 2015 with VMMC clients or (for minors) their caregivers at 25 VMMC facilities supported by the government and the President's Emergency Plan for AIDS Relief in eight of South Africa's nine provinces. The average age of VMMC clients was 22 years and nearly 92% were under 35 years of age. The largest reported out-of-pocket expenditure was transportation, at an average of US$9.20 (R 100). Only eight clients (4%) reported lost days of work. Indirect expenditures were childcare costs (one client) and miscellaneous items such as food or medicine (20 clients). Given competing household expense priorities, spending US$9.20 (R100) per person on transportation to access VMMC services could be a significant burden on clients and households, and a barrier to South Africa's efforts to create demand for VMMC. Thus, we recommend a more focused analysis of clients' transportation costs to access VMMC services.