Expanding two-way texting for post-operative follow-up: A cost analysis of the implementation and scale-up in routine voluntary medical male circumcision settings in South Africa

Molly Unsworth, Isabella Fabens, Geoffrey Setswe, Khumbulani Moyo, Jacqueline Pienaar, Calsile Makhele, Motshana Phohole, Nelson Igaba, Sizwe Hlongwane, Maria Sardini, Tracy Dong, Monisha Sharma, Hannock Tweya, Felex Ndebele, Marrianne Holec and Caryl Feldacker

PLOS Global Public Health, 2025, vol. 5, issue 4, 1-15

Abstract: Up to 98% of adult voluntary medical male circumcision (VMMC) clients heal without adverse events (AEs) in South Africa and in the sub-Saharan Africa region. Yet, all clients in South Africa are required to attend in-person reviews, creating added effort for providers and clients. A randomized controlled trial (RCT) using our fee-free, open-source, two-way texting (2wT) approach showed that males could independently monitor their healing with nurse-led telehealth support. 2wT was more cost-effective than routine visits for quality post-operative monitoring. The objectives of this study were:1) assess the additive cost of 2wT vs. standard of care (SoC) during a stepped wedge design (SWD) expansion trial; 2) determine the cost of augmenting 2wT implementation with dedicated personnel during peak VMMC periods; and 3) estimate the cost savings of 2wT from the payer perspective if scaled in routine settings. Data were collected from routine financial reports and complemented by previous RCT time-motion estimates. We conducted activity-based costing of SWD and peak season periods. Sensitivity analysis to estimates 2wT costs at scale. Data included 6,842 males; 2,586 (38%) opted for 2wT. 2wT participants attended an average of zero in-person visits; SoC males had an average of 2 in-person visits. Under 2wT, quality care improved: AE ascertainment increased while loss to follow-up decreased. Given a VMMC population of 10,000 adults, scenario analysis suggests that: 1) 2wT becomes cost neutral with 45% 2wT enrollment; 2) 2wT saves $0.29/client with 60% 2wT enrollment; and 3) 2wT saves $0.46/client with 80% 2wT enrollment. When scaled, 2wT appears to significantly reduce healthcare system costs while improving the quality of post-operative care without additional client costs. Further scale-up of 2wT for eligible males across VMMC and other post-operative contexts in South Africa would likely increase cost savings while dramatically reducing the burden of in-person visits on patients and clinics.

Date: 2025
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Persistent link: https://EconPapers.repec.org/RePEc:plo:pgph00:0004049

DOI: 10.1371/journal.pgph.0004049

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