The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries

Autoři: Andrea Salas-Ortiz aff001;  Gina La Hera-Fuentes aff001;  Nerissa Nance aff001;  Sandra G. Sosa-Rubí aff001;  Sergio Bautista-Arredondo aff001
Působiště autorů: Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico aff001;  University of York, York, United Kingdom aff002;  University of Newcastle, Newcastle, Australia aff003;  School of Public Health, University of California, Berkeley, California, United States of America aff004
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222180



Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission—the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs.


We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services.


Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices.


No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.

Klíčová slova:

Health services administration and management – HIV – HIV diagnosis and management – Kenya – Outpatients – South Africa – Rwanda – Zambia


1. Joint United Nations Program on HIV/AIDS (UNAIDS). The Gap Report. Geneva; 2014.

2. World Health Organization. WHO | World Health Organization. In: HIV/AIDS Data and Statistics [Internet]. [cited 9 Jun 2017]. Available:

3. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLOS Med. 2005;2: e298. doi: 10.1371/journal.pmed.0020298 16231970

4. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet. 2007;369: 643–656. doi: 10.1016/S0140-6736(07)60312-2

5. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet. 2007;369: 657–666. doi: 10.1016/S0140-6736(07)60313-4

6. Wawer MJ, Tobian AA, Kigozi G, Kong X, Gravitt PE, Serwadda D, et al. Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda. Lancet. 2011;377: 209–18. doi: 10.1016/S0140-6736(10)61967-8 21216000

7. USAID. Accelerating the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention for Maximum Public Health Impact [Internet]. 2017 [cited 21 Mar 2017]. Available:

8. Wamai RG, Morris BJ, Bailis SA, Sokal D, Klausner JD, Appleton R, et al. Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa. J Int AIDS Soc. 2011;14: 49. doi: 10.1186/1758-2652-14-49 22014096

9. Hankins C, Forsythe S, Njeuhmeli E. Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up. PLOS Med. 2011;8: e1001127. doi: 10.1371/journal.pmed.1001127 22140362

10. Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, Heard N, et al. Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa. PLoS Med. 2011;8. doi: 10.1371/journal.pmed.1001132 22140367

11. Binagwaho A, Pegurri E, Muita J, Bertozzi S. Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study. PLOS Med. 2010;7: e1000211. doi: 10.1371/journal.pmed.1000211 20098721

12. Obure CD, Jacobs R, Guinness L, Mayhew S, Integra Initiative, Vassall A. Does integration of HIV and sexual and reproductive health services improve technical efficiency in Kenya and Swaziland? An application of a two-stage semi parametric approach incorporating quality measures. Soc Sci Med. 2016;151: 147–156. doi: 10.1016/j.socscimed.2016.01.013 26803655

13. Mahler HR, Kileo B, Curran K, Plotkin M, Adamu T, Hellar A, et al. Voluntary Medical Male Circumcision: Matching Demand and Supply with Quality and Efficiency in a High-Volume Campaign in Iringa Region, Tanzania. PLOS Med. 2011;8: e1001131. doi: 10.1371/journal.pmed.1001131 22140366

14. Kabene SM, Orchard C, Howard JM, Soriano MA, Leduc R. The importance of human resources management in health care: a global context. Hum Resour Health. 2006;4: 20. doi: 10.1186/1478-4491-4-20 16872531

15. Dickson KE, Reed J, Rech D. Considerations for implementing models for optimizing the volume and efficiency of male circumscision services [Internet]. The World Health Organization; 2010. Available:

16. Gapenski LC, Pink GH. Understanding healthcare financial management. Health Administration Press; 2007.

17. Bloom N, Propper C, Seiler S, Reenen JV. The Impact of Competition on Management Quality: Evidence from Public Hospitals. Rev Econ Stud. 2015;82: 457–489. doi: 10.1093/restud/rdu045

18. Bloom N, Sadun R, Van Reenen J. Does Management Matter in Healthcare. Lond Sch Econ Work Pap. 2013; Available:

19. Bautista-Arredondo S, Sosa-Rubi SG, Opuni M, Contreras-Loya D, La Hera-Fuentes G, Kwan A, et al. Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia. PLoS ONE. 2018;13. doi: 10.1371/journal.pone.0203121 30212497

20. Bloom N, Reenen JV. Measuring and Explaining Management Practices Across Firms and Countries. Q J Econ. 2007;122: 1351–1408. doi: 10.1162/qjec.2007.122.4.1351

21. Bautista-Arredondo S, Sosa-Rubí SG, Opuni M, Kwan A, Chaumont C, Coetzee J, et al. Assessing cost and technical efficiency of HIV prevention interventions in sub-Saharan Africa: the ORPHEA study design and methods. BMC Health Serv Res. 2014;14: 599. doi: 10.1186/s12913-014-0599-9 25927555

22. Charnes A, Cooper W, Rhodes E. Measuring the efficiency of decision making units. Eur J Oper Res. 1978;

23. Banker RD, Charnes A, Cooper WW. Some Models for Estimating Technical and Scale Inefficiencies in Data Envelopment Analysis. Manag Sci. 1984;30: 1078–1092. doi: 10.1287/mnsc.30.9.1078

24. Giorgio LD, Flaxman AD, Moses MW, Fullman N, Hanlon M, Conner RO, et al. Efficiency of Health Care Production in Low-Resource Settings: A Monte-Carlo Simulation to Compare the Performance of Data Envelopment Analysis, Stochastic Distance Functions, and an Ensemble Model. PLoS ONE. 2016;11. doi: 10.1371/journal.pone.0147261 26812685

25. Zeng W, Shepard DS, Chilingerian J, Avila-Figueroa C. How much can we gain from improved efficiency? An examination of performance of national HIV/AIDS programs and its determinants in low- and middle-income countries. BMC Health Serv Res. 2012;12: 74. doi: 10.1186/1472-6963-12-74 22443135

26. Zeng W, Rwiyereka AK, Amico PR, Ávila-Figueroa C, Shepard DS. Efficiency of HIV/AIDS Health Centers and Effect of Community-Based Health Insurance and Performance-Based Financing on HIV/AIDS Service Delivery in Rwanda. Am J Trop Med Hyg. 2014;90: 740–746. doi: 10.4269/ajtmh.12-0697 24515939

27. Omondi Aduda DS, Ouma C, Onyango R, Onyango M, Bertrand J. Voluntary Medical Male Circumcision Scale-Up in Nyanza, Kenya: Evaluating Technical Efficiency and Productivity of Service Delivery. PLoS ONE. 2015;10. doi: 10.1371/journal.pone.0118152 25706119

28. Leonard, K., Jishnu Das. Using Vignettes to Measure the Quality of Health Care [Internet]. World Bank; Available:

29. Tavakol M, Dennick R. Making sense of Cronbach’s alpha. Int J Med Educ. 2011;2: 53–55. doi: 10.5116/ijme.4dfb.8dfd 28029643

30. Mosadeghrad Ali Mohammad. Factors Influencing Healthcare Service Quality. International Journal of Health Policy and Management. 2014;3: 77–89. doi: 10.15171/ijhpm.2014.65 25114946

31. Bautista-Arredondo S, Sosa-Rubi S, Condo J, et al. Determinants of Technical Efficiency of HIV Prevention Interventions in four African Countries [Internet]. American Public Health Association. 142nd Annual Meeting & Expo.; 2014. Available:

32. Park RE. Estimation with heteroscedastic error terms. Econometrica. 1966;34.

33. Jennings L, Bertrand J, Rech D, Harvey SA, Hatzold K, Samkange CA, et al. Quality of Voluntary Medical Male Circumcision Services during Scale-Up: A Comparative Process Evaluation in Kenya, South Africa, Tanzania and Zimbabwe. PLOS ONE. 2014;9: e79524. doi: 10.1371/journal.pone.0079524 24801073

34. Dickson KE, Tran NT, Samuelson JL, Njeuhmeli E, Cherutich P, Dick B, et al. Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa. PLOS Med. 2011;8: e1001133. doi: 10.1371/journal.pmed.1001133 22140368

35. AVERT. Voluntary medical male circumcision for HIV prevention [Internet]. [cited 30 May 2017]. Available:

36. UNAIDS. On the fast-track to ending AIDS by 2030: focus on location and population [Internet]. 2015. Available:

37. De Walque D, Gertler P, Bautista-Arredondo S, Kwan A, Bizimana J de D, Binagwaho A, et al. Using Provider Perrformance Incentives to increase HIV Testing and Counseling Services in Rwanda. J Health Econ. 2015;40: 1–9. doi: 10.1016/j.jhealeco.2014.12.001 25554976

38. Suthar AB, Nagata JM, Nsanzimana S, Bärnighausen T, Negussie EK, Doherty MC. Performance-based financing for improving HIV/AIDS service delivery: a systematic review. BMC Health Serv Res. 2017;17. doi: 10.1186/s12913-016-1962-9 28052771

39. Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of Vignettes, Standardized Patients, and Chart Abstraction: A Prospective Validation Study of 3 Methods for Measuring Quality. JAMA. 2000;283: 1715–1722. doi: 10.1001/jama.283.13.1715 10755498

40. Das J, Hammer J. Which doctor? Combining vignettes and item response to measure clinical competence. J Dev Econ. 2005;78: 348–383. doi: 10.1016/j.jdeveco.2004.11.004

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