Discussion
In this costing analysis, we determined that 2wT-based VMMC follow-up saved an average of $3.56 per client across settings, with savings ranging from $2.16 to $7.02. 2wT improves the quality of post-VMMC follow-up care at lower overall cost by providing an SMS-based mHealth option for clients with access to cell phones, encouraging visits when needed instead of compulsory visits on day 2 and/or day 7. Savings using the 2wT approach were higher in rural as compared to urban areas–an important finding as the majority of VMMC program implementation occurs in rural areas [Cost savings from 2wT vary by adherence to required attendance at post-VMMC visits and by location. Given that moderate and severe AE rates in male circumcisions are low (1%-2%) [2wT may increase some costs that are likely offset by additional quality care benefits. Firstly, enhanced counselling incurred a minimal cost of $0.63, but enabled the clients to effectively identify and communicate AE concerns in daily SMS–a worthwhile cost. Second, daily SMS communication improved early detection of AEs and subsequent swift referral of those in need for in-person clinical visits. This triaging process led to identification of AEs earlier with less severity, likely averting costs of more severe AEs [Quality assurance likely also benefits from 2wT improvements in verification of, and supervision for, quality post-operative care. For NDoH, 2wT follow-up adhered to government regulations regarding client privacy and complied with required NDoH documentation for VMMC client follow-up. The 2wT system provides verification of timely, nurse-led, post-operative support in line with PEPFAR guidelines, facilitating quality follow-up regardless of client location. 2wT documentation also provides another layer of quality assurance to confirm program performance. Unique client verification via the 2wT system increases confidence in program productivity, providing another data source to prevent duplication in reporting. Although not formally considered in the costing analysis, supervision costs of 2wT may be lower than those for routine care. Routine monitoring of care quality via review of paper forms is time-consuming, requiring intensive efforts. However, 2wT dashboards and system-embedded hierarchies allow for remote client oversight and access to data for timely program monitoring. Supervisors can access 2wT messages, reports, tasks, and client records from multiple sites or remotely from a central location. Similarly, quality assurance activities can also take place virtually, allowing managers and program administrators to review data and provide clinical oversight, informing improvements. In future, calculation of these costs may demonstrate further benefit of the 2wT approach for routine VMMC follow-up.