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Background  In this study, we described facility-level voluntary medical male circumcision (VMMC)  unit cost , examined  unit cost  variation across facilities, and investigated key facility characteristics associated with  unit cost  variation.    Methods  We used data from 107 facilities in Kenya, Rwanda, South Africa, and Zambia covering 2011 or 2012. We used micro-costing to estimate economic costs from the service provider’s perspective. Average annual costs per client were estimated in 2013 United States dollars (US$). Econometric analysis was used to explore the relationship between VMMC  total  and  unit cost  and facility characteristics.    Results  Average VMMC  unit cost  ranged from US$66 (SD US$79) in Kenya to US$160 (SD US$144) in South Africa.  Total cost  function estimates were consistent with economies of scale and scope. We found a negative association between the number of VMMC clients and VMMC  unit cost  with a 3% decrease in  unit cost  for every 10% increase in number of clients and we found a negative association between the provision of other HIV services and VMMC  unit cost . Also, VMMC  unit cost  was lower in primary health care facilities than in hospitals, and lower in facilities implementing task shifting.    Conclusions  Substantial efficiency gains could be made in VMMC service delivery in all countries. Options to increase efficiency of VMMC programs in the short term include focusing service provision in high yield sites when demand is high, focusing on task shifting, and taking advantage of efficiencies created by integrating HIV services. In the longer term, reductions in VMMC  unit cost  are likely by increasing the volume of clients at facilities by implementing effective demand generation activities.

Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia