BackgroundPerformance-based incentives (PBIs) have garnered global attention as a promising strategy to improve healthcare delivery to vulnerable populations. However, literature gaps in the context in which an intervention is implemented and how the PBIs were developed exist. Therefore, we (1) characterized the barriers and promoters to prevention of vertical transmission of HIV (PVT) service delivery in rural Mozambique, where the vertical transmission rate is 12 %, and (2) assessed the appropriateness for a PBI’s intervention and application to PVT.MethodsWe conducted 24 semi-structured interviews with nurses, volunteers, community health workers, and traditional birth attendants about the barriers and promoters they experienced delivering PVT services. We then explored emergent themes in subsequent focus group discussions (n = 7, total participants N = 92) and elicited participant perspectives on PBIs. The ecological motivation-opportunity-ability framework guided our iterative data collection and thematic analysis processes.ResultsThe interviews revealed that while all health worker cadres were motivated intrinsically and by social recognition, they were dissatisfied with low and late remuneration. Facility-based staff were challenged by factors across the rest of the ecological levels, primarily in the opportunity domain, including the following: poor referral and record systems (work mandate), high workload, stock-outs, poor infrastructure (facility environment), and delays in obtaining patient results and donor payment discrepancies (administrative). Community-based cadres’ opportunity challenges included lack of supplies, distance (work environment), lack of incorporation into the health system (administration), and ability challenges of incorrect knowledge (health worker). PBIs based on social recognition and that enable action on intrinsic motivation through training, supervision, and collaboration were thought to have the most potential for targeting improvements in record and referral systems and better integrating community-based health workers into the health system. Concerns about the implementation of incentives included neglect of non-incentivized tasks and distorted motivation among colleagues.ConclusionsWe found that highly motivated health workers encountered severe opportunity challenges in their PVT mandate. PBIs have the potential to address key barriers that facility- and community-based health workers encounter when delivering PVT services, specifically by building upon existing intrinsic motivation and leveraging highly valued social recognition. We recommend a controlled intervention to monitor incentives’ effects on worker motivation and non-incentivized tasks to generate insights about the feasibility of PBIs to improve the delivery of PVT services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12960-016-0157-0) contains supplementary material, which is available to authorized users.

Background: Despite increased access to treatment and reduced incidence, vertical transmission of HIV continues to pose a risk to maternal and child health in sub-Saharan Africa. Performance-based financing (PBF) directed at healthcare providers has shown potential to improve quantity and quality of maternal and child health services. However, the ways in which these PBF initiatives lead to improved service delivery are still under investigation. Methods: Therefore, we implemented a longitudinal-controlled proof-of-concept PBF intervention at health facilities and with community-based associations focused on preventing vertical transmission of HIV (PVT) in rural Mozambique. We hypothesized that PBF would increase worker motivation and other aspects of the workplace environment in order to achieve service delivery goals. In this paper, we present two objectives from the PBF intervention with public health facilities (n=6): first, we describe the implementation of the PBF intervention and second, we assess the impact of the PBF on health worker motivation, key factors in the workplace environment, health worker satisfaction, and thoughts of leaving. Implementation (objective 1) was evaluated through quantitative service delivery data and multiple forms of qualitative data (eg, quarterly meetings, participant observation (n=120), exit interviews (n=11)). The impact of PBF on intermediary constructs (objective 2) was evaluated using these qualitative data and quantitative surveys of health workers (n=83) at intervention baseline, midline, and endline. Results: We found that implementation was challenged by administrative barriers, delayed disbursement of incentives, and poor timing of evaluation relative to incentive disbursement (objective 1). Although we did not find an impact on the motivation constructs measured, PBF increased collegial support and worker empowerment, and, in a time of transitioning implementing partners, decreased against desire to leave (objective 2). Conclusion: Areas for future research include incentivizing meaningful quality- and process-based performance indicators and evaluating how PBF affects the pathway to service delivery, including interactions between motivation and workplace environment factors.

A management strategy to achieve financial sustainability of urban water cycle services in developing countries is presented, based on the development of the Long Term Water Supply and Sanitation Services Investment Plan for the Water and Sanitation Infrastructure Administration (Administração de Infra-estruturas de Água e Saneamento (AIAS)) of Mozambique. AIAS is responsible for water supply and sanitation systems of 151 cities and towns (9.38 million inhabitants in 2015, 17.55 million expected in 2040). The needs in this sector are considerable, financial resources are scarce and, as a result, the Millennium Development Goals are still off track to be achieved. An integrated approach was applied to estimate the investments needs, considering differentiated levels of service depending on the urban area characteristics and taking into consideration the household income limitations, in order to achieve an economically sustainable increase in coverage and service level. The work developed resulted in an action plan aligned with the national strategy vision and adaptable to every city and town of Mozambique, including two decision support tools to enable stakeholders' decision making on potential investments: the Water and Wastewater Database (Base de Informação de Água e Saneamento) and the Dynamic Economic tool to support investments in water supply and sanitation services.

Performance‐based incentives (PBIs) have shown potential to improve the delivery of health and nutrition services to vulnerable populations. Strikingly, assessments of PBIs rarely incorporate qualitative approaches, making it difficult for policymakers to fully evaluate their utility. We employed evaluative ethnography to assess the impact of a longitudinal‐control PBI intervention to improve prevention of vertical transmission of HIV service delivery in rural Mozambique.Evaluative ethnography is a structured and theory‐grounded approach to qualitative research. The motivation, opportunity, and ability framework and focused ethnographic methods characterized our evaluative ethnographic approach.image Table 1. Utilization of focused ethnography and quantitative methods to assess impact of the performance‐based incentive intervention on delivery of prevention of vertical transmission of HIV (PVT) services Method Participants Intervention Phase n Evaluative Ethnography Methodology Semi‐structured interviews Women accessing PVT services, their family members, community leaders, facility‐ and community‐based health workers Formative 67 Group discussions Facility‐ and community‐based health workers, district leaders Formative, on‐going implementation 100 Participant observation Facility‐ and community‐based health workers On‐going implementation 140 Semi‐structured interviews Facility‐ and community‐based health workers, district leaders Final evaluation 15 Quantitative Assessment Methodology Surveys of health worker motivation Facility‐ and community‐based health workers Formative, on going implementation, final evaluation 147 Participant observation and exit interviews revealed the major barriers to the intervention (e.g. obstructionist officials, resource constraints). This was critical to understanding the quantitative finding that the PBIs did not significantly affect health worker motivation or delivery of services within the 12‐month implementation period.Although PBIs did not impact service delivery, evaluative ethnography allowed us to identify the principal problem areas. Considering the challenging nature of nutrition and health interventions in low‐resource health systems, we demonstrate that evaluative ethnography can augment conventional quantitative assessments.