Is it all about the money? A qualitative exploration of the effects of performance-based financial incentives on Zimbabwe's voluntary male medical circumcision program

Abstract

BackgroundIn 2013, Zimbabwe’s voluntary medical male circumcision (VMMC) program adopted performance-based financing (PBF) to speed progress towards ambitious VMMC targets. The $25 USD PBF intended to encourage low-paid healthcare workers to remain in the public sector and to strengthen the public healthcare system. The majority of the incentive supports healthcare workers (HCWs) who perform VMMC alongside other routine services; a small portion supports province, district, and facility levels.MethodsThis qualitative study assessed the effect of the PBF on HCW motivation, satisfaction, and professional relationships. The study objectives were to: 1) Gain understanding of the advantages and disadvantages of PBF at the HCW level; 2) Gain understanding of the advantages and disadvantages of PBF at the site level; and 3) Inform scale up, modification, or discontinuation of PBF for the national VMMC program. Sixteen focus groups were conducted: eight with HCWs who received PBF for VMMC and eight with HCWs in the same clinics who did not work in VMMC and, therefore, did not receive PBF. Fourteen key informant interviews ascertained administrator opinion.ResultsFindings suggest that PBF appreciably increased motivation among VMMC teams and helped improve facilities where VMMC services are provided. However, PBF appears to contribute to antagonism at the workplace, creating divisiveness that may reach beyond VMMC. PBF may also cause distortion in the healthcare system: HCWs prioritized incentivized VMMC services over other routine duties. To reduce workplace tension and improve the VMMC program, participants suggested increasing HCW training in VMMC to expand PBF beneficiaries and strengthening integration of VMMC services into routine care.ConclusionIn the low-resource, short-staffed context of Zimbabwe, PBF enabled rapid VMMC scale up and achievement of ambitious targets; however, side effects make PBF less advantageous and sustainable than envisioned. Careful consideration is warranted in choosing whether, and how, to implement PBF to prioritize a public health program.

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

“…Few schemes rewarded only one activity. For instance, a P4P scheme in Zimbabwe focused on HIV prevention [43] tied payments exclusively to the number of male circumcisions and a P4P intervention in Chinese schools [44] only incentivised students' haemoglobin level. Schemes rewarding multiple outcomes differed dramatically in their complexity.…”

Implementing voluntary medical male circumcision using an innovative, integrated, health systems approach: experiences from 21 districts in Zimbabwe

“…Additional ZAZIC-specific expenditure includes VMMC training, supervision, occasional supplies, minor refurbishment, coordination, and M&E. Complementary program costs for disposable VMMC kits, site-level personnel, hospital administration, and most medical supplies are largely borne by the MoHCC or directly by donors. Previous exploration of the PBF effects found increased VMMC team motivation and improved facilities where VMMC services occur; however, the PBF also created some discord, suggesting efforts to broaden the reach of the incentives would reduce staff tension [37]. …”

“…The overall PBF study methodology and the broader results from the PBF-focused research were published previously [37]. In brief, for the PBF study, eight ZAZIC VMMC sites within six provinces were selected in a convenience sample to represent high- and low-performing VMMC sites: 14 key informant (KI) interviews were conducted with MoHCC administrators at the provincial, district, and clinic levels.…”

Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe

“…The drive to achieve targets is largely motivated by money. It is unsurprising that financial incentives were a motivator to VMMC productivity all along the service delivery continuum-from providers to support staff, and government leadership all benefit [24]. Patients also seem motivated by the reduced risk of HIV acquisition and other demand creation strategies.…”