Performance-based incentives may be appropriate to address challenges to delivery of prevention of vertical transmission of HIV services in rural Mozambique: a qualitative investigation

Abstract

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.

Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique

“…During the period of formative work and intervention design (July 2012-July 2013), 37 CARE International provided funding and technical support for HIV prevention and treatment for the districts as the PEPFAR-implementing partner. During intervention implementation (August 2013-July 2014), the Center for Collaboration for Health, a Mozambican NGO new to these districts, transitioned into the role of the PEPFAR-implementing partner.…”

“…Our participatory approach to intervention design began with an 8-month formative assessment of the barriers that health workers experience in delivering PVT services and the appropriateness of PBF to address them. 37 Following the formative assessment, repeated meetings with intervention health centers, district authorities, and health system implementing partners were held to discuss, debate, and design the intervention. The intervention district’s senior health administrator also visited another district in Mozambique with an on-going performance-based financing intervention to learn about challenges and facilitators to implementation.…”

“…Ability encompasses the skills and knowledge to execute action. Our previous work has identified that the range of factors in the opportunity domain is most limiting, and that knowledge, particularly in PVT, was not limiting 32 , 37 Therefore, we focus on the intermediary workplace environment constructs as representative of the opportunity domains in addition to the motivation this is still central to PBF.…”

Mobilizing community action to improve maternal health in a rural district in Tanzania: lessons learned from two years of community group activities

“…Nevertheless, all stakeholders involved in our project commented on the lack of financial contributions or incentive to participate, which may have contributed to some groups discontinuing and reduces the likelihood of sustaining groups after ending the project. The impact of incentives on sustaining a community group in a resource-poor setting cannot be underestimated [60], and could therefore be considered as a limitation of our research. However, the increase in funding and financial incentives would be unlikely to have resulted in sustained commitment as soon as the funds subside.…”

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“…8 Thus, human resource factors have been identified as potential targets for strengthening primary healthcare services, including immunization services. 9,10…”