Abstract
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.
Highlights
Performance-based financing (PBF) has been cautiously embraced as a strategy to improve delivery of health services in low- and middle-income countries.[1,2,3,4] Here we use Renmans and colleagues’ definition of performance-based financing (PBF) as “an incentive scheme directed to health providers, but accompanied by a new level of autonomy of the health facility, increased monitoring, and a separation of functions between the purchaser, provider and/or the newly created verification officer of health services.”[5]
Well-timed longitudinal mixed methods evaluation of impact of PBF on and interactions between workplace factors are necessary to better ascertain how PBF leads to changes in service delivery
We use Renmans and colleagues’ definition of PBF as “an incentive scheme directed to health providers, but accompanied by a new level of autonomy of the health facility, increased monitoring, and a separation of functions between the purchaser, provider and/or the newly created verification officer of health services.”[5]. PBF purportedly works by aligning the motivation of health workers with that of the health system, a reflection of principle-agent theory.[6]
Summary
Performance-based financing (PBF) has been cautiously embraced as a strategy to improve delivery of health services in low- and middle-income countries.[1,2,3,4] Here we use Renmans and colleagues’ definition of PBF as “an incentive scheme directed to health providers (facilities and/or health workers), but accompanied by a new level of autonomy of the health facility (eg, to decide on the use of resources), increased monitoring, and a separation of functions between the purchaser, provider and/or the newly created verification officer of health services.”[5]. Despite recent successes in increased access to maternal antiretroviral therapy, early testing and treatment for infants and young children, and reduced incidence rates, vertical transmission of HIV still poses risk to maternal and child health, in sub-Saharan Africa.[26] In 2015, 150 000 children were infected by HIV, the vast majority through vertical transmission.[27] Early evidence of PBF impact from the large, well-designed intervention in Rwanda has shown PBF to increase on HIV testing[28] and key maternal and child health indicators, including quantity and quality of antenatal care and number of facility births and child preventative visits.[29] Following this, PBF was proposed as a means to support the scaling up of preventing vertical transmission of HIV (PVT) services while motivating health workers through monetary and non-monetary incentives.[30] A recent systematic review of impacts on HIV/AIDS services found PBF was associated with reduced patient drop-out and treatment failure but failure to clearly replicate results necessitates further validation.[31] Challenges to implementation of national PVT policies and best practices are numerous at the point of care[32] and are linked with delivery of the specific services critical to PVT.[33,34] evaluation of the implementation of PBF interventions and the impact of PBF on intermediary constructs in the context of PVT are lacking. The second objective is to assess how PBF affects health worker motivation, key factors in the workplace environment, and health worker satisfaction and thoughts of leaving their position
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