Feldacker Caryl, Bochner Aaron F, Herman-Roloff Amy, Holec Marrianne, Murenje Vernon, Stepaniak Abby, Xaba Sinokuthemba, Tshimanga Mufata, Chitimbire Vuyelwa, Makaure Shingirai, Hove Joseph, Barnhart Scott, Makunike Batsirai
International Training and Education Center for Health (I-TECH), Seattle, WA United States of America.
Department of Global Health, University of Washington, Seattle, WA, United States of America.
PLoS One. 2017 Mar 16;12(3):e0174047. doi: 10.1371/journal.pone.0174047. eCollection 2017.
In 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.
This 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.
Findings 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.
In 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.
2013年，津巴布韦的自愿男性医学包皮环切术（VMMC）项目采用了基于绩效的融资（PBF）方式，以加快实现宏伟的VMMC目标。这25美元的PBF旨在鼓励低薪医护人员留在公共部门，并加强公共医疗体系。大部分激励措施用于支持同时开展VMMC及其他常规服务的医护人员；一小部分用于支持省、区和医疗机构层面。
这项定性研究评估了PBF对医护人员积极性、满意度和职业关系的影响。研究目标如下：1）了解PBF在医护人员层面的优缺点；2）了解PBF在机构层面的优缺点；3）为全国VMMC项目扩大、调整或终止PBF提供参考。研究开展了16个焦点小组讨论：8个小组的参与者是因VMMC获得PBF的医护人员，另外8个小组的参与者是来自相同诊所但未参与VMMC工作、因此未获得PBF的医护人员。还进行了14次关键 informant访谈以确定管理人员的意见。
研究结果表明，PBF显著提高了VMMC团队的积极性，并有助于改善提供VMMC服务的机构。然而，PBF似乎导致了工作场所的对抗，造成了可能超出VMMC范围的分裂。PBF还可能导致医疗体系的扭曲：医护人员将获得激励的VMMC服务置于其他常规职责之上。为了减少工作场所的紧张关系并改进VMMC项目，参与者建议增加VMMC方面的医护人员培训，以扩大PBF受益群体，并加强将VMMC服务纳入常规护理。
在津巴布韦资源匮乏、人员短缺的情况下，PBF使VMMC得以迅速扩大规模并实现宏伟目标；然而，副作用使PBF不如预期的那么有利和可持续。在选择是否以及如何实施PBF以优先开展一项公共卫生项目时，需要谨慎考虑。
