Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
Center for Global Health, School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, USA.
Int J Health Policy Manag. 2018 Jul 1;7(7):630-644. doi: 10.15171/ijhpm.2017.137.
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.
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.
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).
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.
尽管获得治疗的机会增加，发病率降低，但艾滋病毒的垂直传播继续对撒哈拉以南非洲的母婴健康构成威胁。针对医疗保健提供者的基于绩效的融资（PBF）已显示出有潜力提高母婴保健服务的数量和质量。然而，这些 PBF 计划如何导致服务提供的改善仍在调查中。
因此，我们在莫桑比克农村的卫生设施和以预防艾滋病毒垂直传播（PVT）为重点的社区基层协会实施了一项纵向对照的基于绩效的概念验证 PBF 干预。我们假设 PBF 将提高工人的积极性和工作场所环境的其他方面，以实现服务提供目标。在本文中，我们介绍了公共卫生设施（n=6）的 PBF 干预的两个目标：首先，我们描述了 PBF 干预的实施情况，其次，我们评估了 PBF 对卫生工作者积极性、工作场所环境的关键因素、卫生工作者满意度和离职意愿的影响。实施（目标 1）通过定量服务提供数据和多种形式的定性数据（例如，季度会议、参与观察（n=120）、离职访谈（n=11））进行评估。使用这些定性数据和对干预基线、中期和终线的卫生工作者（n=83）进行的定量调查，评估了 PBF 对中间结构（目标 2）的影响。
我们发现，实施受到行政障碍、激励延迟支付以及激励支付与评估之间时机不当的挑战（目标 1）。尽管我们没有发现对所测激励结构的影响，但 PBF 增加了同事支持和工人赋权，并且在过渡实施伙伴的时期，减少了离职的愿望（目标 2）。
未来的研究领域包括激励有意义的基于质量和过程的绩效指标，并评估 PBF 如何影响服务提供的途径，包括激励和工作场所环境因素之间的相互作用。
