Support, Research and Development Center, Kyiv, Ukraine.
Support, Research and Development Center, Kyiv-Mohyla Academy Doctoral School, Kyiv, Ukraine.
Harm Reduct J. 2019 Jan 28;16(1):8. doi: 10.1186/s12954-019-0279-5.
To improve healthcare entry and antiretroviral therapy (ART) initiation for HIV-positive people who inject drugs (PWID) in Ukraine, an intervention built upon a successful community-based harm reduction project and the existing best practices was developed. In this article, we present the results of the study conducted in collaboration with one of the recipient organizations of the intervention in Kyiv. The research question was formulated as follows: how does the interaction between different actors work to lead it to a positive outcome (initiation PWIDs into ART) within the limited period of the intervention implementation?
The central focus of the study was on the work activities of case managers. Their daily routines as well as their interactions with their clients and medical workers were observed and analyzed. Using the institutional ethnography approach, we explore the institutional orders, power imbalances, and social factors that play different roles in coordinating the process of PWIDs entry into healthcare and HIV treatment.
The most intriguing result of the study is that the performance indicator that must be completed in order to receive a full salary-as a way to manage the activities of case managers-produces conditions for them to develop their cooperation with medical workers but leaves the clients and their needs out of this "boat" because interaction with them, in fact, does not help to meet case managers' goals.
Accountability of case managers' work assumes the primacy of the result over the process, which makes the process itself less important and the need to achieve the goal becomes the main and the only goal. This can be identified as an unintended consequence of the intervention implementation on the ground, or wider-an unintended consequence of the payment by results practice as a part of the general number-based policy.
为改善乌克兰艾滋病毒阳性吸毒者（PWID）获得医疗保健和开始抗逆转录病毒治疗（ART）的机会，在一个成功的基于社区的减少伤害项目和现有最佳实践的基础上，制定了一项干预措施。在本文中，我们展示了在基辅与干预措施的一个受援组织合作进行的研究结果。研究问题如下：在干预措施实施的有限时间内，不同行为者之间的相互作用如何导致积极的结果（使 PWID 开始接受 ART）？
该研究的核心重点是个案经理的工作活动。观察和分析了他们的日常工作以及与客户和医务人员的互动。我们使用机构民族志方法，探讨了在协调 PWID 进入医疗保健和 HIV 治疗过程中发挥不同作用的机构秩序、权力失衡和社会因素。
该研究最有趣的结果是，为了获得全额工资而必须完成的绩效指标——作为管理个案经理活动的一种方式——为他们与医务人员发展合作创造了条件，但将客户及其需求排除在这个“范围”之外，因为与他们的互动实际上无助于实现个案经理的目标。
个案经理工作的问责制假设结果优于过程，这使得过程本身变得不那么重要，实现目标的需求成为主要和唯一的目标。这可以被认为是干预措施在实地实施的意外后果，或者更广泛地说，是按成果付费做法作为一般数字政策的一部分的意外后果。
