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

Document Type : Original Article


1 Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA

2 Center for Global Health, School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, USA

3 CARE Mozambique, Maputo, Mozambique

4 Mailman School of Public Health, Columbia University, New York, NY, USA

5 International Medical Corps, Washington, DC, USA

6 Cornell Statistical Consulting Unit, Cornell University, Ithaca, NY, USA

7 Global Alliance for Improved Nutrition (GAIN), Washington, DC, USA

8 Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA

9 Department of Anthropology, Northwestern University, Evanston, IL, USA.


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.


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  • Receive Date: 31 January 2017
  • Revise Date: 28 September 2017
  • Accept Date: 20 November 2017
  • First Publish Date: 01 July 2018