title: Performance-based incentives may be appropriate to address challenges to delivery of prevention of vertical transmission of HIV services in rural Mozambique: a qualitative investigation.
abstract: Performance-based incentives (PBIs) have garnered global attention as a promising strategy to improve healthcare delivery to vulnerable populations. However, literature gaps in the context in which an intervention is implemented and how the PBIs were developed exist. Therefore, we (1) characterized the barriers and promoters to prevention of vertical transmission of HIV (PVT) service delivery in rural Mozambique, where the vertical transmission rate is 12 %, and (2) assessed the appropriateness for a PBI's intervention and application to PVT.
  
  
  
  We conducted 24 semi-structured interviews with nurses, volunteers, community health workers, and traditional birth attendants about the barriers and promoters they experienced delivering PVT services. We then explored emergent themes in subsequent focus group discussions (n = 7, total participants N = 92) and elicited participant perspectives on PBIs. The ecological motivation-opportunity-ability framework guided our iterative data collection and thematic analysis processes.
  
  
  
  The interviews revealed that while all health worker cadres were motivated intrinsically and by social recognition, they were dissatisfied with low and late remuneration. Facility-based staff were challenged by factors across the rest of the ecological levels, primarily in the opportunity domain, including the following: poor referral and record systems (work mandate), high workload, stock-outs, poor infrastructure (facility environment), and delays in obtaining patient results and donor payment discrepancies (administrative). Community-based cadres' opportunity challenges included lack of supplies, distance (work environment), lack of incorporation into the health system (administration), and ability challenges of incorrect knowledge (health worker). PBIs based on social recognition and that enable action on intrinsic motivation through training, supervision, and collaboration were thought to have the most potential for targeting improvements in record and referral systems and better integrating community-based health workers into the health system. Concerns about the implementation of incentives included neglect of non-incentivized tasks and distorted motivation among colleagues.
  
  
  
  We found that highly motivated health workers encountered severe opportunity challenges in their PVT mandate. PBIs have the potential to address key barriers that facility- and community-based health workers encounter when delivering PVT services, specifically by building upon existing intrinsic motivation and leveraging highly valued social recognition. We recommend a controlled intervention to monitor incentives' effects on worker motivation and non-incentivized tasks to generate insights about the feasibility of PBIs to improve the delivery of PVT services.
authors.affiliation: Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, 14853, United States of America. rcs346@cornell.edu.|School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, 85287-2402, United States of America. rcs346@cornell.edu.
authors.forename: Roseanne C
authors.initials: RC
authors.lastname: Schuster
authors.affiliation: CARE Mozambique, 596 Av. Mártires de Mueda, Maputo, Mozambique.
authors.forename: Octávio
authors.initials: O
authors.lastname: de Sousa
authors.affiliation: Division of Nutritional Sciences, Cornell University, Ithaca, NY, 14853, United States of America.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Rivera
authors.affiliation: Humphrey School of Public Affairs, University of Minnesota, 310 19th Street S, Minneapolis, MN, 55455, United States of America.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Olson
authors.affiliation: CARE Uganda, CARE Mozambique, 596 Av. Mártires de Mueda, Maputo, Mozambique.
authors.forename: Delphine
authors.initials: D
authors.lastname: Pinault
authors.affiliation: Program in International Nutrition, Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, 14853, United States of America.|Department of Anthropology, Northwestern University, 515 Clark Street, 60208, Evanston, IL, United States of America.
authors.forename: Sera L
authors.initials: SL
authors.lastname: Young
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003150:Community Health Workers; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D008880:Midwifery; D009042:Motivation; D009073:Mozambique; D009726:Nurses; D010559:Personnel Management / Q000379:methods*; D036301:Qualitative Research; D060926:Remuneration; D012201:Reward; D019035:Rural Health Services; D012424:Rural Population; D014838:Volunteers
keywords: Community health workers; Health systems; Maternal and child health nurses; Motivation; Mozambique; Performance-based incentives; Prevention of mother-to-child transmission of HIV; Traditional birth attendants