title: Is it all about the money? A qualitative exploration of the effects of performance-based financial incentives on Zimbabwe's voluntary male medical circumcision program.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: Caryl
authors.initials: C
authors.lastname: Feldacker
authors.affiliation: International Training and Education Center for Health (I-TECH), Seattle, WA United States of America.
authors.forename: Aaron F
authors.initials: AF
authors.lastname: Bochner
authors.affiliation: U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe.
authors.forename: Amy
authors.initials: A
authors.lastname: Herman-Roloff
authors.affiliation: International Training and Education Center for Health (I-TECH), Seattle, WA United States of America.
authors.forename: Marrianne
authors.initials: M
authors.lastname: Holec
authors.affiliation: International Training and Education Center for Health (I-TECH), Harare, Zimbabwe.
authors.forename: Vernon
authors.initials: V
authors.lastname: Murenje
authors.affiliation: International Training and Education Center for Health (I-TECH), Seattle, WA United States of America.
authors.forename: Abby
authors.initials: A
authors.lastname: Stepaniak
authors.affiliation: Ministry of Health and Child Care, Harare, Zimbabwe.
authors.forename: Sinokuthemba
authors.initials: S
authors.lastname: Xaba
authors.affiliation: Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe.
authors.forename: Mufata
authors.initials: M
authors.lastname: Tshimanga
authors.affiliation: Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe.
authors.forename: Vuyelwa
authors.initials: V
authors.lastname: Chitimbire
authors.affiliation: Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe.
authors.forename: Shingirai
authors.initials: S
authors.lastname: Makaure
authors.affiliation: Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe.
authors.forename: Joseph
authors.initials: J
authors.lastname: Hove
authors.affiliation: 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.|Department of Medicine, University of Washington, Seattle, WA, United States of America.
authors.forename: Scott
authors.initials: S
authors.lastname: Barnhart
authors.affiliation: International Training and Education Center for Health (I-TECH), Harare, Zimbabwe.
authors.forename: Batsirai
authors.initials: B
authors.lastname: Makunike
mesh_terms: D002944:Circumcision, Male / Q000191:economics*; D017144:Focus Groups; D006801:Humans; D008297:Male; D009042:Motivation; D036301:Qualitative Research; D015030:Zimbabwe