Abstract
Background: 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.
Methods: 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.
Results: 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).
Conclusion: 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.