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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

Author

Listed:
  • Caryl Feldacker
  • Aaron F Bochner
  • Amy Herman-Roloff
  • Marrianne Holec
  • Vernon Murenje
  • Abby Stepaniak
  • Sinokuthemba Xaba
  • Mufata Tshimanga
  • Vuyelwa Chitimbire
  • Shingirai Makaure
  • Joseph Hove
  • Scott Barnhart
  • Batsirai Makunike

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. Conclusion: 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.

Suggested Citation

  • Caryl Feldacker & Aaron F Bochner & Amy Herman-Roloff & Marrianne Holec & Vernon Murenje & Abby Stepaniak & Sinokuthemba Xaba & Mufata Tshimanga & Vuyelwa Chitimbire & Shingirai Makaure & Joseph Hove , 2017. "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," PLOS ONE, Public Library of Science, vol. 12(3), pages 1-15, March.
  • Handle: RePEc:plo:pone00:0174047
    DOI: 10.1371/journal.pone.0174047
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    References listed on IDEAS

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    1. Gertler, Paul & Vermeersch, Christel, 2012. "Using performance incentives to improve health outcomes," Policy Research Working Paper Series 6100, The World Bank.
    2. Grant Miller & Kimberly Singer Babiarz, 2013. "Pay-for-Performance Incentives in Low- and Middle-Income Country Health Programs," NBER Working Papers 18932, National Bureau of Economic Research, Inc.
    3. de Walque, Damien & Gertler, Paul J. & Bautista-Arredondo, Sergio & Kwan, Ada & Vermeersch, Christel & de Dieu Bizimana, Jean & Binagwaho, Agnès & Condo, Jeanine, 2015. "Using provider performance incentives to increase HIV testing and counseling services in Rwanda," Journal of Health Economics, Elsevier, vol. 40(C), pages 1-9.
    4. Elisabeth Paul, 2015. "Performance-Based Aid: Why It Will Probably Not Meet Its Promises," Development Policy Review, Overseas Development Institute, vol. 33(3), pages 313-323, May.
    5. Magrath, Priscilla & Nichter, Mark, 2012. "Paying for performance and the social relations of health care provision: An anthropological perspective," Social Science & Medicine, Elsevier, vol. 75(10), pages 1778-1785.
    6. Daniel Low-Beer & Houtan Afkhami & Ryuichi Komatsu & Prerna Banati & Musoke Sempala & Itamar Katz & John Cutler & Paul Schumacher & Ronald Tran-Ba-Huy & Bernhard Schwartländer, 2007. "Making Performance-Based Funding Work for Health," PLOS Medicine, Public Library of Science, vol. 4(8), pages 1-4, August.
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    1. Caryl Feldacker & Vernon Murenje & Batsirai Makunike-Chikwinya & Joseph Hove & Tinashe Munyaradzi & Phiona Marongwe & Shirish Balachandra & John Mandisarisa & Marrianne Holec & Sinokuthemba Xaba & Vuy, 2020. "Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe," PLOS ONE, Public Library of Science, vol. 15(10), pages 1-16, October.
    2. Singh, Neha S. & Kovacs, Roxanne J. & Cassidy, Rachel & Kristensen, Søren R. & Borghi, Josephine & Brown, Garrett W., 2021. "A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries," Social Science & Medicine, Elsevier, vol. 270(C).

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