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

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Study Justification:
– The study aims to address the challenges in delivering prevention of vertical transmission of HIV (PVT) services in rural Mozambique, where the vertical transmission rate is 12%.
– Performance-based incentives (PBIs) have been identified as a promising strategy to improve healthcare delivery to vulnerable populations, but there are gaps in the literature regarding the context of implementation and the development of PBIs.
– This study seeks to fill those gaps by characterizing the barriers and promoters to PVT service delivery in rural Mozambique and assessing the appropriateness of PBIs for addressing these challenges.
Study Highlights:
– The study conducted 24 semi-structured interviews with various healthcare workers involved in PVT service delivery, followed by focus group discussions with a total of 92 participants.
– The interviews revealed that health workers were motivated intrinsically and by social recognition, but they were dissatisfied with low and late remuneration.
– Facility-based staff faced challenges in the opportunity domain, including poor referral and record systems, high workload, stock-outs, poor infrastructure, and delays in obtaining patient results and donor payment discrepancies.
– Community-based health workers faced challenges such as lack of supplies, distance, lack of incorporation into the health system, and incorrect knowledge.
– PBIs based on social recognition and enabling action on intrinsic motivation through training, supervision, and collaboration were considered most effective in addressing these challenges.
Recommendations for Lay Reader and Policy Maker:
– The study recommends a controlled intervention to monitor the effects of incentives on worker motivation and non-incentivized tasks to gain insights into the feasibility of PBIs for improving the delivery of PVT services.
– PBIs that build upon existing intrinsic motivation and leverage social recognition are recommended for targeting improvements in record and referral systems and better integrating community-based health workers into the health system.
Key Role Players Needed to Address Recommendations:
– Nurses, volunteers, community health workers, and traditional birth attendants involved in PVT service delivery.
– District health authorities and implementing partners.
– Ministry of Health.
– Activista associations.
– Malaria Consortium.
Cost Items to Include in Planning Recommendations:
– Training programs for health workers.
– Supervision and support for health workers.
– Collaboration initiatives.
– Improvement of record and referral systems.
– Infrastructure development.
– Provision of necessary supplies.
– Monitoring and evaluation of incentives’ effects on worker motivation and non-incentivized tasks.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it presents findings from a qualitative investigation conducted through semi-structured interviews and focus group discussions. The study design was guided by two complementary frameworks, and the data analysis followed a thematic analysis approach. The study provides detailed information about the barriers and promoters to prevention of vertical transmission of HIV (PVT) service delivery in rural Mozambique and assesses the appropriateness of performance-based incentives (PBIs) for addressing these challenges. The findings highlight the potential of PBIs to improve record and referral systems, integrate community-based health workers, and leverage intrinsic motivation. To improve the evidence, the abstract could include information about the sample sizes for each cadre and the saturation achieved, as well as the specific themes identified through the thematic analysis. Additionally, it would be helpful to mention any limitations of the study and recommendations for future research.

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Two complimentary frameworks were applied to guide the study design and data analysis [6] (Fig. 1). The first was the ecologically embedded determinants of performance research agenda, which is embedded within an ecological framework that places the health worker at the center and moves outwards towards the political and economic environment [19]. The second was the motivation-opportunity-ability framework, which is grounded in human resources and operations management [20] and posits that three domains are required for optimal worker performance [21]. In integrating these frameworks, we operationalized “motivation” as the individual’s desire and willingness to act. “Opportunity” encompassed the many contextual factors that enable action beyond the individual. “Ability” included the skills and knowledge to execute action and overlaps with both the individual level and more distal levels of the ecological determinants of performance framework [6]. The integrated ecological motivation-opportunity-ability framework for health workers delivering prevention of vertical transmission of HIV services, modified from [6] p. 785 Mozambique’s legacy of colonization, war for independence (1964–1974), and civil war (1977–1992) left its health system and infrastructure unprepared for the HIV/AIDS epidemic [22]. Today, Mozambique has only 4 physicians and 41 nurses per 100 000 people, far below the regional average [23]. Task-shifting initiatives such as training mid-level técnicos de cirúrgia (surgical technicians) have helped address the skilled labor shortage for surgical needs [24] but have not alleviated the workload of nurses and midwives who deliver PVT services, which were integrated into antenatal care at the primary care level and free to patients [25]. We conducted this research in 2012 in a rural district in northern Inhambane Province, where CARE International was the PEPFAR-implementing partner. The district had a population of 56 000, few maintained roads, and irregular public transportation. In 2012, there were approximately 2700 pregnancies in the district, with an estimated 53 % of births occurring at health facilities [26]. HIV prevalence among pregnant women attending antenatal care was 10.5 % [27]. The public health system was comprised of one type III health facility in the district capital, one type III peripheral health facility, and four type II peripheral health facilities. The two physicians for the entire district were based at the type III facility in the district capital. A técnico led the largest peripheral health facility and nurses led the others. At the time of the study, the district and large peripheral type III facilities were the only facilities where patients could access ART (when CD4 count ≤350 cells/mm); only antiretroviral prophylaxis was available at the type II peripheral facilities. There were no private health facilities or physicians. A number of curandeiros (traditional healers) practiced in the district. Four cadres of health workers provided PVT services within the district (Table 1). Maternal and child health nurses provided the majority of clinical PVT services at health facilities. Activistas, or community volunteers, provided home care and counseling to individuals living with HIV/AIDS and received supervision and financial support from CARE International. Community health workers (CHWs) provided a broad portfolio of health services to households within 10 km2 of their home [28]. CHWs were trained in late 2011 and began working in early 2012 and received support and supervision from the implementing partner Malaria Consortium in addition to the Ministry of Health [29]. Traditional birth attendants (TBAs) historically assisted with home births but now increasingly focused on referral for health facility deliveries. TBAs were not systematically organized or supervised. Organizational structure and description of key services provided by the four health worker cadres preventing vertical transmission of HIV in rural Mozambique a60 % of the minimum monthly salary, per government recommendations To characterize health workers’ barriers and promoters (objective 1), we recruited members of the four cadres for semi-structured interviews. Maternal and child health nurses were purposively sampled based on their role and type of health facility (district, large peripheral, small peripheral). Key informants from two activista associations identified activistas, who were purposively sampled based on level of engagement. CHWs were identified by their district coordinator and were invited to participate when they visited the health facility to stock-up on supplies. A convenience sample of TBAs attending a training jointly facilitated by the district health authority and CARE International was invited to participate. Sample sizes for each cadre were based upon achieving the saturation needed to outline overarching themes [30], with the intent to expound upon these in subsequent focus group discussions. The interview guide contained questions about participants’ experiences delivering care to HIV-infected women and their HIV-exposed children, as well as their perceptions of the barriers and facilitators mothers face in the uptake of PVT services (Additional File 1). The guide was modified for each health worker cadre and pre-tested with the corresponding cadres in a neighboring district. Two Mozambican research assistants experienced in qualitative research conducted the interviews from September 2012 to January 2013. Interviews were conducted in Xitswa or Portuguese per participant preference and took approximately 60 min. Participants were interviewed in private spaces at health facilities (nurses, activistas), in their communities (CHWs), and training site (TBAs). To share, validate, and expound upon early findings from the interviews (objective 1) and assess the appropriateness of PBIs for PVT service delivery (objective 2), activistas, TBAs, and an array of facility-based health workers were recruited for focus group discussions. Representatives of each health sector at the district and large peripheral facilities and all staff at the small peripheral health facility were invited to participate because key informants strongly felt that all staff contributed to PVT care. All members of the two activista associations were invited to participate. TBAs known to be active in their communities were invited through key informants and snowball recruitment. No focus group was conducted with CHWs because concurrent interviews with HIV-infected mothers did not show women were receiving PVT services from them at that time. We conducted a total of seven focus groups lasting 90–120 min in March 2013. Participants were asked about types of incentives, how goals should be set and assessed, and concerns about implementing PBIs. One focus group was conducted at each of the three health facilities (district type III facility (n = 12); peripheral type III facility (n = 12); type II (n = 3)) in Portuguese. One focus group was conducted with each of the two activista associations in Xitswa at their respective meeting locations (n = 22 each). A sixth focus group with TBAs (n = 6) was conducted in Xitswa at a community meeting location. The final focus group was conducted with representatives from each of the three health facilities and two activista associations (total n = 13). The interviews and focus groups were complimented by participant observation primarily conducted at the three health facilities and at activista meetings between July 2012 and March 2013. Participant observation at the two type III and one type II facilities was conducted at minimum on a biweekly basis at each facility, during facility business hours, and included a few facility-wide meetings on strategies for integrated HIV/AIDS case management. Participant observation at activista association meetings was conducted once per month. Handwritten notes were recorded and were subsequently typed. The interviews and focus groups were audio recorded and accompanied by detailed handwritten notes. The interviews were transcribed into Portuguese, and the detailed notes from the focus groups were typed in Portuguese with the support of the audio recording. All transcripts were translated into English and were coded by two co-authors using the thematic analysis approach [31]. Interview results were shared with focus group participants to prompt further discussion, creating an iterative analysis process. Participant observation data was used to triangulate themes and validate findings [32].

Based on the provided information, here are some potential recommendations for innovations to improve access to maternal health:

1. Performance-based incentives (PBIs): The study suggests that PBIs have the potential to address key barriers faced by health workers in delivering prevention of vertical transmission of HIV (PVT) services. PBIs could be designed to provide social recognition and incentives for health workers, such as training, supervision, and collaboration, to improve record and referral systems and better integrate community-based health workers into the health system.

2. Improved referral and record systems: The study identified poor referral and record systems as a major barrier to delivering PVT services. Innovations could focus on developing digital or mobile-based systems that facilitate efficient and accurate referral and record-keeping processes. This could help streamline communication between health facilities and ensure that patients receive timely and appropriate care.

3. Strengthening infrastructure: Poor infrastructure was identified as a challenge for facility-based health workers. Innovations could focus on improving the physical infrastructure of health facilities, such as ensuring adequate space, equipment, and supplies. This could help create a more conducive environment for delivering maternal health services.

4. Addressing stock-outs: Stock-outs of essential supplies were identified as a challenge for community-based health workers. Innovations could focus on developing supply chain management systems that ensure consistent availability of necessary medications, equipment, and other supplies at health facilities and within the community. This could help prevent disruptions in service delivery and improve access to maternal health services.

5. Training and capacity building: The study highlighted the importance of training and capacity building for health workers. Innovations could focus on developing innovative training programs that provide health workers with the necessary knowledge and skills to deliver high-quality maternal health services. This could include the use of technology-based training platforms or simulation-based training methods.

6. Collaboration and coordination: The study emphasized the need for better integration of community-based health workers into the health system. Innovations could focus on developing mechanisms for improved collaboration and coordination between different cadres of health workers, such as through the use of digital platforms or regular meetings and communication channels. This could help ensure a more holistic and coordinated approach to maternal health service delivery.

It is important to note that these recommendations are based on the specific context and findings of the study mentioned in the description. Further research and evaluation would be needed to assess the feasibility and effectiveness of these innovations in improving access to maternal health in other settings.
AI Innovations Description
The recommendation from the study is to implement performance-based incentives (PBIs) to improve the delivery of prevention of vertical transmission of HIV (PVT) services in rural Mozambique. The study found that health workers in this context were motivated intrinsically and by social recognition, but were dissatisfied with low and late remuneration. They also faced challenges in the opportunity domain, such as poor referral and record systems, high workload, stock-outs, and poor infrastructure. 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 addressing these barriers. However, concerns were raised about neglect of non-incentivized tasks and distorted motivation among colleagues. The study recommends a controlled intervention to monitor the effects of incentives on worker motivation and non-incentivized tasks to gain insights about the feasibility of PBIs to improve the delivery of PVT services.
AI Innovations Methodology
Based on the provided description, the study aims to investigate the barriers and promoters to the delivery of prevention of vertical transmission of HIV (PVT) services in rural Mozambique and assess the appropriateness of using performance-based incentives (PBIs) to address these challenges. The study utilized two complementary frameworks: the ecologically embedded determinants of performance research agenda and the motivation-opportunity-ability framework.

To improve access to maternal health, here are some potential recommendations that can be considered:

1. Strengthening referral and record systems: Implementing a robust referral system and improving record-keeping processes can enhance the coordination and continuity of care for pregnant women, ensuring that they receive the necessary maternal health services.

2. Addressing infrastructure and resource gaps: Investing in improving healthcare infrastructure, such as facilities and equipment, and ensuring the availability of essential supplies and medications can contribute to better access to maternal health services.

3. Enhancing training and supervision: Providing comprehensive training programs for healthcare providers, including nurses, volunteers, community health workers, and traditional birth attendants, can improve their knowledge and skills in delivering maternal health services. Regular supervision and mentoring can also help ensure the quality of care provided.

4. Integrating community-based health workers into the health system: Strengthening the integration of community-based health workers into the formal healthcare system can enhance their role in delivering maternal health services, including prenatal care, postnatal care, and health education.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the number of pregnant women receiving prenatal care, the percentage of facility-based deliveries, and the maternal mortality rate.

2. Collect baseline data: Gather data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, and existing health records.

3. Implement the recommendations: Introduce the recommended interventions, such as strengthening referral systems, improving infrastructure, providing training and supervision, and integrating community-based health workers.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through regular data collection, surveys, and interviews with healthcare providers and pregnant women.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on the selected indicators. Compare the post-intervention data with the baseline data to determine any improvements in access to maternal health.

6. Adjust and refine: Based on the findings, make adjustments and refinements to the interventions as needed. This could involve scaling up successful interventions, addressing any challenges or barriers identified, and continuously monitoring and evaluating the impact.

By following this methodology, it would be possible to simulate the impact of the recommended interventions on improving access to maternal health and make evidence-based decisions on scaling up successful strategies.

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