Just as my time in the serene, seaside town of Vilankulo, Mozambique is coming to a close, our project is getting ready to launch. My practicum is with Cooperative for Assistance and Relief Everywhere (CARE) in collaboration with Cornell University, and I’m working on a project called Começando Saudável that will pilot performance based financing (PBF). The overarching goal is to help improve services in the area of prevention of vertical transmission of HIV.
Supported by a two-year grant, the first year of the project focused on investigating the barriers to care experienced by pregnant women living with HIV and designing an incentive scheme to help health workers improve prevention of vertical transmission (PVT) services. The second year, which begins in August, will be the piloting of the PBF scheme. Unique from other PBF pilots, we are incentivizing community based health workers, HIV patient advocates (activistas) and traditional birth attendants (matronas), in addition to public sector health care workers.
When I arrived in May we had to finalize all of our reports on the work done in the first year and start partnering on an incentive plan with the health centers and the associations of activistas and matronas. I helped by using statistics from the previous year to create a baseline to set goals. When we reach our goals related to prenatal care, births in health units, and postnatal care, our partners will be given money to divide among health workers for their performance and to reinvest in the health center or associations for future activities and improvements. The idea being that the extra funds will motivate workers to improve services and attend to more women.
We hope to create evidence to advocate for the use of performance based incentives in improving health care services; therefore, it is imperative that we accurately measure performance and motivation in order to show changes. These past two weeks have been hectic and involved a lot of field time with partners as we are put our measurement tools into place. We have been busy testing our survey to measure healthcare worker motivation and have also helped train health workers in using our reporting tools for maternal and child health services.
In order to explore PBF’s effects on motivation, we will measure health care worker motivation, in addition to measuring services rendered.. Designing a motivation survey has been a learning process for us. First of all, how do you even start to measure someone’s motivation? It’s multifactorial and not easy to simplify, but we’ve tried to paint a picture of motivation by asking about workload, feeling of preparedness, support from colleagues, perceived closeness with colleagues, supervision style and feedback, and sense of appreciation. Then, after designing the ideas we want to capture, we’ve had to pose our questions in a way that is clear and holds the same meaning for everyone.
I’ve had fun working with our team through training, practicing administering the survey, and laughing at my spelling errors in Portuguese. Most of our surveys will be administered in Xitswa, a local language that is rarely written, so our interviewers have to practice orally and make sure they use the same translations for consistency. It was fun seeing my colleagues sit around and debate which words to use.
Xitswa was also used in our trainings to community based health workers in PVT messages and reporting tools. It’s hard to follow, but I could at least enjoy watching the role-playing, songs and cheers our participants did. There was some laughter and I was happy to see our participants so animated. I feel inspired to meet the people who work with the community’s interest at heart and earn little or nothing in return. Having met hard working and inspiring health care workers, I feel fortunate to see their dedication, and receive such great support from my colleagues at CARE.