Cornell’s Atkinson Center for a Sustainable Future and CARE are working together to improve health services for HIV in Mozambique.

Empowerment key to HIV health worker retention in Mozambique

A Cornell collaboration with international humanitarian agency CARE has found that providing health workers with financial incentives tied to their performance could boost their sense of empowerment and improve health services treating women and children with HIV in Mozambique.

Transmission of HIV from mothers to children via pregnancy, birth and breastfeeding is an urgent health issue in Mozambique, where approximately 1.8 million adults and children are living with HIV, according to the Joint United Nations Programme on HIV/AIDS. Complicating matters, the national health system has struggled to train and retain motivated, skilled health workers to provide services that prevent the transmission of HIV among these women and children.

“In a public health system — where one can easily make more money working for an NGO or even in the private sector opening a clinic — retaining motivated health workers in a low-resource, understaffed and perhaps overworked facility can be a challenge,” said Roseanne Schuster, Ph.D. ’16, a co-leader of the study with her then-doctoral adviser Sera Young, now an assistant professor of anthropology and global health at Northwestern University.

Over the past decade, one promising approach has been performance-based financing (PBF), a strategy that aims to improve health worker motivation by offering financial incentives tied to performance and the achievement of organizational goals. However, there has been a growing debate about whether PBF is effective.

“It’s a real challenge for program buy-in when working closely with leaders to co-create and co-design PBF with health facilities,” said Schuster, director of monitoring, evaluation and learning practice and innovation for the Global Impact Collaboratory at Arizona State University. “We need to be careful when adding extra tasks onto health workers in a system that is already overburdened … health workers often face longer hours, have access to fewer resources and face constant pressure to provide critical services that save lives.”

“In a public health system — where one can easily make more money working for an NGO or even in the private sector opening a clinic — retaining motivated health workers in a low-resource, understaffed and perhaps overworked facility can be a challenge.” — Roseanne Schuster, Ph.D. ’16

But the Cornell-led research team found that PBF does, in some contexts, lead to increased teamwork and empowerment, and retention. The team discovered that health workers who determined how financial incentives would be dispersed among themselves and the facilities, and were involved with setting organizational goals, felt more deeply engaged with their colleagues, patients and workplace.

The study, “Performance-based financing empowers health workers delivering prevention of vertical transmission of HIV services and decreases desire to leave in Mozambique” was published in January in the International Journal of Health Policy and Management.

The Cornell-CARE research team spent two years in northern Inhambane province, co-designing and implementing a one-year trial with three health facilities, the District Health Authority and CARE Mozambique. Financial incentives were dispersed each quarter, based on meeting predetermined health facility-specific goals tied to the number of women and children served. Forty-five percent of PBF incentives earned were directed to health workers as personal incentives. The remainder was allocated for health facility improvements determined by committees at each facility, which included physical upgrades to the maternity wards and improved hygiene and privacy conditions to incentivize women to visit the health facilities. The maximum financial incentive over one year was equivalent to one month’s salary.

The researchers noted that involving health workers in developing group goals allowed them to see for themselves what was working and what they could improve to receive their incentive. This sense of autonomy empowered the workers to demand greater accountability from the health facility’s administration.

While PBF shows promise in retaining skilled health workers, Schuster warns that it is not a panacea, and requires careful consideration before deciding if it is an appropriate strategy for a given health environment.

“What are the motivational forces, what is the workload and what is the burnout context — you really need to look at all of these when thinking about whether PBF is a sustainable solution. Otherwise it can distort motivation and lead to long-term, unintended and likely negative consequences,” said Schuster.

The study was supported by the Atkinson Center for a Sustainable Future and CARE.


Liz Gustafson is a freelance writer for the Atkinson Center for a Sustainable Future.