Project Summary

With funding from the CDC, ThinkWell collaborated with Mozambique’s government to implement the country’s first HIV and MCH-focused performance-based financing (PBF) program across 170 CDC-supported facilities in Nampula and Gaza provinces. We provided technical assistance to guide the program’s design, implementation, institutionalization, and scale-up. Additionally, we worked with provincial health management teams to address health worker policy issues. To ensure program effectiveness and to inform decision-making and adaptive programming, we conducted an impact evaluation of the program. The evaluation’s findings on PBF’s effect on health services in Mozambique were published in Health Policy and Planning. Our findings on PBF’s effects on health worker motivation were published in Human Resources for Health. Our policy analysis of the PBF program’s scale-up was published in the African Journal of AIDS Research.


Since the aftermath of the civil war, Mozambique made remarkable progress on MDGs 4 and 5. Between 1997 and 2011, it halved infant mortality from 147 to 71 deaths per 1000 live birth and reduced maternal mortality from 692 to 408 per 100,000 live births. While these gains were impressive, the devastating impact of the generalized HIV epidemic stagnated progress in the health sector. In 2009, 11.5% of the adult population were living with HIV, accounting for 18.2% of maternal deaths. At the same time, low motivation and poor retention of health workers have crippled the country’s ability to respond to its health challenges. Like many post-colonial countries, Mozambique’s health system was traditionally financed through centralized input provision, which does not directly incentivize productivity. Human resources management systems are weak, further exacerbating motivation and retention issues.


Supporting the implementation of performance-based financing

In 2012, EGPAF implemented the world’s first HIV-focused PBF program as a response to the systemic challenges in the health system. ThinkWell provided overall strategic support to guide the direction of the EGPAF PBF program. Leveraging our wealth of expertise gained from supporting PBF globally, ThinkWell supported the incorporation of global best practices, both strategic and operational. We provided on-going program assessment and review, as well as data analytics for program management.

Strengthening human resources for health

ThinkWell implemented a multi-pronged approach to ensure that well-managed, highly motivated, well-resourced health workers are available. Beyond PBF, ThinkWell worked to improve availability of human resources by developing an innovative HRH Distribution tool. To ensure human resources remain motivated, we worked at the policy level to develop career management systems, supporting the institutionalization of routine in-service training. We also supported the provincial governments of Nampula and Gaza to analyze policy options to provide allowances such as hardship grants, housing, and transport. Finally, ThinkWell supported the development and deployment of a HR management dashboard that contains analytics including workload, attrition rate, transfer rate, and deployment speed.

Providing evidence for policy action

ThinkWell aimed to answer critical questions about the effectiveness and impact of various health systems interventions. Studies included:

  • Impact evaluation of PBF program
  • Qualitative study on factors influencing PBF indicator responsiveness
  • Qualitative study on impact of PBF on human resources motivation and retention
  • Qualitative study on the system-wide effects of PBF
  • Cost-effectiveness analysis of SMS reminders for HIV patients
  • Cost-effectiveness of index-case tracing of HIV patients
  • Impact evaluation of point-of-care data capture