The impact of facility audits, evaluation reports and incentives on motivation and supply management among family planning service providers: an interventional study in two districts in Maputo Province, Mozambique

Abstract

Backrgound: Good progress is being made towards universal access to contraceptives, however stock-outs still jeopardize progress. A seldom considered but important building block in optimizing supply management is the degree to which health workers feel motivated and responsible for monitoring supply. We explored how and to what extent motivation can be improved, and the impact this can have on avoiding stock-outs.

Methods: Fifteen health facilities in Maputo Province, Mozambique, were divided into 3 groups (2 intervention groups and 1 control), and 10 monthly audits were implemented in each of these 15 facilities to collect data through examination of stock cards and stock-counts of 6 contraceptives. Based on these audits, the 2 intervention groups received a monthly evaluation report reflecting the quality of their supply management. One of these 2 groups was also awarded material incentives conditional on their performance. A Wilcoxon-Mann Whitney test was used to detect differences between the groups in the average number of stocked-out centres, while changes over time were verified through applying a Friedman test. Additionally, staff motivation was measured through interviewing health care providers of all centres at baseline, and after 5 and 10 months. To detect differences between the groups and changes over time, a Kruskal Wallis and a Wilcoxon signed-rank test were applied, respectively.

Results: Motivation reported by providers (n = 55, n = 40 and n = 39 at baseline, 1st and 2nd follow-up respectively) was high in all groups, during all rounds, and did not change over time. Facilities in the intervention groups had better supply management results (including less stock-outs) during the entire intervention period compared with those in the control group, but the difference was only significant for the group receiving both material incentives and a monthly evaluation. However, our data also suggest that supply management also improved in control facilities, receiving only a monthly audit. During this study, more stock-outs occurred for family planning methods with lower demand, but the number of stock-outs per family planning method in the intervention groups was only significantly lower, compared with the control group, for female condoms.

Conclusions: While a rise in motivation was not measurable, stock management was enhanced possibly as a result of the monthly audits. This activity was primarily for data collection, but was described as motivating and supportive, indicating the importance of feedback on health workers' accomplishments. More research is needed to quantify the additional impact of the interventions (distribution of evaluation reports and material incentives) on staff motivation and supply management. Special attention should be paid to supply management of less frequently used contraceptive methods.

Keywords: Contraceptives; Family planning services; Health care providers; Incentives; Motivation; Mozambique; Stock-outs; Supply management.

Fig. 1

Project overview

Fig. 2

Baseline supply management. At baseline, out of the 30 stock cards requested in each group (5X6), 25, 27 and 21 stock cards were presented in group 1, 2 and 3, respectively. Calculation mistakes were found on 8 (1/4, 2/4, 3/5, 1/6 and 1/6), 9 (1/4, 1/5, 1/6, 3/6 and 3/6) and 9 (0/2, 2/4, 2/4, 3/5 and 2/6) of the cards in group 1, 2 and 3 (lower estimations), leading to 13/30, 12/30 and 18/30 mistakes according to the upper estimations in these groups, respectively. Similarly, stock were reported on 8 (0/4, 0/4, 3/5, 2/6 and 3/6), 6 (2/4, 0/5, 0/6, 2/6 and 2/6) and 5 (1/2, 0/4, 2/4, 1/5 and 1/6) of the cards in group 1, 2 and 3 (lower estimations), leading to 17/30, 14/30 and 20/30 stock-outs according to the upper estimations in these groups, respectively

Fig. 3

Evaluating supply management per group over 10 months: credits earned each month

Fig. 4

Stock cards of 6 family planning methods available per group over 10 months

Fig. 5

Percentage of stock cards with a calculation mistake per group over 10 months

Fig. 6

Percentage of stock cards reporting a stock-out per group over 10 months

Fig. 7

Number of stock-outs counted at the day of the assessment, per group over 10 months. Group 2: Only 4 centres were assessed during round 1 and 6, instead of 5

Fig. 8

Percentage of stocked out health centres, per method per group over 10 months