Performance indicator as the main and the only goal: a “dark side” of the intervention aims to accelerate HIV treatment entry among people who inject drugs in Kyiv, Ukraine

BACKGROUND: To improve healthcare entry and antiretroviral therapy (ART) initiation for HIV-positive people who inject drugs (PWID) in Ukraine, an intervention built upon a successful community-based harm reduction project and the existing best practices was developed. In this article, we present the results of the study conducted in collaboration with one of the recipient organizations of the intervention in Kyiv. The research question was formulated as follows: how does the interaction between different actors work to lead it to a positive outcome (initiation PWIDs into ART) within the limited period of the intervention implementation? METHODS: The central focus of the study was on the work activities of case managers. Their daily routines as well as their interactions with their clients and medical workers were observed and analyzed. Using the institutional ethnography approach, we explore the institutional orders, power imbalances, and social factors that play different roles in coordinating the process of PWIDs entry into healthcare and HIV treatment. RESULTS: The most intriguing result of the study is that the performance indicator that must be completed in order to receive a full salary—as a way to manage the activities of case managers—produces conditions for them to develop their cooperation with medical workers but leaves the clients and their needs out of this “boat” because interaction with them, in fact, does not help to meet case managers’ goals. CONCLUSIONS: Accountability of case managers’ work assumes the primacy of the result over the process, which makes the process itself less important and the need to achieve the goal becomes the main and the only goal. This can be identified as an unintended consequence of the intervention implementation on the ground, or wider—an unintended consequence of the payment by results practice as a part of the general number-based policy.