Counting results: performance-based financing and HIV testing among MSM in China

Abstract

In this paper, I examine the use of performance-based financing to scale-up HIV testing in men who have sex with men, or MSM, by global health initiatives in China. This mechanism, which ties financing directly to the achievement of targets and indicators, assures that measurable results are produced from health interventions and accounts for financial spending. On the one hand, its adoption into HIV programming in China articulates with broader shifts in global health that place currency on particular forms of evidence. At the same time, performance-based financing reshapes how HIV interventions are carried out and what counts in these programmes. The suturing of financing to outputs directs what gets counted and how, and as a consequence leads to the production of measurable results as an end in and of themselves. Based on 22 months of ethnographic research carried out in China, I explore the effects of this mechanism and, in doing so, ask what gets left out in the pursuit of evidence. In particular, I demonstrate how the demand for outputs undermines HIV prevention in MSM, thus risking the very lives these interventions are intended to save.

Keywords:

• HIV/AIDS
• MSM
• evidence
• global health
• China
• ethnographic research

Acknowledgements

Thanks to Elanah Uretsky and all of the contributors to this special section in bringing it together. I also thank Kirsten Bell, Denielle Elliott and the anonymous reviewers for valuable feedback on earlier versions of this piece. Support for this research came from the Wenner-Gren Foundation, National Science Foundation, Institute for Global Conflict and Cooperation and Webster University.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. All names of people in this paper are pseudonyms in order to protect their confidentiality. Places are identified by region only.

2. This is a pseudonym.

3. In China, all HIV screening and confirmation testing must be streamlined through the Chinese CDC in order to be eligible for free ART. Any person referred by an organization for testing must therefore go to the CDC to be tested, and the CDC maintains a record of the referrals by each organization, which is used to confirm payments to the organization by donors.

4. As of 2013, ART is available for anyone with a CD4 count of <500 cells/μL, although in some cities, treatment is administered upon diagnosis (Liu et al., 2015).

5. All US$ figures are based on currency estimates from September 2016.

6. See also the special issue on enumeration, identity and health in Medical Anthropology edited by Sangaramoorthy and Benton (2012).