Political Prioritisation for Performance-Based Financing at the County Level in Kenya: 2015 to 2018

Document Type : Original Article

Authors

1 Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya

2 Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

3 Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

4 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK

5 Health Systems Research Group, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya

Abstract

Background 
Performance-based financing (PBF) was introduced to Kilifi county in Kenya in 2015. This study investigates how and why political and bureaucratic actors at the local level in Kilifi county influenced the extent to which PBF was politically prioritised at the sub-national level.

Methods 
The study employed a single-case study design. The Shiffman and Smith political priority setting framework with adaptations proposed by Walt and Gilson was applied. Data was collected through document review (n = 19) and in-depth interviews (n = 8). Framework analysis was used to analyse data and generate findings.

Results 
In the period 2015-2018, the political prioritisation of PBF at the county level in Kilifi was influenced by contextual features including the devolution of power to sub-national actors and rigid public financial management (PFM) structures. It was further influenced by interpretations of the idea of ‘pay-for-performance,’ its framing as ‘additional funding,’ as well as contestation between actors at the sub national level about key PBF design features. Ultimately PBF ceased at the end of 2018 after donor funding stopped.

Conclusion 
Health reformers must be cognisant of the power and interests of national and sub national actors in all phases of the policy process, including both bureaucratic and political actors in health and non-health sectors. This is particularly important in devolved public governance contexts where reforms require sustained attention and budgetary commitment at the sub national level. There is also need for early involvement of critical actors to develop shared understandings of the ideas on which interventions are premised, as well as problems and solutions.

Keywords


  1. World Health Organization (WHO). Health Financing for Universal Coverage. 2019. https://www.who.int/health_financing/topics/performance-based-financing/universal-health-coverage/en/.
  2. Eichler R, Auxila P, Antoine U, Desmangles B. Performance-Based Incentives for Health: Six Years of Results from Supply-Side Programs in Haiti. Washington, DC: Centre for Global Development; 2007.
  3. World Health Organization (WHO). Aid Effectiveness and Health. WHO; 2007.
  4. Meessen B, Soucat A, Sekabaraga C. Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform? Bull World Health Organ. 2011;89(2):153-156. doi:2471/blt.10.077339
  5. Morgan L. Results-Based Financing for Health (RBF): What’s All the Fuss About? 2014. https://www.rbfhealth.org/resource/results-based-financing-health-rbf-what%E2%80%99s-all-fuss-about.
  6. Shroff ZC, Bigdeli M, Meessen B. From scheme to system (part 2): findings from ten countries on the policy evolution of results-based financing in health systems. Health Syst Reform. 2017;3(2):137-147. doi:1080/23288604.2017.1304190
  7. Gautier L, De Allegri M, Ridde V. How is the discourse of performance-based financing shaped at the global level? A poststructural analysis. Global Health. 2019;15(1):6. doi:1186/s12992-018-0443-9
  8. Oxman AD, Fretheim A. Can paying for results help to achieve the Millennium Development Goals? Overview of the effectiveness of results-based financing. J Evid Based Med. 2009;2(2):70-83. doi:1111/j.1756-5391.2009.01020.x
  9. De Allegri M, Bertone MP, McMahon S, Mounpe Chare I, Robyn PJ. Unraveling PBF effects beyond impact evaluation: results from a qualitative study in Cameroon. BMJ Glob Health. 2018;3(2):e000693. doi:1136/bmjgh-2017-000693
  10. Soucat A, Dale E, Mathauer I, Kutzin J. Pay-for-performance debate: not seeing the forest for the trees. Health Syst Reform. 2017;3(2):74-79. doi:1080/23288604.2017.1302902
  11. Waithaka D, Cashin C, Barasa E. Is performance-based financing a pathway to strategic purchasing in sub-Saharan Africa? A synthesis of the evidence. Health Syst Reform. 2022;8(2):e2068231. doi:1080/23288604.2022.2068231
  12. Paul E, Renmans D. Performance-based financing in the heath sector in low- and middle-income countries: is there anything whereof it may be said, see, this is new? Int J Health Plann Manage. 2018;33(1):51-66. doi:1002/hpm.2409
  13. Paul E, Albert L, Bisala BN, et al. Performance-based financing in low-income and middle-income countries: isn't it time for a rethink? BMJ Glob Health. 2018;3(1):e000664. doi:1136/bmjgh-2017-000664
  14. Antony M, Bertone MP, Barthes O. Exploring implementation practices in results-based financing: the case of the verification in Benin. BMC Health Serv Res. 2017;17(1):204. doi:1186/s12913-017-2148-9
  15. Ridde V, Yaogo M, Zongo S, Somé PA, Turcotte-Tremblay AM. Twelve months of implementation of health care performance-based financing in Burkina Faso: a qualitative multiple case study. Int J Health Plann Manage. 2018;33(1):e153-e167. doi:1002/hpm.2439
  16. Zitti T, Gautier L, Coulibaly A, Ridde V. Stakeholder perceptions and context of the implementation of performance-based financing in district hospitals in Mali. Int J Health Policy Manag. 2019;8(10):583-592. doi:15171/ijhpm.2019.45
  17. Gautier L. From Ideas to Policymaking: The Political Economy of the Diffusion of Performance-Based Financing at the Global, Continental, and National Levels [thesis]. Université de Montréal; 2019.
  18. Barnes A, Brown GW, Harman S. Locating health diplomacy through African negotiations on performance‐based funding in global health. Journal of Health Diplomacy. 2015;1(3):1-19.
  19. Kiendrébéogo JA, Shroff ZC, Berthé A, Yonli L, Béchir M, Meessen B. Why performance-based financing in Chad failed to emerge on the national policy agenda. Health Syst Reform. 2017;3(2):80-90. doi:1080/23288604.2017.1280115
  20. Chimhutu V, Tjomsland M, Songstad NG, Mrisho M, Moland KM. Introducing payment for performance in the health sector of Tanzania- the policy process. Global Health. 2015;11:38. doi:1186/s12992-015-0125-9
  21. Sieleunou I, Turcotte-Tremblay AM, Fotso JT, et al. Setting performance-based financing in the health sector agenda: a case study in Cameroon. Global Health. 2017;13(1):52. doi:1186/s12992-017-0278-9
  22. Government of Kenya (GoK). Constitution of Kenya. National Council for Law; 2010.
  23. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370(9595):1370-1379. doi:1016/s0140-6736(07)61579-7
  24. World Bank. The KHSSP implementation completion and results report. World Bank; 2019.
  25. Waweru E, Goodman C, Kedenge S, Tsofa B, Molyneux S. Tracking implementation and (un)intended consequences: a process evaluation of an innovative peripheral health facility financing mechanism in Kenya. Health Policy Plan. 2016;31(2):137-147. doi:1093/heapol/czv030
  26. Opwora A, Kabare M, Molyneux S, Goodman C. Direct facility funding as a response to user fee reduction: implementation and perceived impact among Kenyan health centres and dispensaries. Health Policy Plan. 2010;25(5):406-418. doi:1093/heapol/czq009
  27. Ministry of Health (MoH). Results Based Financing (RBF) Scale Up 2014-2016: Draft 1 of the Operational Manual. MoH; 2014.
  28. Tsofa B, Molyneux S, Gilson L, Goodman C. How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya. Int J Equity Health. 2017;16(1):151. doi:1186/s12939-017-0649-0
  29. Government of Kenya (GoK). Public Financial Management Act, 2012. GoK; 2012.
  30. Barasa EW, Manyara AM, Molyneux S, Tsofa B. Recentralization within decentralization: county hospital autonomy under devolution in Kenya. PLoS One. 2017;12(8):e0182440. doi:1371/journal.pone.0182440
  31. Walt G, Gilson L. Can frameworks inform knowledge about health policy processes? Reviewing health policy papers on agenda setting and testing them against a specific priority-setting framework. Health Policy Plan. 2014;29 Suppl 3:iii6-22. doi:1093/heapol/czu081
  32. Tomlinson M, Lund C. Why does mental health not get the attention it deserves? An application of the Shiffman and Smith framework. PLoS Med. 2012;9(2):e1001178. doi:1371/journal.pmed.1001178
  33. Shawar YR, Shiffman J, Spiegel DA. Generation of political priority for global surgery: a qualitative policy analysis. Lancet Glob Health. 2015;3(8):e487-e495. doi:1016/s2214-109x(15)00098-4
  34. Prata N, Summer A. Assessing political priority for reproductive health in Ethiopia. Reprod Health Matters. 2015;23(46):158-168. doi:1016/j.rhm.2015.11.004
  35. Daire J, Kloster MO, Storeng KT. Political priority for abortion law reform in Malawi: transnational and national influences. Health Hum Rights. 2018;20(1):225-236.
  36. Yin RK. Case Study Research: Design and Methods. 5th ed. Thousand Oaks, CA: ‎SAGE Publications; 2014.
  37. County Government of Kilifi. Kilifi County Integrated Development Plan 2018-2022. Kilifi: County Government of Kilifi; 2018.
  38. Barasa E, Boga M, Kagwanja N, et al. Learning sites for health system governance in Kenya and South Africa: reflecting on our experience. Health Res Policy Syst. 2020;18(1):44. doi:1186/s12961-020-00552-6
  39. National Treasury. County Allocation of Revenue Act (CARA) of 2015. National Treasury of Kenya; 2015.
  40. Financing agreement between International Development Agency and the republic of Kenya. GoK; 2014.
  41. Results Based Financing (RBF) Scale Up 2015-2018: Final draft of the Operational Manual. MoH; 2017.
  42. National Treasury. National guidelines on the transfer of conditional grants (such as PBF) to county governments. Nairobi: In: National Treasury; 2015.
  43. Kilifi county financial guidelines on disbursement, use and reporting PBF. Nairobi: MoH; 2017.
  44. Capacity building for PBF scale up: invitation to facilitate as PBF master trainer of trainees (TOT). Nairobi: MoH; 2015.
  45. Capacity building for PBF scale up: Nominees for PBF trainer of trainees (ToT) workshop 14th-18th September at the Kenya School of Government, Nairobi. Nairobi: MoH; 2015.
  46. Capacity building for PBF scale up: Cascading PBF training in the counties. Nairobi: MoH; 2016.
  47. PBF Progress Update for the Financial Year 2015/2016. MoH; 2016.
  48. PBF procurement guidelines for essential equipment. MoH; 2017.
  49. Kilifi sub-county health managers appointment letters to the Joint verification Team. Kilifi: CDoH; 2018.
  50. Alliance for Health Policy and Systems Research (AHPSR). The Piloting and Scaling Up of Performance-Based Financing (PBF) in Healthcare in a Devolved Governance System: Experiences from Kenya Between July 2011 and May 2015. AHPSR; 2015.
  51. World Bank. Implementation completion and results report: The Kenya Health Sector Support Project (KHSSP). World Bank; 2019.
  52. Obare F, Bellows B. Technical Assessment of the Performance-Based Finance Samburu Pilot Program in Kenya. Nairobi: Population Council; 2014.
  53. Population Council. Evaluation of Performance-Based Finance (PBF) Pilot in Samburu County, Kenya-Qualitative Research Findings. Population Council; 2013.
  54. World Bank Group. RBF Health Kenya. 2014. https://www.rbfhealth.org/rbfhealth/country/kenya.
  55. The Standard- Health. Kenya receives 2.5 billion Kenyan Shillings to improve healthcare. 2016.
  56. Green J. Qualitative Methods for Health Research. 3rd ed. Los Angeles: SAGE Publications; 2014.
  57. Bryman A. Analyzing Qualitative Data. New York: Routledge; 1993.
  58. Nxumalo N, Gilson L, Goudge J, et al. Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa. BMJ Glob Health. 2018;3(4):e000842. doi:1136/bmjgh-2018-000842
  59. Sriram V, Topp SM, Schaaf M, et al. 10 best resources on power in health policy and systems in low- and middle-income countries. Health Policy Plan. 2018;33(4):611-621. doi:1093/heapol/czy008
  60. Agyepong IA, Adjei S. Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health Policy Plan. 2008;23(2):150-160. doi:1093/heapol/czn002
  61. Lavers T. Towards universal health coverage in Ethiopia's 'developmental state'? The political drivers of health insurance. Soc Sci Med. 2019;228:60-67. doi:1016/j.socscimed.2019.03.007
  62. Tsofa B, Goodman C, Gilson L, Molyneux S. Devolution and its effects on health workforce and commodities management–early implementation experiences in Kilifi County, Kenya. Int J Equity Health. 2017;16(1):169. doi:1186/s12939-017-0663-2
  63. Frasca T, Fauré YA, Atlani-Duault L. Decentralisation of Brazil's HIV/AIDS programme: intended and unintended consequences. Glob Public Health. 2018;13(12):1725-1736. doi:1080/17441692.2018.1455888
  64. Kolehmainen-Aitken RL, Newbrander WC. Decentralizing the Management of Health and Family Planning Programs: Lessons from FPMD. FPMD Project, Management Sciences for Health; 1997.
  65. Lewis BD. Indonesian local government spending, taxing and saving: an explanation of pre- and post-decentralization fiscal outcomes. Asian Econ J. 2005;19(3):291-317. doi:1111/j.1467-8381.2005.00214.x
  66. Chemouni B. The political path to universal health coverage: power, ideas and community-based health insurance in Rwanda. World Dev. 2018;106:87-98. doi:1016/j.worlddev.2018.01.023
  67. Grindle M, Thomas J. Public Choices and Policy Change: The Political Economy of Reform in Developing Countries. Johns Hopkins University Press; 1991.
  68. Crichton J. Changing fortunes: analysis of fluctuating policy space for family planning in Kenya. Health Policy Plan. 2008;23(5):339-350. doi:1093/heapol/czn020
  69. Gilson L. Reflections from South Africa on the value and application of a political economy lens for health financing reform. Health Syst Reform. 2019;5(3):236-243. doi:1080/23288604.2019.1634382
  70. Gilson L, Orgill M, Shroff ZC. A Health Policy Analysis Reader: The Politics of Policy Change in Low- and Middle-Income Countries. World Health Organization; 2018.
  • Receive Date: 02 November 2021
  • Revise Date: 24 October 2022
  • Accept Date: 17 January 2023
  • First Publish Date: 18 January 2023