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The bumpy trajectory of performance-based financing in Sierra Leone _ agency, structure and frames shaping the policy process


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Presentation given by Maria Paula Bertone at the 5th Global Symposium on Health Systems Reseach in Liverpool on Wednesday 10th October 2018.

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The bumpy trajectory of performance-based financing in Sierra Leone _ agency, structure and frames shaping the policy process

  1. 1. ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID) The bumpy trajectory of performance-based financing in Sierra Leone: agency, structure and frames shaping the policy process Maria Bertone; Haja Wurie; Mohamed Samai; Sophie Witter IGHD, Queen Margaret University, Edinburgh COMAHS, University of Sierra Leone ReBUILD Research Consortium Funded by
  2. 2. Introduction  Performance-based financing (PBF) is increasingly implemented in LMICs, including fragile settings  Growing literature on its effects, but less attention to the context and the processes around PBF adoption and implementation  We analyse the processes of negotiation and re-negotiation of PBF in Sierra Leone in the period between 2010 and 2017.  Particularly interesting case because of the ‘start-stop-(start again?)’ trajectory of PBF  This is just a teaser! Full article out soon with Globalization & Health
  3. 3. Methods  Retrospective, qualitative case study  Document review (n=68)  Key informant interviews (n=25)  Direct observation  Analytical framework  ‘Complementary approach’ (Cairney, 2013)  Drawing from political economy analysis and interpretive policy analysis (framing theory and frame-critical analysis)
  4. 4. Policy process Frames & framing Agency features Structural features • Frames/framing • Ideas • Meanings • Narratives/stories • ‘Names’ & naming • Metaphors Frames & framing • Socio- political context • Other contextual features • Historical legacies • Disrupting events • Imposed timings Structural features • Actors • Roles & responsibilities • Interests & agendas • Relative power & influence • ‘Winners & losers’ Agency features
  5. 5. Timeline PBF in Sierra Leone 2009 2010 2011 2012 2013 2014 2015 2016 2017 FHCI announ- cement FHCI launch ‘Simple’PBF at primary care level (start) GAVI scandal PBF external verif. PBF Plus (1 district) End of ‘simple’ PBF (now called ‘PBF Light’) Discussions on new PBF schemeEbola epidemic Salary increase for HWs (HRH TWG+D-HRH) Nationwide PBF implementation (limited changes) PBF negotiations (WB + DPPI)
  6. 6. Actors  Ministry of Health  Lack of capacity: number and skills (esp. after GAVI scandal, but related to hist. legacies)  Internal divisions: different views, agendas, interests  opposition from those not directly involved (other Dept, DHMTs, hospitals, etc.) + donors holding ‘parallel conversations’: venue shopping  Other national bodies  Ministry of Finance: support of the department involved  President: focus on Social Health Insurance (SLeSHI)  External actors  Technical and financial support of the World Bank, but not from HRITF, high staff turn- over – wanting to distance themselves from ‘unsuccessful’ project?  Cordaid’s role in trying to shift narrative to one of ‘success’  Less prominent role of other actors: other agendas (salary supplem.) or ideological opposition, lack of technical skills, staff turnover.
  7. 7. Structure  Historical legacies  Lack of opportunities for specialised education  low technical skills, weak capacity for assessment and evaluation  lack of data and evidence.  Aid dependency  ‘Actual’ frames  Donors’ funding cycles and decisions over timing of negotiations, duration projects, etc.  Disruptions at small scale (GAVI scandal) or larger scale (Ebola epidemic) have major knock-on effects
  8. 8. Frames  Initial narrative  PBF as extra payment to motivate health workers (incentive effect)  PBF as mechanism to provide funds to facilities (income effect)  Later, attempt to shift the narrative to a broader one focused on,  Improvements to working environment and support (intrinsic rewards effect)  Freedom to manage resources (autonomy effect)  Clearer roles and responsibilities, less opportunities for corruption (accountability effect)  All element together: PBF as systemic reform  End of ‘Simple’ PBF (2016):  Narrative was stuck between the problems of the ‘simple’ PBF and the costs of PBF PLUS (high and unsustainable)  Dissonance in framing of the same concept, between national and international actors  Discontinuation of PBF
  9. 9. Conclusions  Retrospective view has analytical advantages, but some guidance for practice emerges  Power and rent-seeking issues are difficult to overcome  More attention could be paid to other elements to ensure political support and sustainability of reforms  Adopting shared (metaphorical) frames to ensure a common and inclusive understanding of technical concepts such as PBF  ‘Actual frames’ should remain flexible, allowing for disrupting events as well as for time to develop national capacity and ownership Bertone MP et al, The bumpy trajectory of performance-based financing in Sierra Leone: agency, structure and frames shaping the policy process. Globalization and Health (forthcoming).