Presentation given by Maria Bertone of Queen Margaret University, UK at the International Health Economics Association congress in Basel July 2019

1. ReBUILD is a 6 year £6million research project funded by the UK Department for International Development (DFID)
Political economy approaches to explore
PBF’s adoption, adaption and
implementation in fragile settings
Sophie Witter1, Maria Bertone1, Haja Wurie2, Yotamu Chirwa3, Pamela Chandiwana3
1 IGHD, Queen Margaret University, Edinburgh
2 College of Medicine and Allied Health Sciences, Freetown
3 Biomedical Research and Training Institute, Harare
ReBUILD Research Consortium
Funded by

2. Introduction
 Performance-based financing (PBF) is increasingly implemented in
LMICs, including fragile settings
 Growing literature on its impact, but less attention to the context and
the processes around PBF adoption and implementation
 Why political economy analysis (PEA) for PBF?
 Contested nature of the policy
 Roles of ideas and ideology in the debate
 Focus on financing and resource (re)distribution
 We analyse two case studies:
 Sierra Leone (2010-2017): interesting case because of the ‘start-stop-(start again?)’
trajectory
 Zimbabwe (2011-2018): one of the few nation-wide PBF scheme in SSAfrica

3. Methods
 Retrospective, qualitative case studies
 Analytical frameworks drawing from political economy analysis
 Bringing together the economics of reforms with the politics of change
 Looking at how power and resources are distributed and contested and how interests,
incentives and institutions enable or hinder change
[DfID (2009), Political Economy Analysis How To Note]
Sierra Leone Zimbabwe
Document review n=68 n=60
Key informant interviews n=25 n=40
Direct observation √ √

4. Methods (Sierra Leone)
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. • Decision making
• Roles and power
relationships
• Donors roles and
coordination
Methods (Zimbabwe)
• Support for reform
• Ownership structure and
financing
• Corruption and rent
seeking
• Service delivery
Distribution of resources
• Historical legacies
• Ideologies and values
• Framing of concept
Context Actors
[adapted from DfID (2009),
Political Economy Analysis How To Note]

6. 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)
Pilot by
Cordaid
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
PBF negotiations
(WB + DPPI)
Short
negotiation
process • Resourced-strapped environment (aid
dependency)
• Internal divisions w/in MoH
• Negotiations moved bilaterally (venue
shopping)
Little adaptation
Low capacity
• Challenges of Simple PBF
• (Unsuccessful) attempt to
shift the narrative
• Externally imposed
timing/ funding
cycles
• Dissonance in
framing
Bertone et al (2018), Globalization and Health

7. Timeline
RBF in Zimbabwe
2008 2010 2011 2012 2013 2014 2015 2016 2017
Peak
political
and econ
crisis
Govt of
National
Unity
Pilot in 2
districts
(start)
WB technical
review (price adj)
Pilot scaled
up (18 distr)
HTF support
Mid-term
review
(Cordaid)
RBF impact eval
Quality checklist revised
Tech review
(indicators, bonus)
Sustainability TWG
Start RBF discussion
(WB & MoHCC)
2009 2018
HTF adopts RBF for
PCUs (42 distr)
Pol upheaval
‘new dispensation’
RBF
institutionalisation
in MoHCC (increased
funding), district
hosp included
(Relatively)
longer
negotiation
process
Initially, RBF =
resources in
cash-strapped
environment
• Ownership develops
• Regular adaptations
and changes
• Model fits the existing
system (eg., RBM)
• Careful not to
marginalise some actors
(district managers)
Residual capacity
Remaining challenges:
institutionalisation,
funding, transaction costs
Witter et al (2019), Global Health Research and Policy

8. Discussion
 Differences between FCAS settings
 Lack of resources, but residual capacity in Zimbabwe
 Resource and capacity-strapped environment, internal divisions/external influences in Sierra
Leone
 Structural issues (e.g., power, rent-seeking) are difficult to overcome
 More attention could be paid to other elements to ensure political support and
sustainability of reforms
 ‘Actual frames’ (timing) should remain flexible, allowing for disrupting events as well as for
time to develop national capacity and ownership
 Adopting shared (metaphorical) frames to ensure a common and inclusive understanding of
technical concepts such as PBF
 Some critical elements emerge across the literature:
 Taking time, participatory approaches, tailored design, iterative learning from pilots, local
ownership [see also “four phases framework” for PBF scale-up, Meessen et al (2017)]

9. Methodological reflections
 Advantages of PEA
 Elements identified by PEA contribute to explain implementation outcomes and sustainability,
as well as appropriation and ownership of different actors/groups
 It allows combining insights from multiple theories and approaches (interpretive policy
analysis and framing theory, political settlement theory, process-tracing, etc.)
[‘complementary approach’ in Cairney (2013)]
 Flexibly tailored to the context and issues of interest [‘problem-driven PEA’ in Harris (2013)]
 Relative comparability of findings on key elements also when slightly different approaches
are adopted
 Problematic aspects of PEA
 Difficult to generalise and draw higher level conclusions – though some is possible by
comparing case studies
 “So what?” – usually retrospective analyses, unravelling processes that are context- and time-
specific and issues that are structural and entrenched in the interests and incentives of the
different actors. How can PEA guide practice?
 Multiple roles of some actors as key informants, ‘actors’ within the PE arena and beneficiaries
of potential guidance and/or commissioning research

10. Acknowledgements
This work is part of the ReBUILD research project
(https://rebuildconsortium.com/), funded by the UK’s Department for
International Development (DFID).
The views expressed do not necessarily reflect the UK government’s official
policies.