BackgroundPerformance based financing (PBF) has been increasingly implemented across low and middle-income countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn.MethodsOur comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities.ResultsOur analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called ‘PBF principles’ that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes.ConclusionsOur study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.Electronic supplementary materialThe online version of this article (10.1186/s13031-018-0166-9) contains supplementary material, which is available to authorized users.

Background: Relationships of power, responsibility and accountability between health systems actors are considered central to health governance. Despite increasing attention to the role of accountability in health governance a gap remains in understanding how local accountability relations function within the health system in Central Asia. This study addresses this gap by exploring local health governance in two districts of Tajikistan using principal-agent theory. Methods: This comparative case study uses a qualitative research methodology, relying on key informant interviews and focus group discussions with local stakeholders. Data analysis was guided by a framework that conceptualises governance as a series of principal-agent relations between state actors, citizens and health providers. Special attention is paid to voice, answerability and enforceability as crucial components of accountability. Results: The analysis has provided insight into the challenges to different components making up an effective accountability relationship, such as an unclear mandate, the lack of channels for voice or insufficient resources to carry out a mandate. The findings highlight the weak position of health providers and citizens towards state actors and development agents in the under-resourced health system and authoritarian political context. Contestation over resources among local government actors, and informal tools for answerability and enforceability were found to play an important role in shaping actual accountability relations. These accountability relationships form a complex institutional web in which agents are subject to various accountability demands. Particularly health providers find themselves to be in this role, being held accountable by state actors, citizens and development agencies. The latter were found to have established parallel principal-agent relationships with health providers without much attention to the role of local state actors, or strengthening the short accountability route from citizens to providers. Conclusion: The study has provided insight into the complexity of local governance relations and constraints to formal accountability processes. This has underlined the importance of informal accountability tools and the political-economic context in shaping principal-agent relations. The study has served to demonstrate the use and limitations of agency theory in health governance analysis, and points to the importance of entrenched positions of power in local health systems.

Background Community health workers (CHWs) are crucial for increasing access to health services to communities. Due to decades of conflict and under-funding, access to health care in South Sudan remains severely limited. To improve equitable access to healthcare, the government has introduced “the Boma Health Initiative (BHI)”, a strategy to harmonise community health programmes across the country. In order to scale up the BHI, it is necessary to assess the recent CHW programmes and draw lessons for future implementation. This study aimed to explore the characteristics, barriers, and facilitators to the implementation of CHW interventions in South Sudan between 2011 and 2019. Methods The study used a qualitative approach drawing from 26 key informant interviews and a scoping review of 21 Health Pooled Fund (HPF) programme reports from October 2016 to June 2018 and policy documents from 2011 to 2019. The results were thematically analysed based on a conceptual framework on factors influencing the performance of CHWs. Results Funding of CHW programmes has come from international donors, channelled through non-governmental organisations (NGOs) that have implemented a variety of CHW programmes. Communities have been participating in the selection of voluntary CHWs, intervention areas, and occasionally in the supervision of activities performed by CHWs. The coordination mechanisms among stakeholders have been weak, leading to wastage and duplication of resources. Although training of CHWs is done, training duration was short, and refresher-trainings were rare. There were and still are disparities in the type of incentives provided to CHWs. Monitoring and supportive supervision activities have been insufficient; drug misuse and stock-outs were common. Conclusion Despite their challenges, CHW programmes can be implemented in conflict-affected South Sudan if the local human capital is leveraged and engaged by NGOs as implementing partners. Robust coordination efforts are required to build synergies among stakeholders for the effective implementation of the BHI strategy.

Background As performance-based financing (PBF) is increasingly implemented across sub-Saharan Africa, some authors have suggested that it could be a 'stepping stone' for health-system strengthening and broad health-financing reforms. However, so far, few studies have looked at whether and how PBF is aligned to and integrated with national health-financing strategies, particularly in fragile and conflict-affected settings. Objective This study attempts to address the existing research gap by exploring the role of PBF with reference to: (1) user fees/exemption policies and (2) basic packages of health services and benefit packages in the Central African Republic, Democratic Republic of Congo and Nigeria. Methods The comparative case study is based on document review, key informant interviews and focus-group discussions with stakeholders at national and subnational levels. Results The findings highlight different experiences in terms of PBF's integration. Although (formal or informal) fee exemption or reduction practices exist in all settings, their implementation is not uniform and they are often introduced by external programmes, including PBF, in an uncoordinated and vertical fashion. Additionally, the degree to which PBF indicators lists are aligned to the national basic packages of health services varies across cases, and is influenced by factors such as funders' priorities and budgetary concerns. Conclusions Overall, we find that where national leadership is stronger, PBF is better integrated and more in line with the health-financing regulations and, during phases of acute crisis, can provide structure and organisation to the system. Where governmental stewardship is weaker, PBF may result in another parallel programme, potentially increasing fragmentation in health financing and inequalities between areas supported by different donors.

Background Health reform is a fundamentally political process. Yet, evidence on the interplay between domestic politics, international aid and the technical dimensions of health systems, particularly in the former Soviet Union and Central Asia, remains limited. Little regard has been given to the political dimensions of Tajikistan’s Basic Benefit Package (BBP) reforms that regulate entitlements to a guaranteed set of healthcare services while introducing co-payments. The objective of this paper is therefore to explore the governance constraints to the introduction and implementation of the BBP and associated health management changes. Methods This qualitative study draws on literature review and key informant interviews. Data analysis was guided by a political economy framework exploring the interplay between structural and institutional features on the one hand and agency dynamics on the other. Building on that the article presents the main themes that emerged on structure-agency dynamics, forming the key governance constraints to the BBP reform and implementation. Results Policy incoherence, parallel and competing central government mandates, and regulatory fragmentation, have emerged as dominant drivers of most other constraints to effective design and implementation of the BBP and associated health reforms in Tajikistan: overcharging and informal payments, a weak link between budgeting and policymaking, a practice of non-transparent budget bargaining instead of a rationalisation of health expenditure, little donor harmonisation, and weak accountability to citizens. Conclusion This study suggests that policy incoherence and regulatory fragmentation can be linked to the neo-patrimonial character of the regime and donor behaviour, with detrimental consequences for the health system.. These findings raise questions on the unintended effects of non-harmonised piloting of health reforms, and the interaction of health financing and management interventions with entrenched power relations. Ultimately these insights serve to underline the relevance of contextualising health programmes and addressing policy incoherence with long horizon planning as a priority.

Background In fragile and conflict affected settings (FCAS) such as South Sudan, where health needs are immense, resources are scarce, health infrastructure is rudimentary or damaged, and government stewardship is weak, adequate health intervention priority-setting is especially important. There is a scarcity of research examining priority-setting in FCAS and the related political economy. Yet, capturing these dynamics is important to develop context-specific guidance for priority-setting. The objective of this study is to analyze the priority-setting practices in the Health Pooled Fund (HPF), a multi-donor fund that supports service delivery in South Sudan, using a political economy perspective. Methods A multi-method study was conducted combining document review, 30 stakeholder interviews, and an examination of service delivery. An adapted version of the Walt and Gilson policy analysis triangle guided the study’s design and analysis. Results Priority-setting in HPF occurs in a context of immense fragility where health needs are vast, service delivery remains weak, and external funding is essential. HPF's service package gives priority to the health of mothers and children, gender-sensitive programming, immunization services, and a community health initiative. HPF is structured by a web of actors at national and local levels with pronounced power asymmetries and differing vested interests and ideas about HPF’s role. Priority-setting takes place throughout program design, implementing partner (IP) contract negotiation, and implementation of the service package. In practice the BPHNS does not provide adequate guidance for priority-setting because it is too expansive and unrealistic given financial and health system constraints. At the local level, IPs must manage the competing interests of the HPF program and local health authorities as well as challenging contextual factors, including conflict and shortages of qualified health workers, which affect service provision. The resulting priority-setting process remains implicit, scarcely documented, and primarily driven by donors’ interests. Conclusion This study highlights power asymmetries between donors and national health authorities within a FCAS context, which drive a priority-setting process that is dominated by donor agendas and leave little room for government ownership. These findings emphasize the importance of paying attention to the influence of stakeholders and their interests on the priority-setting process in FCAS.

Social accountability has become a favoured approach among most major multilateral and bilateral donors to develop grass roots mechanisms for democratic governance. In a successful scenario, citizen participation can promote more responsive governments and better provision of basic services by linking users’ feedback to the policy design, implementation and monitoring activities typically undertaken by the state. However, there is a lack of agreement about which specific types of social accountability interventions yield the best results and what are the causal pathways that are critical to generate positive changes. This paper presents an analytical framework that identifies the key components that are required to exercise effective direct accountability and provides a blueprint to assess social accountability initiatives. This paper appeared in eucrim, the European Criminal Law Associations’ Forum, 2013/2, published by Max Planck Society for the Advancement of Science, c/o Max Planck Institute for Foreign and International Criminal Law, Freiburg i. B., Germany.

Abstract Despite overwhelming interest in the role of social capital in international development, attention to the interplay of community-based development aid with local collective-action dynamics in Central Asia and particularly Tajikistan has remained limited. This paper investigates donor-induced local institutions for collective action in rural Tajikistan with a focus on the introduction of a community-based health insurance. Social capital and collective-action theories are used to interpret results from qualitative research in two Rushan District villages in the Gorno-Badakhshan region. By highlighting the role of donor embeddedness, and the perceived legitimacy of different decision-making structures, the article contends that the perception of such externally-induced change depends on the community’s capacity to reach beyond the intra-communal solidarity network through bridging and linking capital. The findings suggest this can be fostered by addressing trust, and the role of effective development brokers, with due attention to power relations within communities and towards external agents.