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

Abstract

BackgroundAs performance-based financing (PBF) has been increasingly implemented in low-income countries, a growing literature has developed, assessing its effectiveness and, more recently, focussing on the political dynamics of PBF introduction and implementation. This study contributes to the latter body of literature by exploring decision-making processes on PBF in Sierra Leone during the 2010–2017 period. Sierra Leone presents an interesting case because of the ‘start-stop-start’ trajectory of PBF.MethodsThe qualitative case study is based on a document review and 25 key informant interviews with national stakeholders and international actors. Documents and interviews were analysed based on a political economy framework focusing on actors and structure, but also making use of concepts drawn from interpretive policy analysis to look at frames.ResultsOur analysis describes the process of negotiation and re-negotiation of PBF in Sierra Leone, highlighting the role of different players, both internal and external, their ideas, capacity and power relations, and the shifting narratives around PBF. It is shown that external actors driving the debate make use of ‘frames’, both actual (i.e., defining the timing and pace of the discussions, the funding available, etc.) and metaphorical (i.e., how PBF is interpreted, defined and understood) to fit in and influence the debate. This is facilitated by the lack of capacity and resources in the fragile setting. Other strategies, such as ‘venue shopping’ are employed, though they may add to fragmentation in the volatile context.ConclusionsThe retrospective view of the study has an analytical advantage, but findings are also relevant to guide practice. Although power relations and rent-seeking issues are difficult to overcome in resource and capacity-constrained settings, more attention could be paid to other elements. In particular, adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the ‘actual frames’ which define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) as well as for time to develop national capacity and ownership in order to ensure longer-term political support and better health system integration.

Effects in spite of tough constraints - A theory of change based investigation of contextual and implementation factors affecting the results of a performance based financing scheme extended to malnutrition in Burundi

“…Context has played an important role in the story of PBF-N. This observation is not atypical for an intervention in a FCAS and has been documented in other studies on PBF in such settings [16,[63][64][65].…”

“…Alongside evaluations focused on the impact of PBF [11][12][13], we have now studies investigating the actual theories of change, with a plurality of situations and practices which prevail. One can highlight, for instance, the recent work by the ReBUILD team on how PBF works in Fragile and post-Conflict Affected Settings (FCAS) [14][15][16], the comprehensive analysis of the RBF scheme in Malawi by De Allegri and colleagues [17] or the research program carried out by Borghi and colleagues, mainly in Tanzania [18].…”

Addressing HIV-related stigma and discrimination in healthcare settings: development and contextualization of guideline recommendations

“…Quality of evidence was assigned as high, moderate, low or very low [15]. To assign strength of evidence for each recommendation, we used the World Health Organization (WHO) handbook for guideline development as a guidance [16].…”

“…We worded the recommendations considering the quality and the strength of evidence associated with the recommendations. We worded recommendations having strong evidence for the associated intervention as "must", "should", "need to" and other strong words [16]. On the other hand, we worded recommendations with weak evidence supporting the associated interventions with weak terms such as "may," "might," and similar words [16].…”

“…The quality of evidence of guideline recommendations is assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach [14]. Additionally, strength of a recommendation, or the extent to which one can be con dent that the desirable effects of the recommended actions outweigh the undesirable effects are incorporated in developing guideline recommendations [15][16][17]. The World Health Organization (WHO) handbook for guideline development provides four criteria to judge the strength of recommendations: a) quality of evidence.…”