Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
Int J Health Policy Manag. 2023;12:6909. doi: 10.34172/ijhpm.2023.6909. Epub 2023 Feb 14.
Performance based financing 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.
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.
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 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.
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.
绩效激励型融资模式于 2015 年在肯尼亚基利菲县引入。本研究旨在调查基利菲县地方一级的政治和官僚行为体如何以及为何影响了该模式在国家以下各级的政治优先程度。
本研究采用单案例研究设计。采用了经 Shiffman 和 Smith 以及 Walt 和 Gilson 调整后的政治优先事项设定框架。通过文件审查（n=19）和深入访谈（n=8）收集数据。采用框架分析法分析数据并得出结论。
在 2015 年至 2018 年期间，基利菲县对绩效激励型融资模式的政治优先程度受到了一些因素的影响，包括权力下放到国家以下各级的行为体以及僵化的公共财务管理结构等背景特征。此外，对“绩效激励”理念的解读、将其框定为“额外资金”以及国家以下各级行为体对关键绩效激励型融资模式设计特征的争议也影响了该模式的政治优先程度。最终，在捐助资金停止后，该模式于 2018 年底停止。
卫生改革者必须认识到国家和国家以下各级行为体在政策制定过程的所有阶段的权力和利益，包括卫生和非卫生部门的官僚和政治行为体。在权力下放的公共治理背景下，这一点尤为重要，因为改革需要在国家以下各级持续关注并承诺预算。还需要让关键行为体尽早参与进来，以便对干预措施的理念、问题和解决方案达成共识。
