Political prioritisation for performance-based financing at the county level in Kenya: 2016 to 2019

Master Thesis


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Background: Performance based financing was introduced to Kilifi county actors in Kenya in 2015. Kilifi was identified by the Kenyan national government as one of the 20 arid and semi-arid counties (out of 47 counties) mandated to start the implementation of the scheme and potentially inform the development of a nation-wide PBF policy. This study investigates how political and bureaucratic actors at the local level in Kilifi county have subsequently influenced the extent to which PBF has been politically prioritised at the sub-national level. Methods: The study employed a single-case study design. The Shiffman and Smith (2007) political priority setting framework with adaptations proposed by Walt and Gilson (2014) was used. Data was collected through document review (n=19) and in-depth interviews (n=8). Framework analysis was used to analyse data and generate findings. Results: Throughout the study period (2015-2018), national policy elites gave sustained attention to PBF as a priority issue for implementation, this sustained attention was however not present at the sub national level in Kilifi county and funding for PBF was not prioritised post donor funding. Key factors that contributed to this in Kilifi county included: redistribution of power from national actors to sub-national actors following devolution, this affected the national Ministry of Health's ability to lead and be an effective guiding organisation; misalignment between the globally advocated idea of ‘pay for performance' and the local pre-existing centralised and rigid approaches to public financial management; and actors at the sub national level who contested the PBF intervention design features and its framing as ‘additional funding'. As a consequence, the implementation of PBF in Kilifi was for a short time only using donor resources and did not last beyond donor timelines and funding. Conclusion: This research shows that for health reforms to gain political priority in highly devolved contexts, there is need to recognise the formal and informal institutions existing at the devolved level of governance and for adequate early involvement and leadership from sub-national bureaucratic and political actors, in health and beyond the health sector. In addition, advocacy for the health reforms should embody frames that align with the political context to increase the chances of gaining political traction. Finally, the political context including political and bureaucratic power at different levels of government are crucial features that will also influence the acceptability of reform and ultimately political prioritisation.