An exploration of the political economy dynamics shaping health worker incentives in three districts in Sierra Leone.

The need for evidence-based practice calls for research focussing not only on the effectiveness of interventions and their translation into policies, but also on implementation processes and the factors influencing them, in particular for complex health system policies. In this paper, we use the lens of one of the health system's 'building blocks', human resources for health (HRH), to examine the implementation of official policies on HRH incentives and the emergence of informal practices in three districts of Sierra Leone. Our mixed-methods research draws mostly from 18 key informant interviews at district level. Data are organised using a political economy framework which focuses on the dynamic interactions between structure (context, historical legacies, institutions) and agency (actors, agendas, power relations) to show how these elements affect the HRH incentive practices in each district. It appears that the official policies are re-shaped both by implementation challenges and by informal practices emerging at local level as the result of the district-level dynamics and negotiations between District Health Management Teams (DHMTs) and nongovernmental organisations (NGOs). Emerging informal practices take the form of selective supervision, salary supplementations and per diems paid to health workers, and aim to ensure a better fit between the actors' agendas and the incentive package. Importantly, the negotiations which shape such practices are characterised by a substantial asymmetry of power between DHMTs and NGOs. In conclusion, our findings reveal the influence of NGOs on the HRH incentive package and highlight the need to empower DHMTs to limit the discrepancy between policies defined at central level and practices in the districts, and to reduce inequalities in health worker remuneration across districts. For Sierra Leone, these findings are now more relevant than ever as new players enter the stage at district level, as part of the Ebola response and post-Ebola reconstruction

Data for: "Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone"

Data collection produced as part of a study on the contribution of performance-based financing (PBF) to health workers’ income in Sierra Leone, and views on PBF bonuses, in comparison to and interaction with other incomes. It includes a longitudinal logbook used to collect information on the income of primary health workers in Sierra Leone over an eight-week period, a questionnaire used for in-depth interviews with selected workers, and an anonymised dataset of survey results

Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone.

BACKGROUND: There is growing interest on the impact of performance-based financing (PBF) on health workers' motivation and performance. However, the literature so far tends to look at PBF payments in isolation, without reference to the overall remuneration of health workers. Taking the case of Sierra Leone, where PBF was introduced in 2011, this study investigates the absolute and relative contribution of PBF to health workers' income and explores their views on PBF bonuses, in comparison to and interaction with other incomes. METHODS: The study is based on a mixed-methods research consisting in a survey and an 8-week longitudinal logbook collecting data on the incomes of primary health workers (n = 266) and 39 in-depth interviews with a subsample of the same workers, carried out in three districts of Sierra Leone (Bo, Kenema and Moyamba). RESULTS: Our results show that in this setting PBF contributes about 10 % of the total income of health workers. Despite this relatively low contribution, their views on the bonuses are positive, especially compared to the negative views on salary. We find that this is because PBF is seen as a complement, with less sense of entitlement compared to the official salary. Moreover, PBF has a specific role within the income utilization strategies enacted by health workers, as it provides extra money which can be used for emergencies or reinvested in income generating activities. However, implementation issues with the PBF scheme, such as delays in payment and difficulties in access, cause a series of problems that limit the motivational effects of the incentives. Overall, staff still favor salary increases over increases in PBF. CONCLUSIONS: The study confirms that the remuneration of health workers is complex and interrelated so that the different financial incentives cannot be examined independently from one. It also shows that the implementation of PBF schemes has an impact on the way it does or does not motivate health workers, and must be thoroughly researched in order to assess the impact of PBF

Sources, determinants and utilization of health workers’ revenues: Evidence from Sierra Leone

Bertone, Maria Paola - ORCID 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XItem previously deposited in London School of Hygiene & Tropical Medicine repository: https://researchonline.lshtm.ac.uk/2536602/Exploring the entire set of formal and informal payments available to health workers (HWs) is critical to understand the financial incentives they face and devise effective incentive packages to motivate them. We investigate this issue in the context of Sierra Leone by collecting quantitative data through a survey and daily logbooks on the incomes of 266 HWs in three districts, and carrying out 39 qualitative in-depth interviews. We find that, while earnings related to the HWs official jobs represent the largest share, their income is fragmented and composed of a variety of payments, and there is a large heterogeneity in the importance of each income source within the total remuneration. Importantly, each income has different features in terms of regularity, reliability, ease of access, etc. Our analysis also reveals the determinants of the incomes received and their level based on individual and facility characteristics, and finds that these are not in line with HRH policies defined at national level. Additionally, from their narratives, it emerges that HWs are ‘managing’, in the sense both of ‘getting by’ and of enacting financial coping strategies, such as mental accounting (spending different incomes differently), income hiding to shelter it from family pressures, and re-investment of incomes to stabilize overall earnings over time, in order to ensure their livelihoods and those of their families. These strategies question the assumption of fungibility of incomes and the neutrality of increasing or regulating one rather than another of them. Together, our findings on earning and income use patterns have important policy implications for how we go about (re)thinking financial incentive strategies.https://doi.org/10.1093/heapol/czw03131pubpub

Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems

** From PLOS via Jisc Publications Router. ** History: received 11-07-2017; collection 2018; accepted 20-03-2018; epub 03-04-2018. ** Licence for this article: http://creativecommons.org/licenses/by/4.0/Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.sch_iih13pub5303pub4 [e0195301

Exploring implementation practices in results-based financing: The case of the verification in Benin

Bertone, Maria Paola - ORCID 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XBackground Results-based financing (RBF) has been introduced in many countries across Africa and a growing literature is building around the assessment of their impact. These studies are usually quantitative and often silent on the paths and processes through which results are achieved and on the wider health system effects of RBF. To address this gap, our study aims at exploring the implementation of an RBF pilot in Benin, focusing on the verification of results.Methods The study is based on action research carried out by authors involved in the pilot as part of the agency supporting the RBF implementation in Benin. While our participant observation and operational collaboration with project’s stakeholders informed the study, the analysis is mostly based on quantitative and qualitative secondary data, collected throughout the project’s implementation and documentation processes. Data include project documents, reports and budgets, RBF data on service outputs and on the outcome of the verification, daily activity timesheets of the technical assistants in the districts, as well as focus groups with Community-based Organizations and informal interviews with technical assistants and district medical officers.Results Our analysis focuses on the actual practices of quantitative, qualitative and community verification. Results show that the verification processes are complex, costly and time-consuming, and in practice they end up differing from what designed originally. We explore the consequences of this on the operation of the scheme, on its potential to generate the envisaged change. We find, for example, that the time taken up by verification procedures limits the time available for data analysis and feedback to facility staff, thus limiting the potential to improve service delivery. Verification challenges also result in delays in bonus payment, which delink effort and reward. Additionally, the limited integration of the verification activities of district teams with their routine tasks causes a further verticalization of the health system.Conclusions Our results highlight the potential disconnect between the theory of change behind RBF and the actual scheme’s implementation. The implications are relevant at methodological level, stressing the importance of analyzing implementation processes to fully understand results, as well as at operational level, pointing to the need to carefully adapt the design of RBF schemes (including verification and other key functions) to the context and to allow room to iteratively modify it during implementation. They also question whether the rationale for thorough and costly verification is justified, or rather adaptations are possible.https://doi.org/10.1186/s12913-017-2148-917pubpu

Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone

motivation and performance. However, the literature so far tends to look at PBF payments in isolation, without reference to the overall remuneration of health workers. Taking the case of Sierra Leone, where PBF was introduced in 2011, this study investigates the absolute and relative contribution of PBF to health workers' income and explores their views on PBF bonuses, in comparison to and interaction with other incomes. Methods: The study is based on a mixed-methods research consisting in a survey and an 8-week longitudinal logbook collecting data on the incomes of primary health workers (n = 266) and 39 in-depth interviews with a subsample of the same workers, carried out in three districts of Sierra Leone (Bo, Kenema and Moyamba). Results: Our results show that in this setting PBF contributes about 10 % of the total income of health workers. Despite this relatively low contribution, their views on the bonuses are positive, especially compared to the negative views on salary. We find that this is because PBF is seen as a complement, with less sense of entitlement compared to the official salary. Moreover, PBF has a specific role within the income utilization strategies enacted by health workers, as it provides extra money which can be used for emergencies or reinvested in income generating activities. However, implementation issues with the PBF scheme, such as delays in payment and difficulties in access, cause a series of problems that limit the motivational effects of the incentives. Overall, staff still favor salary increases over increases in PBF. Conclusions: The study confirms that the remuneration of health workers is complex and interrelated so that the different financial incentives cannot be examined independently from one. It also shows that the implementation of PBF schemes has an impact on the way it does or does not motivate health workers, and must be thoroughly researched in order to assess the impact of PBF.sch_iih1. 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Health Policy Plan. 2014;30:1251-60. 6. Bonfrer I, Van de Poel E, Van Doorslaer E. The effects of performance incentives on the utilization and quality of maternal and child care in Burundi. Soc Sci Med. 2014;123:96-104. 7. Binyaruka P, Patouillard E, Powell-Jackson T, Greco G, Maestad O, Borghi J. Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study. PLoS One. 2015;10:8. 8. Huillery E, Seban J. Financial Incentives Are Counterproductive in Non-Profit Sectors: Evidence from a Health Experiment. Paris: Science Po, Department of Economics - Working Paper; 2015. 9. Binyaruka P: Measuring Quality of Care in Tanzania. Dar es Salaam: Presentation at the workshop Payment for Performance: a health systems perspective- (24-26 November 2015); 2015. Available at: http://www.slideshare.net/ resyst/measuring-quality-of-care-in-tanzania-55931507. Accessed 8 Dec 2015. 10. Meessen B, Kashala JPI, Musango L. Output-based payment to boost staff productivity in public health centres: Contracting in Kabutare district, Rwanda. Bull World Health Organ. 2007;85:108-15. 11. Kalk A, Paul FA, Grabosch E. Paying for performance- in Rwanda: does it pay off? Trop Med Int Health. 2010;15:182-90. 12. Paul E, Sossouhounto N, Eclou DS. Local stakeholders' perceptions about the introduction of performance-based financing in Benin: a case study in two health districts. Int J Health Policy Manag. 2014;3:207-14. 13. Patouillard E, Borghi J, Binyaruka P, Powell-Jackson T, Greco G, Torsvik G: Do Financial Incentives Undermine Health Workers Intrinsic Motivation? Evidence from a Pay-for-Performance Scheme in One Region of Tanzania. Dar es Salaam: Presentation at the workshop Payment for Performance: a health systems perspective- (24-26 November 2015); 2015. Available at: http://www.slideshare.net/resyst/do-financial-incentives-underminehealth- workers-intrinisc-motivation-borghi-et-al. Accessed 8 Dec 2015. 14. Witter S: Growing Pains (and Gains): Reflections on the Current State of Play and Future Agenda for Performance Based Financing. Harmonization for Health in Africa Blog; 2015. Available at: http://www.healthfinancingafrica. org/home/growing-pains-and-gains-reflections-on-the-current-state-of-playand- future-agenda-for-performance-based-financing. Accessed 8 Dec 2015. 15. McCoy D, Bennett S, Witter S, Pond B, Baker B, Gow J, Chand S, Ensor T, McPake B. Salaries and incomes of health workers in sub-Saharan Africa. Lancet. 2008;371:675-81. 16. Roenen C, Ferrinho P, Van Dormael M, Conceio MC, Van Lerberghe W. How African doctors make ends meet: an exploration. Trop Med Int Health. 1997;2:127-35. 17. Bertone MP, Witter S. The complex remuneration of Human Resources for Health in low-income settings: policy implications and a research agenda for designing effective financial incentives. Hum Resour Health. 2015;13:62. 18. Bertone MP, Samai M, Edem-Hotah J, Witter S. 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Health financing in fragile and conflict-affected settings: What do we know, seven years on?

Maria Paola Bertone - ORCID: 0000-0001-8890-583XSophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.The authors acknowledge funding from DfID UK under the Making Health Systems Stronger grant to WHO.232pubpu

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

Maria Paola Bertone - orcid: 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XBackground - As 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. Methods - The 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. Results - Our 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. Conclusions - The 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.Funder: Department for International Development (DFID), Grants: 201401Funder: Department for International Development, Grants: ReBUILD project14pubpub9

Health financing in fragile and conflict-affected situations: A review of the evidence

Witter, Sophie - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Bertone, Maria Paola - ORCID 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XReplaced with final published version 2020-04-16WHO has well-developed guidance for health financing policy, which supports progress towards universal health coverage (UHC) and overall health system goals. Central to this is the importance of public finances, and the role of government in using those finances in the best way, to strengthen their health system to maximize progress towards UHC. Fragile and conflict affected settings (FCAS) present a growing challenge for countries trying to make progress towards UHC and improve health. This paper examines the core features of FCAS, including deficits in capacity, legitimacy, and security, and considers their implications for efforts to build resilient health systems. Health financing interventions pursued in FCAS in response to both the challenges and opportunities arising from the different deficits are summarized using the WHO health financing functional approach as the organizing framework. Data analysis shows that FCAS countries have significantly higher out of pocket expenditures, greater external dependency and health-related impoverishment, as well as lower mean government expenditure on health. There are substantial challenges for health financing in FCAS settings but considerable ingenuity has also been shown in addressing them, often driven by external stakeholders. Certain approaches, such as performance-based contracting and funding emerged in FCAS settings out of the need to innovate but leave a longer legacy which is given close consideration. This paper forms provides the background to and informs a second paper which revises and adapts WHO’s health financing guidance in the context of FCAS.Financial support was provided by the United Kingdom’s Department for International Development (Making Country Health Systems Stronger programme).https://www.who.int/publications-detail/health-financing-policy-in-fragile-conflict-affected-situations/pubpu