Performance-Based Financing, Basic Packages of Health Services and User-Fee Exemption Mechanisms: An Analysis of Health-Financing Policy Integration in Three Fragile and Conflict-Affected Settings

The political economy of priority-setting for health in South Sudan: a case study of the health pooled fund

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.

Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence

Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF “works”—that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank’s repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region—either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.