Table 3. Summary of the Key Themes Through the Lens of the Adapted Shiffman and Smith^23,31 Political Priority Setting Framework .

Framework Category	Findings
Intersection between the political context, intervention design and actor power	Adoption of new constitution and devolution (change in political context) led to: 1. Introduction of a new PFM Act29 which resulted in contestation between national and county levels, over the initial design of the PBF policy (‘intervention design’ as an issue characteristic). This led to roughly over a year’s delay in implementing PBF, and changes to the PBF policy design. 2. The national MoH’s inability to be an effective guiding organisation. 3. Introduction of new county level non-health sector bureaucrats (ie, county treasury and legal team) and politicians (county governor and members of county assembly) who then played key roles in PBF’s implementation by the county beyond donor timelines. As they had not been involved in PBF’s earlier stages of inception, piloting and design and, the subsequent PBF sensitization, training and decision-making spaces,they had limitedunderstanding of and buy-in to PBF.
Issue characteristics	In the newly devolved context of Kilifi county, the underlying features of the problem which PBF sought to address (health worker motivation and MCH indicators) were rarely discussed outside the health sector, and were uncontested by health sector actors. However, the intervention design (the solution) was contested by the county treasury and legal team.
Ideas	The internal framing of PBF by the national MoH and CDoH may have affected the public positioning of PBF and whether/how it attracted the attention of the county political elites. Specifically: 1. The idea of ‘pay for performance’ was perceived as contradictory to the PFM Act’s29 planning and budgeting processes and timelines. 2. The framing of PBF as a donor-funded programme providing much-needed ‘additional funding’ for healthcare providers became interpreted as an ‘additional expense’ when it needed to be funded by the county government in the long-term following the end of World Bank PBF funding.
Actor power	The failure to mobilise key county politicians (specifically, MCAs) who have high political power was a challenge since their support was essential in passing relevant county legislation and approving financial allocation for PBF beyond the World Bank’s funding period.
Outcome	There was contestation within Kilifi county in the period 2015-2018 about the prioritisation of PBF. PBF implementation stopped at the end of 2018 when donor funding concluded, as no resources were allocated by the County to continue implementation and no further arrangement was made with external actors.

Abbreviations: PBF, Performance-based financing; MoH, Ministry of Health; MCAs, Members of the County Assembly; MCH, maternal and child health; PFM, public financial management; CDoH, County Department of Health.