SOML gave priority to a package of health interventions known as ‘the six pillars’.<sup>19</sup> The World Bank actively supported SOML, using its “Program for Results” instrument<sup>20</sup> to financially reward Nigerian states based on improvements from their previous best performance on six key indicators.<sup>21</sup> Improvements were to be measured through yearly household surveys providing robust estimates at the state level.

In practice, of course, these six pillars (or intervention areas) were wildly different in their drivers and complexity – improvement within them was therefore destined to move at different trajectories and different speeds for different groups in different places. State actors, keen to raise their aggregate measure of success and get paid for it, soon realized that there was some gaming to be done. Our field research documented how the emphasis on singular measures of success introduced a perverse incentive for states to focus on the easier metrics at the expense of the hard (Bridges and Woolcock 2019). Interviews with state officials revealed that front-line staff were increasingly focusing their time and energies on those constituent variables that they discerned were easiest to accomplish (e.g., dispensing vitamin supplements) over those that were harder or slower – typically those that involved a plethora of “pesky human elements” – such as lowering maternal mortality or increasing contraceptive use. Thus, in selecting certain outcomes for measurement and managing these alone, others inevitably end up being sidelined.

Likewise, a recent report on Results-based Financing (RBF) in the Education Sector (Dom et al. 2020) finds evidence of a “diversion risk” associated with the signposting effect of certain reward indicators, with important areas deprioritized because of the RBF incentive. For example, in Mozambique they find that an emphasis on simple process indicators and focus on targets appears to have led to officials diverting resources and attention away from “more fundamental and complex issues”, such as power dynamics in the school council, the political appointment of school directors, or the teachers’ use of training. Dom et al. also report evidence of “cherrypicking risks”, in which less costly or politically favored subgroups or regions see greater resources, in part because they are more likely to reach a target. For example, in Tanzania, they found evidence that the implementation of school rankings based on exam results was correlated with weaker students not sitting, presumably in an effort by the schools to raise average exam pass rates.

<mark>This tendency becomes a particular issue when the sidelined outcomes end up being the ones we care most about. Andrew Natsios (2011), the former Director of the United States Agency for</mark>

> 19 The six pillars were (i) Maternal, newborn and child health; (ii) Childhood essential medicines and increasing treatment of important childhood diseases; (iii) Improving child nutrition; (iv) Immunization; (v) Malaria control; and (vi) the Elimination of Mother to Child Transmission (EMTCT) of HIV.

> 20 A PfR is one of the World Bank’s three financing instruments. Its unique features are that it uses a country’s own institutions and processes, and links disbursement of funds directly to the achievement of specific program results. Where ‘traditional’ development interventions proceed on the basis of ex ante commitments (e.g., to designated ‘policy reforms’, to the adoption of procedures compliant with international standards), PfR-type interventions instead reward attainment of predetermined targets, typically set on the basis of extrapolating from what recent historical trajectories have attained.

> 21 According to the Program Appraisal Document “each state would be eligible for a grant worth $325,000 per the percentage point gain they made above average annual gain in the sum of six indicators of health service coverage.” The six indicators are: Vitamin A, Pentavalent3 immunization, Use of ITNs by children under 5, Skilled birth attendance, Contraceptive prevalence rate, and Prevention of mother-to-child transmission of HIV.

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