One year later… yes, we are still talking about PBF in low- and middle-income countries!

By on January 18, 2019

Lara is a PhD Candidate in Public health and Economics at the University of Montreal and at Paris-Diderot University. 

Academic publishers’ timelines are interesting. Exactly a year ago, Paul et al.’s paper received unprecedented attention in the global health stratosphere. Acclaimed by some, criticised by others, the paper certainly sparked much debate on the relevance of performance-based financing (PBF) in low- and middle-income countries (LMICs). This made an analysis of the PBF discourse at the global level all the more relevant – which was the exact purpose of my first empirical PhD thesis paper. The latter, co-authored by my supervisors Manuela De Allegri and Valéry Ridde, got published this Tuesday in Globalization & Health. I was asked to “put in simpler terms” the key findings of this research, so that even my grandma would understand.

Why? Well, applying Carol Bacchi’s Foucault-inspired poststructural approach to analyse how policy proposals contain within them implicit representations of problems (I know, I’ve lost some of you already!) isn’t exactly easy to explain in everyday language. I’ll try anyway!

After a lengthy – and sometimes challenging – data collection with 57 consultants, employees of international organisations, academics, and national policymakers, I was looking for an analytical framework that could help me link the representation systems (i.e., the overarching roadmaps, paradigms, and ideologies that shape policy actors’ understanding of the world) of PBF proponents and non-proponents (among them of course, some PBF opponents, but also many wait-and-see folks) and their shaping of the discourse of PBF at the global level. Bacchi’s “What’s the problem represented to be?” approach, which highlights how policies represent the problems they intend to address and how governing takes place through this “problematisation”, came in handy: we could highlight the specific representation systems of PBF proponents and non-proponents by demonstrating how their cultural and training background features were shaping their underlying problem representations. Using the first six questions of Bacchi’s approach, we could critically link these problem representations to their understanding and framing of PBF as the most (or the least) opportune policy solution to these deep-seated problem representations (yes, I know, my grandma is now rolling her eyes). We specifically looked at how the use of economic sciences/management sciences/clinical sciences/social sciences language categories reflected their background. The results pointed to quite different understandings of the world, and highlighted several limitations (including eluding issues left “unproblematic”) of both proponents’ and non-proponents’ problem representations – thus calling for much nuancing. For instance, for a long time, equity issues were largely ignored in PBF proponents’ discourse, while PBF opponents omitted to address the dire financial and working conditions faced by most health professionals in LMICs. Importantly, interview data also led me to realise that despite similar training (usually in economics), not all PBF proponents shared the exact same deep-seated presuppositions. This entailed numerous debates including among the most enthusiastic PBF proponents – those we called PBF “diffusion entrepreneurs”.

In several instances, we showed that the proponent/opponent debate which transpired in interviews led these diffusion entrepreneurs (DEs) to reframe PBF so as to increase its political momentum. Several “non-DE” respondents expressed concerns that PBF represented a policy innovation that failed to address structural issues of health systems in LMICs (“icing on the cake with no cake”), and/or a “piecemeal reform”. This criticism prompted DEs to gradually shift their discourse in 2011-2012. They emphasised the fact that PBF could close the can do-will do gap, not only by providing financial incentives, but also by increasing resource generation to enable better performance – notably through work environment improvements and closer performance feedback cycles. A lot of the proponents gradually also acknowledged that PBF indeed needed to be supplemented by other health system reforms. Some DEs strategically framed PBF as a systemic reform with the potential to leverage all health systems reforms, be it as an “entry point” for strategic purchasing, improving health workers’ motivation, or yielding the so-called health systems “data revolution”.

Shifting the attention to strong PBF proponents, Bacchi’s third question, i.e. How has this representation of the problem come about?, enabled to examine DEs’ motivations to deal with the problem, their resources (i.e., knowledge, material, social, political and temporal resources), and their expert/scientific/financial/moral authority at the global level. Using interview data, we showed that DEs were driven by a complex set of motivations: a genuine interest to improve health systems in LMICs, political interests (e.g., gaining visibility on the global arena), and financial interests (e.g., matching PBF with donors’ output-based aid “trend”). We also shed light on how DEs pooled their resources and sources of authority to make an impact and spread the policy proposal that matched their problem representations, i.e. PBF.

Empowered by such resources and authorities, DEs still had to seek relevant modes of operation to boost their discourse globally. Here we used Bacchi’s sixth question, i.e., How and where has this representation of the ‘problem’ been produced, disseminated and defended?, to illustrate the strategies used by DEs to propel the solution to their problem representations. These strategies entailed controlling the learning agenda, shaping the rules of PBF policy experimentation, and spurring policy emulation by using powerful PBF success stories to inspire LMIC policymakers. One of the key activities catalysing these three endeavours was the organisation of multiple study tours across sub-Saharan African countries. DEs’ strategies also had a snowball effect – creating “second wave DEs” spreading PBF on the African continent. Stay tuned for my next PhD paper to get more information on this!

So yes, one year after Paul et al.’s notorious paper in BMJ Global Health, we’re still talking about PBF because in my personal opinion, there’s still much to say about this policy while trying to avoid the strongly politicised debates that developed last year. With less passion, more nuance, and more listening to LMICs’ own problem representations (provided that these too are not shaped by global DEs) and their contextualised adaptation of PBF maybe?

I’m guessing my grandma lies on the floor by now, out of this world. Fortunately, when she wakes up, she can read the full story in Globalization and Health!

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2 Responses to “One year later… yes, we are still talking about PBF in low- and middle-income countries!”

  1. Robert Soeters

    Dear Lara,

    Thanks for posting the publication and the simple version, which I read with much interest. Congratulations!

    The Paul, et al paper to which you refer in the simple version, may have had a positive influence on advancing PBF, RBF or strategic contracting in the sense that it energized African experts and policymakers to make their voice heard that they felt marginalized and belittled for their decennia-long efforts by the paper. This was well expressed by the recent paper of Mayaka Ma-Nitu S, Tembey L, Bigirimana E, et al. Towards constructive rethinking of PBF: perspectives of implementers in sub-Saharan Africa. BMJ Glob Health 2018;3:e001036. doi:10.1136/ bmjgh-2018-001036.. You captured this sentiment by referring to the second generation of diffusion entrepreneurs.

    Yet, a small nuance to your excellent publication is that you have probably praised the first generation of diffusion entrepreneurs too much by underestimating the continuous role of Asian and African experts and policymakers. My understanding is that from the beginning African and Asian individuals and organizations were at the roots of the performance paradigm and that they initiated new ideas and tools. So, the perception of Paul et al that a few “white” Europeans and Americans had promoted the PBF reform approach and “imposed” it on other continents is inherently wrong. If we (the white guys) played a role, it was to simply observe with an open mind what was happening in the field and we recorded those events and debates.

    You mentioned my experience in Mozambique (1980-1984) where I came with preconceived ideas to Africa about the perceived merits of socialism, the primary health care from Alma Ata (a city in the former Soviet Union) and this translated into African socialism as the solution of the continent’s (health) problems. This turned out to be completely wrong and unworkable in the African context in practice and African colleagues explained this to me and Frelimo changed the Marxist-Leninist dogmas towards a more open market-oriented policy in 1986. This was the opposite of whites imposing ideas on Africa.

    Later, when I worked in Zambia (1988-1993) as the coordinator of a province-wide PHC programme, it was the same thing with the ineffective and calcified humanitarian socialism of Kenneth Kaunda, which was then replaced in 1991 by political change in Zambia toward more democracy, and market-oriented thinking under Frederick Chiluba.

    Maybe also interesting to mention that during 2018 and after we had our Skype interview in August 2017 for your publication, and after the Paul et al publication in January 2018, things have started moving even faster towards PBF type health systems and the ideas have even become more radical of for example not mixing any more input financing with performance financing. The Cameroun experience shows the merits of putting all regulatory authorities under “pure” performance contracts without any inputs. The Cameroonian staff I met the last year are super-enthusiastic about this deepening of change, and their enthusiasm seems to spread quickly towards other countries. So there is still enormous unfulfilled potential to even more effective PBF reforms.

    During the 10 PBF courses we organized in 2018 with more than 400 participants from 19 African countries, we observed that participants have accepted the “PBF, RBF or strategic contracting” paradigm shifts and there is little debate (contrary to previous years) about the underlying theories and best practices. The paradigms of Alma Ata and the perceived advantages of centralized planning, input monopolies and skepticism about the private sector are a sort of fading away. We observe the same tendency among international organizations towards “performance thinking”.

    Hope these thoughts are useful and success with finalizing your Ph.D.

    Kindest regards, Robert

    • Lara

      Dear Robert,

      Thanks a lot for your thorough review. I am happy you liked the paper. You will be able to read more on the 2nd generation of diffusion entrepreneurs in my third and fourth papers.

      Your comments are quite interesting. By email yesterday you gave me specific examples of African & Asian individuals initiating “new ideas and tools”. Along the course of my research, I realised there were indeed some initiatives to adapt PBF to local realities, but those were not always possible to implement within quite restrictive PBF standard designs. Personally, I believe African experts’ influence was powerful in their implementation and sharing of knowledge with other African individuals (which also enabled a certain transfer of passion for PBF, hence policy emulation), but not on initiating the PBF idea or its design itself. The example of Cameroon you are giving is indeed an initiative to scale-up of the “results-based” paradigm to regulatory officers, but it’s different from a “Cameroonian version” of (the core elements & functioning of) PBF, in my opinion. Happy to discuss this further with you.

      In general, I believe policy implementation might fail also because lessons learnt from past and current reforms are not sufficiently drawn by proponents of a new policy/reform. This has to do with path dependency. Also crucial, the existing structures in place are not necessarily favourable to PBF implementation. For instance, strong power hierarchies and lack of effective decentralisation is an issue; PBF claims to enable/foster decentralisation but many informants argued that it can’t really work if decentralisation is not already effective. I believe that “political realities” matter much more than what a lot of PBF proponents may think. Issues of political economy should probably get more attention.


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