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!

Although we agree with many things said by the authors, a more practical message could have contrasted significantly with the overly enthusiastic rhetoric of the SDGs. Like most in the development field, the authors tend to use phrases or “woolly jargon” referring to “politically-smart approaches” that are “fit for purpose”, advance “human dignity”, and “leav[e] no one behind” without defining these expressions and without, more importantly, providing clear insights “on what [they are] supposed to look like” (see Hickel).

The focus of their piece, i.e., asking whether the world is “ready for a paradigm shift” is not really itself elaborated – if a paradigm shift refers to “a change in the basic assumptions…within the ruling theory of science” (Kuhn, 1962) this would require (we agree) not only a shift in framing – from poverty eradication to more holistic and sustainable pathways to development but also changes in the way power is allocated within global governance for development. Essentially, this would mean a departure from the way development is currently envisioned. From a top-down/North-South and often paternalistic enterprise (in which philantrocapitalists play a growing and controversial role) based on a post WWII geo-political order, we could move toward a new balance of power that is inclusive with changed infrastructure for decision-making.

In the authors’ narrative, there is no indication that development will be “done” differently, and thus no paradigm shift.  Their analysis omits issues of equity and any allusion to SDG 10 (reduce inequality between and among countries) in dealing with the political economy of health (or at best only hints at these key political and global governance questions in a rather diplomatic way).  As regards to health we sense a bit of Western righteousness when the authors say that “[t]he achievement of many health targets will require leadership from ministries other than health, which will require reforms in the health governance architecture for many countries” without actually providing any kind of tangible framework or guidelines. So much for enabling the shaping of Foucault’s biopolitics (i.e., creating a welfare state), which aim at strengthening the state’s legitimacy. While Foucault’s arguments have been developed in the French context (and mostly focus on domestic policy), other authors (such as M.G.E Kelly) have sought to apply his concepts in the context of globalization and development assistance. For Kelly, the neoliberal ideology behind foreign aid undermines the foundations of biopower (i.e., the “development of a government and social system”) in developing countries, because it reflects an obvious “lack of appreciation of the importance of the state” (Kelly, p.21).

In our opinion, a true paradigm shift would instead mean accompanying the countries in the establishment of decent social safety protection that would be tailored to their contexts, with well-defined guidelines. Universal health coverage – if articulated clearly with measurable indicators – could lead the way. Even in 2013 this was not thought to be politically viable in the report of the High Level Panel (HLP) of Eminent Persons on the Post-2015 Development Agenda but the deadly Ebola outbreak in the last year has highlighted the importance of resilient health systems in addition to disease control. Although UHC is now a key target in the SDG health goal, and many influential global health actors can’t stop talking about it, one still has the feeling that that the global health community wants to do UHC and resilient health systems “on a shoestring”.

As for the goals themselves, we do feel that the MDGs’ measurable targets and indicators were helpful in providing a realistic framework for progress in development. While there were some obvious flaws (think dubious methods of measurement, particularly for poverty) these told us a story about the effectiveness and outreach of programs with very focused aims for human development that involved only a few sectors.  In contrast, the SDGs are an articulation of very different fields with limited congruence, though one useful visualization is offered by Waage et al. (in the Lancet Global Health) where they separate 16 goals into three categories – well-being, infrastructure, and natural environment – all under the overarching goal of a global partnership for sustainable development. And of course there are the cross-cutting issues across the SDGs, and Buse and Hawkes have very neatly isolated what they see as health-related targets under other SDG goals. Still, multiple sectors are called upon for action on climate change and human and economic development, and the goals themselves read awkwardly – with the exception of the 6 goals around human well-being, all others are two- or three-fold commitments.

We wonder if this well-intentioned but overzealous approach results from the sheer magnitude of the post-2015 consultations, which were far-reaching. With an open consultation online and country consultations in 88 countries yielding responses from over 7 million people, it is fair to say that the UN has made sincere and laudable efforts at inclusiveness instead of setting new goals arbitrarily (by “experts” only). Civil society, the general public, governments, and academics all responded to this call with enthusiasm at this unprecedented willingness to let people have their say in how they prioritize global goals. It is doubtful, however, that marginalized communities faced the same opportunities to participate; their needs do not appear to be addressed in the SDGs.

Which finally brings us to the sheer size of the SDGs – 17 goals with 169 targets – did the MDGs go so wrong that a full-blown search to add eggs to the basket became necessary? As far as we know, the MDGs, albeit based on a framework of poverty and disease that was very quantitatively and questionably measured, did result in change for some countries. In order to achieve any concrete step toward state-led social protection, human and environmental well-being must be addressed at a structural level, that is, there must be a willingness to take advantage of the current policy window (for instance, are we ready to raise the international poverty line to $5/day, as UNCTAD proposes?) of the SDGs.

Perhaps underlying the SDGs is the belief that one cannot have too much of a good thing. If the SDGs are adopted as they are now, however, we can only imagine a future proliferation of government and NGO development programs and projects gone out of control. Anyone willing to take a bet on the number of indicators?

Several scholars, development experts and commentators had great expectations that BRICS become important players of the post-2015 discussions. Given their demographic, economic, and political weight, their involvement would somehow counter-balance traditional donors’ hegemony in the debate. But do they really undertake this role as a coordinated political body?

During the 5^th BRICS Summit in South Africa in March 2013, the BRICS welcomed the establishment of the Open Working Group (OWG) on the Sustainable Development Goals (SDGs), agreeing to commit to a coordinated intergovernmental process for the elaboration of the new UN development agenda. The following common features can be identified across the five giants’ aspirations in the broader post-2015 agenda: finishing the MDGs business, committing traditional donors to universal targets, enhancing access to technologies, and respecting national sovereignty on political issues. While their concerns overlap in these official debates, they do not speak as a single voice, not unlike in the WHO arena. And it is probably too early to say whether their concerns will be fully acknowledged by the OWG and within the SDG process.

What about the specific health agenda? In their 2012 Geneva meeting on the sidelines of the 65th World Health Assembly, BRICS health ministers did commit to “work collaboratively to shape debate on MDGs and beyond 2015.” Later on in Cape Town, the same ministers “called upon Member States to consider health as an important issue in post-2015”.

Therefore what is their take on the post-2015 global health debate so far? Many of you have come across a plethora of recent literature on BRICS’ influence on major global health major issues ranging from governance to universal health coverage (UHC) ( see recent Contemporary Politics and WHO Bulletin special issues, etc.). But despite the BRICS’ predominant place in today’s global health discussions, only three of these recent publications (Creswell et al., Harmer & Buse; Kickbusch) directly tackle how they weigh on the burning post-2015 health debate.

We know that in their various declarations, the BRICS have repeatedly affirmed their support to UHC (McKee et al). They even said that UHC is “an essential instrument for the achievement of the right to health”. But unlike WHO and other UHC partisans, they do not go as far as pushing it to be the ultimate health goal. Indeed, China (together with Kazakhstan and Indonesia) clearly states that UHC cannot be the “overarching goal of the health sector”. Building from this argument, Chinese delegates added that before we decide on UHC as a key target “we have to ensure that we have adequate means that can support national effort to fulfill this target”. Others somehow corroborate this opinion, with Russia speaking about UHC simply as an “interesting idea”, and India recognizing its “importance”. And while South Africa is “fully supportive of the proposal for the implementation of UHC”, it warns that “it should be noted that countries have different ‘starting points’ in their readiness to implement it”.Interestingly, without apparent coordination both China and South Africa speak about a more limited version of UHC: universal access to healthcare services. Brazil seems to be the most supportive of UHC in the post-2015 discussions, proposing to adopt the very comprehensive Resolution 67/81’s definition from the Rio+20 outcome document.

Overall BRICS countries, and particularly China, South Africa and Russia are in favor of pursuing the “unfinished business” of the health MDGs, i.e. lowering maternal and child mortality and fighting AIDS, TB and malaria. China particularly advocates for “finishing the unfinished business of […] MDG5b on universal access to reproductive health, including access to modern use of contraception for all […]”. Brazilian and South African delegates fully support this proposal.

South African delegates also ask for greater focus on prevention of communicable and non-communicable diseases. Similarly, and not surprisingly – as one the strongest advocates, Russia is pushing for NCDs to be a key target of the future global health agenda. In fact, all the BRICS countries agree to have NCDs fully covered by future health-related targets – which is in full coherence with their own epidemiologic profiles and efforts to reform their health systems.

Kickbusch believes that BRICS will get strongly involved in “global governance for health that reaches beyond the health sector”, covering trade, intellectual property, food security, climate change, and biodiversity. However, none of them explicitly make the link between these topics and health in post-2015 discussions, except for trade and intellectual property. In this field, Brazil appears to be particularly vocal: within health-related means of implementation, Brazil asks for an “indispensable sub-item” which would reaffirm countries’ right to fully use existing flexibilities in the TRIPS agreement. Such call for preserving trade flexibilities is also supported by India.

In a nutshell, for BRICS countries the post-2015 health development agenda should build on the MDG framework. As such, maternal and child health, controlling HIV, malaria, and TB, and NCDs (which is the only significant change) should be the top priorities. In terms of global governance, they emphasize the need for discussions to be framed in a universal, more inclusive and transparent intergovernmental process. To date, these contributions are not so different from what traditional donors have been promoting. Therefore it appears that BRICS are not (yet?) the anticipated ‘power brokers’ or ‘Southern voice advocates’ in the discussions on the health development agenda, at least not within traditional intergovernmental fora.

While I agree with Harmer and Kickbuschthat BRICS ought to play an increasing role in global health governance in the next future, I do not think that it will happen inside of the UN framework. Referring to the broader development agenda, my take is that they are thinking about building their own framework for international cooperation (perhaps along the lines of the ‘win-win’ South-South cooperation model, rather than the ‘donor-recipient’ model of the 2000s), substantially different from the already existing one – which is already challenged by the Busan process. They advocate for a different way of doing cooperation, based on mutual understanding, sharing experiences, and exchanging simpler and less costly technologies. Let’s see how the soon-to-be-launched BRICS development bank concretizes this new concept of development assistance.