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!