In this blog post, Bruno Meessen reflects on the criticism he has heard on PBF over the past years. He identifies seven main causes of disagreement and offers each time ways to improve the debate and have a more fruitful discussion.

 

In almost 15 years of commitment to a cause which is now known as PBF, I’ve heard plenty of different criticisms on PBF. Let’s say I’ve had my share. These criticisms are sometimes cautiously formulated or formulated as questions or hypotheses, but you often sense that the real dispute goes much deeper. Also, unfortunately, critics often mix different types of arguments. If such a strategy can be effective as a rhetorical strategy for a specific audience, it doesn’t necessarily help the debate, I believe.

To enable a more constructive discussion, it’s important to clarify the nature of criticisms by trying to identify the underlying causes of disagreement. In this blog post, I  distinguish seven main elements of criticism. For each, we can also identify a possible solution.

 

1st pattern: a different informational basis

I have observed over the years that one possible cause of disagreement is a different ‘informational basis’, for lack of a better word. We have encountered a lot of situations like this in recent years. A case in point was the debate  held last summer between researchers who had conducted a Cochrane Review ‘from their office’ and PBF experts who answered them ‘from the ground’.  Faced with such a problem, the obvious recommendation is to try to reduce the information gap between the two sides. Both sides can do their share. I often recommend, for example, external commentators to go and see a PBF experience with their own eyes. Maybe then they will discover aspects (both positive and negative ones) that they didn’t know before. Conversely, it is the responsibility of PBF proponents to convert their experience-based knowledge into more explicit knowledge, for example by describing PBF experiences in written documents and papers. They must also make the effort to try to understand the information base of ‘adversaries’ as it can be partly complementary, as this summer’s debate has shown. When talking to each other, the aim should always be to learn from each other.

 

2nd pattern: different analytical frameworks

The second cause of disagreement may arise from the use of different analytical frameworks. When I talk about an ‘analytical framework’, I refer to Elinor Ostrom’s (2005) definition of an analytical framework: “the analytical level that identifies the elements and relationships among these elements that one needs to consider for an analysis”.

As an analytical framework strongly influences the information we deal with, this second cause of disagreement is related to the first one. The underlying idea is that, faced with the same raw data, two people starting from different analytical frameworks will not necessarily see the same thing. Here, the recommendation for a good dialogue is of course to make the analytical framework one uses as explicit as possible, to allow other people to assess it (What are the underlying assumptions? Does it capture the important elements? Is it consistent? ) From our side, we have tried to be as explicit as possible about the analytical framework we use. I have even written a Phd thesis on the topic (for a simplified version, see here ). Our framework has helped, I think, to highlight weaknesses of previous analytical frameworks (which have shaped the political vision of an earlier generation of experts, see also point 6).

It’s on this basis that I dismiss all criticisms made on PBF referring to European P4P experiences or arguments relying on experiences in Costa Rica or China. PBF is much more than just a strict provider payment mechanism or a contract for performance related bonuses: it’s a substantial revision of institutional arrangements to structure health systems. The discussion should be based on a thorough understanding of the intricate web of institutions and contextual elements. Discussing the effect of a contract while ignoring all contracts in which the economic agent inserts itself, is not only bad economics, it’s also lousy social science.

 

3rd pattern: different normative choices

A third cause of disagreement has its  roots in what economists would call different normative preferences. One could imagine a scenario in which two experts share the same information and analytical framework, but have a different opinion on the political conclusions to draw from these.

For example, those in favour of PBF probably think the rule ‘to each according to his effort (and the quality of his effort)’ should also apply to health staff, whereas others might think that the rule ‘to each according to his needs’ also pertains to health staff.

This third cause of disagreement is more difficult to manage. On the one hand, because the question ‘what is a just society’ does not have a unique answer. On the other hand, because this source of disagreement is sometimes confused with the second source of disagreement. Some will rely on their own normative vision of human beings to reject some analytical frameworks (eg, a framework based on economics). With respect to this, I would recommend that we make a clear distinction between  three things: what human beings really are, how we, scientists, model human beings,  and finally, how we, as individuals, would like human beings to be. I don’t deny that there are links between these three elements; as a citizen, I’m well aware that the policy proposals inspired by an economic framework, when accumulated, are not value-free. Yet, I’m also convinced that such blueprints can be extremely useful in some contexts today, for improving the welfare of the most vulnerable populations, and that justice dictates that we worry about them first. This rational and pragmatic choice is a deeply humanistic one, I believe, so I decided to act upon it. Personally I prefer this approach to a discourse starting from a perhaps more generous vision of mankind, which is, I fear, based on a fantasy idea of what humanity is and will be in the coming years.

 

4th source of disagreement: speculation on different trajectories

To the extent that PBF addresses complex social systems, it is inevitable that large areas remain undetermined – these gaps will be filled through speculation. This is the fourth source of disagreement.

Ideally, of course, the knowledge gap would be filled. The first recommendation is therefore to design an ambitious scientific program. In this respect, PBF is very fortunate, thanks to the Health Results Innovation Trust Fund. I like to say (without having it checked though) that the PBF research program coordinated by the World Bank is probably the most important research program, size wise, in the history of health economics.

If I can’t deny my commitment as a ‘policy entrepreneur’ in favour of PBF, I also try to contribute to the debate as a scientist, by conducting empirical studies (ITM has just been tasked to do an impact study in Burundi), but more fundamentally by supporting researchers keen on studying PBF. For example, I co-organize a scientific workshop  on 13-14 June, in Bergen, Norway, where some of the issues raised  by my colleague Jean-Pierre Unger will be discussed.

However, I also know that in health policy, research does not have all the answers. Very often, research follows, with some delay, political developments (see for example  free maternal health care policies).

There is thus room for speculation, and this speculation will inevitably be influenced (or is it ‘polluted’ ?) by faith or personal distrust. My recommendation would be to try to reduce the emotional aspects of the equation by formulating what hasn’t been proven yet as a hypothesis (and not as a principle or fact). This recommendation applies to both PBF champions and critics… by the way, I think we have our work cut out here.

 

5th source of disagreement: a conflict of interests

The fifth source of disagreement is much more prosaic (and brings us back to the notorious ‘homo economicus’ !): personal/institutional interests. In 15 years of PBF related activities, I have learnt who could be the losers of the PBF momentum.  These include the aid technocrats whose job it often is to find and implement solutions instead of others (with all the bureaucracy this involves), and whose expertise will be made obsolete by PBF. They  tend to reside in a comfort zone of the type ‘in poor countries, progress comes slowly’ and are typically found in agencies with no desire to change their ways and procedures (plan, build, equip, train). Losers can also be found among the national bureaucrats who want to control everything but make sure to attribute their poor performance to the context, the lack of resources or to other stakeholders.

The winners are also obvious: the health staff of course, but also African and international experts who will build their careers on PBF: PBF has indeed also become an enormous market of expertise recently (and we are particularly pleased that this time it’s the Southern experts who are in charge).

 

6th source of disagreement: the sociology of the field of international health

Linked to the fifth cause of disagreement is a sixth element: there exists a certain sociology of international health. There are exceptions, of course, but I’ve found, by and large, that the PBF opponents often come from a population of older experts, Europeans mostly. I do not believe that one generation can be smarter than the previous one. I believe instead that in international health we all formulate hypotheses (as mentioned under point 4), based on values (point 3), analytical frameworks (point 2) and experience (point 1), marked by a certain era, one in which our professional commitment began. It is obvious, for example, that if you could build local health systems in the 80s without needing PBF, you know that PBF is not indispensable and you thus hope that your conceptual and operational toolbox has lost nothing of its relevance. Maybe you also developed a certain affection for your solutions over the years. Conversely, if you subscribe to the contemporary ‘results culture’ (see the MDGs), the solutions of the past definitely seem to require a thorough revision. My main recommendation is to go beyond the caricature and try to talk with each other. By way of example, I hope that at the  upcoming conference on health districts, PBF experiences will be presented. A synthesis is possible.

7th source of disagreement: our “all too human” flaws

Maybe I don’t need to mention this last reason, but there is a seventh source of disagreement: the human factor. Many people involved in this debate, as proponents or adversaries, are not always consistent with themselves, we have noticed. For example, some people are critical of PBF, but try to “do PBF” at an operational  level themselves.  I have also encountered at least one stubborn (pro-PBF) expert, who refused all cooperation with other PBF-minded actors. I have also sometimes observed a certain amount of ‘bad faith’ on both sides. As a PBF advocate, I have to say I don’t feel comfortable when I hear a too rosy vision of PBF, when people hide failures or when rhetoric doesn’t match reality. I’ve also seen some awkward communication by PBF proponents which sometimes radicalized the opposition of certain strategic actors with whom an alliance needed to be set up. In short, just like in every human activity, we will not avoid the clashing of egos in the PBF debate, occasionally. I don’t have much else to offer here than pleading for a real dialogue, mutual respect and introspection.

 

Conclusion

The PBF debate is crucial for the future of health systems in Africa in particular. We have crossed the Rubicon: the strategy is now present in almost all African countries. We thus encourage all PBF stakeholders and actors to focus on constructive contributions in order to ensure that these reforms are well done, and/or quickly  amended if necessary.

The strategy can be improved and will continue to evolve: a health system should be seen in a dynamic way, and institutional arrangements which structure health systems should be revised when disadvantages outweigh benefits.

So we urge both critics and supporters of PBF to engage in a constructive discussion. This will ultimately benefit the population we have in mind.

12 Responses to Performance based financing: let’s try to have a more constructive conversation

  1. Aad van Geldermalsen says:

    In his article, ‘Performance based financing: let’s try to have a more constructive conversation’, Bruno Meessen has tried to find the underlying causes for criticism on PBF and lists elements of argumentation he identifies as spoilers to the discussion on this topic. He does this by taking on the role alternatively of political and social analyst and philosopher, hardly as an economist and never as a medical specialist which is of course all right, because the discussion is one of methodology and strategy of PBF as an aim to a goal, and that goal that apparently is not, and doesn’t seem to at this moment, defined properly.

    To me this discussion is indicative how far we have drifted from the focus our efforts should have, that is, to provide optimal health services. It is also indicative of the apparent strong feelings about the issue and that appear to be divisive, why otherwise this appeal to ‘pour oil on the waves’ and for a more sane and constructive dialogue. It is commendable that Bruno wants to steer this discussion into more constructive waters, and so we have to weigh his arguments critically. But by doing so, one will let one’s opinion about PBF filter through on this type of ‘talks about talks’ and Bruno clearly does so himself.

    So first of all we have to clear the stage when replying to Bruno’s appeal.

    For me, I have to explain that I understand PBF as a strategy that is chosen to optimally(?) organise health services (presumable in a resource poor and/or African setting) and that by its very title, implies an approach to these services that is based on an economic paradigm. To me, the fundamental approach to the problem of organising (public) health services is that one of defined (patient / community) needs, thus implying a Needs based approach of service organisation and financing, thus ‘NBF’. This starting point will not automatically lead to financing the service on the basis of itemized performance (and consequent payment) of its providers however defined and in whatever context. PBF will thus be one strategy, and a way of addressing the need for health services and, I repeat my opinion, one based excessively on the often weak grounds of economical theory.

    As we know strategies based on multi-interpretable theories can be divergent and lead to diverging actions, in this case implementation of programmes that Bruno is distancing himself from (Costa Rica, China). But one can also maintain that the argument put in the form of “the medicine wasn’t taken as prescribed’ (wrongly understood and applied, etc.), “the intricate context wasn’t considered”, etc. doesn’t hold. It is the excuse to used by quacks when their remedies don’t’ work. Snake Oil, doesn’t work, however you take it, during full moon or in the early morning on an empty stomach, Snake Oil will be snake oil. As Bruno states, assessment of PBF inspired programmes should be done on verifiable results and using scientific analytical tools, but we should be open to the possibility that PBF is intrinsically the wrong approach, whatever useful elements it may apply in certain contexts.
    So, yes, let’s engage in a meaningful constructive discussion but let’s not forget the possible necessity to de-construction some of the arguments.

    A point by point comment:

    1. The different informational basis. This is explained as the different viewpoints, one from the office by
    doing a literature review, the other gathering more info ‘on the ground’, implying that a Cochrane review is limited in its information content and that there always things to discover when critically assessing programmes in the field. This is fair comment and of course we should always be open to facts and each other’s ‘verifiable’ contributions.

    2. The different analytical frameworks. The definition referred to looks to me a circular one inside another circular one and is not helpful. If analytical frameworks lead to different results than obviously one framework cannot be correct, unless one believes in many truths, a widely held belief by those of a distinct un-scientific approach, but not really helpful. Bruno confuses the result with the observation: The observation is first and cannot be different as he states, it is the interpretation, the ‘colored glasses’ or ‘analytical framework’ that make conclusions divergent. So let’s be clear on what we observe and define the perception unequivocally. And analytical frameworks should not only be explicit, as they should; they should also be the same! The two sides have to agree on that first, as this whole discussion attempts to do. Also, analytical frameworks should not contain unproven assumptions as inferences in sociological and economical theories often do. The discussion on the ‘intricate web of institutions and contextual elements’ allows for post-hoc explanations, a characteristic of all economics and social science, good or bad.

    3. The different normative perspective. What each of us thinks is good or bad, or should or should not be, ‘colors’ every discussion. How we feel we should react to established conclusions is partly culturally set. Bruno sees three components; ‘what we like human beings to be’ but, I think , more prominently, what nature destines us to be (‘what human beings really are’). How we act morally in this world is rather universal and as with the analytical frameworks above, we have to agree on this point as well or at least make our own viewpoint explicit, to get to the same conclusions and actions.

    4. Speculation on different trajectories. Some facts or interaction will remain unknown or undetermined; the consequence of the earlier quoted ‘intricacies of the social fabric’. Hoping that these knowledge gaps can be filled may be idle. I agree we have our work cut out here, but I remain skeptical about big research initiatives funded by ‘interested parties’, a point taken up under the next point . Effect-of-tobacco research funded by Reynolds, evolutionary scientific research funded by the Templeton Foundation, and Public Health Research on PBF by the World Bank, all fall in the same category in this respect and their results need to be exhaustively scrutinised.

    5. Conflict of interest. This is where our nature as human beings, alluded to under point 3 comes into play. Before being homo economicus we are homo naturalis et socialis with all its trappings. Obviously man (and woman) first thinks and takes care of himself, then of their immediate relatives, tribe, etc. before the wider humanity.
    Interesting that Bruno thinks that PBF would put ‘Aid-Technocrats’ out of work because their expertise will be obsolete and that health staff and African and international PBF schooled experts (these are NOT Aid-Technocrats, but level-headed economists apparently) will be ‘winners’, presumably because they apply the winning economic theory. Bruno demonstrates his own biased inputs into points 1 to 4 in this presentation. I agree that personal-, or group-interests and motives should be more often considered and be made explicit in discussions of this kind. My experience is that this is very well realized and implicit in discussions and reasoning in African, where making it explicit is deemed bad manners (if not dangerous).

    6. The sociology of international health. This non-descript heading is used to suggest that PBF critics are old-hat. They may have been in the right during the 80s, but now we have to move with the times: we have to set results as if they are physical constructions (MDGs indeed) and leave an old, outdated and rusty conceptual ‘toolbox’ behind. In this way, Bruno invokes the caricature he tries to do away with.

    7. The human factor. This is a repetition of the earlier point 3, 4, and 5. His plea for real dialogue, mutual respect and introspection are necessary, even if they ring a bit hollow after the earlier remarks.

    My conclusion

    PBF proponents may cry victory and it is true that while this strategy is tried widely, it does not mean it is universally accepted and that it is here to stay or that it is to become the only acceptable manner of financing health care and its providers. It is introduced, I would say, forced on countries and policy makers with all the political power international institutions (WB!) and market economists can muster. It doesn’t mean however that this strategy is a panacea. In future it may prove again one of those ideologically driven fashions that were thought to be a cure to all ills.

    The whole discussion on what drives people to do a job that needs to be done, has to be taken up. Performance by health workers is just one in a spectrum of human activities that ranges from tasks like parenting and educating to wage earning labour and entrepreneurial activities, and the quality and ‘rewardability’ of health workers, however defined, needs to be put into perspective and not only expressed in financial terms .
    A continuous discussion, dialogue between actors and service providers and planners is necessary. It is equally clear that this shaky economical paradigm that now holds sway should be challenged and improvements and alternatives developed through the same ‘constructive dialogue’ that is proposed.

    • Bruno Meessen says:

      Thanks Aad for this comment and your extensive discussion of the different points. Much appreciated.

      I understand that your main concern is about the ‘constructiveness’ of the dialogue. Maybe you feel I set overly restrictive boundaries for the PBF discussion. So let me explain a bit why I wrote the blog.

      The background behind this blog post was my personal frustration with the fact that most adversaries of PBF mix very different types of arguments when they oppose PBF, often coupled with a lack of knowledge of what is really taking place in Africa. You are based in Zimbabwe and I look forward to your views, which will be more informed.

      You may have been puzzled by the fact that I did not leave much space for radically debating PBF (to the point that it could be discarded), in my guest editorial/blog post. My main message at the academic conference was indeed that the fact that PBF is now present in nearly all African countries moves the debate to another level: we are not talking about an idea anymore, but about actual interventions and forthcoming policies. Any debate disconnected from this dynamic will appear from now on as very ‘academic’, and from the country perspective not very useful. People are of course free to write anything they want, but I doubt that many experts on the PBF side are still looking for exchanges at this level: their main responsibility is now, increasingly, to try to make a success of what they are in charge of (and they have their hands full in this respect). I think I am a fair broker when I share this reality.

      On the dominance of economic frameworks: I do believe that new institutional economics (NIE) brings something crucial for our understanding of health systems: institutions matter. This insight was to a large extent missing in the past. Please, note that accepting this view does not imply one has to accept PBF. Also, one can of course also try to discard this new institutional economics toolbox – I will be happy to react on any alternative proposition.

      On disagreement of type 2: it would be great to have a single framework but it seems to me that we would then have a theory that would explain the whole of life and all social processes. As an economist, I have been trained in Marxist and Marxian economics, in classical, neoclassical and new classical economics, in Keynesian, post Keynesian and neo-Keynesian economics… and I discovered 10 years ago new institutional economics (including, complete/incomplete contract theory economics, property right economics, transaction cost economics…). I have accepted that different frameworks put emphasis on different dimensions and can help to reveal different phenomena. I believe that making assumptions is very acceptable, as long as you make them explicit.

      On disagreement of type 4: I agree that research on PBF should be sufficiently independent. I see things improving in this respect. It was clear at the workshop in Bergen last week.

      On disagreement of type 5: Yes, I formulated some normative appreciations on the profile of the relative ‘losers’ (the term is a bit harsh, I know, but for lack of a better word, I use here the terms ‘winners and losers’).
      Of course, there are many very good aid technocrats… but there are also aid bureaucrats mainly busy with planning, procurement and administration because of a lack of harmonization in aid instruments. As in any sector, there is resistance to change in the aid sector – and I am not talking here about acceptance or not of PBF. One can assume that the opposition to change also comes from those who benefit from the status quo. This does not mean of course that all those opposing the changes are opposing because of their own stakes. I just meant that it can be a reason for some. Over the last 10 years, I have seen experts opposing reforms with very sincere motives (especially because of a disagreement of type 2 or 3) who were probably not noticing that by doing so they were also helping – in the process – some stakeholders who were obstacles to genuine development. About the winners: of course, they are not necessarily right.

      On disagreement of type 6: A challenge for any group of people who derived policy solutions from a certain view of the world and framework is to put enough effort in mechanisms to question their own views and solutions. If a group which has been successful in the past, in terms of getting its ideas integrated into policy, has failed to set up such mechanisms, there is a high probability that the “updates” (required for instance by some contextual changes) will be done by another group, which will, logically, be younger. I knew that this point on the importance of different generations would be the most sensitive one – especially because I sit myself on one side. Nevertheless, I felt it deserved to be mentioned. See also Marcel’s comment.

      We do our best to set up such self-critical processes within the PBF community. I do believe that several prescriptive statements made by PBF experts still need to be scrutinized. If there are negative side-effects to be identified in 10-15 years, I would prefer that they are effects that one could not have anticipated in 2013.

      I can reassure you: I still very much enjoy a good debate with ‘old hats’: their criticisms are often stimulating, their toolbox is powerful … and towards the end of many of these discussions, we often agree that we agree on many things. For instance, I believe that a well-coordinated local health system is key. In fact, I see PBF more as completing the previous toolbox than as an approach which wants to throw away everything from the past. The new tool we add is mainly a ‘pair of glasses’ which help to appreciate the importance of institutional arrangements and the influence of incentives (those which are in place even if there is no PBF) on the performance of health systems. I do not blame the previous generation for not having brought this on the agenda / in their framework. Even in economics, these concepts became only popular in the nineties. However, I would perceive the refusal to pay attention to this (NIE) recommendation as a bit stubborn. Note that adopting these lenses does not mean at all that one has to drop one’s critical look at PBF.

      To conclude, I certainly don’t say that PBF is the panacea, and neither is it an end per se: I suspect that it will progressively be integrated in the general corpus of policy tools to move towards universal health coverage and more accountable health systems: so it will be part of a broader movement of reforms (see for instance, the comment by Alex Ergo). It is also obvious that PBF is not the right approach to address the emerging causes of poor health such as inappropriate diet or climate change.

      About your final sentence: one of our frustrations in the debate with ‘opponents’ has been the lack of clear and concrete (i.e. politically and socially feasible) alternative propositions. Much more than alternatives, I believe that at the end of the day, we will often find complementary strategies. I do believe for instance that it is possible to combine PBF with an approach reinforcing professionalism. Thus my sincere hope that critics of PBF would help to improve the strategy, by being “in”. If, unfortunately, they prefer to stay out, they are expected to come up with other propositions tested on the field. This would make the discussion much more significant for countries. My general assessment is that there has been a dearth of new ideas for health systems of LICs.
      I hope this answer addresses some of your points.

  2. Marcel Reyners says:

    Dear Bruno,

    It was a pleasure to read your blog..
    It reminds me what P.O Hubinont learned me, a long time ago in Tunesia 1974: (or was he quoting Paul Verlaine??): « « si tu penses comme moi, sois mon ami; si tu ne penses pas comme moi, sois deux fois mon ami » …and he added : enrichissons-nous de nos mutuelles divergences..

    I learned a lot the last 3 years on Cambodia’s health financing (battle-)field and can confirm what you summarized in 7 paragraphs, and, most of all, what you state in numbers 5, 6 and 7 cannot be over-emphasized enough.

    I know, systems and structures are important but even more are the people behind. What would it be good for those people in need for basic health care if efforts are joined instead of competing projects and approaches. Or when Real Politik is applied instead of beliefs.

    Not being a health financing person. I had to go through a bunch of literature to become more or less familiar with the different systems of SHP. Lastly on CBHI and I saw a couple of critical articles and reviews (published in 2004 and 2007) with a lot of lessons learned on what works and what not. But many seem to persevere in doing things that failed and that makes me think that the reasons you mention in your last 3 paragraphs are maybe more relevant than the scientific approaches you describe earlier. As Paul Collier repeats in his Bottom Billions: there are crooks and villains out there, but also heroes and let us support these ones!!

    Go on with your excellent CONSTRUCTIVE work, Bruno: highly appreciated!! I do like your style, your competences, your energy!!

    Greetings from the Kingdom of Wonder!

    Marcel Reyners

  3. Alex Ergo says:

    Hi Bruno,
    Thanks for writing this blog. I really appreciate your attempt to bring both camps closer to one another and to encourage constructive dialogue.
    I’m very tempted to take your argument a small step further and to question the relevance itself of the whole ‘we versus them’ discourse in the context of PBF. The polarization of the two camps is undeniably a reality, and it has many roots, as you rightly point out in your blog. This polarization is not only harmful; in my opinion, it is also unnecessary. I don’t think there should be two camps in the first place. What does it mean to be pro-PBF or anti-PBF? What exactly is it that a pro-PBF’er values that an anti-PBF’er would not value?
    As health economists and public health professionals, we all want to see stronger health systems that are able to better support the effective delivery of proven life-saving interventions. We all acknowledge that the actions of each actor in the system are influenced by a complex mix of incentives – better aligning these incentives with the system’s goals is an important aspect of our daily work. We all recognize the importance of greater accountability in the system. We all want to see more reliable health data – data that is not only reported to a higher level in the system, but that is also used at the local level to guide decision-making. We all want to encourage health workers to come up with innovative ways to overcome the many challenges they face. PBF is a potentially powerful approach to promoting these valuable improvements in a health system. I should insist on ‘potentially powerful’, because I believe it all depends on the way it is designed and implemented. There is no one-size-fits-all. PBF is an approach that consists of key functions, that all need to be tailored to the realities of a given context. I have seen very effective schemes and very dysfunctional ones. That doesn’t say anything at all about the approach per se, i.e., about whether PBF is good or bad; it only reflects the way a particular scheme was designed and/or implemented.
    I’m personally encouraged by recent efforts, in many countries, to better integrate PBF into a broader health financing strategy, and by the increased recognition that PBF can contribute to the universal coverage agenda; that it is all about using it for the right thing in the right way, and in the right combination with all the other tools – not only health financing tools, but also, more generally, health system strengthening tools. I believe these trends will help reduce the unnecessary polarization.
    Alex

    • Bruno Meessen says:

      Dear Alex,

      Thanks for this very helpful comment.

      In fact, I could have started the blog post by sharing my own frustration with the acronym “PBF”. I recently said to my students that in PBF, I do not like the “P”, nor the “B”, nor the “F”.

      By the way, this makes me realised that I should maybe have identified the acronym (and the rhetoric which goes with it) as another source of unnecessary polarization. By experience, I know how some economical terms, which are value-free for economists, can antagonize colleagues from other disciplines. From time to time, it is a source of misunderstanding with my medical colleagues here at ITM (fortunately, they know me ;-). A good example is the word ‘incentive’.

      Still, the ‘PBF’ formula and the unavoidable standardisation which goes with it were key for broad and rapid dissemination in Africa of the principles you identify. The core proposition is a quite coherent package of institutional changes to improve performance of public health systems.

      I fully agree that it is the institutional changes in the box which matter and not the box itself. I fully agree that these institutional changes have to be adapted to the specific context. Cut/paste approach to PBF will lead to disappointment. This is also one of the reasons why I believe we should be cautious with systematic reviews of PBF schemes.

      As you, I am happy of the convergence between the PBF agenda and the one of UHC. The speech at Geneva of Jim Kim was very clear in this respect. In fact, I believe that the pro- versus anti- PBF debate is, some way, over (but some readers probably disagree). As I wrote in the blogpost, most African countries have crossed the Rubicon, at least with a pilot experiment. Now we have to work all together to combine strategies susceptible to strengthen health systems. I believe that things are going in the right direction.

  4. Seye Abimbola says:

    Thank you very much Bruno for this well thought out, erudite and brilliant analysis of the explanations of responses to PBF. It reminds me of Albert O Hirshman’s The Rhetoric of Reaction (1991) which explores potential reactionary objections to policy reform. The potential responses include:

    1. Perversity – the proposed reform will make the problem even worse
    2. Futility – the reform will do nothing to solve the problem, and
    3. Jeopardy – the reform will endanger some hard-won social gain.

    According to Hirschman, and I agree, these responses tend to be hyperbolic, and therefore wrong.

    Please see this recent article on Hirshman in the New York Review of Books: http://www.nybooks.com/articles/archives/2013/may/23/albert-hirschman-original-thinker/

    • Bruno Meessen says:

      Dear Seye,

      Thanks for alerting me about this article on Hirschman.

      By the way, “Exit, Voice and Loyalty” is a book that I recommend to everyone. It was one my favourite references when we started to conceptualise what we were experimenting in Cambodia and later in Rwanda. The book is easy to read and full of illustrations (even if some may require to be a bit familiar with the US politics in the late 60ies)

      Starting from the observation that voice does not work well, PBF tries to increase the power of the exit mechanism. Indeed, every mother who does not come with her child for immunisation equates to a loss of revenue for the health facility.

      In the World Development Report 2004, they referred to the ‘long route’ and ‘short route’ of accountability. It is quite the same vision.

  5. I was rather perplexed to read a constructive-wannabe blog entry full of “ad hominem” arguments, including the very scientific statement that some experts are wrong because they are old. Well, dear, I won’t take it personal 🙂
    The problems with PBF are well identified and not exclusive of European experiences. For a summary of issues, read this enlightening news piece: http://www.guardian.co.uk/society/sarah-boseley-global-health/2012/dec/05/vaccines-polio
    What I find also rather peculiar, to say the least, is the repeated argument that when PBF programs do not seem to work in real life as expected, is somebody else fault – those who did not design it correctly, or did not performed it as it was thought – and not the model itself. It reminds me when drug companies are challenged with the fact that their product is less effective than they claimed: “But, it worked very well in the clinical trial! There must be something wrong with how it is being administered!”.
    Trials and real life are two different things, and at the end of the day evidence on tangible outcomes is what we need.

    • Bruno Meessen says:

      Dear Joan,

      I do identify here an #1-type disagreement: the scheme reported by Sarah Boseley is not at all what we call a PBF scheme. The PBF package, as implemented for instance in Burundi or Rwanda, actually fights against such verticalisation or focus on 1 disease only. More secondarily, I even suspect that the polio scheme in Nigeria is about paying per diem for days in outreach.

      About the type 6 disagreement: it is not an issue of age per se, it refers to the fact that each generation develops bonds with the solutions it contributed to design, implement or study. I believe that as professors, we must be very aware of our own positionality (just like it is expected from the researchers): indeed, part of our responsibility is to transfer knowledge to the next generation.

      Please read also my reply to Alex Ergo: let’s not get our common reflection stuck because of the uggly formula “performance-based financing”.

  6. GASHUBIJE says:

    Cher Bruno ,
    Toutes mes félicitations .
    Je ne peux que me réjouir de ton grade de Professeur acquis après un très dur labeur.
    Je peux te rassurer que j’ai beaucoup de respect et d’estime depuis le jour où on s’est rencontré. J’apprécie surtout ta capacité de modération dans un monde assez complexe.
    Je suis actuellement un appuis au Gouvernement de Djibouti (short term consultant) pour la mise en oeuvre du RBF.
    Success

  7. Godelieve van Heteren says:

    Dear Bruno,
    Many congratulations with your professorship, which you have started ‘in style’: critical and constructive…this has been your hallmark these last few years, it can be the honorary subtitle to your new role. Very deserved, chapeau!
    Godelieve

  8. Divine Ikenwilo says:

    Many thanks for the blog, Bruno. For me, the highlight of the argument is around the acknowledgement that health systems need to and do evolve. I consider the PBF more descriptive (or positive) than prescriptive (normative), and thus fits rather well with constant changes happening in most African countries.

    At the end of the day, objective dialogue is key in whatever we do. That is the best way to get the best solutions.

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