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.
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.