From ideas to policymaking : the political economy of the diffusion of performance-based financing at the global, continental, and national levels.

Abstract

Over the past 20 years, the polycentric nature of global health governance has shaped the emergence of autonomous actors with political influence at different levels. Since the late 2000s, influential policy actors have been supporting the implementation of a health financing reform: Performance-based financing (PBF). PBF relies on the transfer of financial resources conditional on the performance of health providers. Despite mixed scientific evidence, the policy has been tested in more than 70% of 46 sub-Saharan African countries. PBF projects are promoted by transnational expert networks (i.e., autonomous actors of polycentric governance), funded by donors, and supported by technical assistants, mostly coming from Europe. Beyond their financial power, these actors exert other less visible forms of power to stimulate the diffusion of PBF. Introducing the concept of diffusion entrepreneurs, we use a political economy approach to explore the social interactions at play in the diffusion process between actors across global/continental/national levels, and the asymmetrical power relations embedded within those interactions. To do so, we carry out an interpretative study with nested analysis levels (global, continental, national). Conceptual Framework: We use an interdisciplinary conceptual framework borrowing from the fields of public policy, international relations, and global health. We analyse the characteristics of diffusion entrepreneurs — their representation systems (their underlying assumptions about the world), resources, types of authority, and motivations — and the strategies they use to promote the diffusion of PBF. These strategies include: policy framing, stimulating emulation through policy emulation, driving the learning agenda on policy learning (FBP), and the setting of standards and frameworks of collaboration to ensure a successful experimentation of the FBP (policy experimentation).Methods: The thesis research object is the diffus