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

Background: 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. In contrast to input financing systems, this mechanism focuses on achieving results based on performance targets. Despite a lack of consensus on the scientific evidence of its effectiveness, 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 and North America. 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 diffusion of PBF in sub-Saharan Africa, which involves influential diffusion entrepreneurs (five organisations, three transnational networks, and about two dozen individuals). Three studies were conducted at three different levels: global level (global health policy arenas and European research institutes), continental level (sub-Saharan Africa), and national level (Mali case). The analysis approach is mainly qualitative: we collected data from in-depth interviews (N = 57), participant observations (N = 13) and documents (N = 41). In the study on continental-level diffusion, qualitative data are supplemented by social network analyses and semantic discourse analyses based on 1,346 forum posts. These quantitative data complement the characterisation of a transnational network’s structure and how it influences policy diffusion. Research value: This research is the first political economy analysis detailing multilevel and multifaceted processes (discourse, networks, and production and dissemination of multiple forms of knowledge) led by influential policy actors — diffusion entrepreneurs — to foster the expansion of a policy innovation (PBF) in the specific context of polycentric governance. This study makes important theoretical and empirical contributions to the literature. First, it offers an innovative conceptual framework adapted to the contexts of global health and polycentric governance. The framework can be applied to a variety of research designs. Second, it provides useful insights on the processes of policy diffusion in polycentric governance, thereby filling a research gap on the phenomenon of polycentrism. By highlighting European and North American actors’ exercise of power in their interaction with African consultants and policymakers, this study also paves the way for future research — particularly on the phenomenon of the making of an African expertise.

Keyphrases: policy diffusion, political economy analysis, performance-based financing, sub-Saharan Africa