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Drawing on qualitative research with African actors and global health institutions, the authors explore the politics of how performance funding modalities and participation are used to shape health reform in African countries as well as the role of African actors, global policy elites and international donors within these processes.



1. Introduction: Global Politics of Health Reform in Africa

Participation and performance have become two master concepts for wider health reform in Africa. These concepts were initially used in the delivery of HIV/AIDS and maternal and newborn child health programmes as part of the UN Millennium Development Goals; however, key international donors such as the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria are now seeing the potential of such concepts in mechanisms of wider health reform in Africa. This chapter introduces the context, aims, and argument of the book and provides a detailed account of the qualitative methods used to conduct research in South Africa, Tanzania, and Zambia and two global health hubs: Geneva and Washington, DC.

Amy Barnes, Garrett Wallace Brown, Sophie Harman

2. The Performance-Based Funding (PBF) Debate

This chapter outlines the main debate over results and performance-based funding (PBF) and the application of PBF to health system reform in Africa. It introduces the reader to principal-agent theory as the central approach to PBF adopted by the World Bank and Global Fund and outlines the many concerns and contentions associated with PBF. In so doing the chapter begins to show how global health institutions have adopted a positive bias to PBF as a tool for health system reform and that we know little about the role of African actors in the shaping and implementing of PBF programmes and in generating the evidence base that underpins them.

Amy Barnes, Garrett Wallace Brown, Sophie Harman

3. The Politics of Performance-Based Funding (PBF)

This chapter introduces the reader to how performance-based funding (PBF) works in practice in South Africa, Tanzania, and Zambia and where the idea for PBF came from. In so doing it reviews how health workers in these countries understand PBF, the problems associated with implementing PBF and its multiple levels of governance, and the origins of PBF as a health reform tool. The chapter shows evidence of discontent towards PBF in South Africa and how a positive bias is reproduced by donors in Tanzania and Zambia through the promise of finance and study tours to ‘success story’ countries. The chapter outlines the role of consultants and international agencies, which increasingly have a brokerage role in global health governance that challenges the practical application of the principal-agent model of PBF.

Amy Barnes, Garrett Wallace Brown, Sophie Harman

4. The Politics of Participation in Health Reform

This chapter examines how multi-sectoral and multi-level stakeholders have participated in the formation of performance-based funding (PBF) design and implementation at the global and national levels in South Africa, Tanzania, and Zambia. The chapter looks at what is meant by participation and what we know about its role in health system reform, and formal and informal mechanisms of participation at multiple levels of governance. In so doing, it demonstrates the dominance of informal mechanisms that undermine meaningful participation as they privilege elites, lock out other stakeholders from the participatory process, and maintain a positive bias towards PBF with little meaningful engagement. The chapter also explores the problems of participation fatigue and the culture of per diems and paying for participation.

Amy Barnes, Garrett Wallace Brown, Sophie Harman

5. Conclusion

This chapter outlines the three key findings of the book with regard to the role of African agency; participation and the global health policy elite; and principals, agents, and accountancy in the global health policy market. The chapter then outlines the four problems that the politics of participation and performance demonstrate for health system reform in Africa. Drawing on findings from South Africa, Tanzania, and Zambia, the chapter argues that the theory and practice of participation and performance-based funding remain tenuous, participatory processes of engagement in health system reform are weak, and African agency limited by the robustness of a health system and the nature of existing donor-recipient relations.

Amy Barnes, Garrett Wallace Brown, Sophie Harman


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