http://ijhpm.com Int J Health Policy Manag 2018, 7(1), 35–47 doi 10.15171/ijhpm.2017.42 Original Article http://ijhpm.com doi 10.15171/ijhpm.2015.188 Performance-BasedInt J Health Policy Manag 2016, 5(2), 117–119 Financing to Strengthendoi the10.15171 /ijhpm.Health2015.188 System in Benin: Challenging the Mainstream Approach Commentary Elisabeth Paul1*, Mohamed Lamine Dramé2, Jean-Pierre Kashala2, Armand Ekambi Ndema2, Marcel Kounnou3, Julien Codjovi Aïssan4, Karel Gyselinck5 Politics and Power in Global Health: The Constituting Role Abstract Article History: Background:of Performance-basedConflicts financing (PBF) is often proposed as a way to improve health system performance. In of Conflicts Received: 4 January 2017 Benin, PBF was launched in 2012 through a World Bank-supported project. The Belgian Development Agency (BTC) Comment on “Navigating Between Stealth Advocacy and Unconscious Dogmatism: TheAccepted: 25 March 2017 followed suit through a health system strengthening (HSS) project. This paper analyses and draws lessons from the experience ePublished: 15 April 2017 of BTC-supportedChallenge PBF alternative of Researching approach – especiallythe Norms, with regards Politics to institutional and Power aspects, of the Global role of demand-side Health” actors, ownership, and cost-effectiveness – and explores the mechanisms at stake so as to better understand how the “PBF package” * functionsClemet and produces Askheim, effects. Kristin Heggen, Eivind Engebretsen Methods: An exploratory, theory-driven evaluation approach was adopted. Causal mechanisms through which PBF is hypothesised to impact on results were singled out and explored. This paper stems from the co-authors’ capitalisation of Abstract Article History: experiences; mixed methods were used to collect, triangulate and analyse information. Results are structured along WitterArticle History: In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of Received: 5 September 2015 et al framework. global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing Accepted: 13 October 2015 Results: Influencethe politics of ofcontext global is health strong as overa question PBF in of Benin;individual the morality.policy is Drawingdonor-driven. on the BTC theoretical did not works adopt of the WorldePublished: 15 October 2015 Bank’s mainstreamChantal Mouffe, PBF model, we introduce but developed a conflictual an alternative concept of approach the political in lineas an with alternative its HSS to support Ooms’ conception.programme, which is grounded onUsing existing controversies domestic surrounding institutions. medical The main treatment features of AIDS of this patients approach in developing are described countries (decentralised as a case we governance, peer reviewunderline verification, the opportunity counter-verification for political entrusted changes, to through health servicepolitical users’ articulation platforms), of an asissue, well and as itscollective adaptive process. PBF has contributedmobilization to basedstrengthen on such various an articulation. aspects of the health system and led to modest progress in utilisation of health View Video Summary services, butKeywords: noticeable Global improvements Health, Liberal in healthcare Politics, quality.Chantal ThreeMouffe, mechanisms Conflict, AIDS,explaining Antiretroviral observed (ARV)outcomes within the contextTreatment are described: comprehensive HSS at district level; acting on health workers’ motivation through a complex package of Copyright:incentives; and© 2016 increased by Kerman accountability University byof Medicalreinforcing Sciences dialogue with demand-side actors. Cost-effectiveness and sustainabilityCitation: issues Askheimare also C,discussed. Heggen K, Engebretsen E. Politics and power in global health: the constituting role of conflicts: Comment on “Navigating between stealth advocacy and unconscious dogmatism: the challenge Conclusion: BTC’s alternative PBF approach is both promising in terms of effects, ownership and sustainability, and *lessCorrespondence to: of researching the norms, politics and power of global health.” Int J Health Policy Manag. 2016;5(2):117– resource consuming. This experience testifies that PBF is not a uniform or rigid model, and opens the policy groundEivind Engebretsen 119. doi:10.15171/ijhpm.2015.188 for recipient governments to put their own emphasis and priorities and design ad hoc models adapted to their contextEmail: [email protected] specificities. However, integrating PBF within the normal functioning of local health systems, in line with other reforms, is a big challenge. Keywords: Performance-Basedn a recent contribution Financing to (PBF), the ongoing Health Systemdebate Strengthening about the (HSS),take Local the Healthpolitical System, as the Benin, primary Low- level and the normative as and Middle-Incomerole of Countriespower in (LMICs), global health, Demand-Side Gorik ActorsOoms emphasizes secondary, or derived from the political? Copyright: ©the 2018 normative The Author(s); underpinnings Published by of Kerman global Universityhealth politics. of Medical Sciences.That is This what is anwe open-access will try toarticle do here, by introducing an distributedIHe under identifies the terms three of relatedthe Creative problems: Commons (1) Attributiona lack of agreement License (http://creativecommons.org/licenses/by/4.0 alternative conceptualization of the), political and hence free IHe identifies three related problems: (1) a lack of agreement alternative conceptualization of the political and hence free which permitsamong unrestricted global health use, scholars distribution, about and their reproduction normative in premises, any medium, providedus from the the original “false work dilemma” is properly Ooms also wants to escape. cited. (2) a lack of agreement between global health scholars and “Although constructivists have emphasized how underlying *Correspondence to: Citation:policy-makers Paul E, Dramé regardingML, Kashala the JP, normative et al. Performance-based premises underlying financing to strengthennormative the structureshealth system constitute in Benin: actors’ identities and challengingpolicy, the mainstreamand (3) a approach. lack of Intwillingness J Health Policy among Manag. scholars 2018;7(1):35–47. to interests, doi:10.15171/ijhpm.2017.42 they have rarely treated these normativeElisabeth Paul structures policy, and (3) a lack of willingness among scholars to interests, they have rarely treated these normativeEmail: [email protected] structures clearly state their normative premises and assumptions. This themselves as defined and infused by power, or emphasized confusion is for Ooms one of the explanations “why global how constitutive effects also are expressions of power.”2 This Backgroundhealth’s policy-makers are not implementing the knowledge Saharanis the Africa starting in point the forpast the decade. political To theorist our knowledge, Chantal Mouffe, PBF Health systemsgenerated in bymany global low- health’s and middle-income empirical scholars.” countries He calls implementationand her response in LMICs is to develop has almost an ontological always been conception supported of (LMICs)for face greater a numberunity between of structural scholars andproblems between andscholars by donors,the political, particularly where “the the political World Bankbelongs which to our administers ontological 3 inefficiencies.and policy-makers, In view of the concerning lack of success the underlying of most reform normative the Healthcondition.” Results3 According Innovation to TrustMouffe, Fund society (HRITF) is instituted created 1 attempts,premises performance-based and greater openness financing when (PBF) it comes has to advocacy.been in 2007through to support conflict. results-based “[B]y ‘the political’ financing I mean approaches the dimension in the of We commend the effort to reinstate power and politics in antagonism which I take to be constitutive of human societies, proposedWe as commenda way to thecatalyse effort comprehensiveto reinstate power reforms and politics and in healthantagonism sector (see which https I take:// wwwto be constitutive.rbfhealth.org of human). The societies,Belgian global health and agree that “a purely empirical evidence-based while by ‘politics’ I mean the set of practices and institutions help improveglobal health health andsystem agree performance. that “a purely empirical1 PBF is evidence-baseda supply- Developmentwhile by ‘politics’ Agency I mean (BTC) the hasset of also practices supported and institutions PBF in approach is a fiction,” and that such a view risks covering up through which an order is created, organizing human side form of results-based financing whose core features are several countries among which Rwanda and Burundi. “the role of politics and power.” But by contrasting this fiction coexistence in the context of conflictuality provided by the the following: performance-based incentives are earned by In Benin, after3 two inconclusive experiences led by the Ministry with global health research “driven by crises, hot issues, and political.”3 An issue or a topic needs to be contested to become service providers;the concerns payments of organized are targeted interest atgroups,” individual as a “path health we are of Healthpolitical, (MoH) and such in 2007a contestation and BTC concerns in 2008-2009, public action PBF wasand facilities tryingand administrations,