Negotiation of a health policy controversy: Application of an indirect dialogue approach to performance-based financing in sub-Saharan Africa

Objectives: This article assesses the controversy around performance-based financing (PBF) and its contribution to the reform of health systems. It aims to reduce tensions between the different camps by restructuring the debate. Methods: Our approach was to organize an indirect dialogue between critics and supporters of PBF, based on the framework developed by Norman Daniels. This analytical framework is non-partisan and uses clear and objective criteria. The interviews were carried out in two rounds (first the critics, then the supporters) and were then analyzed. Parts of answers were regrouped according to the most common sectoral themes while also highlighting major areas of disagreement. Results: The interviews revealed some areas of convergence around PBF; the strategy is considered to be a complementary strategy to other strategies; such as those which aim to improving financial access to health care. The analysis also revealed disagreements based on misunderstandings of claims often ascribed to PBF, or lack of sufficient evidence, or asymmetrical information between experts. Conclusions: Several questions polarize PBF discussions. However, better structuring of convergent and divergent areas and arguments should facilitate a synthesis, at least to some extent. Experts need to adopt an objective approach with universally accepted criteria, for the benefit of all.