INTRODUCTION: Performance–Based Grant Agreements are increasingly being used in Nepal in the healthcare sector, especially at public-private partnership hospitals. As interest in these agreements grows, it is essential to understand the process of implementation so that Nepali healthcare policy–makers can make better informed decisions about how they impact the public health situation of Nepal. This project studied the process of implementing Performance–Based Grant Agreements using qualitative research methods to interview key informants about their opinions, perceptions, and experiences associated with these agreements. METHODS: Semi–structured interviews with open–ended questions were conducted with key informants who have direct knowledge and experience about the design, implementation, and impact of the Performance–Based Grant Agreements. The key informants included healthcare administrators and healthcare workers at the various implementing hospitals, Government of Nepal officials, and members of various External Development Partners; these participants were chosen using a combination of purposive and convenience sampling methods in an attempt to triangulate responses and to generate a diversity of opinions, and perspectives. Participants were asked about their experiences with the Performance–Based Grant Agreements and interviews focused on associated challenges, opportunities, learned experiences, and both expected and unexpected consequences. Data analysis was overlapping with data collection and concentrated on identifying recurrent themes and ideas from transcribed interviews. These themes and ideas along with illustrative quotes guided discussion and results. RESULTS: A total of 16 interviews, ranging from 12 minutes to 75 minutes in length, were conducted with different hospital administrators, Government of Nepal officials, and members of different External Development Partners about the Performance–Based Grant Agreements. Participants had widely varying experiences about the process of implementing these agreements, which yielded a diversity of responses. DISCUSSION: There was an awareness gradient among the participants about the agreements as some participants had barely heard of the contracts while others had detailed knowledge of how their institution was implementing them. The process of implementation for participants and their institutions included grappling with the concept of conditionally tying funding to performance, figuring out how to do monitoring and evaluation, understanding the barriers to implementation, and using new technology and practices to meet the demands of the agreements. Despite the varying experiences associated with implementation or a lack thereof, participants were unanimous in their support for the adoption of these agreements and hopeful that these agreements can enhance partnership while improving the delivery of health services in Nepal.

Background: Performance-based financing (PBF) is a healthcare reform that is widely adopted in low- and middle-income countries (LMICs). PBF is an intervention designed to strengthen healthcare systems in LMICs. It represents a fundamental shift towards improving healthcare amongst the most vulnerable, with a focus on maternal and child health services. Broadly, there are gaps regarding PBF’s effect on healthcare systems and various aspect of healthcare, including efforts to implement universal healthcare coverage. PBF introduced an innovative component—the PBF equity instrument—geared towards achieving universal health coverage. The effect of this equity instrument has not been studied. There is significant gap regarding how it is defined and implemented in various context. Cameroon has one of the highest maternal mortality rates in sub–Saharan Africa and with high out-of-pocket expenses that impede access to maternal health services. PBF was introduced in Cameroon in 2012 with a focus on maternal health services and was adopted in 2017 as a national strategy towards achieving universal coverage, however, the definition and implementation of the PBF equity elements remain a gap in Cameroon and sub-Saharan Africa. This dissertation is focused on studying the PBF equity elements in Cameroon in order to get a broader perspective on the effect of the PBF equity elements as a policy tool in improving the lives of the most vulnerable population to ensure no one is left behind in the efforts towards achieving universal health coverage. Objectives: This dissertation aimed (1) to investigate and characterize the effect of the PBF equity elements in improving equity in access to selected maternal services (2) to understand how the equity elements is defined and implemented in Cameroon; and (3) to generate a framework that will facilitate the identification of gaps and challenges, in turn informing policy development that is relevant to PBF equity elements in Cameroon and PBF research on equity in other countries; and (4) to explore health providers experiences before and after the introduction of PBF in Cameroon. Methods: This dissertation employed a mixed methods approach to address the above objectives, involving the use of multiple frameworks and triangulation across and within objectives. First, to investigate the effect of PBF on equity in improving access to maternal services, I designed a systematic review with a focus on one of the equity elements—subsidizing user fees to reduce out-of-pocket expenses to improve access to maternal health services. The aim was to get a broader overview of the PBF equity element and to understand the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services in sub–Saharan Africa. Second, I narrowed the assessment to a specific context-Cameroon. Given the heterogenous nature of care delivery in Cameroon, I investigated the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services across healthcare sectors using a before-and-after study design. The rationale was to address the limitations of an earlier PBF impact evaluation in Cameroon, in particular, potential heterogeneity across settings and sectors which had not been considered. Third, to describe and define the implementation of the PBF equity elements in Cameroon, I conducted a grounded theory study -given that it is a new policy that has not been well studied -to understand the social processes and actions from health facilities, health providers, PBF managers and the community, and generated a theoretical framework to inform the challenges and gaps in the implementation process. Finally, as a newly adopted health reform, I conducted an in-depth qualitative study to understand the experiences of health care provides before -and-after the implementation of PBF and its equity elements and the potential for sustainability of the policy especially the equity strategies in Cameroon. Findings: The findings provide an overarching understanding on the effect of one of the PBF equity elements in improving access to maternal health services in sub–Saharan Africa, and in particular, an understanding of the effect of the PBF equity elements in improving access and utilization of selected maternal services in Cameroon. At the health system level, the findings provide an understanding of the focus of the equity elements within the context of Cameroon and further insight on the gaps and limitations in the implementation of the PBF equity elements and the potential challenges in sustainability towards achieving universal health coverage. At the health facility level, it provides an understanding on how the PBF equity elements is understood, defined, and implemented and provides directions on the challenges to inform policy and to guide research. At the individual level, it provides an overview of the expectations of health care providers from a supply side perspective and the potential effect it has on demand creation from women and households in improving access to maternal health services. Overall, the findings provide insight on how the equity elements are defined and implemented but also provides opportunity and areas of improvement and detailed how PBF equity elements can be further assessed and how delays in payment of PBF incentives can potentially affect the realization of the equity elements in improving access and utilization of maternal health services amongst the poor and vulnerable. Conclusion: Equity is central and essential to the delivery of services to achieve universal health coverage. The adoption of PBF in Cameroon is a step toward achieving universal health coverage with the recognition that universal health coverage cannot be effectively implemented in an institution without good governance. The PBF initiative is viewed as an entry point for universal health coverage, in order to evaluate the level of preparedness of health facilities to embrace universal health coverage in terms of quality of health care, production, good managerial skills, and financial management. However, due to administrative bottlenecks, the government has yet to accept some of the established principles of PBF—this in turn causes delays in payment and this hampers the effective implementation of some of the PBF equity strategies. Therefore, though PBF is a national policy, the actors at the central level, i.e., the Ministry of Public Health, are not playing their role effectively in enabling full implementation of PBF best practices and theories.

Background: Performance based financing was introduced to Kilifi county actors in Kenya in 2015. Kilifi was identified by the Kenyan national government as one of the 20 arid and semi-arid counties (out of 47 counties) mandated to start the implementation of the scheme and potentially inform the development of a nation-wide PBF policy. This study investigates how political and bureaucratic actors at the local level in Kilifi county have subsequently influenced the extent to which PBF has been politically prioritised at the sub-national level. Methods: The study employed a single-case study design. The Shiffman and Smith (2007) political priority setting framework with adaptations proposed by Walt and Gilson (2014) was used. Data was collected through document review (n=19) and in-depth interviews (n=8). Framework analysis was used to analyse data and generate findings. Results: Throughout the study period (2015-2018), national policy elites gave sustained attention to PBF as a priority issue for implementation, this sustained attention was however not present at the sub national level in Kilifi county and funding for PBF was not prioritised post donor funding. Key factors that contributed to this in Kilifi county included: redistribution of power from national actors to sub-national actors following devolution, this affected the national Ministry of Health's ability to lead and be an effective guiding organisation; misalignment between the globally advocated idea of ‘pay for performance' and the local pre-existing centralised and rigid approaches to public financial management; and actors at the sub national level who contested the PBF intervention design features and its framing as ‘additional funding'. As a consequence, the implementation of PBF in Kilifi was for a short time only using donor resources and did not last beyond donor timelines and funding. Conclusion: This research shows that for health reforms to gain political priority in highly devolved contexts, there is need to recognise the formal and informal institutions existing at the devolved level of governance and for adequate early involvement and leadership from sub-national bureaucratic and political actors, in health and beyond the health sector. In addition, advocacy for the health reforms should embody frames that align with the political context to increase the chances of gaining political traction. Finally, the political context including political and bureaucratic power at different levels of government are crucial features that will also influence the acceptability of reform and ultimately political prioritisation.

<p>This thesis explores and explains the existence of a best practice model to optimise the transfer of funds (&ldquo / the transfer funding process&rdquo / ) between funders and service providers in the public sector. Using ideas about best practice in a specific context, the Health environment, it investigates the perceptions of managers about the transfer of funds between the Provincial Government of the Western Cape and the Local Authority of the City of Cape Town, the existence of a formula that will indicate appropriate amounts to transfer to service providers, and how information systems might assist with the process and the formula.</p>

<p>This thesis explores and explains the existence of a best practice model to optimise the transfer of funds (&ldquo / the transfer funding process&rdquo / ) between funders and service providers in the public sector. Using ideas about best practice in a specific context, the Health environment, it investigates the perceptions of managers about the transfer of funds between the Provincial Government of the Western Cape and the Local Authority of the City of Cape Town, the existence of a formula that will indicate appropriate amounts to transfer to service providers, and how information systems might assist with the process and the formula.</p>

Magister Commercii (Information Management) - MCom(IM) / This thesis explores and explains the existence of a best practice model to optimise the transfer of funds (the transfer funding process) between funders and service providers in the public sector. Using ideas about best practice in a specific context, the Health environment, it investigates the perceptions of managers about the transfer of funds between the Provincial Government of the Western Cape and the Local Authority of the City of Cape Town, the existence of a formula that will indicate appropriate amounts to transfer to service providers, and how information systems might assist with the process and the formula. / South Africa

Le financement basé sur la performance est une approche gestionnaire promue par la Banque Mondiale (BM) et United States Agency for International Development (USAID), qui connaît une rapide diffusion dans les programmes d’aide au développement. Dans un contexte où de nombreux travaux ont démontré la subjectivité du lien entre la lutte contre la pauvreté et les « bonnes politiques » recommandées par la BM dans le cadre de l’allocation basée sur la performance (ou sélectivité), il apparaît pertinent de s’interroger sur la performativité de ce nouvel instrument. En mobilisant conjointement la théorie de l’acteur-réseau et les théories néo-institutionnelles,cette thèse analyse, au niveau global puis dans un cadre national, le processus de conception, d’expérimentation, de diffusion et de mise en œuvre de l’instrument dans le domaine de la réforme des systèmes de santé. Au niveau global, nous étudions la conceptualisation de l’instrument, que nous replaçons dans une généalogie de la performation, par le réseau néolibéral, des politiques d’aide au développement et de santé globale. Nous analysons ensuite son expérimentation au Rwanda,dans le cadre d’un dispositif de régulation par le marché des systèmes de santé mis en œuvre à travers : (I) la mise en place d’une tarification à l’activité visant à transformer les structures de santé en acteurs économiques autonomes (volet offre), et (II) la création de mutuelles privées communautaires à même de développer des stratégies d’achats (volet demande). Nous étudions enfin sa diffusion institutionnelle sous l’effet (i) d’une valorisation de l’expérimentation rwandaise sans prise en compte de son contexte spécifique, et (II) d’un dispositif incitatif permettant l’enrôlement des responsables de la BM et des ministères bénéficiaires. Au niveau national, nous étudions la stratégie d’influence de la BM et de l’USAID en faveur de la diffusion de ces réformes au Sénégal. Nous présentons le processus d’adoption de ces réformes par le Ministère de la santé, la mise en échec d’un modèle de régulation concurrent en voie d’expérimentation par la coopération technique belge, puis les pressions exercées parla BM pour contraindre le gouvernement à internaliser le modèle promu. Nous mettons ensuite en perspective l’abandon du modèle de régulation par le marché qui était initialement affiché,au profit d’une nouvelle régulation transnationale, matérialisée par un contrat de financement basé sur l’activité directement contrôlé par la BM. / Performance-based financing is a management approach promoted by the World Bank (WB) and the United States Agency for International Development (USAID) that is rapidly being mainstreamed in development assistance programs. In a context where many studies have demonstrated the subjectivity of the link between the fight against poverty and the "good policies" recommended by the WB in the context of performance-based allocation (or selectivity), it seems relevant to question the performativity of this new instrument. Drawing jointly on actor-network theory and neo-institutional theories, we analyze the process of designing, experimenting, disseminating and implementing the instrument in the field of health policy reforms at the global level and then at the national level.At the global level, we study the conceptualization of the instrument, which we place in agenealogy of the neoliberal network's performance of development aid and global healthcarepolicies. We then analyze its experimentation in Rwanda, as part of a market-based regulationfor healthcare systems implemented through: (I) the deployment of activity-based payments to transform healthcare structures into autonomous economic actors (on the supply side), and (II) the creation of private community-based insurance structures designed to develop purchasing strategies (on the demand side). Finally, we study the instrument’s institutional diffusion under the effects of (I) a promotion of the Rwandan experiment decontextualized from the country’sspecific political situation, and (II) an incentive mechanism allowing the enrolment of both WB’sofficials and the ministries that are benefitting from the WB’s aid. At the national level, we have studied the influence strategy of a coalition of actors composedof the WB and USAID to promote the dissemination of these reforms in Senegal. We present the process of adoption of the reforms by the Ministry of Health, the failure of a competing regulatory model that was being tested by Belgian technical cooperation, and then the pressure exerted by the WB to coerce the government into internalizing the promoted model.We then put into perspective the abandonment of the market-based regulatory model that was initially announced, in favor of a new transnational regulation, materialized by activity-basedfinancing contracts that are directly controlled by the WB.

Thèse de doctorat de l’Université de Montréal en cotutelle avec l’Université Paris-Diderot. Présentée et soutenue publiquement à Paris le 3 juillet 2019. / Problématique : Le caractère polycentrique de la gouvernance de santé mondiale fait émerger depuis une vingtaine d’années des pôles d’influence politique de différents niveaux. Depuis la fin des années 2000, des acteurs influents appuient la mise en œuvre d’une réforme de financement de la santé : le financement basé sur la performance (FBP). Le FBP repose sur le transfert de ressources financières conditionnelles à la performance des prestataires de santé. En dépit d’une absence d’unanimité sur les preuves scientifiques de son efficacité, la politique a été expérimentée dans plus de 70% des 46 pays d’Afrique subsaharienne. Les projets de FBP sont promus par des réseaux d’experts transnationaux (nouveaux acteurs de la gouvernance polycentrique), financés par des bailleurs de fonds, et appuyés par des assistants techniques provenant le plus souvent d’Europe et d’Amérique du Nord. Au-delà du pouvoir financier, ces acteurs exercent d’autres formes de pouvoir moins visibles pour stimuler la diffusion de cette politique. Introduisant le concept d’“entrepreneurs de la diffusion”, nous utilisons une approche d’économie politique pour comprendre les interactions sociales en jeu dans le processus de diffusion entre les acteurs agissant aux niveaux global, continental et national, ainsi que les relations de pouvoir asymétriques inhérentes à ces interactions. Pour cela, nous réalisons une étude interprétative à niveaux d’analyse imbriqués (global, continental, national). Cadre conceptuel : Nous utilisons un cadre conceptuel interdisciplinaire empruntant aux champs des politiques publiques, des relations internationales, et de la santé mondiale. Nous analysons les caractéristiques des entrepreneurs de la diffusion – leurs systèmes de représentation (leur perception du monde et présupposés sous-jacents), ressources, types d’autorité, et motivations – et les stratégies qu’ils utilisent pour favoriser la diffusion du FBP. Ces stratégies incluent : l’ancrage idéationnel de la politique (policy framing), la stimulation de l’émulation par la constitution de réseaux (policy emulation), la conduite de l’agenda d’apprentissage sur le FBP (policy learning), et la fixation de standards et cadres de collaboration pour assurer une expérimentation réussie du FBP (policy experimentation). Méthodologie : L’objet principal de la thèse est la diffusion du FBP en Afrique subsaharienne, qui s’articule autour d’influents « entrepreneurs de la diffusion » (cinq organisations, trois réseaux transnationaux, et plus d’une vingtaine d’individus). Trois études ont été réalisées à trois niveaux différents : niveau global (arènes politiques de santé mondiale et instituts de recherche européens), niveau continental (Afrique subsaharienne), et niveau national (cas du Mali). L’approche d’analyse est principalement qualitative : nous avons collecté des données d’entretiens approfondis (N=57), d’observations participantes (N=13) et de documents (N=41). Dans l’étude à échelle continentale, ces données qualitatives sont complétées par des analyses de réseaux sociaux et des analyses sémantiques à partir de 1 346 messages de forum. Ces données quantitatives complètent la caractérisation de l’un des réseaux transnationaux et son influence sur la diffusion du FBP. Valeur de la recherche : Cette recherche constitue la première analyse d’économie politique détaillant des processus multiniveaux et protéiformes (discours, constitution en réseaux, et production et dissémination de multiples formes de savoirs) conduits par des acteurs influents – les entrepreneurs de la diffusion – afin de faciliter la diffusion d’une innovation politique (le FBP) dans le contexte particulier de la gouvernance polycentrique. Cette étude apporte d’importantes contributions théoriques et empiriques à la littérature. Premièrement, elle offre un cadre conceptuel novateur adapté au contexte de la santé mondiale et de la gouvernance polycentrique, qui peut être appliqué à divers types de recherche. Deuxièmement, elle fournit des analyses empiriques utiles sur les processus de gouvernance polycentrique, qui ont été jusqu’ici peu étudiés. Mettant en lumière l’exercice du pouvoir d’acteurs européens et nord-américains dans leur interaction avec des consultants et décideurs africains, cette étude ouvre également la voie à d’autres recherches, notamment sur le phénomène de fabrique d’une expertise africaine. / 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.

Contexte : La mauvaise qualité et la faible utilisation des services de santé contribuent aux taux élevés de morbidité et de mortalité dans plusieurs pays à faible et à moyen revenu. Face à cette situation, le gouvernement du Burkina Faso a testé une intervention novatrice qui combine le financement basé sur la performance (FBP) à des mesures d'équité en santé. Les formations sanitaires ont reçu des prix unitaires pour des services de santé fournis ainsi que des bonus conditionnels à la qualité des soins. Des comités communautaires ont sélectionné les indigents pour leur octroyer des exemptions de paiements des soins. Malgré le peu d’études sur le sujet, des acteurs en santé mondiale craignent que l’intervention puisse avoir des conséquences non intentionnelles importantes. Objectif : Cette thèse vise à accroître les connaissances scientifiques sur les conséquences non intentionnelles du FBP combiné à des mesures d'équité en santé dans un environnement à faible revenu. Méthodes : Nous avons développé un cadre conceptuel basé sur la théorie de la diffusion des innovations. Une étude de cas multiples a été réalisée avec neuf formations sanitaires au Burkina Faso. Cinq mois sur le terrain ont permis d’effectuer 104 entrevues semi-structurées, 266 séances d'observation et des conversations informelles avec un large éventail d'acteurs incluant les prestataires de soins, les patients et les vérificateurs. Les données qualitatives ont été codées avec QDA miner pour faciliter l’analyse thématique. Nous avons également utilisé des données quantitatives du système de gestion pour décrire l'évolution des services et trianguler les résultats. Résultats : La nature et la mise en œuvre de l'intervention ont interagi avec le système social et les caractéristiques de ses membres pour engendrer des conséquences non intentionnelles importantes, dont la plupart étaient indésirables. Les prestataires de soins ont démontré une fixation sur les mesures de rendement, ont falsifié les registres médicaux et ont enseigné de mauvaises pratiques aux stagiaires pour augmenter leurs subsides et bonus. Comme conséquence non intentionnelle désirable, certaines formations sanitaires ont limité la vente de médicaments sans prescriptions pour encourager les consultations. Les vérifications communautaires, durant lesquelles les patients sont retrouvés pour vérifier les services déclarés, ont entraîné la falsification des données de vérification, la perte de la confidentialité des patients et certaines craintes chez les patients, bien que certains étaient heureux de partager leurs opinions. Enfin, les prestataires de soins ont limité les services offerts gratuitement aux indigents, ce qui a déclenché des conflits. Discussion : Cette thèse contribue au développement des connaissances scientifiques sur la façon dont le FBP, combiné à des mesures d'équité, peut engendrer des conséquences non intentionnelles. Les résultats sont utiles pour affiner ce type d’intervention et éclairer une mise en œuvre efficace dans le secteur du financement de la santé. Plus largement, cette thèse démontre la faisabilité et la valeur ajoutée d'utiliser un cadre conceptuel pour étudier les conséquences non intentionnelles. Elle pourra guider les chercheurs à élargir leur angle d’analyse afin de rendre compte des conséquences intentionnelles et non intentionnelles des interventions complexes en santé. / Background: Poor quality and low utilization of healthcare services contribute to high levels of morbidity and mortality in many low- and middle-income countries (LMICs). In response, the government of Burkina Faso tested an innovative intervention that combines performance-based financing (PBF) with health equity measures. Healthcare facilities received unit fees for targeted services and bonuses conditional upon the quality of care. To reduce inequities in access to care, community-based committees selected indigents, i.e., the poorest segment of the population, to offer them user fee exemptions. Facilities were also paid more for services delivered to indigents. Despite the potential of this type of intervention, many global health actors argue that it could lead to important unintended consequences that influence its overall impact. Yet, little attention has been given to studying the unintended consequences of this complex intervention. Objective: This thesis aims to increase the scientific knowledge on the unintended consequences of PBF combined with health equity measures in a low-income setting. Methods: We developed a conceptual framework based on the diffusion of innovations theory. Using a multiple case study design, we selected nine healthcare facilities in Burkina Faso. Over five months of fieldwork, we collected multiple sources of qualitative data including 104 semi-structured interviews, 266 recorded observation sessions, informal conversations and documentation. Participants included a wide range of stakeholders, such as providers, patients, and PBF verifiers. Data were coded using QDA miner to conduct a thematic analysis. We also used secondary data from the PBF routine management system to describe the evolution of services and triangulate results. Results: Interactions between the nature and implementation of the intervention, the nature of the social system, and its members’ characteristics led to important unintended consequences, most of which were undesirable. Providers were fixated on performance measures rather than on underlying objectives, falsified medical registers, and taught trainees improper practices to increase subsidies and bonuses. As a desirable unintended consequence, we found that some facilities limited the sale of non-prescribed medication to encourage patients to consult. Community verifications, in which patients are traced to verify the authenticity of reported services and patient satisfaction, also led to unintended consequences, such as the falsification of verification data, the loss of patient confidentiality, and fears among patients, although some were pleased to share their views. Lastly, health equity measures also triggered changes that were not intended by program planners. For example, providers limited the free services and medication delivered to indigents, which led to conflicts between parties. Discussion: This thesis contributes to the development of scientific knowledge on how PBF interventions, combined with equity measures, can trigger unintended consequences in a low-income setting. The results are useful to inform effective implementation and refine interventions, particularly in the health financing sector. More broadly, this thesis demonstrates the feasibility and added value of using a conceptual framework to study the unintended consequences of complex health interventions. This thesis can inspire and guide future researchers to broaden their analytical horizons to capture both intended and unintended consequences of health interventions.

L'accès aux médicaments essentiels (ME) est un élément clé de la qualité des soins dans un système de santé. Par ailleurs, le financement basé sur la performance (FBP) attire de plus en plus l'attention des décideurs comme une intervention pour améliorer la prestation des services de santé, y compris l’accès aux ME, dans les pays à faible et moyen revenus (PFMR). Malgré l’intérêt croissant de la recherche sur le FBP, très peu d’étude ont porté sur la mise à l’agenda d’une telle réforme ou son maintien à l’ordre du jour au fil du temps, encore moins sur l’influence de celle-ci sur l’accès aux ME dans les PFMR. A travers une analyse du programme de FBP au Cameroun, la présente thèse vise à faire avancer les connaissances en examinant les questions suivantes : qu’est-ce qui explique l’apparition du FBP au niveau de la politique nationale de la santé et quel est l’impact de ce programme sur l’accès aux ME? Le devis de recherche est celui d’une étude de cas et la démarche analytique s’appuie sur la combinaison des données qualitatives, à travers des entrevues réalisées auprès des acteurs clés du programme FBP au Cameroun, et quantitatives, issues de l’évaluation d’impact de ce programme. La perspective conceptuelle est celle des cycles de politique, du cadre de transfert des politiques et de la recherche interventionnelle. Les résultats sont structurés en quatre articles scientifiques. La mise du FBP à l’agenda au Cameroun s’est construite à partir des rapports et événements identifiant l'absence d'une politique de financement de la santé adaptée comme une question importante à laquelle il fallait s'attaquer (article 1). L'évolution du discours politique vers une plus grande responsabilisation a permis de tester de nouveaux mécanismes. Un groupe d'entrepreneurs politiques de la Banque mondiale, par le biais de nombreuses formes d'influence (financière, conceptuelle, fondée sur la connaissance et les réseaux) et en s'appuyant sur plusieurs réformes en cours, a collaboré avec de hauts fonctionnaires du gouvernement pour mettre le programme FBP à l'ordre du jour. Des organisations non gouvernementales internationales ont été recrutées au début du programme pour assurer sa mise en œuvre rapide. Toutefois, il a fallu transférer ce rôle aux organisations nationales pour assurer la pérennité, l'appropriation et l'intégration de l'intervention du FBP dans le système de santé (article 2). L'expérience de ce transfert montre que les éléments favorisant la réussite d’un tel processus incluent des directives structurées, une appropriation et planification conjointe de la transition par toutes les parties, et un soutien post-transition aux nouveaux acteurs. Les données qualitatives suggèrent que la mise en œuvre du programme FBP influence l’accès aux médicaments essentiels par l’entremise de plusieurs facteurs, notamment une plus grande autonomie des formations sanitaires, une régulation appliquée des équipes cadre de santé, une plus grande responsabilisation des acteurs du médicament et la libéralisation du système d’approvisionnement (article 3). Cependant, le programme a eu un impact très limité sur la disponibilité des ME (article 4). L'intervention n’a été associée à aucune réduction des ruptures de stock de ME, sauf pour la planification familiale (PF), avec une hétérogénéité des effets entre les régions et les zones urbaines et rurales. Ces résultats sont la conséquence d'un échec partiel de la mise en œuvre de ce programme, allant de la perturbation et de l'interruption des services à une autonomie limitée des formations sanitaires dans la gestion des décisions et à un retard considérable dans le paiement des prestations. / Access to essential medicines (EM) is a key element of quality of care in a health system. Accordingly, performance-based financing (PBF) is increasingly attracting the attention of policy makers as a promising intervention to improve health service delivery, including access to essential medicines, in low and middle-income countries (LMICs). Despite the growing interest in PBF research, very few studies have focused on how such a reform has been put on the agenda or how it has been maintained over time, much less how it has influenced access to EMs in low- and middle-income countries. Through an analysis of the PBF program in Cameroon, this thesis aims to advance knowledge by examining the following questions: What explains the emergence of PBF at the level of national health policy and what is the impact of this program on access to EMs? The research design is a case study and the analytical approach is based on a combination of qualitative data, through interviews conducted with key actors of the PBF program in Cameroon, and quantitative data from the impact evaluation of this program. The conceptual perspective is that of policy cycles, the policy transfer framework and intervention research. The results are structured into four scientific articles. Putting the PBF on the agenda in Cameroon was built from reports and events identifying the lack of an appropriate health financing policy as a critical issue that needed to be addressed (article 1). The evolution of political discourse towards greater accountability made it possible to test new mechanisms. A group of political entrepreneurs from the World Bank, through many forms of influence (financial, conceptual, knowledge-based and networked) and building on several ongoing reforms, worked with senior government officials to put the PBF reform on the agenda. International non-governmental organizations were recruited at the beginning of the programme to ensure its rapid implementation. However, this role had to be transferred to national organizations to ensure sustainability, ownership and integration of the PBF intervention into the health system (Article 2). The experience of this transfer shows that the elements for the success of such a process include structured guidelines, joint ownership and planning of the transition by all parties, and post-transition support to new actors. The implementation of the PBF programme influences access to essential medicines through several factors, including greater autonomy of health v facilities, enforced regulation of district medical teams, greater accountability of drug stakeholders and liberalization of the supply system (Article 3). However, the programme had a very limited impact on the availability of EMs (Article 4). The intervention was not associated with any reduction in EM stock-outs, except for family planning (FP), where the reduction was 34% (P = 0.028), with a heterogeneity of effects between regions and urban and rural areas. These poor results were likely the consequence of partial implementation failure, ranging from disruption and discontinuation of services to limited facility autonomy in managing decision‐making and considerable delay in performance payment.