Implementing pay-for-performance in primary health care: the role of institutional entrepreneurs

© 2017 The Author(s). Institutional entrepreneurs are vital for facilitating non-incremental health policy change in complex institutional settings where established traditions and practices carry considerable weight. This paper describes a comparative case study of health policymaking which shows that Kingdon’s Multiple Streams Framework for non-incremental policy change requires enhancement to explain results in policy-making in two Westminster unitary majoritarian jurisdictions. The most similar systems comparative study found that historical, rational choice, organisational and discursive institutionalist approaches explained the policy change and variation observed better than agency-based approaches did. However, institutional entrepreneurs were important in both cases. Differences in coordinative discourse help to explain the differences in degree of change achieved in each case study and highlight the importance of discursive institutionalist approaches in bridging institutional and agency-based approaches.