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Combining Theory-Driven Evaluation and Causal Loop Diagramming for Opening the ‘Black Box’ of an Intervention in the Health Sector: A Case of Performance-Based Financing in Western Uganda

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  • Dimitri Renmans

    (Institute of Development Policy and Management (IOB), University of Antwerp, Antwerp, 2000, Belgium
    Department of Public Health, Institute of Tropical Medicine, Antwerp, 2000, Belgium)

  • Nathalie Holvoet

    (Institute of Development Policy and Management (IOB), University of Antwerp, Antwerp, 2000, Belgium)

  • Bart Criel

    (Department of Public Health, Institute of Tropical Medicine, Antwerp, 2000, Belgium)

Abstract

Increased attention on “complexity” in health systems evaluation has resulted in many different methodological responses. Theory-driven evaluations and systems thinking are two such responses that aim for better understanding of the mechanisms underlying given outcomes. Here, we studied the implementation of a performance-based financing intervention by the Belgian Technical Cooperation in Western Uganda to illustrate a methodological strategy of combining these two approaches. We utilized a systems dynamics tool called causal loop diagramming (CLD) to generate hypotheses feeding into a theory-driven evaluation. Semi-structured interviews were conducted with 30 health workers from two districts (Kasese and Kyenjojo) and with 16 key informants. After CLD, we identified three relevant hypotheses: “success to the successful”, “growth and underinvestment”, and “supervision conundrum”. The first hypothesis leads to increasing improvements in performance, as better performance leads to more incentives, which in turn leads to better performance. The latter two hypotheses point to potential bottlenecks. Thus, the proposed methodological strategy was a useful tool for identifying hypotheses that can inform a theory-driven evaluation. The hypotheses are represented in a comprehensible way while highlighting the underlying assumptions, and are more easily falsifiable than hypotheses identified without using CLD.

Suggested Citation

  • Dimitri Renmans & Nathalie Holvoet & Bart Criel, 2017. "Combining Theory-Driven Evaluation and Causal Loop Diagramming for Opening the ‘Black Box’ of an Intervention in the Health Sector: A Case of Performance-Based Financing in Western Uganda," IJERPH, MDPI, vol. 14(9), pages 1-20, September.
  • Handle: RePEc:gam:jijerp:v:14:y:2017:i:9:p:1007-:d:110727
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    References listed on IDEAS

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    1. Franco, Lynne Miller & Bennett, Sara & Kanfer, Ruth, 2002. "Health sector reform and public sector health worker motivation: a conceptual framework," Social Science & Medicine, Elsevier, vol. 54(8), pages 1255-1266, April.
    2. Mayumana, Iddy & Borghi, Jo & Anselmi, Laura & Mamdani, Masuma & Lange, Siri, 2017. "Effects of Payment for Performance on accountability mechanisms: Evidence from Pwani, Tanzania," Social Science & Medicine, Elsevier, vol. 179(C), pages 61-73.
    3. Sarriot, Eric & Morrow, Melanie & Langston, Anne & Weiss, Jennifer & Landegger, Justine & Tsuma, Laban, 2015. "A causal loop analysis of the sustainability of integrated community case management in Rwanda," Social Science & Medicine, Elsevier, vol. 131(C), pages 147-155.
    4. Government of India, 2017. "National Health Policy 2017," Working Papers id:11664, eSocialSciences.
    5. Lannes, Laurence, 2015. "Improving health worker performance: The patient-perspective from a PBF program in Rwanda," Social Science & Medicine, Elsevier, vol. 138(C), pages 1-11.
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    Cited by:

    1. Samuel Bosongo & Zakaria Belrhiti & Faustin Chenge & Bart Criel & Bruno Marchal & Yves Coppieters, 2024. "How Does the Context Shape the Technical Support from the Provincial Health Administration to District Health Management Teams in the Democratic Republic of Congo? A Realist Evaluation," IJERPH, MDPI, vol. 21(12), pages 1-24, December.

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