Exploring the influence of context on complex, health system strengthening interventions: a mixed methods study of Performance-based financing in Zamb

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Performance-based financing (PBF) is a group of complex supply-side reform packages to improve performance in the health system. Although their distinctive component are the financial incentives for health providers linked to services and quality measures, they also include other interacting components such as enhanced supervision, more spending autonomy or training. PBF has expanded quickly across low and middle-income countries, however, evidence on impact has been variable. Context, the set of characteristics and circumstances that surround and interact with the implementation and functioning of an intervention, is likely to influence the implementation and effectiveness of PBF components in different settings. The literature points at different contextual factors influencing implementation and effectiveness, including financial, human and material resources in the facility and the broader health system, barriers to the demand of services targeted by PBF and broader factors such as guidelines and regulations. The importance of interactions between components and adapting to context has also been suggested. However, most research so far has focused only on a couple of components and has not explored what are the differences between the contextual factors influencing implementation and effectiveness of the different PBF components. Moreover, qualitative research has not been used to inform the analyses of existing impact evaluation data so far. This research will explore how the context influences intervention's implementation and effectiveness in PBF. The primary focus of study will be a PBF intervention for maternal and child health conducted in Zambia. The research will include, first, a systematic review on contextual factors reported to influence the implementation and effectiveness of PBF interventions for maternal health in LMICs. Second, a case study involving primary qualitative data collection to characterize the contextual factors currently influencing the implementation and effectiveness of PBF in a Zambian district. Third, a secondary data analysis of impact evaluation data.This project will contribute to knowledge on the field of evaluation of complex interventions, allowing me to develop my skills in: - Process evaluation. - The conduction and analysis of case studies and qualitative research- The use of impact evaluation data- Skills on systematic reviews and narrative synthesis- Advance quantitative skills (analysing impact evaluation data with Stata, Difference in differences analysis, subgroup analysis)- The cross-over between with social sciences using mixed methods that combine qualitative (interviews) and quantitative data.Keywords: Process evaluation, impact evaluation, performance-based financing, case study, complex interventions, health systems strengthening, context, implementation, LMICs, implementation science, mixed methods, health records, routine data, surveys, quantitative, qualitative, knowledge transfer.