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

绩效融资(PBF)是一组复杂的供给侧改革方案，旨在提高医疗体系的绩效。虽然其独特的组成部分是对与服务和质量措施挂钩的保健提供者的财政激励，但它们也包括其他相互作用的组成部分，如加强监督、更多的支出自主权或培训。PBF在低收入和中等收入国家迅速扩大，然而，关于影响的证据一直不尽相同。背景，即围绕干预措施的实施和运作并与之相互作用的一系列特征和情况，可能会影响不同情况下方案支助框架组成部分的实施和效力。文献指出了影响执行和有效性的不同背景因素，包括设施和更广泛的卫生系统中的财政、人力和物力资源，对PBF目标服务的需求的障碍，以及诸如指导方针和条例等更广泛的因素。还提出了组件之间的相互作用和适应上下文的重要性。然而，到目前为止，大多数研究只集中在几个组成部分上，而没有探索影响PBF不同组成部分的实施和有效性的语境因素之间的差异。此外，到目前为止，定性研究还没有被用来为现有影响评价数据的分析提供信息。本研究将探讨情境如何影响PBF中干预的实施和效果。研究的主要重点将是在赞比亚开展的建设和平基金对孕产妇和儿童健康的干预。这项研究将包括，首先，对报告的影响低收入中等收入国家孕产妇健康PBF干预措施的实施和有效性的背景因素进行系统审查。第二，一个案例研究，涉及主要的定性数据收集，以确定目前影响赞比亚一个地区的方案预算框架的实施和有效性的背景因素。第三，对影响评估数据进行二次数据分析。该项目将有助于提高复杂干预措施评估领域的知识，使我能够发展我在以下方面的技能：-过程评估。--案例研究和定性研究的开展和分析--影响评价数据的使用--系统审查和叙述综合的技能--高级量化技能(用STATA分析影响评价数据、差异分析、分组分析)--使用定性(访谈)和定量数据相结合的混合方法与社会科学交叉使用。关键词：过程评价、影响评价、基于绩效的筹资、个案研究、复杂干预措施、卫生系统加强、背景、执行、小岛屿发展中国家、实施科学、混合方法、健康记录、常规数据、调查、定量、定性、知识转让。

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.