ArticleInternational journal of environmental research and public health2017
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.
Article in International journal of environmental research and public health, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 19 papers.
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Who cites it
19 citing papers in PubMed.
- Unravelling the implementation of the technical support from the provincial health administration to district health management teams in the democratic Republic of Congo: a realist evaluation.BMC health services research · 2026Article
- Identifying the active ingredients in payment for performance programmes using system dynamics modelling.SSM - health systems · 2025Article
- 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.International journal of environmental research and public health · 2024Article
- Systems thinking methods: a worked example of supporting emergency medical services decision-makers to prioritize and contextually analyse potential interventions and their implementation.Health research policy and systems · 2023Article
- How to do (or not to do)…using causal loop diagrams for health system research in low and middle-income settings.Health policy and planning · 2022Article
- Participatory Causal Loop Mapping of the Adoption of Organic Farming in Nigeria.Environmental management · 2022Article
- Does decentralization of health systems translate into decentralization of authority? A decision space analysis of Ugandan healthcare facilities.Health policy and planning · 2021Article
- Understanding the maternal and child health system response to payment for performance in Tanzania using a causal loop diagram approach.Social science & medicine (1982) · 2021Article
- Advancing sustainable development goals through immunization: a literature review.Globalization and health · 2021Review
- How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia.BMJ open · 2021Article
- Mechanisms of scaling up: combining a realist perspective and systems analysis to understand successfully scaled interventions.The international journal of behavioral nutrition and physical activity · 2021Article
- Using implementation science theories and frameworks in global health.BMJ global health · 2020Review
- Article
- Determinants of effective organisational capacity training: lessons from a training programme on health workforce development with participants from three African countries.BMC public health · 2019Article
- The Importance of Leadership and Organizational Capacity in Shaping Health Workers' Motivational Reactions to Performance-Based Financing: A Multiple Case Study in Burkina Faso.International journal of health policy and management · 2019Article
- Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries.BMJ global health · 2019Article
- Effect of results-based financing on facility-based maternal mortality at birth: an interrupted time-series analysis with independent controls in Malawi.BMJ global health · 2019Article
- Methods to improve quality performance at scale in lower- and middle-income countries.Journal of global health · 2018Article
- Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?BMJ global health · 2018Review
Corrections and comments
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Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
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.
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