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

Dimitri Renmans, Nathalie Holvoet and Bart Criel
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Dimitri Renmans: Institute of Development Policy and Management (IOB), University of Antwerp, 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

IJERPH, 2017, vol. 14, issue 9, 1-20

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.

Keywords: complexity; performance-based financing; LMIC; Uganda; systems thinking; theory-driven evaluation; health systems; methodology; causal loop diagramming (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2017
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (1)

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