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Table 1 Framework for monitoring and evaluating PBF’s health systems effects

From: Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation

Result chain Service delivery Human resources Governance Health financing
Inputs Development of quality assurance/improvement tools (like treatment protocols, scorecards) Changes to working conditions for staff and staff remuneration Development of governance capacity & systems – e.g. separation of functions Volume of funds, relative to other sources (globally, and at facility level); and their predictability and variability over time
  Changes to the availability of necessary infrastructure, medicines and supplies Any change to central level HRH policies and allocation Investments in improving information and M&E systems Costs of related investments
   Changes to training (e.g. on good prescribing and evidence-based treatment protocols) Changes to participation of external stakeholders – especially those representing demand-side Effect on other financing sources, as relevant. Changes to funds reaching front-line providers
Processes Changes to organization of services -Effects on quality and convenience for users (“acceptability”). Effects on availability of services, including support services, like diagnostics, lab tests Changes to availability, retention and distribution of staff (of different types). Change to staff motivation, job satisfaction, teamwork and working patterns, and skills sets Changes in performance management systems at all levels. Changes to accountability, autonomy, organizational culture and contractual obligations of main actors. Development of leadership skills, at different levels Allocation of funds (across services, facility types and areas) & link to local needs. Changes to transactions costs (including costs of new governance arrangements, monitoring etc.). How funds are used and any knock-on financial effects (e.g. changes to charges for users)
Outputs Changes to utilization of services (targeted and untargeted). Changes to coverage – absolute and for different socioeconomic groups. Changes to quality of care (cure rates, readmission, detection etc.). Changes to range and type of services (appropriate to local needs or not) Changes to staff behavior (working hours, absenteeism, dual practice, informal charging etc.). Evidence of changes to responsiveness and quality of care provided by staff Changes to health data: regularity, reliability, comprehensiveness. Greater (or less) voice for stakeholders, especially patients. Strategic purchasing practiced. Centralisation/decentralization of functions within sector; changed power relationships within system Changes to technical & allocative efficiency of services. Sustainability of funding mechanisms & their synergies over time. Changes to affordability for users & financial protection – overall and disaggregated
Health system goals Better health; greater equity in health; financial protection; responsiveness of health system