Strengthening health system delivery and quality: Mechanisms and Effects of Performance Based Financing in the Sub-Saharan context Health care providers can be paid in a variety of ways. They can be given an annual budget for agreeing to provide a service or be paid on the basis of the size of the population covered. Payment according to achievement of specific standards or patient outcomes has been widely applied in the health sector.  Such schemes are called Performance Based Financing. These schemes aim to focus health workers and their managers on specific outcomes and to change the way they behave to improve the quality of health care services and population health. Over 40 low and middle-income countries are currently implementing performance based financing schemes in the health sector. However, to date the focus of researchers and practitioners has been mainly on assessing the short term impact of performance based financing schemes on the performance targets. We understand little about how performance based financing affects health workers and the organisations they work in and how this translates into improvements in service delivery and health outcomes. We also do not know if the effects are sustained over time. The design of performance based financing schemes also varies from place to place and we have limited understanding of the factors that influence this variation nor how this affects the way performance based financing is implemented and its subsequent results. Most evaluations collect data specifically for each project, which limits the range of health outcomes that are considered and makes it difficult to compare across studies.  This research project will engage stakeholders involved in running performance based financing schemes and evaluating them in two countries: Mozambique and Zimbabwe. We will work together to clarify how performance based financing has been conceptualised and implemented in each setting. We will also identify how performance based financing is expected to affect health workers and their work environment to bring about better care, and what elements of performance based financing are most critical.  We will use national level data on health system inputs to examine the effects of performance based financing on the health system over time. We will use data from household Demographic and Health Surveys to examine the effects on health outcomes and on the delivery of services that were not targeted by performance based financing. Finally we will seek to understand how performance based financing brings about changes to service delivery by identifying how and which changes in health system inputs are related to improvements in care delivery. We will also examine how the effects of performance based financing vary according to population and health facility characteristics. Performance based financing is sometimes accompanied by separate efforts to increase access to care and we will examine if this matters. Finally, we will look across the two countries to examine if the way in which the performance based financing scheme is designed affects the results.  The project will support knowledge sharing and learning across institutions in the United Kingdom, Mozambique, Zimbabwe and the wider Sub-Saharan African region. The Global Challenges Research Fund (GCRF) supports cutting-edge research to address challenges faced by developing countries. The fund addresses the UN sustainable development goals. It aims to maximise the impact of research and innovation to improve lives and opportunity in the developing world.