indicators and the presence of positive impact on immunizations, we also noted some discrepancies. In some cases, because of the nature of the information collected, one of the two data collection methods might be superior. For example, patients might be more open about reporting unofficial payments in a household survey than during an exit interview conducted within or in the vicinity of the facility. In contrast, women might be reluctant to report family planning utilization at home and therefore facility-level data for this indicator might be more reliable.

Another potential limitation is that the differences between the three intervention study groups were sometimes subtle. This was certainly the case, as discussed above, between the PBF group and the C1 group that offered all the elements of PBF except the direct link between individual facility performance and additional financing.<sup>8</sup> It is not obvious that all these differences in intervention design have been fully grasped by staff and management. We should also acknowledge that the monitoring of adherence to national guidelines done as part of the monitoring and supervision intervention in T1, C1 and C2 facilities was not ideal from an evaluation point of view because it means that all three treatment groups receive a separate intervention which the control group does not receive. This is obviously not something that could have easily been avoided from an implementation perspective, and it seems likely that the impact of these protocols is small.

Finally, this report relies on quantitative household and health facility surveys. A companion qualitative study has been conducted and its analysis is ongoing. The qualitative analysis will help understand and interpret some of the impacts measured – or their absence – and will shed light on possible mechanisms.

From a policy point of view, these impact evaluation results suggest the following lessons. In general, PBF is an effective mechanism to bring payments and funding at the provider level, leading to significant increases in coverage (child and maternal immunization, family planning, HIV testing) and improvements in structural quality of care. It also leads to a decrease in out-ofpocket payments, in particular unofficial payments. For many of those outcomes, the differences between the PBF group (T1) and the additional financing group (C1) are not significant. It should be noted that the C1 group offered all the elements of PBF except the direct link between individual facility performance and additional financing. It is not obvious these differences in intervention design have been salient enough for staff and management. There was, however, a clear effect for the importance of additional financing plus reinforced supervision through PBF instruments (comparing groups T1 and C1 vs groups C2 and C3). Enhanced supervision and monitoring are not sufficient to improve MCH outcomes.

Given the way the public budget for health in Cameroon is currently organized and allocated, the results from the evaluation suggest that several modifications in the structure and prioritization of public financing would lead to improved health service delivery outcomes in the country. First,

> 8 In appendix tables A12-A15, we present results from a specification where we pooled the T1 and C1 group into one group, to see whether this specification – which is not as per the initial evaluation design – would yield different results. Compared to the main tables 4-7, this new specification does not yield qualitatively different results.

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