# **1. Introduction**

Confronted with slow progress on the health-related Millennium Development Goals (United Nations Statistical Division, 2015) and the Sustainable Development Goals, various countries have introduced and experimented with Results-Based Financing (RBF) in the health sector. RBF is an approach that aims to improve health systems and prioritize health outcomes by using financial incentives paid after predefined results have been attained and verified. Among the RBF approaches, Performance-Based Financing (PBF) is a specific supply-side intervention which comprises a set of health system reforms meant to increase the coverage and quality of essential health services, as well as efficiency and equity, often with a special focus on maternal and child health. PBF program models differ but all involve the purchasing of health services using a predefined list of services and prices (Fritsche, Soeters, & Meessen, 2014). Performance-based financing also includes a strong verification system that relies on systematic and detailed review of health facility records as well as community-level client tracing whereby reported patients are asked a series of questions to confirm health care receipt (Fritsche et al., 2014). Many PBF programs also involve increasing health facility autonomy.

Over time, PBF has been implemented in a growing number of countries. Several studies have shown a positive impact of PBF on health service coverage, often coupled with improvements in quality. An early impact evaluation in Rwanda where districts were randomly assigned to treatment (PBF) and comparison (input financing with matched financial resources) found large and statistically significant positive impacts on institutional deliveries and preventive care visits from young children and also on quality of prenatal care (Basinga et al., 2010). After this promising start, many other quasi-experimental studies have shown similarly positive results (Gertler & Giovagnoli, 2014; Ir et al., 2015; Zeng, Cros, Wright, & Shepard, 2013) and several others have shown favorable results for many – though not all – outcomes assessed (Basinga et al., 2010; Binyaruka et al., 2015; Bonfrer, Soeters, et al., 2014; Bonfrer, Van de Poel, & Van Doorslaer, 2014; Falisse, Ndayishimiye, Kamenyero, & Bossuyt, 2015). Despite this, other studies have found only limited positive results and the research community has not reached a consensus about the effectiveness of PBF at increasing health service coverage (Huillery & Seban, 2014).

While the evidence about the impacts of PBF accumulates, few studies have examined the factors and mechanisms that influence its impact, an area of substantial theoretical and practical significance since PBF often involves a package of interventions: linking payment and results, independent verification of results, managerial autonomy to facilities and enhanced systematic supervision and coaching of facilities. We designed the impact evaluation of the PBF package in Cameroon to try to understand better the role of some of these mechanisms. In particular, we tried to isolate the role of explicit financial incentives as opposed to additional funding not linked to performance, as well as separating the impact of enhanced supervision and monitoring. Specifically, the evaluation compared four arms: (1) the standard PBF package (T1), (2) the same level of financing as T1 but not linked to performance, and with the same levels of supervision, monitoring, and autonomy as PBF (C1), (3) no additional resources or autonomy, but the same levels of supervision and monitoring as PBF (C2), and (4) pure comparison (C3).

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