Kambala et al., 2017). However, despite an increase in providers and supplies available at health facilities, PBF did not increase the completeness of service provision during antenatal care and child health consultations. Importantly, out-of-pocket health expenditures decreased for households in the PBF arm, including unofficial payments and this decrease in revenue did not come at the cost of process quality: there were no negative spillover effects on completeness of services and advice provided during antenatal visits and consultations for children under 5. Perhaps not surprisingly, then, given decreased out of pocket costs, and improvements in structural and process quality, client satisfaction also increased for medical consultations for children younger than 5.

While some – but not all - of the improvements measured for PBF were also observed in the additional financing arm C1, few improvements were observed in the group C2 offering enhanced supervision without additional financing or financial incentives. The comparison between the PBF and the C1 group is delicate because the two interventions share many similarities: same supervision and monitoring mechanisms, same level of managerial autonomy and increased financing. The only difference was that in the PBF group (T1) the additional financing was linked to the performance of the individual facility while in the C1 group it was linked to the average performance of the PBF facilities in the same district. It is possible that this distinction might not have been salient enough among the health facility management and staff for them to act upon it and modify their practice, explaining overall similar results.

The lower impacts obtained in the C2 group however suggest that reinforced supervision is not sufficient to change behaviors and improve outcomes. Additional financing appears to be required and its impact seems in some instances stronger when linked to results as in PBF.

This study has several limitations that we have tried to acknowledge in this report. The randomization for this study was at the health facility level. This is beneficial from the point of view of statistical power. From an operational and public health perspective, however, randomizing at the district level would have made more sense given the proximity of some facilities. Indeed, the risk with facility-level randomization is that neighboring facilities from different groups might learn from each other or from supervising staff and apply principles outside their treatment group. However, this was not feasible given that the Government of Cameroon had already decided and announced which districts would be included in the PBF pilot. Randomization at the district level was therefore not an option.

We have analyzed in detail the phenomenon of health care bypassing behavior whereby households look for health care beyond the closest health facility. We found that <mark>health care shopping behavior by households was widespread in Cameroon at baseline in 2012 and continues to be widespread at endline in 2015, but does not appear to be a consequence of the introduction of PBF. Overall, the results do not suggest that the health care seeking behavior is driven or even significantly influenced by the introduction of PBF or the other interventions in C1 and C2 limiting the concerns for systematic bias. However, this bypassing behavior l</mark> ikely leads to estimates which are below the true causal effect of the intervention. This is a substantial limitation of the household survey analysis that needs to be kept in mind.

While overall we found that the results from the household survey and the health facility survey analyses were consistent, for example on the absence of impacts for the ANC and skilled delivery 27