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The Study

The ResQ study has two main objectives:

  1. Address the lack of a theory of performance-based financing (PBF) in the healthcare sector of low and middle-income countries (LMIC)

  2. The development of an innovative complexity-sensitive methodology that combines realist evaluation science (RES) with qualitative comparative analysis (QCA)

Obj. 1: A theory of PBF

The last decade saw a strong rise in studies of PBF (see Renmans et al., 2016) and in the couple of years there has been a focus on the specific mechanisms of PBF (De Allegri et al., 2018; Gergen et al., 2018; Lohmann et al., 2018; Turcotte-Tremblay et al., 2017). However, these studies are single case studies lacking cross-case generalizability. At the same time, there has been very little investment in the development of a unified theory of PBF. Thus, we remain without a comprehensive evidence-based theory of PBF that is able to shed light on the many mixed results of PBF and its effects on the wider health system (Borghi et al., 2018; Renmans et al., 2017).

Therefore, one main objective of the ResQ study is to develop a theory of PBF. This theory will not only be based on evidence from the PBF literature but also from what we know of similar interventions in the healthcare and other sectors. This approach will help strengthen our understanding of PBF and ultimately of the healthcare system at large.

Obj. 2: An innovative multimethod approach

The lack of a theory of PBF is mainly due to the complex nature of PBF: it is implemented in very differing contexts, has a multitude of components and modalities, and triggers many mechanisms, as put forward in an earlier paper (Renmans et al., 2017). Therefore, to achieve the first objective, the ResQ study will develop and apply an innovative and complexity-sensitive methodology (i.e. the second main objective). This methodology is called the 'ResQ approach' and combines realist evlauaiotn science with qualitaitve comparative analysis (QCA).

Study phases

Study phases

The study consists of six phases. In what follows, we will give a short overview of what the different phases entail. 

Clicking on the phases will bring you to a page that summarizes the work that already has been done.

You can find the (intermediate) findings of the study here. 


The mechanism is central to this research approach and to realist evaluation in general. However, what a mechanism actually is, is a contentious issue within the literature. Many words have been written down in papers to define and describe it, yet confusion remains. We therefore set out to make an inventory of all the mechanisms used in published realist evaluations and syntheses.

Moreover, we also look into theories and theoretical and conceptual papers and books to find realist mechanisms.

Phase 2
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Using the mechanisms identified during 'phase 1' as guidelines, we review documents on performance-based financing to identify the theoretically most common identified mechanisms in relation to PBF.

We then choose the mechanisms that we will focus on during our analysis. For each of the mechanisms we search for relevant scientific theories that help us to identify the contextual conditions involved in triggering the mechanisms.

We are here

Phase 3

We perform a thorough case-based review of the literature for each of the mechanisms identified in 'Phase 2' and gather data on each of the mechanisms’ contextual conditions and outcomes (i.e. the CMO configurations). After which the data from the collected studies will be transformed into a data matrix. Each mechanism has its own data matrix which contains information about the conditions and the outcome of each of the cases. This is where the set-theoretic approach (QCA) becomes relevant.

Phase 4
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This phase directly builds on the previous phase and entails the analysis of the data matrices using QCA. We first transform our data matrix into a truth table after which we perform a minimization on the truth table to discover which conditions are necessary and which are sufficient for the mechanism to occur.

Phase 5
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At this point we have synthesized all the available information on the different identified mechanisms. We now bring together the results and adapt the earlier identified CMO configurations (Phase 2) for each of the mechanisms.

We finally bring the different CMO configurations together and create our comprehensive theory of PBF.

Phase 6

In the final phase we give an assessment of the added value of the used multimethod approach. Is the approach worth the effort? How can it be further improved? In what circumstances can it best be used? Does it manage to adhere to the research triad put forward by Goertz (2017)? How can it benefit other research domains? How should researchers use it?

Phase 0
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A high level of transparency is needed in order to ascertain scientific rigor. In order to achieve this, we have created this website on which the protocol and the multimethod approach is  explained extensively. Most importantly, visitors  are able to follow each of the steps in the process and every decision made by the researchers. Hence, it functions as a live research report.

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