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Performance management (PM) reforms have been introduced in health systems worldwide to improve accountability, transparency and learning. However, gaps in evidence exist regarding the ways in which PM contributes to organizational-level outcomes. Between 2015 and 2017, the government of El Salvador and the Salud Mesoamerica Initiative (SMI) introduced team-based PM interventions in the country's primary health care (PHC) system including target setting, performance measurement, provision of feedback and in-kind incentives. The programme's evaluation showed widespread improvements in performance for community outreach and service timeliness, quality and utilization. The current study characterizes how the implementation of team-based PM interventions by SMI implementers contributed to PHC system performance improvements. We used a descriptive, single-case study design informed by a programme theory (PT). Data sources included qualitative in-depth interviews and SMI programme documents. We interviewed the members of four PHC teams (n = 13), Ministry of Health (MOH) decision makers (n = 8) and SMI officials (n = 6). Coded data were summarized, and thematic analysis was employed to identify broader categories and patterns. The outcomes chain in the PT was refined based on empirical findings that revealed the convergence of two processes: (1) increased social interactions and relationships among implementers that enhanced communication and created opportunities for social learning and (2) cyclical performance monitoring that generated novel flows of information. These processes contributed to emergent outcomes including the uptake of performance information, altruistic behaviours in service delivery and organizational learning. Through time, the cyclical nature of PM appears to have led to the spread of these behaviours beyond the teams studied here, thus contributing to system-wide effects. Findings illustrate the social nature of implementation processes and describe plausible pathways through which lower-order implementation programme effects can contribute to higher-order changes in system performance., (© The Author(s) 2023. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Introduction: We mapped available evidence on performance measurement and management (PMM) strategies in primary healthcare (PHC) systems of low-income and middle-income countries (LMICs). Widely used, their effectiveness remains inconclusive. This evidence gap map characterises existing research and evidence gaps., Methods: Systematic mapping of performance measurement and management research in LMICs from 2000 to mid-2018; literature searches of seven academic databases and institutional repositories of impact evaluations and systematic reviews. Using a combination of manual screening and machine learning, four reviewers appraised 38 088 titles and abstracts, and extracted metadata from 137 impact evaluations and 18 systematic reviews that met the inclusion criteria. The resulting visual representation of the evidence base was uploaded to a web-based platform., Results: Since 2000, the number of studies has increased; the first systematic reviews were completed in 2010. Two-thirds of the studies were conducted in sub-Saharan Africa and South Asia. Randomised controlled trials were the most frequently used study design. The evidence is concentrated in two types of PMM strategies: implementation strategies (in-service training, continuing education, supervision) and performance-based financing. Major gaps exist in accountability arrangements particularly the use of audit and feedback. The least studied types of outcomes were unintended effects, harm and social equity., Conclusions: The evidence is clustered around interventions that are unlikely to achieve transformational change in health outcomes. The gaps identified suggest that routinely used PMM strategies are implemented without sufficient knowledge of their effects. Future efforts at redesigning PHC systems need to be informed by evidence on the most effective approaches for using PMM strategies., Competing Interests: Competing interests: None declared.

Background . For the last two decades there has been growing interest in governmental and global health stakeholders about the role that performance measurement and management systems can play for the production of high-quality and safely delivered primary care services. Despite recognition and interest, the gaps in evidence in this field of research and practice in low- and middle-income countries remain poorly characterized. This study will develop an evidence gap map in the area of performance management in primary care delivery systems in low- and middle-income countries. Methods. The evidence gap map will follow the methodology developed by 3Ie, the International Initiative for Impact Evaluation, to systematically map evidence and research gaps. The process starts with the development of the scope by creating an evidence-informed framework that helps identify the interventions and outcomes of relevance as well as help define inclusion and exclusion criteria. A search strategy is then developed to guide the systematic search of the literature, covering the following databases: Medline (Ovid), Embase (Ovid), CAB Global Health (Ovid), CINAHL (Ebsco), Cochrane Library, Scopus (Elsevier), and Econlit (Ovid). Sources of grey literature are also searched. Studies that meet the inclusion criteria are systematically coded, extracting data on intervention, outcome, measures, context, geography, equity, and study design. Systematic reviews are also critically appraised using an existing standard checklist. Impact evaluations are not appraised but will be coded according to study design. The process of map-building ends with the creation of an evidence gap map graphic that displays the available evidence according to the intervention and outcome framework of interest. Discussion .  Implications arising from the evidence map will be discussed in a separate paper that will summarize findings and make recommendations for the development of a prioritized research agenda., Competing Interests: No competing interests were disclosed.

Background . For the last two decades there has been growing interest in governmental and global health stakeholders about the role that performance measurement and management systems can play for the production of high-quality and safely delivered primary care services. Despite recognition and interest, the gaps in evidence in this field of research and practice in low- and middle-income countries remain poorly characterized. This study will develop an evidence gap map in the area of performance management in primary care delivery systems in low- and middle-income countries. Methods. The evidence gap map will follow the methodology developed by 3Ie, the International Initiative for Impact Evaluation, to systematically map evidence and research gaps. The process starts with the development of the scope by creating an evidence-informed framework that helps identify the interventions and outcomes of relevance as well as help define inclusion and exclusion criteria. A search strategy is then developed to guide the systematic search of the literature, covering the following databases: Medline (Ovid), Embase (Ovid), CAB Global Health (Ovid), CINAHL (Ebsco), Cochrane Library, Scopus (Elsevier), and Econlit (Ovid). Sources of grey literature are also searched. Studies that meet the inclusion criteria are systematically coded, extracting data on intervention, outcome, measures, context, geography, equity, and study design. Systematic reviews are also critically appraised using an existing standard checklist. Impact evaluations are not appraised but will be coded according to study design. The process of map-building ends with the creation of an evidence gap map graphic that displays the available evidence according to the intervention and outcome framework of interest. Discussion .  Applications arising from the evidence map will be discussed in a separate paper that will summarize findings and make recommendations for the development of a prioritized research agenda., Competing Interests: No competing interests were disclosed.