How do urban green spaces influence heat-related mortality in elderly? A realist synthesis.

BACKGROUND: An important consequence of climate change for urban health is heat-related mortality. Vulnerable groups, especially elderly, will be the most affected. A solution put forward in many reports and policy documents is the introduction or expansion of urban green spaces. While they have a proven effect in decreasing the ambient temperature and reducing heat related mortality, the causal pathways are far from clear. Moreover, results vary for different contexts, population types and characteristics of green spaces as they are 'complex systems thrusted into complex systems'. To our knowledge, there is no systematic synthesis of the literature that examines the mechanisms by which and the circumstances under which green spaces work to decrease heat-related mortality for elderly. METHODS: We performed a realist synthesis- a theory-driven review method- to develop a complexity- and context-sensitive program theory. As a first step, a causal loop diagram was constructed which describes the possible pathways through which urban green spaces influence heat-related mortality in elderly. In a second step, one of the pathways - how they may lead to a reduction of heat-related mortality by increasing social capital - was further explored for underlying mechanisms, the context in which they work and the differentiated patterns of outcomes they generate. Literature was searched for evidence supporting or contradicting the initial programme theory, resulting in a refined theory. RESULTS: Results show how urban green space can impact on heat-related mortality in elderly by its influence on their exposure to outdoor and indoor heat, by improving their resilience as well as by affecting their access to treatment. Urban green spaces and their interactions with social capital affect the access to health information, social support, and the capacity for effective lobbying. Several mechanisms help to explain these observed demi-regularities, among others perceived behavioural control, perceived usefulness, receptiveness, ontological security, and self-interest. If and how they are triggered depends on the characteristics of the urban green space, the population, and other contextual factors. CONCLUSION: Looking into the impact of urban green spaces on heat-related mortality in elderly, researchers and policy makers should take interest in the role of social capital.

Realist evaluation in times of decolonising global health.

Realist evaluation (RE) is a theory-driven evaluation approach inspired by scientific realism. It has become increasingly popular in the field of global health where it is often applied in low- and middle-income countries. This makes it timely to discuss RE's relationship to the emerging decolonisation of global health movement. In this short perspective, we argue that the principles and practices that underpin RE have great potential to contribute to the decolonisation endeavour. Both the focus on the inclusion of local stakeholders and the openness to the rival theories these stakeholders bring to the fore, are promising. However, in practice, we see that a lack of acknowledgement of power imbalances and different ontologies and an overreliance on Western-based theories thwart this potential. We therefore suggest that realist evaluations performed by external researchers, especially in the field of global health, should actively engage with issues of (power) inequities. This is not only the just thing to do, but will also contribute to a better understanding of the intervention and may facilitate the emancipation of the disenfranchised. One way of doing this is through the adoption of participatory (action) research methods, currently underused in realist evaluations. We finally give a short example of an evaluation that combines emancipatory and participatory practice development with a realist approach. The Afya-Tek project in Tanzania has an innovative bottom-up approach throughout the full evaluation cycle and shows the possible strength of the proposed combination to create better interventions, more empowered stakeholders, and more illuminating programme theories.

Performance-based financing in the heath sector in low- and middle-income countries: Is there anything whereof it may be said, see, this is new?

Whereas performance-based financing (PBF) is now developing fast in the health sector in low- and middle-income countries and is presented an innovative approach-concomitantly, subject to a separate research stream-it shares many features of the "managing for results" (MfR) and performance-based budgeting (PBB) currents that have existed for decades. In this paper, we first argue that PBF as currently developed in the health sector in low- and middle-income countries shares many features and thus can be viewed as an avatar of MfR and more precisely PBB. Secondly, we draw lessons from the literature on MfR and PBB so as to (1) better apprehend PBF conceptually and (2) avoid pitfalls and better design PBF schemes in practice. We argue that the lessons from the theoretical and empirical literature on MfR and PBB offer interesting insights to feed into a "theory of change" of PBF, enabling to analyse critical aspects and better design PBF schemes. Moreover, it is hoped that just like MfR processes have been demonstrated as having the potential to boost individual performance not only through links with financial incentives but also through acting on other sources of motivation, one can demonstrate more accurately by which mechanisms the various elements of the PBF package can help improve health sector results.

Methods in realist evaluation: A mapping review.

Realist evaluation is becoming increasingly popular as an evaluation methodology. Its main objective is to uncover the mechanisms that lead to observed outcomes following an intervention and the contextual conditions that enabled this. The focus is on explaining why, for whom and in what circumstances an intervention works. It is a theory-driven approach and is explicitly method neutral, meaning that both quantitative and qualitative data collection methods can be used to unearth the underlying mechanisms that cause the intervention outcomes. In this review, we aim to map the methods used in realist evaluation studies, to draw lessons from the findings and to reflect on ways forward. We found that qualitative methods and interviews specifically are most commonly used in realist evaluations; that theory is often absent behind the methods and sampling techniques used; and that more innovative methods remain underexplored. We conclude the review by proposing four ways forward: (1) developing realist surveys, (2) exploring the relevance of innovative methods, (3) increasing the attention paid to sampling procedures and (4) strengthening the theory-driven nature of method. We believe that these four action points can strengthen the practice of realist evaluation and its outcomes.

Using causal loop analysis to explore pathways for zoonosis control in low-income setting: The case of dog rabies vaccination in Burkina Faso.

Dog vaccination is an effective pathway to control rabies if a minimum of 70% dog vaccination coverage is achieved. For more than six decades, dog vaccination has been adopted as part of the rabies control measures in Burkina Faso. However, the required vaccination coverage in canine population remains challenging and rabies endemic. This study describes the use of systems thinking to explore the dynamics arising from dog vaccination complexity and explain the possibles causes of low vaccination coverage in the dog population. In-depth interviews were conducted in three administrative regions and included various stakeholders. A thematic analysis was performed to analyze the obtained narratives. Subsequently, causal loop diagrams (CLDs) were developed, depicting the causes of low dog vaccination coverage. The CLDs were composed of reinforcing loops and balancing loops, visualizing how different variables including social, economic, technical, political and organizational factors that affect the implementation of rabies vaccination in the country are causally interrelated. Overall, the results revealed the importance of community awareness raising, strengthening the vaccination workforce, enhanced governance and leadership in the dynamics of dog vaccination. The study calls for wide consideration of all drivers and factors that may affect dog vaccination coverage, for the development of any rabies control strategy or vaccination program. Beyond the dog vaccination problem, the methods and findings from this study could be applied to other critical rabies-related questions such as postexposure prophylaxis, epidemiological surveillance, dog population management, laboratory diagnosis, and the One Health collaboration issues, to understand and improve rabies control.

Combining Theory-Driven Evaluation and Causal Loop Diagramming for Opening the 'Black Box' of an Intervention in the Health Sector: A Case of Performance-Based Financing in Western Uganda.

Increased attention on "complexity" in health systems evaluation has resulted in many different methodological responses. Theory-driven evaluations and systems thinking are two such responses that aim for better understanding of the mechanisms underlying given outcomes. Here, we studied the implementation of a performance-based financing intervention by the Belgian Technical Cooperation in Western Uganda to illustrate a methodological strategy of combining these two approaches. We utilized a systems dynamics tool called causal loop diagramming (CLD) to generate hypotheses feeding into a theory-driven evaluation. Semi-structured interviews were conducted with 30 health workers from two districts (Kasese and Kyenjojo) and with 16 key informants. After CLD, we identified three relevant hypotheses: "success to the successful", "growth and underinvestment", and "supervision conundrum". The first hypothesis leads to increasing improvements in performance, as better performance leads to more incentives, which in turn leads to better performance. The latter two hypotheses point to potential bottlenecks. Thus, the proposed methodological strategy was a useful tool for identifying hypotheses that can inform a theory-driven evaluation. The hypotheses are represented in a comprehensible way while highlighting the underlying assumptions, and are more easily falsifiable than hypotheses identified without using CLD.

Performance-based financing: the same is different.

Although it is increasingly acknowledged within the Performance-Based Financing (PBF) research community that PBF is more than just payments based on outputs verified for quality, this narrow definition of PBF is still very present in many studies and evaluations. This leads to missed opportunities, misunderstandings and an unhelpful debate. Therefore, we reinforce the claim that PBF should be viewed as a reform package focused on targeted services with many different aspects that go beyond the health worker level. Failing to acknowledge the importance of the different elements of PBF negatively influences the task of practitioners, researchers and policymakers alike. After making the case for this wider definition, we propose three research pathways (describing, understanding and framing PBF) and give a short and tentative starting point for future research, leaving the floor open for more in-depth discussions. From these three vantage points it appears that when it comes to PBF 'the same is different'. Notwithstanding the increased complexity due to the use of the wider definition, progress on these three different research pathways will strongly improve our knowledge, lead to better adapted PBF programs and create a more nuanced debate on PBF.

Opening the 'black box' of performance-based financing in low- and lower middle-income countries: a review of the literature.

Although performance-based financing (PBF) receives increasing attention in the literature, a lot remains unknown about the exact mechanisms triggered by PBF arrangements. This article aims to summarize current knowledge on how PBF works, set out what still needs to be investigated and formulate recommendations for researchers and policymakers from donor and recipient countries alike. Drawing on an extensive systematic literature review of peer-reviewed journals, we analysed 35 relevant articles. To guide us through this variety of studies, point out relevant issues and structure findings, we use a comprehensive analytical framework based on eight dimensions. The review inter alia indicates that PBF is generally welcomed by the main actors (patients, health workers and health managers), yet what PBF actually entails is less straightforward. More research is needed on the exact mechanisms through which not only incentives but also ancillary components operate. This knowledge is essential if we really want to appreciate the effectiveness, desirability and appropriate format of PBF as one of the possible answers to the challenges in the health sector of low-and lower middle-income countries. A clear definition of the research constructs is a primordial starting point for such research.