The policy objective of the Impact Evaluation (IE) is to build evidence on the impact and cost-effectiveness of the proposed Performance-Based-Financing (PBF) project in Tajikistan. More specifically, the IE would seek to ascertain: (i) the impact and cost-effectiveness of the PBF model implemented in Tajikistan; and (ii) whether PBF is more effective or cost-effective if implemented in conjunction with additional low cost interventions (Collaborative Quality Improvement, Citizen Report Cards). The results from the IE will help informing the MOH on whether PBF should be scaled-up to additional PHC level institutions in other regions. The Collaborative Quality Improvement intervention responds to policy concerns that performance incentives may not produce the desired improvements if providers lack the necessary competencies, data to inform decisions and knowledge. The Citizen Report Card attempts to improve the effectiveness of PBF by strengthening the 'short route of accountability', i.e., by increasing accountability of health facilities to their local constituents. Since PBF, collaborative quality improvement (CQI), and citizen report cards (CRC) have never been implemented in large scale in Tajikistan, it is to be expected that the results from the IE will be useful for designing national PHC policy in Tajikistan, and that they will also contribute to the larger body of knowledge on these interventions. The IE employs both difference-in-difference and experimental approaches to identify the impact of the different combinations of interventions. Assignment to PBF was not random. Three districts in the Sughd region and 4 districts in the Khatlon region were selected to implement the program. All Rural Health Centers (RHCs) in these seven districts are covered by the program. Nine additional district (two in Sughd and seven in Khatlon) were selected as control districts. The selection of the control districts was guided by geographical proximity to treatment districts and similarity in terms of number of health facilities and doctors per capita. The districts were also selected such that the number of RHCs in treatment and control groups in each region would be similar. Within the chosen 16 districts (treatment and control districts), clusters consisting of a RHC and its subsidiary Health Houses were randomly assigned to implement Collaborative Quality Improvement, Citizen Score Cards, or neither of these two interventions. The randomization was blocked by district. In sum, RHCs were assigned into six study arms. The goal of the Facility-based survey is to measure multiple dimensions of quality of care and collect detailed information on key aspects of facility functioning.Household surveys are primarily used to measure health service coverage at the population level as well as select health outcome indicators measured through anthropometry or tests. The surveys also collect broader data on the health of the households, health seeking behaviors and barriers to use of health services. In addition, PBF and other administrative data would be used to track outcomes over time in the treatment groups 1-3 (the ones receiving performance-based payments). The baseline survey was implemented prior to the implementation of PBF in the 7 study treatment districts and a follow-up survey (endline) is planned to take place after three years of project implementation. The survey is largely based on the HRITF instruments that were modified to the Tajik and project context.
