Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol

Background: . Evaluations of performance measurement and management interventions in public, primary care delivery systems of low- and middle-income countries are scarce. In such contexts, few studies to date have focused on characterizing how, why and under what contextual conditions do such complex, multifaceted arrangements lead to intended and unintended consequences for the healthcare workforce, the healthcare organizations involved, and the communities that are served. Methods: . Case-study design with purposeful outlier sampling of high-performing primary care delivery systems in El Salvador and Honduras, as part of the Salud Mesoamerica Initiative. Case study design is suitable for characterizing individual, interpersonal and collective mechanisms of change in complex adaptive systems. The protocol design includes literature review, document review, non-participant observation, and qualitative analysis of in-depth interviews. Data analysis will use inductive and deductive approaches to identify causal patterns organized as ‘context-mechanism-outcome’ configurations. Findings will be triangulated with existing secondary data sources collected including country-specific performance measurement data, impact, and process evaluations conducted by the Salud Mesoamerica Initiative. Discussion: . This realist evaluation protocol aims to characterize how, why and under what conditions do performance measurement and management arrangements contribute to the improvement of primary care system performance in two low-income countries.