Introduction Despite the growing global application of mobile health (mHealth) technology in maternal and child health, the contextual factors and mechanisms by which interventional outcomes are generated have not been subjected to extensive review. In this study, we sought to identify context, mechanisms and outcome elements from implementation and evaluation studies of mHealth interventions to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and new mothers. Method An electronic search of six online databases (Medline, Pubmed, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate MeSH terms and selection procedure, 32 articles were considered for analysis. A theory-driven approach, narrative synthesis, was applied to synthesise the data. Thematic content analysis was used to delineate the elements of the intervention, including its context, actors, mechanism and outcomes. Retroduction was applied to link these elements using a realist evaluation heuristic to form generative theories. Results Mechanisms that promote the implementation of mHealth by community health workers/health care providers include motivation, perceived skill and knowledge improvement, improved self-e cacy, improved con dence, improved relationship between community health workers and clients, perceived support of community health workers, perceived ease of use and usefulness of mHealth, For pregnant women and new mothers, mechanisms that trigger the uptake of mHealth and use of maternal and child health services included: perceived service satisfaction, perceived knowledge acquisition, support and con dence, improved self-e cacy, encouragement, empowerment and motivation. Information overload was identi ed as a potential negative mechanism for the uptake of maternal and child health services. Conclusion The models developed in this study provide a detailed understanding of the implementation and uptake of mHealth interventions and how they improve maternal and child health services in low and middle income countries. These models provide a foundation for the 'white box' or theory-driven evaluation of mHealth intervention and can improve the rollout and implementation where required.

Realist evaluation submits that theories and models of how, why, for whom and under what circumstances programs work could be formulated by conceptualizing the relational links between the context within which programs are implemented, the generative mechanisms the programs trigger, and the outcomes of interest. Qualitative and quantitative data collection and analysis allow for the description of the relevant context, the generative mechanisms, and the emergent outcomes of programs and provide explanatory power to link these elements. The ‘realist interviewing technique’, whereby interviewees comment on a suggested ‘program theory’ to provide refinement, is proposed as a distinctive approach for conducting interviews in a realist-informed inquiry. However, the application of this interviewing strategy within the realist evaluation studies is underutilized. In this study, we demonstrate how the realist interview technique reinforces and maintains theoretical awareness and contributes to trustworthiness through three theory-building phases: theory gleaning, theory refining, and theory consolidation.

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This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.