title: Factors affecting adoption, implementation fidelity, and sustainability of the Redesigned Community Health Fund in Tanzania: a mixed methods protocol for process evaluation in the Dodoma region.
abstract: BACKGROUND
  Despite the implementation of various initiatives to address low enrollment in voluntary micro health insurance (MHI) schemes in sub-Saharan Africa, the problem of low enrollment remains unresolved. The lack of process evaluations of such interventions makes it difficult to ascertain whether their poor results are because of design failures or implementation weaknesses.
  
  
  OBJECTIVE
  In this paper, we describe a process evaluation protocol aimed at opening the 'black box' to evaluate the implementation processes of the Redesigned Community Health Fund (CHF) program in the Dodoma region of Tanzania.
  
  
  METHODS
  The study employs a cross-sectional mixed methods design and is being carried out 3 years after the launch of the Redesigned CHF program. The study is grounded in a conceptual framework which rests on the Diffusion of Innovation Theory and the Implementation Fidelity Framework. The study utilizes a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews, and document review), and aligns the evaluation to the Theory of Intervention developed by our team. Quantitative data will be used to measure program adoption, implementation fidelity, and their moderating factors. Qualitative data will be used to explore the responses of stakeholders to the intervention, contextual factors, and moderators of adoption, implementation fidelity, and sustainability.
  
  
  CONCLUSIONS
  This protocol describes a systematic process evaluation in relation to the implementation of a reformed MHI. We trust that the theoretical approaches and methodologies described in our protocol may be useful to inform the design of future process evaluations focused on the assessment of complex interventions, such as MHI schemes.
authors.affiliation: Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany.|Department of Community Health, St. Francis University College of Health and Allied Sciences, Ifakara, Tanzania; kaloloa@gmail.com.
authors.forename: Albino
authors.initials: A
authors.lastname: Kalolo
authors.affiliation: Deutsche Gesellschaft für Internationale Zusammenarbeit, Lilongwe, Malawi.
authors.forename: Ralf
authors.initials: R
authors.lastname: Radermacher
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland.
authors.forename: Manfred
authors.initials: M
authors.lastname: Stoermer
authors.affiliation: Health Promotion and System Strengthening (HPSS) project, Dodoma, Tanzania.
authors.forename: Menoris
authors.initials: M
authors.lastname: Meshack
authors.affiliation: Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany.
authors.forename: Manuela
authors.initials: M
authors.lastname: De Allegri
mesh_terms: D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000458:organization & administration; D017144:Focus Groups; D006801:Humans; D007348:Insurance, Health / Q000191:economics / Q000706:statistics & numerical data*; D007407:Interviews as Topic; D011203:Poverty; D015397:Program Evaluation / Q000379:methods*; D011634:Public Health; D011795:Surveys and Questionnaires; D013636:Tanzania
keywords: Community Health Fund in Tanzania; complex interventions; innovations to increase enrollment; low enrollment; micro health insurance; mixed methods; process evaluation