Evaluating large-scale health programmes at a district level in resource-limited countries

recent experience in evaluating large-scale global health programmes has highlighted the need to consider contextual differences between sites implementing the same intervention. traditional randomized controlled trials are ill-suited for this purpose, as they are designed to identify whether an intervention works, not how, when and why it works. in this paper we review several evaluation designs that attempt to account for contextual factors that contribute to intervention effectiveness. using these designs as a base, we propose a set of principles that may help to capture information on context. finally, we propose a tool, called a driver diagram, traditionally used in implementation that would allow evaluators to systematically monitor changing dynamics in project implementation and identify contextual variation across sites. we describe an implementation-related example from south africa to underline the strengths of the tool. if used across multiple sites and multiple projects, the resulting driver diagrams could be pooled together to form a generalized theory for how, when and why a widely-used intervention works. mechanisms similar to the driver diagram are urgently needed to complement existing evaluations of large-scale implementation efforts.