Stakeholder Perceptions and Context of the Implementation of Performance-Based Financing in District Hospitals in Mali

Document Type : Original Article


1 CEPED (UMR 196), Institut de Recherche pour le Développement, ERL INSERM SAGESUD, École doctorale Pierre Louis de santé publique, Université Sorbonne Paris Cité, Paris, France

2 Miseli Research NGO, Bamako, Mali

3 Department of Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada

4 Public Health Research Institute, University of Montreal, Montreal, QC, Canada

5 CESSMA (UMR 245), Institut de Recherche pour le Développement, Université Sorbonne Paris Cité, Paris, France

6 Faculty of Medicine and Odonto-Stomatology, Université des Sciences, des Techniques et des Technologies, Bamako, Mali

7 CEPED (UMR 196), Institut de Recherche pour le Développement, ERL INSERM SAGESUD, Université Sorbonne Paris Cité, Paris, France


To improve the performance of the healthcare system, Mali’s government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa.
This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle’s members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR).
Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership.
The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention.


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Volume 8, Issue 10
October 2019
Pages 583-592
  • Receive Date: 17 January 2019
  • Revise Date: 21 May 2019
  • Accept Date: 02 June 2019
  • First Publish Date: 01 October 2019