Abstract
IntroductionNumerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. To date, few articles have examined the implementation of this type of complex intervention in Francophone West Africa. This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region.MethodWe conducted a contrasted multiple case study of performance in 12 community health centres in three districts. We collected 161 semi-structured interviews, 69 informal interviews and 96 non-participant observation sessions. Data collection and analysis were guided by the Consolidated Framework for Implementation Research adapted to the research topic and local context.ResultsOur analysis revealed that the internal context of the PBF implementation played a key role in the process. High-performing centres exercised leadership and commitment more strongly than low-performing ones. These two characteristics were associated with taking initiatives to promote PBF implementation and strengthening team spirit. Information regarding the intervention was best appropriated by qualified health professionals. However, the limited duration of the implementation did not allow for the emergence of networks or champions. The enthusiasm initially generated by PBF quickly dissipated, mainly due to delays in the implementation schedule and the payment modalities.ConclusionPBF is a complex intervention in which many actors intervene in diverse contexts. The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF. Future work in this area would benefit from an interdisciplinary approach combining public health and anthropology to better understand such an intervention. The deductive–inductive approach must be the stepping-stone of such a methodological approach.
Highlights
Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance
PBF is a complex intervention in which many actors intervene in diverse contexts
The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF
Summary
Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. Few articles have examined the implementation of this type of complex intervention in Francophone West Africa This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region. Thirty-two (out of a total of 46) sub-Saharan African countries have tried PBF with the objective of reforming their health system [4]. This intervention is often promoted with the support of certain international actors, in particular the World Bank. It is criticised for its potential perverse effects, including the fact that it may, weaken the health system [8] and have unintended effects [13]
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