Abstract
Background: 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.
Methods: 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).
Results: 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.
Conclusion: 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