Does the gap between health workers’ expectations and the realities of implementing a Performance-Based Financing project in Mali create frustration?

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Abstract Background: Low- and middle-income countries (LMICs) have seen a shift in the health financing architecture in recent years, particularly in Africa. Performance-Based Financing (PBF) is one of these recent initiatives. Motivating health workers is one of the mechanisms through which PBF is assumed to improve the quality of care. Our study therefore offers a unique opportunity to identifiesy and understand how health workers’ expectations related to their experiences of the first cycle of payment of PBF subsidies, and how it this affected their motivation and sentiments towards the intervention.Our study offers the opportunity to identify and understand, from the first days of implementation of PBF in Mali, how the expectations of health workers related to implementation realities of the first cycle of PBF subsidy payment, and how correspondences and discrepancies affected health worker motivation.Methods: We adopted a qualitative approach using multiple explanatory and contrasting case studies with nested levels of analysis. For our study, we chose three district hospitalsDHs (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation. The different data sources used are: the 53 semi-directive interviews conducted with health workers, following the principle of saturation;, field notes, a;and documents relating to the distribution grids of subsidies for each DH.We conducted 53 semi-structured interviews with health workers in three of ten district hospitals in the Koulikoro region Data was analyzed in a mixed deductive and inductive manner.Results: The results show that the PBF subsidies initially led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work better. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. This, in turn, decreased motivation. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention.Conclusion: The PBF implementation in Mali left health workers with initial frustrations. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive and negative. This result underlines how short-term interventions might not just only lack impact, but also instill negative sentiments likely to carry on into the future.

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