User-satisfaction assessment of health facilities is increasingly considered for quality improvement in health care (OECD et al., 2019). It is widely used in low- and middle-income countries (LMICs) (Aldana & Piechulek, 2001). However, the definition of user satisfaction is complex and still not consensual (Linder-Pelz, 1982; Williams, 1994; Ng & Luk, 2019). Pascoe (1983) defined user satisfaction as the level of compliance between their expectations and the services they received. Cultural, sociodemographic, cognitive, and affective factors influence the measurement of user satisfaction (Ng & Luk, 2019). In Mali, from July 2016 to February 2017, a performance-based financing (PBF) pilot was implemented in ten health districts in the Koulikoro region (World Bank, 2017). It aimed to improve the quality of reproductive health care by increasing the motivation, responsibility, and accountability of health workers (Ministère de la Santé et de l’Hygiène Publique, 2016). During its implementation, several activities were carried out: training, development of results plans, signing of contracts, and producing results by health facilities, reporting, verifying quantity and quality of care results, paying subsidies, and providing community verification (CV) (Cissouma et al., 2017; KIT et al., 2017). CV is one of the main functions of PBF implementation. It monitors the effectiveness of the services reported by the health facilities to provide them with subsidies and to conduct a satisfaction survey of users who have benefited from health care.
In general, the methods used to conduct user-satisfaction surveys are quantitative, based on standardized questionnaires administered to users (self-reported or administered), and qualitative (semi-structured interviews and focus groups) (Sitzia, 1999; Quintana et al., 2006; Beattie et al., 2015). For Beattie et al. (2015) and Almeida et al. (2015), regardless of the survey methods and measurement tools chosen, some dimensions are essential to the construction of patient satisfaction measurement tools such as interactions between patients and health professionals, the physical environment, and the management process of the health facility. The community-user survey method is often used for user-satisfaction surveys during PBF implementation in Africa (Antony et al., 2017; Turcotte-Tremblay et al., 2017; Falisse et al., 2012). For example, in Mali, the community-based user survey was the chosen approach for user-satisfaction surveys during the PBF (KIT et al., 2017).
Conducting the CV among users during PBF implementation is not without consequences. In Burkina Faso, Turcotte-Tremblay et al. (2017) noted several unintended consequences of the PBF's CV process: difficulties in identifying patients in the community, overloading of community verifiers, falsification of data by interviewers, and loss of patient confidentiality that led to marital problems between some patients and their spouses. In Burundi, Falisse et al. (2012) indicated that this type of survey does not necessarily lead to a better consideration of the “voices” of the population in improving the quality of care. In addition, the transmission of people's concerns by community-based organizations to health authorities did not lead to change in Burundi. In Malawi, Petross et al. (2020) showed that community members had mixed views on the positive effect of PBF on the quality of care in health facilities. The positive effects of the PBF in Malawi, they noted, were better availability of drugs, improved quality of infrastructure, and better hygiene in health facilities. However, they argued that some of the negative effects that existed prior to the PBF, such as health-worker overload and overcapacity of delivery beds in maternity facilities, have been exacerbated by the PBF. These studies demonstrated that community-based user-satisfaction surveys have unintended consequences and are influenced by the local context (geographic, sociocultural, health) (Falisse et al., 2012; Antony et al., 2017; Turcotte-Tremblay et al., 2017; Petross et al., 2020).
It is important to consider the sociocultural context when conducting user-satisfaction surveys (Baumann & Amara, 2007). To our knowledge, there is no published scientific study in Mali on the process of client satisfaction during the implementation of the PBF and its impact on improving the quality of care in health facilities. Our article aims to analyze the CV process during the implementation of the PBF in the Koulikoro region of Mali. More specifically, it allows us to describe the CV system, the dysfunctions observed during its implementation, and the perceptions and interactions between the different actors involved.
Description of the PBF community verification process in Mali
In Mali, the PBF CV had several objectives. First, it intended to verify the accuracy of health workers' statements regarding patients reported to have consulted them. Second, it intended to measure the level of user satisfaction with the quality of care received. Finally, the results of the CV were to be used to finalize the payment procedures for the first and only cycle of PBF subsidies to health facilities. The PBF pilot was very short, lasting only eight months (July 2016 to February 2017), which justifies the only PBF subsidies payment cycle in Mali. Apart from the CV, the challenges observed during the PBF implementation process in Mali have been published in several articles (Zitti et al., 2019; Coulibaly et al., 2020; Zitti et al., 2021).
The CV was conducted in February 2017, i.e., at the end of the PBF pilot in Mali. The KIT–Cordaid–CGIC consortium, which acts as the PBF implementing agency (contracting and verification) on behalf of the Ministry of Health and Public Hygiene, recruited a local NGO in each of the ten health districts to conduct the CV. These NGOs were recruited following a call for tenders. Following the selection process, each NGO selected ten interviewers who were trained by the local company (Clinique de Gestion et d’Innovation des Connaissances [CGIC]) team on behalf of the consortium. The training lasted two days in January 2017. In order to conduct the CV in a short time frame, some local NGOs had to train additional interviewers themselves. To assist local actors in implementing the PBF, ten technical advisors (five national and five international) were made available to the ten health districts (one advisor per health district). The list of patients for CV was to be provided by the district hospitals (DHs) with the support of the PBF technical advisors. However, numerous shortcomings led the investigators to redo some of the lists from the health facilities' registers. These samples were drawn from the patients present in the health facility registers and who were seen during the PBF implementation period (November to December 2016). To conduct the CV at the DH level, the agency responsible for monitoring PBF implementation (Table 1) selected three indicators.
Table 1
List of indicators considered for CV at the district hospital level
Indicators |
Complicated deliveries/Caesarean sections performed by qualified personnel |
Patients received from the Community Health Centers (Centres de santé communautaires [CSCom]), who were properly cared for in the DHs and who were redirected to the CSCom |
Severe malaria in children properly treated |
In order to constitute a sample of patients in each DH, ten patients were selected for each of the three indicators (i.e., thirty patients per DH). The ten patients selected per indicator were chosen according to their distance from the health facility: three patients within 0 km, three patients within 1–5 km, two patients within 6–10 km, and two patients within 11–15 km and beyond. Local NGOs had between five and ten days to conduct the CV.