How to exempt the vulnerable? The succesfull application of the 6 PBF equity elements in Mali

Mali demonstrates that some past academic criticisms of PBF were wrong

We report the success achieved in Mali with an almost “pure” PBF approach (feasibility score of 92%). Mali demonstrated, for the first time, unambiguously, that when the standard six PBF equity instruments are applied correctly, the results are very significant for vulnerable people and areas, including those affected by political insecurity.

The PBF program in Mali provided care (including consultations, admissions, deliveries, and surgeries) to 460,000 vulnerable patients over four years, 7 to 8 times more than the project had anticipated. The PBF equity approach includes targeted free care for vulnerable populations (25% of all patients) and geographic equity bonuses for districts and health facilities.

The regional Contracting and Verification Agencies are integrated into the already existing Mandatory Health Insurance (CANAM) structure. PBF strengthened the health system with an administrative cost of only 15% for the regional Contracting Development and Verification Agencies. The project demonstrated a significantly higher cost-benefit ratio than initially anticipated. The decentralized quality improvement bonuses of between USD 1000 and 5000 showed remarkable results that enabled health facilities and regulatory authorities to invest in rehabilitation, equipment, transportation, and the recruitment of qualified personnel.

The above findings are demonstrated in several published articles (Bagayoko et al, 2025[1]) (Bagayoko et al, 2025[2]) and the World Bank’s final report on the “Accelerating Progress Towards Universal Health Coverage (PACSU) Project 2019-2024” (World Bank, 2025[3]).

Two critical conditions for success in Mali were: a. The regular payment of the PBF subsidies, and b. The selection of vulnerable groups was carried out by health facilities with their communities, rather than through a centralized, complex, and costly identification of vulnerable groups.

These two conditions were not met in other countries, notably the PBF programs in Burkina Faso (2013-2018) and Benin (2013-2018). In Cameroon (2012-2022), there were significant delays of up to a year in subsidy payments, so that the staff of health facilities stopped assisting vulnerable patients free of charge due to the lack of funds.

Thus, according to the PBF best practices and the failure to implement the PBF equity instruments and regular payments, it was conceptually also impossible to achieve good results for the poorest in these countries.

However, despite these conceptual and practical flaws, some academic authors have used these examples to demonstrate in their view that PBF is not a good approach for equity, that PBF weakens the health system, and is inefficient (Paul E, Ridde V, et al 2018[4], Turcotte, Ridde, et al 2018[5]). The example of Mali now demonstrates that the above arguments and conclusions were flawed. Unfortunately, this led many decision-makers to mistakenly perceive PBF as an ineffective approach. The Mali case, in our opinion, corrects this misconception.

We also recommend that the actors involved in the Mali programme conduct a quantitative and qualitative intervention-control study. This investigation aims to further examine the effects of the PBF programme on effectiveness, efficiency, quality, and output results, with a particular focus on the vulnerable.

[1] Bagayoko, M., Diabaté, M., Tamga, D., & Keita, Y. (2025). Strengthening Equity in Access to Basic Health Care for Indigents via PBF : Selected Key Results in Koulikoro Region, Mali. SAS Journal of Medicine, 11(05), 530‑537. https://doi.org/10.36347/sasjm.2025.v11i05.026

[2] Bagayoko, M., Diabate, M., & Tamga, D. (2025). The Granting of Special Quality Improvement Bonuses is an Efficient Means of Correcting Inequities and Accelerating Health Coverage in Mali’s Results-Based Financing Model. SAS J Med, 5, 526‑529.

[3] Implementation Completion Report Mali – Accelerating Progress Towards Universal Health Coverage February 2025, World Bank

[4] Paul E, Ridde V, et al Performance-based financing in low-income and middle-income countries. Isn’t it time for a rethink BMJ Global Health https://doi.org/10.1136/bmjgh-2017-000664

[5] Turcotte-Tremblay, Ridde V et al. The unintended consequences of combining equity measures with performance-based financing in Burkina Faso International Journal for Equity in Health (2018) 17:109 https://doi.org/10.1186/s12939-018-0780-6

 

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