From Measuring User Satisfaction to Improving Quality of Care: Community Verifications and Performance-Based Financing in District Hospitals in Mali

Abstract Context: User satisfaction in health facilities is increasingly taken into account to improve the quality of care. In Mali, performance-based financing (PBF) aims to improve the quality of care by increasing the motivation, responsibility, and accountability of health workers. Community verification (CV) is one of the main functions of the PBF. CV makes it possible to monitor the effectiveness of the services reported by the health facilities and to conduct satisfaction surveys of the users who have received care. This paper aims to analyze the CV process during the implementation of the PBF in the Koulikoro region of Mali. Methods: We adopted a qualitative approach based on a multiple case study design corresponding to the district hospitals (DH) and stakeholder groups. We conducted thirty-nine semi-structured interviews with investigators, patients, and health workers in three of the ten DHs in the Koulikoro region. We designed three interview guides and inductively analyzed our data. Results: The CV process was well perceived and welcomed. However, the vast majority of interviewers reported difficulties locating some patients in the community for several reasons: incorrect spelling of names, illegible cards, lack of telephone contact information and incomplete information on the cards, and cases of homonymity. All of this was due to poor record-keeping at the health facilities. Some investigators fraudulently filled out forms without investigating users in the communities. They justified this by the lack of time available to them to conduct the CV. No feedback on the results of the CV was possible from the health workers. Conclusion: The CV is an essential component of PBF implementation. The validity, reliability and efficiency of the measurement instruments must be considered in user satisfaction surveys. In addition, emphasis should be placed on data analysis and the use of CV results.