Grant: Travel Awards - Institute Community Support

Results-based financing (RBF) is emerging as a new alternative to finance health systems in African countries. In Mali, an NGO-assisted pilot project was conducted to assess the potential for national scale-up of RBF. Few studies have described the RBF implementation process, and none have explored whether results are sustainable. This study's objectives were to understand how sustainability was taken into account in planning and implementing the pilot project and to assess whether its outcomes were sustained. Sustainability was examined through five dimensions: organizational memory, values/codes, rules/procedures, adaptation, and stakeholder relationships. Forty-nine stakeholders were interviewed, including health practitioners, administrators, and those involved in implementing and conceptualizing the program. Six community and two referral health centres served as study sites; these were chosen with the participation of different stakeholders. While some gains of the project could be sustained, others could not. Organizational memory was fostered through investments in short- and long-term resources. However, the instability of resources, mainly through the project's ending, demonstrated how precarious some gains were. While the project's values and codes were highly compatible with those of the host institutions, very few cultural artefacts were shared. Rules and procedures were clear and time was built-in for planning, two facilitating factors for sustainability. The RBF project was tailored to the various contexts in which it was conducted, but did not offer incentives for all participating actors. Therefore, stakeholders only shared a temporary ownership of the project. The results raise questions regarding what motivations are most appropriate to sustain the gains of a successful RBF project. While current RBF programs finance organizations and practitioners, perhaps a greater focus on evaluation would be a stronger motivation than financial incentives.