Abstract
Performance-based financing (PBF) has been widely implemented across sub-Saharan Africa to improve health service delivery. Its specific impact on maternal healthcare utilisation within the Malian context, particularly at the primary care level, remains insufficiently explored from a frontline implementation perspective. This perspective piece aims to critically examine the mechanisms through which PBF influences the uptake of maternal health services in rural primary healthcare clinics, focusing on intended and unintended consequences for service provision and community engagement. The analysis draws on the direct professional experiences and observations of healthcare providers and district managers within the Koulikoro Region, synthesising these insights with a review of relevant programme documentation and regional health data. A key theme identified is that while PBF incentives for quantified outputs, such as antenatal care attendance, led to an initial increase in reported coverage, they simultaneously diverted clinical attention and resources away from less-easily measured aspects of quality care, including patient counselling and postnatal support. The PBF model, as implemented, produced a dual effect: it stimulated measurable gains in service utilisation metrics but risked undermining the holistic, relationship-based care essential for sustained maternal health improvements. Future health financing reforms should integrate qualitative care indicators into incentive structures, ensure more equitable resource allocation to remote clinics, and strengthen community accountability mechanisms alongside financial incentives. performance-based financing, maternal health, primary healthcare, health systems, Mali, health policy This perspective provides novel, grounded analysis of the on-the-ground operational tensions between quantitative targets and qualitative care under PBF, offering critical lessons for designing more effective health financing policies in similar resource-constrained settings.