Toure L. auteur aut IRD Boivin P. auteur aut IRD Diarra Y. auteur aut IRD Diabate S. auteur aut IRD Ridde Valéry auteur aut IRD text journalArticle eng text/pdf reformatted digital access Background Many Sahel countries in Africa are looking for solutions for universal health coverage (UHC). Mali is in the process of adopting the Universal Health Insurance Plan, which allows for the mutualisation of existing schemes. Its operationalisation requires numerous adjustments to the current mutualist proposal and innovations in the system. The study focuses on innovations experienced in mutuality and their conditions of scale for UHC in Mali.Methods This is qualitative research by multiple case studies. It is based on the collection of data by interviews (n=136), at a national and local level, on the analysis of documents (n=42) and a long field observation (7 months). The analytical framework concerns the dissemination and maintenance of health innovations (Greenhalgh et al, 2004).Result The analysis of this innovation shows an interest in the technical and institutional viability that determines its performance and scale-up. The procrastination and scepticism displayed at the highest level of the state and the international level, the reluctance, both financial and ideological, to renew the old mutualist proposal, penalise this Malian experiment.Conclusion This innovation is a decisive step in ensuring the health coverage of Mali's agricultural and informal sectors. The reform will need to be amplified and supported in the future to expect the scale-up of a cheaper, technically and institutionally more efficient system. Without a political intention to mobilise national resources and accept a fundamental paradigm shift in health financing, the search for the financial viability of mutuality may, again, be at the expense of the performance. specialized health insurance health systems MALI 056 7 Suppl. 9 e011055 [10 p.] 2023 2059-7908 https://www.documentation.ird.fr/hor/fdi:010087599 10.1136/bmjgh-2022-011055 2059-7908 [F B010087599] https://www.documentation.ird.fr/hor/fdi:010087599 https://horizon.documentation.ird.fr/exl-doc/pleins_textes/2023-06/010087599.pdf IRD - Base Horizon / Pleins textes 2023-06-30 2025-02-24 fdi:010087599 fre