Economic analysis of a health system strengthening program in the Democratic Republic of the Congo

INTRODUCTION

Due to the Democratic Republic of the Congo’s (DRC) precarious health system that provides only limited access to health care, the European Union, via Memisa Belgium, implemented a program to strengthen provision of and access to health care (known as PRO DS) in the provinces of Kongo Central and Ituri. This program took a holistic approach, seeking to improve equitable access and combat malnutrition.

METHODS

To measure the program’s social return on investment and to estimate the cost per capita and effectiveness per euro invested (efficiency), a 61-month (1 July 2017 to 31 July 2022) cost-effectiveness evaluation with a societal perspective was carried out. The double-difference method was used to compare the results of PRO DS and non-PRO DS zones. The social return on investment was assessed via the ratio of effectiveness to costs.

RESULTS

Analyses revealed the program cost between 3.72 and 3.96 euros per capita per year (2022) in Kongo Central, and between 3.12 and 3.36 euros in Ituri. Importantly, it was cost-effective in the areas of reproductive health, nutrition, and the use of health and nutrition services.

CONCLUSIONS

The program’s strong nutritional component and overall holistic vision may explain why it was so efficient. PRO DS stands out from other programs that focus solely on one specific problem or population. Although the program has some limitations, it would be worthwhile for the government to invest in it.

Community perceptions of a biopsychosocial model of integrated care in the health center: the case of 4 health districts in South Kivu, Democratic Republic of Congo

BACKGROUND

Biopsychosocial care is one of the approaches recommended in the health system by the WHO. Although efforts are being made on the provider side to implement it and integrate it into the health system, the community dynamic also remains to be taken into account for its support. The objective of this study is to understand the community's perceptions of the concept of integrated health care management according to the biopsychosocial approach (BPS) at the Health Center of a Health District and its evaluation in its implementation.

METHODS

This cross-sectional study was done in six Health Areas belonging to four Health Districts in South Kivu, DRC. We conducted 15 semi-directive individual interviews with 9 respondents selected by convenience, including 6 members of the Development Committees of the Health Areas, with whom we conducted 12 interviews and 3 patients met in the health centers. The adapted Normalization MeAsure Development (NoMAD) tool, derived from the Theory of the Normalization Process of Complex Interventions, allowed us to collect data from November 2017 to February 2018, and then from November 2018 to February 2019. After data extraction and synthesis, we conducted a thematic analysis using the NoMAD tool to build a thematic framework. Six themes were grouped into three categories.

RESULTS

Initially, community reports that the BPS approach of integrated care in the Health Centre is understood differently by providers; but then, through collective coordination and integrated leadership within the health care team, the approach becomes clearer. The community encouraged some practices identified as catalysts to help the approach, notably the development of financial autonomy and mutual support, to the detriment of those identified as barriers. According to the community, the BPS model has further strengthened the performance of health workers and should be expanded and sustained.

CONCLUSIONS

The results of our study show the importance of community dynamics in the care of biopsychosocial situations by providers. The barriers and catalysts to the mechanism, both community-based and professional, identified in our study should be considered in the process of integrating the biopsychosocial model of person-centered health care.

Is a bio-psychosocial approach model possible at the first level of health services in the Democratic Republic of Congo? An organizational analysis of six health centers in South Kivu

BACKGROUND

The health system, in the Democratic Republic of Congo, is expected to move towards a more people-centered form of healthcare provision by implementing a biopsychosocial (BPS) approach. It's then important to examine how change is possible in providing healthcare at the first line of care. This study aims to analyze the organizational capacity of health centers to implement a BPS approach in the first line of care.

METHODS

A mixed descriptive and analytical study was conducted from November 2017 to February 2018. Six health centers from four Health Zones (South Kivu, Democratic Republic of Congo) were selected for this study. An organizational analysis of six health centers based on 15 organizational capacities using the Context and Capabilities for Integrating Care (CCIC) as a theoretical framework was conducted. Data were collected through observation, document review, and individual interviews with key stakeholders. The annual utilization rate of curative services was analyzed using trends for the six health centers. The organizational analysis presented three categories (Basic Structures, People and values, and Key Processes).

RESULT

This research describes three components in the organization of health services on a biopsychosocial model (Basic Structures, People and values, and Key processes). The current functioning of health centers in South Kivu shows strengths in the Basic Structures component. The health centers have physical characteristics and resources (financial, human) capable of operating health services. Weaknesses were noted in organizational governance through sharing of patient experience, valuing patient needs in Organizational/Network Culture, and Focus on Patient Centeredness & Engagement as well as partnering with other patient care channels.

CONCLUSION

This study highlighted the predisposition of health centers to implement a BPS approach to their organizational capacities. The study highlights how national policies could regulate the organization of health services on the front line by relying more on the culture of teamwork in the care structures and focusing on the needs of the patients. Paying particular attention to the values of the agents and specific key processes could enable the implementation of the BPS approach at the health center level.

Opportunities and challenges of trilateral South‒South cooperation for transforming development assistance for health: evidence from a DRC-UNICEF-China maternal, newborn, and child health project

BACKGROUND

Trilateral South‒South cooperation is envisioned as an equal and empowering partnership model but still faces certain challenges. This study addresses whether and how trilateral South‒South cooperation can transform traditional development assistance for health (DAH) and explores the opportunities and challenges of trilateral South‒South cooperation for transforming future DAH, in the theme of "the emerging development partner's DAH transformation facilitated by a multilateral organization".

METHODS

We evaluate a maternal, newborn, and child health (MNCH) project involving the Democratic Republic of Congo (DRC), the United Nations Children's Fund (UNICEF), and China (hereinafter referred to as the "DRC-UNICEF-China project"). We analyze data from project documents and seventeen semi-structured interviews using a pragmatic analytical framework based on the DAH program logic model and the OECD's trilateral cooperation framework.

RESULTS

Evidence from the DRC-UNICEF-China MNCH project suggests that trilateral South‒South cooperation facilitated by a multilateral organization can provide transformative opportunities for emerging development partners' DAH to generate and deliver context-based, demand-oriented solutions, harmonize rules and procedures, institutionalize mutual learning and knowledge sharing, and increase the visibility of emerging development partners as sources for South‒South development experience transfer. However, the project revealed some challenges, including the neglect of key stakeholders in the complex governance structure, the high transaction costs needed to ensure transparency, and the harm local absence of the emerging development partner poses to long-term DAH engagement.

CONCLUSIONS

This study echoes some of the findings in trilateral SSC literature that claim power structures and philanthropic, normative justification for health equity are often juxtaposed in trilateral SSC partnerships. The opportunities offered by the DRC-UNICEF-China project align with China's cognitive learning process for strengthening international engagement and global image building. However, challenges may arise as a result of complex governance structures and the entrustment of facilitating partners, which can threaten the effectiveness of trilateral cooperation. We call for strengthening the beneficiary partner's ownership at all levels, engaging the emerging development partner to better understand the beneficiary partner's local context(s) and needs, and ensuring available resources to support programmatic activities and long-term partnerships for the health and well-being of the beneficiaries.

First recourse for care-seeking and associated factors among rural populations in the eastern Democratic Republic of the Congo

BACKGROUND

Access to quality healthcare is a global fundamental human right. However, in the Democratic Republic of the Congo, several parameters affect the choices of health service users in fragile, rural contexts (zones). The overarching aim of this study was to identify the first recourse of healthcare-seeking and the determinants of utilization of health centers (primary health care structures) in the rural health zones of Katana and Walungu.

METHODS

A cross-sectional survey was conducted from June to September 2017. Consenting respondents comprised 1751 adults. Continuous data were summarized using means (standard deviation) and medians (interquartile range). We used Pearson's chi-square test and Fisher exact test to compare proportions. Logistic regression was run to assess socio-determinants of health center utilization.

RESULTS

The morbidity rate of the sample population for the previous month was 86.4% (n = 1501) of which 60% used health centers for their last morbid episode and 20% did not. 5.3% of the respondents patronized prayer rooms and 7.9% resorted to self-medication principally because the cost was low, or the services were fast. Being female (OR: 1.51; p = 0.005) and a higher level of education (OR: 1.79; p = 0.032) were determinants of the use of health centers in Walungu. Only the level of education was associated with the use of health centers in Katana (OR: 2.78; p = 0.045).

CONCLUSION

Our findings suggest that health centers are the first recourse for the majority of the population during an illness. However, a significant percentage of patients are still using traditional healers or prayer rooms because the cost is low. Our results suggest that future interventions to encourage integrated health service use should target those with lower levels of education.

Barriers and facilitators in the implementation of bio-psychosocial care at the primary healthcare level in South Kivu, Democratic Republic of Congo

Background

In the Democratic Republic of Congo (DRC), healthcare services are still focused on disease control and mortality reduction in specific groups. The need to broaden the scope from biomedical criteria to bio-psychosocial (BPS) dimensions has been increasingly recognized.

Aim

The objective of this study was to identify the barriers and facilitators to providing healthcare at the health centre (HC) level to enable BPS care.

Settings

This qualitative study was conducted in six HCs (two urban and four rural) in South-Kivu (eastern DRC) which were selected based on their accessibility and their level of primary healthcare organization.

Methods

Seven focus group discussions (FGDs) involving 29 healthcare workers were organized. A data synthesis matrix was created based on the Rainbow Model framework. We identified themes related to plausible barriers and facilitators for BPS approach.

Results

Our study reports barriers common to a majority of HCs: misunderstanding of BPS care by healthcare workers, home visits mainly used for disease control, solidarity initiatives not locally promoted, new resources and financial incentives expected, accountability summed up in specific indicators reporting. Availability of care teams and accessibility to patient information were reported as facilitators to change.

Conclusion

This analysis highlighted major barriers that condition providers’ mindset and healthcare provision at the primary care level in South-Kivu. Accessibility to the information regarding BPS status of individuals within the community, leadership of HC authorities, dynamics of HC teams and local social support initiatives should be considered in order to develop an effective BPS approach in this region.

Gestion adaptative des centres de santé dans un environnement changeant en République démocratique du Congo

INTRODUCTION

For three decades, the Democratic Republic of the Congo has faced recurrent wars. These have caused a significant burden of morbidity and mortality. In this context, the Katana Health Zone experienced several events that could have hampered the functioning of its health centers, which nevertheless continued to operate.Purpose of research: This study aims to identify specific determinants that have enabled health centers to adapt to a changing context. This is a cross-sectional study using mixed data, carried out in the Mugeri, Ihimbi and Ciranga health centers during the period 1990-2017 for qualitative data and from 2013 to 2017 for the quantitative data. It is based on observation, documentary review and individual interviews with 55 informants.

RESULTS

The main events identified are the recurring rebellions, the massive arrival of refugees, the arrival of humanitarian aid, the earthquakes and the instability of human resources. The supply of services and care has continued thanks to the adaptation mechanisms developed, including the development and application of new directives and standards and dynamic community participation.

CONCLUSIONS

On the one hand, the study demonstrates the value of adapting the procedures for managing financial aid and the operation of a health center in the event of a change in context; the effectiveness of a more structured and regular collaboration between different actors and the appropriation of the activities of the health center by the community. On the other hand, the study identifies the limits of selective and ad hoc interventions, which do not favor the effective development of health centers.

Are people most in need utilising health facilities in post-conflict settings? A cross-sectional study from South Kivu, eastern DR Congo

Background: The disruptive effect of protracted socio-political instability and conflict on the health systems is likely to exacerbate inequities in health service utilisation in conflict-recovering contexts.Objective: To examine whether the level of healthcare need is associated with health facility utilisation in post-conflict settings.Methods: We conducted a cross-sectional study among adults with diabetes, hypertension, mothers of infants with acute malnutrition, informal caregivers (of participants with diabetes and hypertension) and helpers of mothers of children acutely malnourished, and randomly selected neighbours in South Kivu province, eastern DR Congo. Healthcare need levels were derived from a combination, summary and categorisation of the World Health Organisation Disability Assessment Schedule 2.0. Health facility utilisation was defined as having utilised in the first resort a health post, a health centre or a hospital as opposed to self-medication, traditional herbs or prayer homes during illness in the past 30 days. We used mixed-effects Poisson regression models with robust variance to identify the factors associated with health facility utilisation.Results: Overall, 82% (n = 413) of the participants (N = 504) utilised modern health facilities. Health facility utilisation likelihood was higher by 27% [adjusted prevalence ratio (aPR): 1.27; 95% CI: 1.13-1.43; p < 0.001] and 18% (aPR: 1.18; 95% CI: 1.06-1.30; p = 0.002) among participants with middle and higher health needs, respectively, compared to those with low healthcare needs. Using the lowest health need cluster as a reference, participants in the middle healthcare need cluster tended to have a higher hospital utilisation level.Conclusion: Greater reported healthcare need was significantly associated with health facility utilisation. Primary healthcare facilities were the first resort for a vast majority of respondents. Improving the availability and quality of health service packages at the primary healthcare level is necessary to ensure the universal health coverage goal advocating quality health for all can be achieved in post-conflict settings.

Réforme et performance de l’Inspection de la santé et de la Division de la santé au Sud-Kivu en République Démocratique du Congo

Reform and Performance of the Provincial Health Inspectorate and the Provincial Division of Health of South Kivu in the Democratic Republic of Congo.

Mutuelles de santé à Bukavu en République Démocratique du Congo: facteurs favorables à l’utilisation des services de santé par des adhérents

Introduction

La présente étude s'intéresse aux déterminants de l'utilisation des services de santé par des adhérents aux trois mutuelles de santé dans la ville de Bukavu en République Démocratique du Congo.

Méthodes

L'étude, de type descriptif transversal, est une enquête de perception menée auprès des utilisateurs des services de santé affiliés aux mutuelles de santé dans les zones de santé de Bukavu. L'encodage et l'analyse statistique ont été réalisés avec le logiciel Epi Info version 2010.

Résultats

Les principaux déterminants de l'utilisation des services de santé par des adhérents aux mutuelles de santé sont: le lieu de résidence de l'adhérent, le niveau d'instruction du responsable du ménage, l'expérience antérieure des soins dans la structure sanitaire partenaire de la mutuelle de santé, la réputation de la structure partenaire des mutuelles de santé et la capacité des ménages à payer le ticket modérateur.

Conclusion

La présente étude révèle, qu'au-delà de la barrière financière, le développement d'une mutuelle de santé devrait permettre de promouvoir une meilleure régulation du ticket modérateur et une bonne qualité des soins pour satisfaire les besoins en soins de ses adhérents. Les facteurs qui ressortent de l'étude en tant que principaux déterminants de l'utilisation des services de santé des adhérents à une mutuelle de santé ne sont pas souvent pris en compte lors de l'implantation des mutuelles de santé dans des contextes similaires à ceux de Bukavu.

The effect of gender inequality on HIV incidence in Sub-Saharan Africa

OBJECTIVE

We aimed to quantify the extent to which country-level trends in HIV incidence in Sub-Saharan Africa (SSA) were influenced by gender inequalities, measured by gender gaps in educational attainment, income, and a Gender Inequality Index (GII).

STUDY DESIGN

We examined the relation between gender inequality and HIV incidence using country-level panel data from 24 SSA countries for the period between 2000 and 2016.

METHODS

Our goal was to estimate the relation between within-country changes in gender inequality and HIV incidence. We compared results from fixed effects and random effects models for estimating the effect of gender inequalities on changes in HIV incidence. Based on the results of the Hausman test, the fixed effects model was selected as the preferred approach.

RESULTS

HIV incidence decreased by nearly one-half over the period from 2000 to 2016. We estimated that a one percent increase in the GII was associated with a 1.6 percent increase in HIV incidence (95% confidence interval = [0.21%; 3.00%]), after adjusting by country-level socio-economic and governance variables.

CONCLUSIONS

Our study suggests that addressing gender inequalities is a potential strategy to reduce HIV incidence in the SSA region. To control HIV infection, policymakers and public health practitioners should support relevant interventions for promoting gender equality. Further work is needed to identify specific interventions to improve gender inequality and to examine their impacts on changes in HIV incidence.

A new look at population health through the lenses of cognitive, functional and social disability clustering in eastern DR Congo: a community-based cross-sectional study

BACKGROUND

The importance of viewing health from a broader perspective than the mere presence or absence of disease is critical at primary healthcare level. However, there is scanty evidence-based stratification of population health using other criteria than morbidity-related indicators in developing countries. We propose a novel stratification of population health based on cognitive, functional and social disability and its covariates at primary healthcare level in DR Congo.

METHOD

We conducted a community-based cross-sectional study in adults with diabetes or hypertension, mother-infant pairs with child malnutrition, their informal caregivers and randomly selected neighbours in rural and sub-urban health zones in South-Kivu Province, DR Congo. We used the WHO Disability Assessment Schedule 2.0 (WHODAS) to measure functional, cognitive and social disability. The study outcome was health status clustering derived from a principal component analysis with hierarchical clustering around the WHODAS domains scores. We calculated adjusted odds ratios (AOR) using mixed-effects ordinal logistic regression.

RESULTS

Of the 1609 respondents, 1266 had WHODAS data and an average age of 48.3 (SD: 18.7) years. Three hierarchical clusters were identified: 9.2% of the respondents were in cluster 3 of high dependency, 21.1% in cluster 2 of moderate dependency and 69.7% in cluster 1 of minor dependency. Associated factors with higher disability clustering were being a patient compared to being a neighbour (AOR: 3.44; 95% CI: 1.93-6.15), residency in rural Walungu health zone compared to semi-urban Bagira health zone (4.67; 2.07-10.58), female (2.1; 1.25-2.94), older (1.05; 1.04-1.07), poorest (2.60; 1.22-5.56), having had an acute illness 30 days prior to the interview (2.11; 1.24-3.58), and presenting with either diabetes or hypertension (2.73; 1.64-4.53) or both (6.37; 2.67-15.17). Factors associated with lower disability clustering were being informally employed (0.36; 0.17-0.78) or a petty trader/farmer (0.44; 0.22-0.85).

CONCLUSION

Health clustering derived from WHODAS domains has the potential to suitably classify individuals based on the level of health needs and dependency. It may be a powerful lever for targeting appropriate healthcare service provision and setting priorities based on vulnerability rather than solely presence of disease.

[Prolonged waiting times for medical consultation services: challenges and opportunities for hospitals in Bukavu, Democratic Republic of the Congo]

Introduction

Le temps d'attente en consultation devient un facteur d'insatisfaction des patients une fois qu'il est prolongé. L'objectif de l'étude est de mesurer les temps d'attente en consultation et d'en identifier les causes et conséquences dans une perspective d'amélioration de l'organisation des services.

Méthodes

L'étude est descriptive transversale, réalisée à l'Hôpital Général Provincial de Référence de Bukavu et au centre hospitalier Biopharm. La revue documentaire, l'observation des temps d'attente et les entrevues individuelles avec des patients et des prestataires des soins ont été utilisées pour collecter les données. Le logiciel Epi Info 7.2.0.1. a servi à l'analyse des données quantitatives. Les données qualitatives ont été analysées par thème.

Résultats

Plus de 70% des patients dans 3 grands services de l'HGPRB ont expérimenté un temps d'attente au-delà 30 minutes avant leur consultation. Pour plus de 40% des patients dans les 4 grands services du CH Biopharm, le temps d'attente a varié entre 0 et 15 minutes. Le service de gynéco-obstétrique de l'HGPRB a enregistré 56% des patients pour lesquels le temps d'attente est meilleur (0 à 15 minutes). Les deux principales causes des temps d'attente prolongés sont la lourdeur administrative des services et le retard des médecins aux consultations. Les conséquences redoutables sont la diminution de la fréquentation, la baisse des recettes et la fatigue des patients. La disponibilité du personnel qualifié, l'informatisation des services hospitaliers et la formation continue du personnel sont prioritaires pour réduire les temps d'attente.

Conclusion

Les temps d'attente varient d'un hôpital à un autre et d'un service à un autre au sein d'un même hôpital en fonction de plusieurs facteurs. L'étude offre des pistes d'amélioration des temps d'attente en consultation médical.

Which priority indicators to use to evaluate nursing care performance? A discussion paper

AIMS

A discussion of an optimal set of indicators that can be used on a priority basis to assess the performance of nursing care.

BACKGROUND

Recent advances in conceptualization of nursing care performance, exemplified by the Nursing Care Performance Framework, have revealed a broad universe of potentially nursing-sensitive indicators. Organizations now face the challenge of selecting, from this universe, a realistic subset of indicators that can form a balanced and common scorecard.

DESIGN

Discussion paper drawing on a systematic assessment of selected performance indicators.

DATA SOURCES

Previous works, based on systematic reviews of the literature published between 1990 - 2014, have contributed to the development of the Nursing Care Performance Framework. These works confirmed a robust set of indicators that capture the universe of content currently supported by the scientific literature and cover all major areas of nursing care performance. Building on these previous works, this study consisted in gathering the specific evidence supporting 25 selected indicators, focusing on systematic syntheses, meta-analyses and integrative reviews.

IMPLICATIONS FOR NURSING

This study has identified a set of 12 indicators that have sufficient breadth and depth to capture the whole spectrum of nursing care and that could be implemented on a priority basis.

CONCLUSIONS

This study sets the stage for new initiatives aiming at filling current gaps in operationalization of nursing care performance. The next milestone is to set up the infrastructure required to collect data on these indicators and make effective use of them.

Analyzing Katana referral hospital as a complex adaptive system: agents, interactions and adaptation to a changing environment

This study deals with the adaptation of Katana referral hospital in Eastern Democratic Republic of Congo in a changing environment that is affected for more than a decade by intermittent armed conflicts. His objective is to generate theoretical proposals for addressing differently the analysis of hospitals governance in the aims to assess their performance and how to improve that performance. The methodology applied approach uses a case study using mixed methods ( qualitative and quantitative) for data collection. It uses (1) hospital data to measure the output of hospitals, (2) literature review to identify among others, events and interventions recorded in the history of hospital during the study period and (3) information from individual interviews to validate the interpretation of the results of the previous two sources of data and understand the responsiveness of management team referral hospital during times of change. The study brings four theoretical propositions: (1) Interaction between key agents is a positive force driving adaptation if the actors share a same vision, (2) The strength of the interaction between agents is largely based on the nature of institutional arrangements, which in turn are shaped by the actors themselves, (3) The owner and the management team play a decisive role in the implementation of effective institutional arrangements and establishment of positive interactions between agents, (4) The analysis of recipient population's perception of health services provided allow to better tailor and adapt the health services offer to the population's needs and expectations. Research shows that it isn't enough just to provide support (financial and technical), to manage a hospital for operate and adapt to a changing environment but must still animate, considering that it is a complex adaptive system and that this animation is nothing other than the induction of a positive interaction between agents.

Referral hospitals in the Democratic Republic of Congo as complex adaptive systems: similar program, different dynamics

Introduction

In many African countries, first referral hospitals received little attention from development agencies until recently. We report the evolution of two of them in an unstable region like Eastern Democratic Republic of Congo when receiving the support from development aid program. Specifically, we aimed at studying how actors’ network and institutional framework evolved over time and what could matter the most when looking at their performance in such an environment.

Methods

We performed two cases studies between 2006 and 2010. We used multiple sources of data: reports to document events; health information system for hospital services production, and “key-informants” interviews to interpret the relation between interventions and services production. Our analysis was inspired from complex adaptive system theory. It started from the analysis of events implementation, to explore interaction process between the main agents in each hospital, and the consequence it could have on hospital health services production. This led to the development of new theoretical propositions.

Results

Two events implemented in the frame of the development aid program were identified by most of the key-informants interviewed as having the greatest impact on hospital performance: the development of a hospital plan and the performance based financing. They resulted in contrasting interaction process between the main agents between the two hospitals. Two groups of services production were reviewed: consultation at outpatient department and admissions, and surgery. The evolution of both groups of services production were different between both hospitals.

Conclusion

By studying two first referral hospitals through the lens of a Complex Adaptive System, their performance in a context of development aid takes a different meaning. Success is not only measured through increased hospital production but through meaningful process of hospital agents’” network adaptation. Expected process is not necessarily a change; strengthened equilibrium and existing institutional arrangement may be a preferable result. Much more attention should be given in future international aid to the proper understanding of the hospital adaptation capacities.

[Stakeholder representations of the role of the intermediate level of the DRC health system]

INTRODUCTION

Intermediate health care structures in the DRC were designed during the setting-up of primary health care in a perspective of health district support. This study was designed to describe stakeholder representations of the intermediate level of the DRC health system during the first 30 years of the primary health care system.

METHODS

This case study was based on inductive analysis of data from 27 key informant interviews..

RESULTS

The intermediate level of the health system, lacking sufficient expertise and funding during the 1980s, was confined to inspection and control functions, answering to the central level of the Ministry of health and provincial authorities. Since the 1990s, faced with the pressing demand for support from health district teams, whose self-management had to deal with humanitarian emergencies, the need to integrate vertical programmes, and cope with the logistics of many different actors, the intermediate heath system developed methods and tools to support heath districts. This resulted in a subsidiary model of the intermediate level, the perceived efficacy of which varies according to the province over recent years.

CONCLUSION

The "subsidiary" model of the intermediary health system level seems a good alternative to the "control" model in DRC.

[Understanding the adaptation of the Hospital of Logo, Democratic Republic of Congo, to an exogenous health program]

Introduction :

L’évaluation d’un programme sanitaire est souvent réalisée de manière linéaire, associant moyens mis en place et performance réalisée. Nous avons pris une autre perspective : celle d’analyser l’hôpital en tant qu’un système adaptatif complexe, partant des effets du programme santé 9ème Fond Européen de Développement sur la production hospitalière, en vue de comprendre l’adaptation de l’hôpital au changement apporté par le programme.

Méthodologie :

Étude de cas rétrospective (2006 à 2010) ciblant l’hôpital de Logo en Ituri couvrant 208 716 habitants en 2010. L’approche a été mixte, combinant des données quantitatives issues des statistiques hospitalières de routine et des informations qualitatives collectées au travers de la revue documentaire et des entrevues. La triangulation des données a permis de générer des théories explicatives sur le lien entre l’évolution de la production des soins et deux activités importantes du programme.

Résultats :

Quinze événements et interventions ont été identifiés et validés lors des entrevues. La variation ou la stabilité de la production n’a pas été systématiquement associée aux interventions du programme.

Discussion :

La stabilité de la production de l’hôpital de Logo ne dépendait pas seulement des interventions du programme mais également d’autres facteurs comme des arrangements institutionnels préexistants ou la nature de l’interaction entre acteurs. L’analyse de l’hôpital en tant qu’un Système complexe adaptatif permet de mieux comprendre son adaptation à un contexte changeant et offre des perspectives de mieux améliorer sa gouvernance.

[Supporting the intermediate level of health care in urban health areas in Kinshasa (1995-2005), DR Congo]

As a result of the decentralization of health systems, some countries have introduced intermediate (provincial) levels in their public health system. This paper presents the results of a case study conducted in Kinshasa on health system decentralization. The study identified a shift from a focus on regulation compliance assessment to an emphasis on health system coordination and health district support. It also highlighted the emergence of a?managerial (as opposed to a bureaucratic) approach to health district support. The performance of health districts in terms of health care coverage and health service use were also found to have improved. The results highlight the importance of intermediate levels in?the health care system and the value of a more organic and managerial rationality in supporting health districts faced with the complexity of urban environments and the integration of specialized multi-partner programs and interventions.

[Impact of mid-level management and support on the performance of a district health system in the Democratic Republic of the Congo]

INTRODUCTION

The aim of this study was to assess the contribution of mid-level management and support practices to the overall performance of a district healthcare system.

METHODS

This case study was carried out in the North Kivu Province of the Democratic Republic of the Congo. It was based on analysis of (i) preventive and curative healthcare services and (ii) management and support practices provided from 2000 to 2008.

RESULTS

In response to recurring sociopolitical unrest since 1992, the mid-level health system (provincial level) in North Kivu has strengthened management and support practices. The main goals have been to optimize allocation of interventions by external emergency organizations and integration of specialized program activities, to harmonize intervention techniques implemented by external partners, to standardize supervision of sanitary districts with regard to care provider skills, and to adapt strategic options defined by the Ministry of Health to the provincial level. Using this comprehensive approach, the performance of the North Kivu Province in terms of curative and preventive care has exceeded the national average since 2001. Between 2001 and 2008, use of curative services progressed from 0.36 to 0.50 new cases/capita/year. Positive results have also been recorded for infrastructure coverage, essential medicine stock, health information system, and emergency preparedness.

CONCLUSION

Stronger mid-level management and support practices have improved care activities in the health district while protecting the population from unstructured interventions by emergency organizations or specialized programs. A comprehensive management approach has also improved the resilience of the district and increased its contribution to Millennium Development Goals.