Economic analysis of a health system strengthening program in the Democratic Republic of the Congo / Analyse économique d'un programme de renforcement du système de santé en République démocratique du 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.

Introduction: Face à l'accès limité aux soins et à la précarité des structures sanitaires en République démocratique du Congo, l'Union européenne par l'intermédiaire de Memisa Belgique avait mis en œuvre le Programme de renforcement de l'offre et développement de l'accès aux soins de santé (PRO DS) dans les provinces du Kongo-Central et de l'Ituri. Ce programme se caractérisait par une approche holistique d'équité d'accès et de lutte contre la malnutrition. Méthodes: Pour mesurer le retour social sur investissement du programme et estimer son coût par habitant et son efficacité par euros investis (efficience), une évaluation coûts-efficacité avec une perspective sociétale de 61 mois (1er juillet 2017 au 31 juillet 2022) a été réalisée. La méthode de double différence, qui compare les résultats des zones PRO DS et des zones non PRO DS, a été utilisée. Le retour social sur investissement a été évalué par le biais du rapport entre l'efficacité et les coûts. Résultats: Les analyses ont montré que le programme coûtait par année et par habitant entre 3,72 et 3,96 euros (2022) au Kongo-Central, et entre 3,12 et 3,36 euros en Ituri. De plus, il était coût-efficace dans plusieurs domaines, telles la santé de la reproduction, la nutrition, l'utilisation des services de santé et nutritionnels. Conclusions: L'efficience du programme pourrait s'expliquer par sa vision holistique avec un fort volet « Nutrition ¼. PRO DS se démarque d'autres programmes qui agissent uniquement sur une problématique ou population spécifique. Malgré ses quelques imperfections, le gouvernement mériterait d'y investir.

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.

An Analysis of the Social Impacts of a Health System Strengthening Program Based on Purchasing Health Services.

Access to universal health coverage is a fundamental right that ensures that even the most disadvantaged receive health services without financial hardship. The Democratic Republic of Congo is among the poorest countries in the world, yet healthcare is primarily made by direct payment which renders care inaccessible for most Congolese. Between 2017 and 2021 a purchasing of health services initiative (Le Programme de Renforcement de l'Offre et Développement de l'accès aux Soins de Santé or PRO DS), was implemented in Kongo Central and Ituri with the assistance of the non-governmental organization Memisa Belgium. The program provided funding for health system strengthening that included health service delivery, workforce development, improved infrastructure, access to medicines and support for leadership and governance. This study assessed the social and health impacts of the PRO DS Memisa program using a health impact assessment focus. A documentary review was performed to ascertain relevant indicators of program effect. Supervision and management of health zones and health centers, use of health and nutritional services, the population's nutritional health, immunization levels, reproductive and maternal health, and newborn and child health were measured using a controlled longitudinal model. Positive results were found in almost all indicators across both provinces, with a mean proportion of positive effect of 60.8% for Kongo Central, and 70.8% in Ituri. Barriers to the program's success included the arrival of COVID-19, internal displacement of the population and resistance to change from the community. The measurable positive impacts from the PRO DS Memisa program reveal that an adequately funded multi-faceted health system strengthening program can improve access to healthcare in a low-income country such as the Democratic Republic of Congo.

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.

Adaptive Mechanisms of Health Zones to Chronic Traumatic Events in Eastern DRC: A Multiple Case Study.

BACKGROUND: The Eastern part of the Democratic Republic of Congo (DRC) has been affected by armed conflict for several years. Despite the growing interest in the impact of these conflicts on health service utilisation, few studies have addressed the coping mechanisms of the health system. The purpose of this study is to describe the traumatic events and coping mechanisms used by the health zones (HZs) in conflict settings to maintain good performance. METHODS: This multiple case study took place from July to October 2022 in four HZs in the South Kivu Province of DRC. HZs were classified into "cases" according to their conflict profile: accessible and stable (Case 1), accessible but remote (Case 2), unstable (Case 3), and intermediate (Case 4). Eight performance indicators and the amount of funding provided to the HZs by non-governmental organizations (NGOs) were recorded. A graph was created to compare their evolution from 2013 to 2018. A thematic analysis of qualitative data from individual interviews with selected health workers was conducted. RESULTS: Both battle-related events (war and its effects) and non-battle-related events (epidemics, disasters, strikes) were recorded according to the case conflict-profile. Although the cases (3 and 4) most affected by armed conflicts occasionally performed better than the stable ones (1 and 2), their operational action plan was poorly carried out. The coping mechanisms developed in cases 3 and 4 were the deployment of military nurses in preventive and supervisory activities, the solicitations of subsidies from NGOs, the relocation of health care facilities and the implementation of negotiation strategies with the belligerents. CONCLUSION: Armed conflict results in traumatic events that disrupt the execution of the operational action plan of HZs. The HZs' management team expertise, its strong leadership, and substantial financial support would enable this system to develop reliable and sustainable adaptive mechanisms.

[Choix thérapeutiques des hypertendus et diabétiques en milieu rural : Une étude mixte dans deux zones de santé de l'Est de la République Démocratique du Congo].

Therapeutic choices of hypertensive and diabetics in rural areas: A mixed study in two health zones in the East of the Democratic Republic of Congo. BACKGROUND: One third of patients in the Democratic Republic of Congo (DRC) do not use the formal health system to access healthcare. AIM: In this manuscript we analyse the therapeutic decisions of hypertensive and diabetic patients in rural eastern DRC and the reasons for these decisions. SETTING: The study was conduct in two health zones (HZ) in South Kivu (Bagira and Walungu), DRC. METHODS: A mixed-methods convergent study was conducted from November 2018 to December 2018. Quantitative data were collected using a questionnaire and qualitative data were collected using focus groups. The quantitative data were analysed using descriptive statistics and a Fischer exact test, while the qualitative data were analysed using thematic analysis. RESULTS: Out of 382 subjects declaring a chronic pathology, hypertensives and diabetics represented 21.5% and 7.9%, respectively. Health facilities were the first therapeutic choice of the chronically affected persons. The alternative therapeutic choices found were the use of prayer rooms, consultation with traditional healers and self-medication. Poverty, ignorance, the pharmaceutical business, and the socio-cultural dimension of the disease are the main causes of alternative therapeutic choices for hypertensives and diabetics. CONCLUSION: To ensure appropriate care for patients with chronic diseases in rural areas, it is important to establish a bridge of regulated collaboration between the formal and informal health sector.

[Contrat unique, une approche innovante de financement du niveau intermédiaire du système de santé en République Démocratique du Congo : processus et défis de mise en œuvre].

Basket fund, an innovative approach for intermediate health system level financing in the Democratic Republic of Congo: Implementation process and challenges. BACKGROUND: Universal health coverage should allow countries to establish a financing strategy in order to guarantee the health of the population. AIM: Our objective was to describe the process and preliminary results of the implementation of the basket fund approach as a mode of financing the intermediate level (provincial health divisions) of the Congolese health system. SETTING: The study was conducted in the provincial health divisions (PHDs), representing the intermediate level of the health system in the Democratic Republic of Congo, where the basket fund approach has been implementedMethods: We conducted a mixed-methods convergent study as part of the evaluation of the basket fund approach in the Democratic Republic of Congo, five years after its introduction (2014-2019). Data was collected through a document review and individual interviews by telephone. A descriptive analysis of the quantitative data was conducted using Statistical Package for Social Sciences (SPSS) version 24 software. The qualitative data were analysed by thematic analysis using a pre-established thematic framework. RESULTS: The implementation of the basket fund approach was effective in some (PHDs) (53.8% in 2016). The operating costs of the PHDs varied according to the size, density and number of health zones covered. In the PHDs where the basket fund was operational, this approach appeared to contribute to improved planning and management in the use of resources, the partnership between technical and financial partners (TFPs and PHDs) and incentives for the performance of PHD agents. CONCLUSION: In the DRC, the basket fund approach has contributed to improved collaboration between donors in the health sector and facilitated the decentralisation of funding planning to the provincial level.

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.

Comparative analysis of the health status of the population in six health zones in South Kivu: a cross-sectional population study using the WHODAS.

BACKGROUND: The eastern Democratic Republic of Congo (DRC) has experienced decades-long armed conflicts which have had a negative impact on population's health. Most research in public health explores measures that focus on a specific health problem rather than overall population health status. The aim of this study was to assess the health status of the population and its predictors in conflict settings of South Kivu province, using the World Health Organization Disability Assessment Schedule (WHODAS). METHODS: Between May and June 2019, we conducted a community-based cross-sectional survey among 1440 adults in six health zones (HZ), classified according to their level of armed conflict intensity and chronicity in four types (accessible and stable, remote and stable, intermediate and unstable). The data were collected by a questionnaire including socio-demographic data and the WHODAS 2.0 tool with 12 items. The main variable of the study was the WHODAS summary score measuring individual's health status and synthesize in six domains of disability (household, cognitive, mobility, self-care, social and society). Univariate analysis, correlation and comparison tests as well as hierarchical multiple linear regression were performed. RESULTS: The median WHODAS score in the accessible and stable (AS), remote and stable (RS), intermediate (I) and unstable (U) HZ was 6.3 (0-28.6); 25 (6.3-41.7); 22.9 (12.5-33.3) and 39.6 (22.9-54.2), respectively. Four of the six WHODAS domain scores (household, cognitive, mobility and society) were the most altered in the UHZs. The RSHZ and IHZ had statistically comparable global WHODAS scores. The stable HZs (accessible and remote) had statistically lower scores than the UHZ on all items. In regression analysis, the factors significantly associated with an overall poor health status (or higher WHODAS score) were advanced age, being woman, being membership of an association; being divorced, separated or widower and living in an unstable HZ. CONCLUSIONS: Armed conflicts have a significantly negative impact on people's perceived health, particularly in crisis health zones. In this area, we must accentuate actions aiming to strengthen people's psychosocial well-being.

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.

[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. BACKGROUND: The intermediate level incorporated both the Provincial Health Inspectorate (IPS) and the Provincial Health Division (DPS) of Health. The new constitution of 2006 gave impetus to decentralisation, which became effective in 2015. The reform introduced at the intermediate level clearly separated the IPS and the DPS. This article assesses the effect of this reform on the performance of IPS and DPS in South Kivu, Democratic Republic of Congo. METHODOLOGY: The study is evaluative before and after and covers the period from 2012 to 2017. It uses mixed methods: three techniques were used to collect data including observation, document review and individual interviews. The analysis of the quantitative data concerned the evolution of the indicators; that of qualitative data was carried out by themes from two theoretical models: the ministerial functional framework and the 'Strengths, Weaknesses, Opportunities and Threats' analysis framework (SWOT analysis). Scores were assigned to each managerial function according to their level of performance for better comparison. RESULTS: After the reform, a decline in the performance score of activities devolved to IPS is noted, mainly due to the low funding of activities. On the other hand, in the DPS, the evolution of the score is favorable, because of the strong support given to the reform at this level by the partners and the government. The alignment of partners to a single contract for funding DPS activities is observed. The weak financing of the health sector by the government remains a weak point, however, and the brain drain a threat to institutional sustainability. The introduction of the single financing contract constitutes an opportunity to improve the performance of the provincial management team. DISCUSSION AND CONCLUSION: The study shows the improvement in the performance of managerial functions of the DPS and the regression to the IPS. The low funding of IPS by the Congolese government could jeopardise the reform.

[Mutual health insurance in Bukavu in the Democratic Republic of the Congo: factors favouring the utilization of health services by adherents]. / Mutuelles de santé à Bukavu en République Démocratique du Congo: facteurs favorables à l'utilisation des services de santé par des adhérents.

INTRODUCTION: This study highlights the determinants of the use of health services by adherents to the three mutual health insurances in the town of Bukavu in the Democratic Republic of the Congo. METHODS: We conducted a descriptive cross-sectional study, based on a perception survey among users of healthcare services affiliated to the mutual health insurances in the Bukavu health zones. The encoding and statistical analysis were carried out using the Epi INFO version 2010 software. RESULTS: The main determinants of the use of healthcare services by adherents to the mutual health insurances are: the member's place of residence, the level of education of the head of household, the previous experience of care in the healthcare structure partner of the mutual health insurances, the reputation of the structure partner of the mutual health insurances and the ability of households to pay the user fee. CONCLUSION: This study highlights that, beyond the financial barrier, the implementation of a mutual health organisation should promote a better regulation of the user fee and a good quality of care to meet the care needs of members. The factors emerging from the study as a major determinant of the use of health services by adherents to a mutual health insurance are often not taken into account in the implementation of mutual health insurance in contexts similar to those of Bukavu.

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.

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.

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]. / Temps d'attente prolongés aux services de consultation médicale: enjeux et perspectives pour des hôpitaux de Bukavu en République Démocratique du Congo.

INTRODUCTION: Prolonged waiting times for medical consultations become a factor in patient dissatisfaction. This study aimed to measure the waiting times for medical consultation and to identify the causes and the consequences from the perspective of improvement of the organisation of medical services. METHODS: We conducted a cross-sectional descriptive study at the General Provincial Reference hospital in Bukavu and at the Biopharm Hospital Center. Data were collected using a literature review, the monitoring of the waiting times and individual interviews of patients and care providers. Quantitative data analysis was accomplished using Epi Info 7.2.0.1.software. Qualitative data were analyzed searching for themes. RESULTS: More than 70% of patients in 3 major Departments at the General Provincial Reference Hospital in Bukavu waited more than 30 minutes before being seen. More than 40% of patients in the 4 major Departments at the Biopharm Hospital Center waited between 0 and 15 minutes. In the Department of Gynecology and Obstetrics at the General Provincial Reference hospital in Bukavu 56% of patients had shorter waiting times (0-15 minutes). The two main causes of prolonged wait times included administrative burden of medical services and physicians delay. Serious implications included a reduction in attendance, in medicinal recipes as well as patients' fatigue. The availability of qualified health staff, the computerization of hospital services and continuous staff training are priorities to reduce waiting times. CONCLUSION: Waiting times vary from one hospital to another and from one department to another within the same hospital, depending on several factors. This study describes possible measures for improvement of waiting times for medical consultations.

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.

Methodological approach and tools for systems thinking in health systems research: technical assistants' support of health administration reform in the Democratic Republic of Congo as an application.

In the field of development cooperation, interest in systems thinking and complex systems theories as a methodological approach is increasingly recognised. And so it is in health systems research, which informs health development aid interventions. However, practical applications remain scarce to date. The objective of this article is to contribute to the body of knowledge by presenting the tools inspired by systems thinking and complexity theories and methodological lessons learned from their application. These tools were used in a case study. Detailed results of this study are in process for publication in additional articles. Applying a complexity 'lens', the subject of the case study is the role of long-term international technical assistance in supporting health administration reform at the provincial level in the Democratic Republic of Congo. The Methods section presents the guiding principles of systems thinking and complex systems, their relevance and implication for the subject under study, and the existing tools associated with those theories which inspired us in the design of the data collection and analysis process. The tools and their application processes are presented in the results section, and followed in the discussion section by the critical analysis of their innovative potential and emergent challenges. The overall methodology provides a coherent whole, each tool bringing a different and complementary perspective on the system.

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.