Ensuring leadership at the operational level of a health system in protracted crisis context: a cross-sectional qualitative study covering 8 health districts in Eastern Democratic Republic of Congo.

BACKGROUND: This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC. METHODS: A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC's health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service's Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes. RESULTS: The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone's external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership. CONCLUSIONS: Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.

A synthesis of concepts of resilience to inform operationalization of health systems resilience in recovery from disruptive public health events including COVID-19.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict' Health systems resilience has become a ubiquitous concept as countries respond to and recover from crises such as the COVID-19 pandemic, war and conflict, natural disasters, and economic stressors inter alia. However, the operational scope and definition of health systems resilience to inform health systems recovery and the building back better agenda have not been elaborated in the literature and discourse to date. When widely used terms and their operational definitions appear nebulous or are not consistently used, it can perpetuate misalignment between stakeholders and investments. This can hinder progress in integrated approaches such as strengthening primary health care (PHC) and the essential public health functions (EPHFs) in health and allied sectors as well as hinder progress toward key global objectives such as recovering and sustaining progress toward universal health coverage (UHC), health security, healthier populations, and the Sustainable Development Goals (SDGs). This paper represents a conceptual synthesis based on 45 documents drawn from peer-reviewed papers and gray literature sources and supplemented by unpublished data drawn from the extensive operational experience of the co-authors in the application of health systems resilience at country level. The results present a synthesis of global understanding of the concept of resilience in the context of health systems. We report on different aspects of health systems resilience and conclude by proposing a clear operational definition of health systems resilience that can be readily applied by different stakeholders to inform current global recovery and beyond.

Developing technical support and strategic dialogue at the country level to achieve Primary Health Care-based health systems beyond the COVID-19 era.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Pursuing the objectives of the Declaration of Alma-Ata for Primary Health Care (PHC), the World Health Organization (WHO) and global health partners are supporting national authorities to improve governance to build resilient and integrated health systems, including recovery from public health stressors, through the long-term deployment of WHO country senior health policy advisers under the Universal Health Coverage Partnership (UHC Partnership). For over a decade, the UHC Partnership has progressively reinforced, via a flexible and bottom-up approach, the WHO's strategic and technical leadership on Universal Health Coverage, with more than 130 health policy advisers deployed in WHO Country and Regional Offices. This workforce has been described as a crucial asset by WHO Regional and Country Offices in the integration of health systems to enhance their resilience, enabling the WHO offices to strengthen their support of PHC and Universal Health Coverage to Ministries of Health and other national authorities as well as global health partners. Health policy advisers aim to build the technical capacities of national authorities, in order to lead health policy cycles and generate political commitment, evidence, and dialogue for policy-making processes, while creating synergies and harmonization between stakeholders. The policy dialogue at the country level has been instrumental in ensuring a whole-of-society and whole-of-government approach, beyond the health sector, through community engagement and multisectoral actions. Relying on the lessons learned during the 2014-2016 Ebola outbreak in West Africa and in fragile, conflict-affected, and vulnerable settings, health policy advisers played a key role during the COVID-19 pandemic to support countries in health systems response and early recovery. They brought together technical resources to contribute to the COVID-19 response and to ensure the continuity of essential health services, through a PHC approach in health emergencies. This policy and practice review, including from the following country experiences: Colombia, Islamic Republic of Iran, Lao PDR, South Sudan, Timor-Leste, and Ukraine, provides operational and inner perspectives on strategic and technical leadership provided by WHO to assist Member States in strengthening PHC and essential public health functions for resilient health systems. It aims to demonstrate and advise lessons and good practices for other countries in strengthening their health systems.

Fonctionnalité des concentrateurs d'oxygène hospitaliers au Nord Kivu, République Démocratique du Congo.

INTRODUCTION: Nord-Kivu is facing a high prevalence of hypoxemia diseases requiring the use of oxygen concentrators. PURPOSE OF RESEARCH: This article describes the level of functionality of oxygen concentrators in 31 hospital structures, in North Kivu province of Democratic Republic of Congo (DRC). METHODS: This descriptive cross-sectional study carried out a survey of managerial and maintenance personnel and the removal of parameters on the operation of oxygen concentrators from 31 hospitals handling Covid19 cases in North Kivu. The collected data was encoded and analyzed using SPSS version 26 software. RESULTS: The oxygen concentrators were of 28 different brands, and in 65.8% of cases with a 5-liter capacity. They were used in 70% of cases in 4 departments (Intensive care, operating room, emergency room, internal medicine). They were donated in 66.2% of cases (n=225), without accessory equipment in33.6% of cases and without training of maintenance technician in three of five cases or users in one in two cases. In 45% of cases, maintenance was provided. In 67.6% of cases oxygen concentrators were not functional (n=225), with impaired volume flow in 54.9% of cases and oxygen levels in 34,6% of cases. The oxygen deficit was variable depending on the type of hospital structures (p=0,005) but not the volume flow (P>0.05). CONCLUSIONS: Low functionality of oxygen concentrators increases patient risk and shows the interest to implement a provincial strategy for the management and maintenance of bio-medical equipment and its integration into regional health development plan.

An assessment of the core capacities of the Senegalese health system to deliver Universal Health Coverage.

Senegal is firmly committed to the objective of universal health coverage (UHC). Various initiatives have been launched over the past decade to protect the Senegalese population against health hazards, but these initiatives are so far fragmented. UHC cannot be achieved without health system strengthening (HSS). Here we assess the core capacities of the Senegalese health systems to deliver UHC, and identify requirements for HSS in order to implement and facilitate progress towards UHC. Based on a critical review of existing data and documents, complemented by the authors' experience in supporting UHC policy making and implementation, we evaluate the main foundational and institutional bottlenecks relative to the six health system building blocks, together with an analysis of the demand-side of the health system, which facilitate or hamper progress towards UHC. Despite the fact that many institutions are now in place to deliver UHC, important weaknesses limit progress along the two dimensions of UHC. Substantial disparities characterise resource allocation in the health sector, and health risk protection schemes are highly fragmented. This spreads down to the rest of the health system including service delivery and consequently, impacts on health outcomes. These constraints are acknowledged by the authorities, solutions have been proposed, but these necessitate strong political will. Moreover, progress towards UHC is constrained by the difficulty to act on social determinants of health and a lack of fiscal space.

Policy dialogue as a collaborative tool for multistakeholder health governance: a scoping study.

INTRODUCTION: Health system governance is the cornerstone of performant, equitable and sustainable health systems aiming towards universal health coverage. Global health actors have increasingly been using policy dialogue (PD) as a governance tool to engage with both state and non-state stakeholders. Despite attempts to frame PD practices, it remains a catch-all term for both health systems professionals and researchers. METHOD: We conducted a scoping study on PD. We identified 25 articles published in English between 1985 and 2017 and 10 grey literature publications. The analysis was guided by the following questions: (1) How do the authors define PD? (2) What do we learn about PD practices and implementation factors? (3) What are the specificities of PD in low-income and middle-income countries? RESULTS: The analysis highlighted three definitions of policy dialogue: a knowledge exchange and translation platform, a mode of governance and an instrument for negotiating international development aid. Success factors include the participants' continued and sustained engagement throughout all the relevant stages, their ability to make a constructive contribution to the discussions while being truly representative of their organisation and their high interest and stake in the subject. Prerequisites to ensuring that participants remained engaged were a clear process, a shared understanding of the goals at all levels of the PD and a PD approach consistent with the PD objective. In the context of development aid, the main challenges lie in the balance of power between stakeholders, the organisational or technical capacity of recipient country stakeholders to drive or contribute effectively to the PD processes and the increasingly technocratic nature of PD. CONCLUSION: PD requires a high level of collaborative governance expertise and needs constant, although not necessarily high, financial support. These conditions are crucial to make it a real driver of health system reform in countries' paths towards universal health coverage.

Realist evaluation of the role of the Universal Health Coverage Partnership in strengthening policy dialogue for health planning and financing: a protocol.

INTRODUCTION: In 2011, WHO, the European Union and Luxembourg entered into a collaborative agreement to support policy dialogue for health planning and financing; these were acknowledged as core areas in need of targeted support in countries' quest towards universal health coverage (UHC). Entitled 'Universal Health Coverage Partnership', this intervention is intended to strengthen countries' capacity to develop, negotiate, implement, monitor and evaluate robust and integrated national health policies oriented towards UHC. It is a complex intervention involving a multitude of actors working on a significant number of remarkably diverse activities in different countries. METHODS AND ANALYSIS: The researchers will conduct a realist evaluation to answer the following question: How, in what contexts, and triggering what mechanisms, does the Partnership support policy dialogue for health planning and financing towards UHC? A qualitative multiple case study will be undertaken in Togo, Liberia, Democratic Republic of Congo, Cape Verde, Burkina Faso and Niger. Three steps will be implemented: (1) formulating context-mechanism-outcome explanatory propositions to guide data collection, based on expert knowledge and theoretical literature; (2) collecting empirical data through semistructured interviews with key informants and observations of key events, and analysing data; (3) specifying the intervention theory. ETHICS AND DISSEMINATION: The primary target audiences are WHO and its partner countries; international and national stakeholders involved in or supporting policy dialogues in the health sector, especially in low-income countries; and researchers with interest in UHC, policy dialogue, evaluation research and/or realist evaluation.

[Stakeholder representations of the role of the intermediate level of the DRC health system]. / Rôles exercés par le Niveau intermédiaire du système sanitaire en République démocratique du Congo: représentations des acteurs.

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.

Health service planning contributes to policy dialogue around strengthening district health systems: an example from DR Congo 2008-2013.

BACKGROUND: This case study from DR Congo demonstrates how rational operational planning based on a health systems strengthening strategy (HSSS) can contribute to policy dialogue over several years. It explores the operationalization of a national strategy at district level by elucidating a normative model district resource plan which details the resources and costs of providing an essential health services package at district level. This paper then points to concrete examples of how the results of this exercise were used for Ministry of Health (MoH) decision-making over a time period of 5 years. METHODS: DR Congo's HSSS and its accompanying essential health services package were taken as a base to construct a normative model health district comprising of 10 Health Centres (HC) and 1 District Hospital (DH). The normative model health district represents a standard set by the Ministry of Health for providing essential primary health care services. RESULTS: The minimum operating budget necessary to run a normative model health district is $17.91 per inhabitant per year, of which $11.86 is for the district hospital and $6.05 for the health centre. The Ministry of Health has employed the results of this exercise in 4 principal ways: 1.Advocacy and negotiation instrument; 2. Instrument to align donors; 3. Field planning; 4. Costing database to extract data from when necessary. CONCLUSIONS: The above results have been key in the policy dialogue on affordability of the essential health services package in DR Congo. It has allowed the MoH to provide transparent information on financing needs around the HSSS; it continues to help the MoH negotiate with the Ministry of Finance and bring partner support behind the HSSS.

[Reorganization of the provincial health system in the Democratic Republic of the Congo]. / Réforme des structures intermédiaires de santé en République démocratique du Congo.

INTRODUCTION: In the framework of implementation of health system reform in the Democratic Republic of the Congo (DRC), and in a context of decentralization dictated by the National Constitution, this study presents the process and results obtained in terms of the provincial level of health care organization in DRC. METHODS: A two-year multidisciplinary interventional research protocol was elaborated with two phases and 9 steps including organizational analysis, team building, and organizational learning. It resulted in transformational actions and improved knowledge, allowing the development of an innovative organizational model of the intermediate level of the health care system in the Democratic Republic of the Congo. RESULTS: This interventional research gave rise to function plans set up by the provincial health division (PHD) in order to develop a more participative management and to compensate for the weaknesses of the current structural organization. Experts provided support to PHD for implementation of a new structure in order to institutionalize this new participative management. The new organizational structure of the PHD is based on 4 professions: i) health district support; ii) control and inspection; iii) information, communication and research and iv) resources management. PHD and experts defined these professions and described the required skills. RESULTS were integrated into the new national health plan. CONCLUSIONS: Apart from the concrete results obtained, two major challenges need to be addressed: i) support the transformation of PHD from the current situation to the new model and ii) extend this new model to the other provinces, according to the same participative approach, a necessary condition to adjust the organization flow-chart to the context.

[Supporting the intermediate level of health care in urban health areas in Kinshasa (1995-2005), DR Congo]. / Soutien du niveau intermédiaire au district sanitaire urbain à Kinshasa (1995-2005), RD 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.

The role of hospitals within the framework of the renewed primary health care (PHC) strategy.

This article summarizes a presentation made at the IHF Leadership Summit held in Chicago, USA in June 2010, by Denis Porignon from the World Health Organization (WHO) and Reynaldo Holder from the Pan American Health Organization (PAHO/WHO). It focuses on the role of hospitals within the framework of the renewed PHC strategy.

The response to flexibility: country intervention choices in the first four rounds of the GAVI Health Systems Strengthening applications.

Since December 2005 the GAVI Alliance (GAVI) Health Systems Strengthening (HSS) window has offered predictable funding to developing countries, based on a combined population and economic formula. This is intended to assist them to address system constraints to improved immunization coverage and health care delivery, needed to meet the Millennium Development Goals. The application process invites countries to prioritize specific system constraints not adequately addressed by other donors, and allows them to allocate their eligible funds accordingly. This article presents an analysis of the first four rounds of countries' funding applications. These requested funding for a variety of health system initiatives that reflected country-specific requirements, and were not limited to improving immunization coverage. Analyses identified a dominance of operational-level health service provision activities, and an absence of interventions related to demand and financing. While the proposed activities are only now being implemented, the results of this study provide evidence that the open application process employed by the HSS window has led to a shift in analysis and planning-from the programmatic to the systemic-in the countries whose applications have been approved. However, the proposed responses to identified constraints are dominated by short-term operational responses, rather than more complex, longer term approaches to health system strengthening.

The contribution of primary care to health and health systems in low- and middle-income countries: a critical review of major primary care initiatives.

It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals. In this systematic review we described and assessed the contributions of major primary care initiatives implemented in low- and middle-income countries in the past 30 years to a broad range of health system goals. The scope of the programs reviewed was substantial, with several interventions implemented on a national scale. We found that the majority of primary care programs had multiple components from health service delivery to financing reform to building community demand for health care. Although given this integration and the variable quality of the available research it was difficult to attribute effects to the primary care component alone, we found that primary care-focused health initiatives in low- and middle-income countries have improved access to health care, including among the poor, at reasonably low cost. There is also evidence that primary care programs have reduced child mortality and, in some cases, wealth-based disparities in mortality. Lastly, primary care has proven to be an effective platform for health system strengthening in several countries. Future research should focus on understanding how to optimize the delivery of primary care to improve health and achieve other health system objectives (e.g., responsiveness, efficiency) and to what extent models of care can be exported to different settings.

Nutritional monitoring of preschool-age children by community volunteers during armed conflict in the Democratic Republic of the Congo.

BACKGROUND: The coverage of preschool preventive medical visits in developing countries is still low. Consequently, very few children benefit from continuous monitoring during the first 5 years of life. OBJECTIVE: To assess community volunteers' effectiveness in monitoring the growth of preschool-age children in a context of endemic malnutrition and armed conflict. METHODS: Community volunteers were selected by village committees and trained to monitor children's growth in their respective villages. Community volunteers monitored 5479 children under 5 years of age in the Lwiro Health Sector of the Democratic Republic of the Congo from January 2004 to December 2005 under the supervision of the district health office. Children's weight was interpreted according to weight-for-age curves drawn on the growth sheet proposed by the World Health Organization and adopted by the Democratic Republic of the Congo. RESULTS: During the 2-year program, the volunteers weighed children under 5 years of age monthly. The median percentage of children weighed per village varied between 80% and 90% for children of 12-59 months, and 80% and 100% for children of less than 12 months even during the conflict period. The median percentage of children between 12 and 59 months of age per village ranked as highly susceptible to malnutrition by the volunteers decreased from 4.2% (range, 0% to 35.3%) in 2004 to 2.8% (range, 0.0% to 18.9%) in 2005. CONCLUSIONS: The decentralization of weighing of children to the community level could be an alternative for improving growth monitoring of preschool-age children in situations of armed conflict or political instability. This option also offers an opportunity to involve the community in malnutrition care and can be an entry point for other public health activities.

Performance-based financing for better quality of services in Rwandan health centres: 3-year experience.

In 2005, the Ministry of Health in Rwanda, with the support of the Belgian Technical Cooperation, launched a strategy of performance-based financing (PBF) in a group of 74 health centres (HCs), covering 2-m inhabitants. In 2006, PBF was extended to an additional group of 85 HCs, thus reaching 3.8-m inhabitants. This study evaluates the effect of PBF on HC performance from 2005 to 2007. Composite indicators for measuring quantity and quality of services were developed and evaluated through monthly formative supervisions by qualified and well-trained district supervisors. The strategy was based on a fixed fee per quality-approved service. The entire budget spent on the implementation of PBF amounted to $0.25/cap/year, of which $0.20/cap/year for subsidies and an estimated $0.05/cap/year for administration, supervision and training. A positive effect on utilization rates was only seen for activities that were previously less well organized; in this case, growth monitoring services and institutional deliveries. The quality of services, defined as the compliance rate with national and international norms, rose considerably for all services in both groups. A sustained level of quality between 80% and 95% was reached within 18 months in the first group. A similar result was reached in the second group in 8 months.

[The prepayment scheme in Rwanda (II): membership and use of services by beneficiaries]. / Le système de prépaiement au Rwanda (II): adhésion et utilisation des services par les bénéficiaires.

In Rwanda, the Ministry of Health is rebuilding the health sector destroyed during the genocide while trying to guarantee the financial accessibility of the population to the services through the setting up of a prepayment scheme. Membership remains low in the three pilot districts where the prepayment scheme was introduced four years before (15,6%). In two of these districts, the curative consultation and maternity utilisation has increased appreciably. The members of the prepayment scheme make greater use of the services than the rest of the population. There is a significantly higher prepayment scheme membership among households with a relatively high income and those with a large family (more than 5 family members). Overall, non-members of the prepayment scheme spend more on health services than members do. There are indications that developing the prepayment scheme would be very useful for the people in Rwanda if specific strategies geared to the poor were set up.