The role of provincial health administration in supporting district health management teams in the Democratic Republic of Congo: eliciting an initial programme theory of a realist evaluation.

BACKGROUND: In 2006, the Ministry of Health in the Democratic Republic of Congo designed a strategy to strengthen the health system by developing health districts. This strategy included a reform of the provincial health administration to provide effective technical support to district health management teams in terms of leadership and management. The provincial health teams were set up in 2014, but few studies have been done on how, for whom, and under what circumstances their support to the districts works. We report on the development of an initial programme theory that is the first step of a realist evaluation seeking to address this knowledge gap. METHODS: To inform the initial programme theory, we collected data through a scoping review of primary studies on leadership or management capacity building of district health managers in sub-Saharan Africa, a review of policy documents and interviews with the programme designers. We then conducted a two-step data analysis: first, identification of intervention features, context, actors, mechanisms and outcomes through thematic content analysis, and second, formulation of intervention-context-actor-mechanism-outcome (ICAMO) configurations using a retroductive approach. RESULTS: We identified six ICAMO configurations explaining how effective technical support (i.e. personalised, problem-solving centred and reflection-stimulating) may improve the competencies of the members of district health management teams by activating a series of mechanisms (including positive perceived relevance of the support, positive perceived credibility of provincial health administration staff, trust in provincial health administration staff, psychological safety, reflexivity, self-efficacy and perceived autonomy) under specific contextual conditions (including enabling learning environment, integration of vertical programmes, competent public health administration staff, optimal decision space, supportive work conditions, availability of resources and absence of negative political influences). CONCLUSIONS: We identified initial ICAMO configurations that explain how provincial health administration technical support for district health management teams is expected to work, for whom and under what conditions. These ICAMO configurations will be tested in subsequent empirical studies.

How capacity building of district health managers has been designed, delivered and evaluated in sub-Saharan Africa: a scoping review and best fit framework analysis.

OBJECTIVES: We aimed to understand how capacity building programmes (CBPs) of district health managers (DHMs) have been designed, delivered and evaluated in sub-Saharan Africa. We focused on identifying the underlying assumptions behind leadership and management CBPs at the district level. DESIGN: Scoping review. DATA SOURCES: We searched five electronic databases (MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library and Google Scholar) on 6 April 2021 and 13 October 2022. We also searched for grey literature and used citation tracking. ELIGIBILITY CRITERIA: We included all primary studies (1) reporting leadership or management capacity building of DHMs, (2) in sub-Saharan Africa, (3) written in English or French and (4) published between 1 January 1987 and 13 October 2022. DATA EXTRACTION AND SYNTHESIS: Three independent reviewers extracted data from included articles. We used the best fit framework synthesis approach to identify an a priori framework that guided data coding, analysis and synthesis. We also conducted an inductive analysis of data that could not be coded against the a priori framework. RESULTS: We identified 2523 papers and ultimately included 44 papers after screening and assessment for eligibility. Key findings included (1) a scarcity of explicit theories underlying CBPs, (2) a diversity of learning approaches with increasing use of the action learning approach, (3) a diversity of content with a focus on management rather than leadership functions and (4) a diversity of evaluation methods with limited use of theory-driven designs to evaluate leadership and management capacity building interventions. CONCLUSION: This review highlights the need for explicit and well-articulated programme theories for leadership and management development interventions and the need for strengthening their evaluation using theory-driven designs that fit the complexity of health systems.

Capacity building of district health management teams in the era of provincial health administration reform in the Democratic Republic of Congo: a realist evaluation protocol.

INTRODUCTION: In 2006, the Congolese Ministry of Health developed a health system strengthening strategy focusing on health district development. This strategy called for reforming the provincial health administration in order to better support the health district development through leadership and management capacity building of district health management teams. The implementation is currently underway, yet, more evidence on how, for whom and under what conditions this capacity building works is needed. The proposed research aims to address this gap using a realist evaluation approach. METHODS AND ANALYSIS: We will follow the cycle of the realist evaluation. First, we will elicit the initial programme theory through a scoping review (completed in December 2022, using MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library, Google Scholar and grey literature), a review of health policy documents (completed in March 2023), and interviews with key stakeholders (by June 2023). Second, we will empirically test the initial programme theory using a multiple-embedded case study design in two provincial health administrations and four health districts (by March 2024). Data will be collected through document reviews, in-depth interviews, non-participant observations, a questionnaire, routine data from the health information management system and a context mapping tool. We will analyse data using the Intervention-Context-Actor-Mechanism-Outcome configuration heuristic. Last, we will refine the initial programme theory based on the results of the empirical studies and develop recommendations for policymakers (by June 2024). ETHICS AND DISSEMINATION: The Institutional Review Board of the Institute of Tropical Medicine and the Medical Ethics Committee of the University of Lubumbashi approved this study. We will also seek approvals from provincial-level and district-level health authorities before data collection in their jurisdictions. We will disseminate the study findings through the publication of articles in peer-reviewed academic journals, policy briefs for national policymakers and presentations at national and international conferences.

The expanding movement of primary care physicians operating at the first line of healthcare delivery systems in sub-Saharan Africa: A scoping review.

INTRODUCTION: In sub-Saharan Africa (SSA), the physicians' ratio is increasing. There are clear indications that many of them have opted to work at the first-line of healthcare delivery systems, i.e. providing primary care. This constitutes an important change in African healthcare systems where the first line has been under the responsibility of nurse-practitioners for decades. Previous reviews on primary care physicians (PCPs) in SSA focused on the specific case of family physicians in English-speaking countries. This scoping review provides a broader mapping of the PCPs' practices in SSA, beyond family physicians and including francophone Africa. For this study, we defined PCPs as medical doctors who work at the first-line of healthcare delivery and provide generalist healthcare. METHODS: We searched five databases and identified additional sources through purposively selected websites, expert recommendations, and citation tracking. Two reviewers independently selected studies and extracted and coded the data. The findings were presented to a range of stakeholders. FINDINGS: We included 81 papers, mostly related to the Republic of South Africa. Three categories of PCPs are proposed: family physicians, "médecins généralistes communautaires", and general practitioners. We analysed the functioning of each along four dimensions that emerged from the data analysis: professional identity, governance, roles and activities, and output/outcome. Our analysis highlighted several challenges about the PCPs' governance that could threaten their effective contribution to primary care. More research is needed to investigate better the precise nature and performance of the PCPs' activities. Evidence is particularly needed for PCPs classified in the category of GPs and, more generally, PCPs in African countries other than the Republic of South Africa. CONCLUSIONS: This review sheds more light on the institutional, organisational and operational realities of PCPs in SSA. It also highlighted persisting gaps that remain in our understanding of the functioning and the potential of African PCPs.

L'influence des prestations des médecins à la première ligne de soins sur le système intégré de district sanitaire à Kisangani, République Démocratique du Congo: une étude qualitative.

INTRODUCTION: in the DRC, doctors, formerly absent, are increasingly being employed as primary care physicians, in particular but not exclusively in urban areas. This study describes and analyses the impact of primary care physician services on the integrated district health system in Kisangani, DRC. METHODS: in the third quarter of 2018, we conducted 40 semi-structured interviews of health district stakeholders (population, nurses, doctors, managers) selected in a reasoned way. Questions focused on doctors' motivation, their package of activities and the perceptions of other district stakeholders on their front-line services. Data were analysed using the thematic content analysis. RESULTS: the services of primary care physicians were a de facto but they were unplanned and unsupported. This derived largely from doctors' need for professional integration. This seemed to improve treatment acceptability but limited their financial accessibility. It was associated with an uncontrolled expansion of the activity packages and caused competition between first-line and second-line physicians. CONCLUSION: physician services are a challenge and an opportunity to strengthen first-line care while preserving complementarity with second-line care. A (re)definition of first-line physicians' role and activity package is then required. Hence, the need to improve the dialogue between different health system actors in order to (re)define consensually a model of first-line care adapted to match physicians' needs.

[Les médecins prestataires à la première ligne des soins dans la ville de Kisangani en République Démocratique du Congo : vers une typologie].

The first-line physicians' practice in Kisangani city in Democratic Republic of Congo: Towards a typology. BACKGROUND: In the Democratic Republic of the Congo (DRC), for a number of years, there has been a spontaneous and growing phenomenon of physicians operating at the front line of the health system, while this role is traditionally devolved to nurse-practitioners. This phenomenon does not align with the current health policy. AIM: The aim of this paper is to develop and discuss the main types of frontline physicians in the city of Kisangani. SETTING: We conducted a descriptive cross-sectional study in two urban districts in the city of Kisangani. METHODS: The study population consisted of all first-line health facilities that employed at least one physician. The construction of a typology of first-line physicians consisted of three stages: identification and definition of relevant dimensions of analysis; grouping cases based on empirical data; and analysis of significant relationships and establishment of the typology itself. RESULTS: An involvement of physicians in healthcare delivery at the first line was observed in 60% of all first line facilities in the two urban districts. Two main types of first-line physicians were identified: firstly, and by large the most prevalent one (96% of cases), the 'hospital-like physician', and secondly, the much less frequent type of the 'supervision physician'. CONCLUSION: The involvement of physicians in first line healthcare is today a growing phenomenon in the DRC, especially in urban areas. The most dominant expression of this phenomenon is a transposition of the hospital-based physician model to the first line healthcare services, which thereby jeopardizing the specificity of first line healthcare.