Abstract: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 conflictrecovering 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 … Show more
“…Aiming to contribute to the strengthening of the DRC's health system through the integrated leadership of the HZ (28, 29), this study describes the state of leadership as experienced by operational-level health managers in rural areas in a context of crisis. The rural health zones in crisis in the DRC are similar in their organization and in the challenges they face (17,20,27,29,41), we believe that the results from these eight study areas will largely re ect the situation of all other areas in the same context. These results could represent one of the worst cases of the state of the DRC health system, with the crisis context playing as an aggravating factor (17,41) on the rural context, which is even worse than the urban context (42)(43)(44).…”
Section: Discussionmentioning
confidence: 86%
“…As a result, along with the combined burden of infectious diseases and malnutrition, additional health problems directly related to crisis and armed con ict emerge, with major consequences for the overall health of the local population (18,19). The province of South Kivu in Eastern DRC is one of the most affected provinces by these recurring con icts (17,20). Hence the need to promote the leadership necessary to achieve greater resilience of the health system (16).…”
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, an inductive analysis extracted emerging subthemes.
Results
The study has revealed deficiencies regarding Management and Organisation 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.
“…Aiming to contribute to the strengthening of the DRC's health system through the integrated leadership of the HZ (28, 29), this study describes the state of leadership as experienced by operational-level health managers in rural areas in a context of crisis. The rural health zones in crisis in the DRC are similar in their organization and in the challenges they face (17,20,27,29,41), we believe that the results from these eight study areas will largely re ect the situation of all other areas in the same context. These results could represent one of the worst cases of the state of the DRC health system, with the crisis context playing as an aggravating factor (17,41) on the rural context, which is even worse than the urban context (42)(43)(44).…”
Section: Discussionmentioning
confidence: 86%
“…As a result, along with the combined burden of infectious diseases and malnutrition, additional health problems directly related to crisis and armed con ict emerge, with major consequences for the overall health of the local population (18,19). The province of South Kivu in Eastern DRC is one of the most affected provinces by these recurring con icts (17,20). Hence the need to promote the leadership necessary to achieve greater resilience of the health system (16).…”
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, an inductive analysis extracted emerging subthemes.
Results
The study has revealed deficiencies regarding Management and Organisation 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.
“…Figure 2 shows a gradual increase in sources published, from 1 in 2006 to 12 in 2020 with dips in 2016 and 2018. Data for most sources were collected during conflict, except for 6 in Burundi, DRC, Kosovo, Myanmar, Nigeria, Sri Lanka, and Uganda that reported data collected after conflict [ 10 , 18 , 35 , 41 , 59 , 61 ]. Fig.…”
Introduction
Strengthening health systems in conflict-affected settings has become increasingly professionalised. However, evaluation remains challenging and often insufficiently documented in the literature. Many, particularly small-scale health system evaluations, are conducted by government bodies or non-governmental organisations (NGO) with limited capacity to publish their experiences. It is essential to identify the existing literature and main findings as a baseline for future efforts to evaluate the capacity and resilience of conflict-affected health systems. We thus aimed to synthesise the scope of methodological approaches and methods used in the peer-reviewed literature on health system evaluation in conflict-affected settings.
Methods
We conducted a scoping review using Arksey and O’Malley’s method and synthesised findings using the WHO health system ‘building blocks’ framework.
Results
We included 58 eligible sources of 2,355 screened, which included examination of health systems or components in 26 conflict-affected countries, primarily South Sudan and Afghanistan (7 sources each), Democratic Republic of the Congo (6), and Palestine (5). Most sources (86%) were led by foreign academic institutes and international donors and focused on health services delivery (78%), with qualitative designs predominating (53%). Theoretical or conceptual grounding was extremely limited and study designs were not generally complex, as many sources (43%) were NGO project evaluations for international donors and relied on simple and lower-cost methods. Sources were also limited in terms of geography (e.g., limited coverage of the Americas region), by component (e.g., preferences for specific components such as service delivery), gendered (e.g., limited participation of women), and colonised (e.g., limited authorship and research leadership from affected countries).
Conclusion
The evaluation literature in conflict-affected settings remains limited in scope and content, favouring simplified study designs and methods, and including those components and projects implemented or funded internationally. Many identified challenges and limitations (e.g., limited innovation/contextualisation, poor engagement with local actors, gender and language biases) could be mitigated with more rigorous and systematic evaluation approaches.
“…As the choice of place of delivery is often linked to women’s degree of autonomy [ 64 , 65 ], literature reports how interventions aimed at empowering women, particularly at the social and educational levels, have had a direct positive impact on MNH [ 66 , 67 ]. In the context of LICs, empowerment of women is crucial, yet decisions on healthcare might encompass factors beyond cost, including accessibility and perceived quality, influencing their preference for some facilities, regardless of the objectivized quality of services, as authors have observed in similar areas [ 68 ]. The government should prioritize providing financial protection or accessible, pro-poor healthcare systems in these areas where the state has little presence [ 69 , 70 ] while continuing to try to implement legislative mechanisms to discourage the unlicensed sector [ 71 ].…”
Background
Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country’s protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu.
Methods
Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation.
Results
The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones.
Conclusions
MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.
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