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

Abstract

IntroductionIn 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.MethodsWe 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.ResultsTwo 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.ConclusionBy 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.

Scoping review of complexity theory in health services research

“…Most studies were qualitative [ 31 – 56 ], followed by quantitative [ 57 – 70 ], and, finally, to a lesser extent, mixed methods [ 71 – 73 ]. Case studies were the most common qualitative [ 31 , 32 , 34 – 37 , 40 – 42 , 44 , 45 , 47 , 50 , 51 , 55 , 63 , 74 ] and mixed method [ 71 – 73 ] design. Action research [ 48 ], ethnography [ 39 ], grounded theory [ 46 , 53 ], and phenomenological designs [ 43 , 49 ] were used less frequently.…”

“…The majority of health services research conducted using complexity theory was based in the United States [ 31 , 32 , 34 , 36 , 37 , 42 , 43 , 46 , 50 – 63 , 65 , 66 , 68 – 70 , 73 , 74 ], followed by the United Kingdom [ 40 , 41 , 49 , 64 , 71 ], Canada [ 44 , 56 ], Norway [ 33 , 39 ], Brazil [ 38 ], Congo [ 45 ], Finland [ 67 ], Italy [ 47 ], Malta [ 35 ], South Africa [ 48 ], and Sweden [ 72 ].…”

“…The settings studied using complexity theory consisted of long term care facilities [ 32 , 34 , 36 , 37 , 39 , 42 , 51 , 54 , 57 , 59 – 61 , 69 , 70 ], primary care [ 31 , 33 , 40 , 41 , 44 , 46 , 47 , 50 , 55 , 62 , 68 , 71 ], hospital [ 35 , 38 , 43 , 45 , 52 , 53 , 58 , 63 , 64 , 66 , 67 , 73 , 74 ], community health centres [ 48 , 62 , 74 ], and other (e.g., not applicable, health care systems, health trusts) [ 49 , 56 , 65 , 72 ]. Despite most of the research being conducted with multiple professions and in settings that depend upon interprofessional collaboration, only 23 % of studies used complexity theory to explicitly explore interprofessional collaboration.…”

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

“…Les autres stratégies concernent la baisse des coûts des soins, le rapprochement des services et le respect du circuit des patients. La mise en place de certaines stratégies peut nécessiter des moyens financiers qui limitent souvent l'organisation des hôpitaux et notamment ceux publics [ 31 - 34 ]. A défaut de réussir la mise en place de ces stratégies, le long temps d'attente est parfois exploité pour organiser des séances d'éducation sanitaire aux patients [ 24 ].…”

We Need to Talk About Complexity in Health Research: Findings From a Focused Ethnography

“…Complexity studies have not just been carried out in the U.K. context as examples abound in other countries such as Australia (e.g., Braithwaite et al, 2017), Canada (e.g., Grudniewicz et al, 2018), the United States (e.g., Lanham et al, 2013), and Africa (Karemere et al, 2015; Mash et al, 2008). It is beyond the scope of this article to provide a full history of complexity theory in applied health and care.…”