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.

[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.