PhD defence Samuel Itigaino Bosango

Supervisors

• Prof. dr. Bruno Marchal (ITM)

• Prof. dr. Yves Coppieters (ULB)

• Prof. dr. Faustin Chenge (University of Kisangani, DRC) 

Abstract

Background

Despite progress, most African countries have not achieved the Millennium Development Goals related to health. They are struggling to progress towards achieving Sustainable Development Goal 3, related to health and well-being. This situation is partly due to the weakness of health systems, highlighting the need for reforms to strengthen them.

Within this context, in 2006, the Ministry of Health of the Democratic Republic of the Congo (DRC) developed the health system strengthening strategy, which focuses primarily on the development of health districts. This strategy recommended reforming the Provincial Health Administration (PHA) to provide effective technical support to District Health Management Teams (DHMTs). This support aims to enhance DHMTs’ leadership and management competencies through training, supervision, and coaching in order to improve the performance of their health districts.

Since the launch of this PHA reform in late 2014 and the subsequent technical support to DHMTs, few studies have been conducted to understand how, for whom, and under what conditions this technical support works or not. This doctoral research aimed to fill this gap.

Methods

In this study, we adopted a realist evaluation approach and a multiple embedded case study design. The study comprised three phases:

The first phase involved eliciting the initial programme theory on the basis of 1) a scoping review on the design, implementation, and evaluation of health district capacity building programmes in sub-Saharan Africa; 2) a desk review of health policy documents in the DRC; and 3) interviews with stakeholders involved in the design of the health administration reform in the DRC.

In the second phase, we carried out two case studies in the provinces of Tshopo and Kasai Central to test the initial programme theory. Data were collected using multiple methods: document review, semi-structured interviews, non-participant observations, questionnaires, and routine data from the national health information system. We analysed data in two stages: 1) the first stage involved identification of the characteristics of the intervention, contextual factors, actors, mechanisms, and effects using descriptive analysis of quantitative data and thematic analysis of qualitative data; 2) in the second stage, we formulated intervention-context-actor-mechanism-outcome (ICAMO) configurations using a retroductive approach.

In the third phase, a cross-analysis of the results from the two case studies allowed us to identify recurring patterns, leading to the formulation of a more refined programme theory.

Results

This study showed that technical support to DHMTs is hindered by several contextual factors: 1) the insufficiency of resources and their inefficient use due to the fragmentation of external aid and weak integration of specialised programmes; 2) constraining organisational factors, such as weak leadership, a strong hierarchical culture, and limited decision spaces; and 3) a challenging political environment marked by increasing politicisation of public administration, with its corollaries such as corruption, clientelism, and impunity.

At the provincial level, these factors hinder the capacity building of PHA staff, which negatively affects their motivation, sense of accountability, psychological safety, reflexivity, and self-efficacy. This results in mixed competencies (technical, relational and facilitation) of PHA staff.

At the interface between PHA staff and DHMT members, the mixed competencies of PHA staff, combined with the aforementioned contextual factors, negatively impact the quality of technical support. This support does not fully meet the criteria of optimal support hypothesized in the initial program theory (i.e. personalized and needs-driven support, problem-solving-centered support, reflection-stimulating support, comprehensive support, and regular support). As a result, the perceived relevance of the support and the perceived credibility of PHA staff among DHMT members decrease, which reduces their active participation and learning, leading to suboptimal managerial capacities.

At the health district level, DHMTs' limited managerial capacities, combined with the above contextual factors, reduce their motivation, perceived autonomy, and self-efficacy. This leads to suboptimal management practices that do not effectively contribute to improving district health performance.

However, in the Kasai Central province, the performance-based financing programme mitigated these effects by providing additional resources, thus stimulating the extrinsic motivation of actors. However, concerns remain about the limited coverage of this programme and its sustainability due to its dependence on external funding.

Conclusion

These results have several implications for policies and practices, including: promoting an organisational culture that is suited to the complexity of the health system, strengthening leadership within the PHAs, improving coordination among actors and financing of technical support, enhancing the competencies of PHA staff, adopting a participatory approach to technical support, and optimising the use of available resources and decision-making spaces. Given the complexity and structural nature of the contextual challenges to be addressed, we proposed an incremental approach in the form of action research, targeting a limited number of PHAs and health districts to test these implications.