Gouvernance hospitalière adaptative en contexte changeant : étude des hôpitaux de Bunia, Logo et Katana en République démocratique du Congo

Introduction: The thesis deals with the adaptation of referral hospitals in two regions of the Eastern Democratic Republic of Congo to a changing environment that have been affected for more than a decade by intermittent armed conflicts : Ituri (Bunia and Logo Hospitals) and South Kivu (Katana Hospital) . The objective is to generate theoretical proposals to address in different ways the governance of hospitals, the analysis of their performance, and how to improve that performance. It confronts in effect the provision of hospital care to the events occurring in the life of the hospital by identifying major changes over time and responsiveness of management teams of hospitals at the time of change. Such work finds its originality and interest in the type of approach for analyzing the referral hospital, not just from the angle of a logical and bureaucratic model where the relationship of cause and effect (means versus results) predominates , but also especially in terms of complexity, according to an adaptive and flexible approach , where the outcome is not predictable but results from the interaction between several actors who sometimes have conflicting interests . Based on the facts observed on field and a series of questions from the interpretive synthesis of the literature on the concepts of complex adaptive systems , strategic management and leadership, adaptive governance and performance, the referral hospital is thus analyzed as a complex adaptive system in order to improve its performance . Methodology: The methodological approach applied uses multiple case studies using mixed methods ( qualitative and quantitative) for data collection. It uses (1) hospital data to measure the output of hospitals , (2) literature review to identify among others , the events and interventions recorded in the history of hospitals during the study period and ( 3) information from individual interviews to validate the interpretation of the results of the previous two sources of data and understand the responsiveness of management teams referral hospitals during times of change. Results: Two case studies . The first study compares the evolution of two referral hospitals in Ituri (Logo and Bunia ) exposed to the same program for four years ( 2006-2010 ) and notes two different paths of development in their provision of care. It describes the main actors in referral hospitals categorized in three key types: the management team , hospital staff, and the owner ; and reveals the characteristics of the interaction between these agents in the two hospitals and in relation to their environment which is marked by an external program with development partners. The characteristics of the agents in the two hospitals are different. This study generates a theoretical proposal that explains the adaptation hospitals to change. It considers that the nature of the interaction between agents plays an important role in the " stability " or " lability" of a hospital and that this interaction is mainly based on institutional arrangements. The more solid these are, the more the interaction between players is balanced and stronger and the hospital is stable. The second case study, conducted in the province of South Kivu, refines previous evolving theory through the analysis of hospital Katana over a longer period, from 1990 to 2010 (20 years). It compares three periods of the life of the hospital separated by events considered major. The period between 1990 and 1995, then the period between 1996 and 2003, and finally the period between 2004 and 2010. It brings new elements to the theoretical propositions namely : (1) The more the interaction between the three key agents is strong and positive , the better the external support is delivered in the form of development cooperation ( participatory support) rather than as the development assistance (substitution) and the better hospitals adapt through their provision health care , (2 ) the strength of the interaction between agents is largely based on existing or new institutional arrangements associated with a new owner of the hospital , (3 ) the transfer of an isolated, independent, autonomous hospital into a hospital network ( diocesan network for example) brings new priorities, those of the network, which must now take into account more of the priorities of population and institution ( Referral Hospital ) , (4) external expertise , national or international , managerial (Logo , Katana , Bunia ) and medical ( Surgery in Katana ) is an essential component for a better functioning referral hospitals in a changing context . The synthesis of case studies develops and reveals theoretical propositions and provides answers to the issues identified in the initial theoretical framework. It presents the role of the management board of the hospital and the role of competition between hospitals, reveals the weak regulation of hospitals by the intermediate level, and comments on hospital performance which is difficult to assess in this study as a multidimensional concept. Discussion and conclusion: In the discussion, the thesis outlines the methodological, theoretical, and practical contributions of this research; addresses the strengths and limitations of this work (in relation to the reliability and validity of results); and discusses the main theories that came from the case studies with a focus on development aid (including the "technical assistance" component), institutional arrangements, interaction between actors, competition between hospitals, the passage of a single hospital into a hospital network, regulation by the intermediate level, and hospital performance . In conclusion, the research shows that it is not enough just to provide support ( financial and technical), or to manage or to evaluate a hospital for it to operate and adapt to a changing environment. It is necessary ( and perhaps especially) to motivate, through inspirational leadership, keeping in consideration that it is a complex adaptive system and that this motivation is nothing other than the induction of a positive interaction between agents. The study suggests that analyzing hospitals this way, taking into consideration that these are complex adaptive systems for multidimensional performance and addressing the determinants of their adaptation to change during the implementation of programs of development assistance, is essential in unstable contexts to improving their performance. These proposed determinants are among others the nature of the interaction between agents, national or international external expertise, and the institutional arrangements in place.Introduction: La thèse traite de l’adaptation d’hôpitaux de référence à un environnement changeant dans deux régions de l’Est de la République Démocratique du Congo qui sont frappées depuis plus d’une décennie par des conflits armés intermittents: l’Ituri (hôpitaux de Bunia et de Logo) et le Sud-Kivu (Hôpital de Katana). Elle a pour objectif de générer des propositions théoriques permettant d'aborder différemment la gouvernance d'hôpitaux, l'analyse de leur performance et la manière d'améliorer cette performance. Elle confronte en effet la production des soins des hôpitaux aux évènements survenus dans la vie de l’hôpital en identifiant les changements majeurs au cours du temps et la réactivité des équipes dirigeantes des hôpitaux au moment des changements. Un tel travail trouve son originalité et son intérêt dans le type d’approche pour analyser l’hôpital de référence, non pas seulement sous un angle de modèle logique et bureaucratique où prédomine la relation de cause à effet (moyens versus résultats), mais aussi et surtout sous l’angle de la complexité, selon une approche adaptative et flexible, où le résultat n’est pas prédictible mais découle de l’interaction entre plusieurs acteurs, qui parfois, ont des intérêts divergents. Sur base des faits observés sur terrain et d’une série de questions issues de la synthèse interprétative de la littérature sur les concepts de système complexe adaptatif, de management stratégique et leadership, de gouvernance adaptative et de performance, l’hôpital de référence est ainsi analysé en tant qu’un système complexe adaptatif dans le but d’améliorer sa performance . Méthodologie: L’approche méthodologique appliquée recourt à une étude de cas multiple utilisant des techniques mixtes (qualitatives et quantitatives) pour la collecte de données. Elle fait appel (1) à des données hospitalières pour mesurer la production des hôpitaux, (2) à la revue documentaire pour identifier entr’autres, les événements et interventions enregistrés dans l’histoire des hôpitaux au cours des périodes d’étude et (3) à des informations issues des entrevues individuelles pour valider l’interprétation des résultats des deux précédentes sources des données et comprendre la réactivité des équipes dirigeantes des hôpitaux de référence pendant des moments de changements. Résultats: Deux études de cas. La première étude compare l’évolution de deux hôpitaux de référence en Ituri (Logo et Bunia) exposés à un même programme durant 4 ans (2006 à 2010) et note deux évolutions différentes au niveau de leurs productions des soins. Elle décrit les principaux acteurs au sein des hôpitaux de référence qu’elle catégorise en 3 agents clés à savoir l’équipe dirigeante, le staff hospitalier et le propriétaire ; et dégage des caractéristiques de l’interaction entre ces agents dans les deux hôpitaux et par rapport à leur environnement marqué par un programme exogène avec des partenaires de développement. Les caractéristiques des agents dans les deux hôpitaux sont différentes. Cette étude génère une proposition théorique qui explique l’adaptation des hôpitaux au changement. Elle considère en effet que la nature de l’interaction entre agents joue un rôle important dans la « stabilité » ou la « labilité » d’un hôpital et que cette interaction repose essentiellement sur les arrangements institutionnels. Plus ces derniers sont solides, plus l’interaction entre acteurs est équilibrée et forte et plus l’hôpital est stable. La seconde étude de cas, réalisée dans la province du Sud Kivu, raffine la théorie évolutive précédente à travers l’analyse de l’hôpital de Katana sur une plus longue période, allant de 1990 à 2010 (20 ans). Elle compare trois périodes de la vie de l’hôpital séparées par des événements jugés majeurs. La période entre 1990 et 1995, ensuite la période entre 1996 et 2003 et enfin la période entre 2004 et 2010. Elle apporte de nouveaux éléments aux propositions théoriques à savoir : (1) Plus l’interaction entre les trois agents clés est solide et positive, mieux les appuis extérieurs se font sous forme de coopération au développement ( accompagnement participatif) plutôt que sous forme de l’aide au développement (substitution) et mieux les hôpitaux s’adaptent au travers de leur production des soins de santé; (2) la solidité de l’interaction entre agents repose notamment sur des arrangements institutionnels préexistants ou nouveaux associés à un nouveau propriétaire de l’hôpital; (3) le passage d’un hôpital indépendant, autonome, isolé, à un réseau hospitalier ( réseau diocésain par exemple) apporte de nouvelles priorités, celles du réseau , dont il faut désormais tenir compte en plus des priorités de la population et de l’institution ( HGR); (4) une expertise externe, nationale ou internationale, managériale (Logo, Katana, Bunia) et médicale (Chirurgie à Katana) constitue une composante incontournable pour un meilleur fonctionnement des hôpitaux de référence en contexte changeant. La synthèse des études de cas dégage et complète les propositions théoriques et apporte des éléments de réponse aux questions initiales définies dans le cadre théorique. Elle présente le rôle du comité de gestion de l’hôpital, aborde la compétition entre hôpitaux, évoque la faiblesse de la régulation des hôpitaux par le niveau intermédiaire et commente la performance hospitalière, difficile à évaluer dans la présente étude en tant que concept multidimensionnel. Discussion et conclusion : Dans la discussion, la thèse précise les apports méthodologiques, théoriques et pratiques de la présente recherche ; traite des forces et des limites de ce travail (en rapport avec la fiabilité et la validité des résultats) et commente les principales théories issues des études de cas avec une insistance sur l’aide au développement (y compris le volet « assistance technique»), les arrangements institutionnels, l’interaction entre agents , la compétition entre hôpitaux, le passage d’un hôpital isolé à un réseau hospitalier, la régulation par le niveau intermédiaire et la performance hospitalière. En conclusion, la recherche démontre qu’il ne suffit pas seulement d’apporter un appui (financier et technique), de gérer ni d’évaluer un hôpital pour qu’il fonctionne et s’adapte à un environnement changeant mais encore faut-il (et peut-être surtout) l’animer, grâce à un leadership inspirant, en considérant que c’est un système complexe adaptatif, et que cette animation n’est rien d’autre que l’induction d’une interaction positive entre acteurs. L’étude suggère ainsi d’analyser autrement les hôpitaux, en considérant que ce sont des Systèmes Complexes Adaptatifs visant une performance multidimensionnelle, et de tenir compte des déterminants de leur adaptation au changement lors de l’implémentation des programmes d’aide au développement, incontournables en contextes instables, en vue d’améliorer leur performance. Ces déterminants proposés sont entr’autres la nature de l’interaction entre agents, l’expertise externe nationale ou internationale et les arrangements institutionnels en place.(SP - Sciences de la santé publique) -- UCL, 201

Comprendre l’adaptation de l’hôpital de Logo en République Démocratique du Congo à un programme sanitaire exogène

Introduction : L’évaluation d’un programme sanitaire est souvent réalisée de manière linéaire, associant moyens mis en place et performance réalisée. Nous avons pris une autre perspective : celle d’analyser l’hôpital en tant qu’un système adaptatif complexe, partant des effets du programme santé 9ème Fond Européen de Développement sur la production hospitalière, en vue de comprendre l’adaptation de l’hôpital au changement apporté par le programme. Méthodologie : Étude de cas rétrospective (2006 à 2010) ciblant l’hôpital de Logo en Ituri couvrant 208 716 habitants en 2010. L’approche a été mixte, combinant des données quantitatives issues des statistiques hospitalières de routine et des informations qualitatives collectées au travers de la revue documentaire et des entrevues. La triangulation des données a permis de générer des théories explicatives sur le lien entre l’évolution de la production des soins et deux activités importantes du programme. Résultats : Quinze événements et interventions ont été identifiés et validés lors des entrevues. La variation ou la stabilité de la production n’a pas été systématiquement associée aux interventions du programme. Discussion : La stabilité de la production de l’hôpital de Logo ne dépendait pas seulement des interventions du programme mais également d’autres facteurs comme des arrangements institutionnels préexistants ou la nature de l’interaction entre acteurs. L’analyse de l’hôpital en tant qu’un Système complexe adaptatif permet de mieux comprendre son adaptation à un contexte changeant et offre des perspectives de mieux améliorer sa gouvernance

Analyzing Katana referral hospital as a complex adaptive system: agents, interactions and adaptation to a changing environment.

This study deals with the adaptation of Katana referral hospital in Eastern Democratic Republic of Congo in a changing environment that is affected for more than a decade by intermittent armed conflicts. His objective is to generate theoretical proposals for addressing differently the analysis of hospitals governance in the aims to assess their performance and how to improve that performance. The methodology applied approach uses a case study using mixed methods ( qualitative and quantitative) for data collection. It uses (1) hospital data to measure the output of hospitals, (2) literature review to identify among others, events and interventions recorded in the history of hospital during the study period and (3) information from individual interviews to validate the interpretation of the results of the previous two sources of data and understand the responsiveness of management team referral hospital during times of change. The study brings four theoretical propositions: (1) Interaction between key agents is a positive force driving adaptation if the actors share a same vision, (2) The strength of the interaction between agents is largely based on the nature of institutional arrangements, which in turn are shaped by the actors themselves, (3) The owner and the management team play a decisive role in the implementation of effective institutional arrangements and establishment of positive interactions between agents, (4) The analysis of recipient population's perception of health services provided allow to better tailor and adapt the health services offer to the population's needs and expectations. Research shows that it isn't enough just to provide support (financial and technical), to manage a hospital for operate and adapt to a changing environment but must still animate, considering that it is a complex adaptive system and that this animation is nothing other than the induction of a positive interaction between agents

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

INTRODUCTION: In 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. METHODS: We 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. RESULTS: Two 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. CONCLUSION: By 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

Gouvernance des hôpitaux de référence en République démocratique du Congo : synthèse critique interprétative de la littérature

Les hôpitaux étant considérés comme des entreprises, on pourrait leur appliquer le terme de gouvernance, et même celui de gouvernance adaptative, étant donné qu’ils constituent des systèmes complexes adaptatifs. Nous nous intéressons à la gouvernance des hôpitaux de Logo, Bunia et Katana, à l’est de la République démocratique du Congo – des régions confrontées aux conflits armés intermittents depuis 1996. Dans un tel contexte, comment interpréter le concept de gouvernance des hôpitaux, ceux-ci étant destinés à s’adapter à leur environnement changeant pour continuer à produire des soins ? Méthodologie. Synthèse critique interprétative de la littérature, dont la recherche s’est faite à partir des mots clés relatifs aux concepts associés à la gouvernance. Résultats. Les concepts de « gouvernance », de « gouvernance adaptative », de « performance », de « leadership » et de « système complexe adaptatif » sont définis, et leur interprétation permet de mieux comprendre (1) l’hôpital en tant que système adaptatif complexe, (2) la gouvernance des hôpitaux de référence, (3) l’analyse de la performance hospitalière et (4) le leadership pour la bonne gouvernance des hôpitaux de Logo, Bunia et Katana. Discussion. L’interprétation de ces concepts suscite plusieurs questions sur leur application au contexte de l’est de la République démocratique du Congo. Conclusion. Cette synthèse critique interprétative ouvre la porte à une nouvelle manière d’explorer les hôpitaux de référence à l’est de la République démocratique du Congo, en ce qui concerne leur gouvernanc

Is a bio-psychosocial approach model possible at the first level of health services in the Democratic Republic of Congo? An organizational analysis of six health centers in South Kivu

Background The health system, in the Democratic Republic of Congo, is expected to move towards a more people-centered form of healthcare provision by implementing a biopsychosocial (BPS) approach. It’s then important to examine how change is possible in providing healthcare at the first line of care. This study aims to analyze the organizational capacity of health centers to implement a BPS approach in the first line of care. Methods A mixed descriptive and analytical study was conducted from November 2017 to February 2018. Six health centers from four Health Zones (South Kivu, Democratic Republic of Congo) were selected for this study. An organizational analysis of six health centers based on 15 organizational capacities using the Context and Capabilities for Integrating Care (CCIC) as a theoretical framework was conducted. Data were collected through observation, document review, and individual interviews with key stakeholders. The annual utilization rate of curative services was analyzed using trends for the six health centers. The organizational analysis presented three categories (Basic Structures, People and values, and Key Processes). Result This research describes three components in the organization of health services on a biopsychosocial model (Basic Structures, People and values, and Key processes). The current functioning of health centers in South Kivu shows strengths in the Basic Structures component. The health centers have physical characteristics and resources (financial, human) capable of operating health services. Weaknesses were noted in organizational governance through sharing of patient experience, valuing patient needs in Organizational/Network Culture, and Focus on Patient Centeredness & Engagement as well as partnering with other patient care channels. Conclusion This study highlighted the predisposition of health centers to implement a BPS approach to their organizationa capacities. The study highlights how national policies could regulate the organization of health services on the front line by relying more on the culture of teamwork in the care structures and focusing on the needs of the patients. Paying particular attention to the values of the agents and specific key processes could enable the implementation of the BPS approach at the health center level

A new look at population health through the lenses of cognitive, functional and social disability clustering in eastern DR Congo: a community-based cross-sectional study

and its covariates at primary healthcare level in DR Congo. METHOD: We conducted a community-based cross-sectional study in adults with diabetes or hypertension, mother-infant pairs with child malnutrition, their informal caregivers and randomly selected neighbours in rural and sub-urban health zones in South-Kivu Province, DR Congo. We used the WHO Disability Assessment Schedule 2.0 (WHODAS) to measure functional, cognitive and social disability. The study outcome was health status clustering derived from a principal component analysis with hierarchical clustering around the WHODAS domains scores. We calculated adjusted odds ratios (AOR) using mixed-effects ordinal logistic regression. RESULTS: Of the 1609 respondents, 1266 had WHODAS data and an average age of 48.3 (SD: 18.7) years. Three hierarchical clusters were identified: 9.2% of the respondents were in cluster 3 of high dependency, 21.1% in cluster 2 of moderate dependency and 69.7% in cluster 1 of minor dependency. Associated factors with higher disability clustering were being a patient compared to being a neighbour (AOR: 3.44; 95% CI: 1.93-6.15), residency in rural Walungu health zone compared to semi-urban Bagira health zone (4.67; 2.07-10.58), female (2.1; 1.25-2.94), older (1.05; 1.04-1.07), poorest (2.60; 1.22-5.56), having had an acute illness 30 days prior to the interview (2.11; 1.24-3.58), and presenting with either diabetes or hypertension (2.73; 1.64-4.53) or both (6.37; 2.67-15.17). Factors associated with lower disability clustering were being informally employed (0.36; 0.17-0.78) or a petty trader/farmer (0.44; 0.22-0.85). CONCLUSION: Health clustering derived from WHODAS domains has the potential to suitably classify individuals based on the level of health needs and dependency. It may be a powerful lever for targeting appropriate healthcare service provision and setting priorities based on vulnerability rather than solely presence of disease

Community perceptions of a biopsychosocial model of integrated care in the health center: the case of 4 health districts in South Kivu, Democratic Republic of Congo

Summary Background Biopsychosocial care is one of the approaches recommended in the health system by the WHO. Although efforts are being made on the provider side to implement it and integrate it into the health system, the community dynamic also remains to be taken into account for its support. The objective of this study is to understand the community's perceptions of the concept of integrated health care management according to the biopsychosocial approach (BPS) at the Health Center of a Health District and its evaluation in its implementation. Methods This cross-sectional study was done in six Health Areas belonging to four Health Districts in South Kivu, DRC. We conducted 15 semi-directive individual interviews with 9 respondents selected by convenience, including 6 members of the Development Committees of the Health Areas, with whom we conducted 12 interviews and 3 patients met in the health centers. The adapted Normalization MeAsure Development (NoMAD) tool, derived from the Theory of the Normalization Process of Complex Interventions, allowed us to collect data from November 2017 to February 2018, and then from November 2018 to February 2019. After data extraction and synthesis, we conducted a thematic analysis using the NoMAD tool to build a thematic framework. Six themes were grouped into three categories. Results Initially, community reports that the BPS approach of integrated care in the Health Centre is understood differently by providers; but then, through collective coordination and integrated leadership within the health care team, the approach becomes clearer. The community encouraged some practices identified as catalysts to help the approach, notably the development of financial autonomy and mutual support, to the detriment of those identified as barriers. According to the community, the BPS model has further strengthened the performance of health workers and should be expanded and sustained. Conclusions The results of our study show the importance of community dynamics in the care of biopsychosocial situations by providers. The barriers and catalysts to the mechanism, both community-based and professional, identified in our study should be considered in the process of integrating the biopsychosocial model of person-centered health care

Community perceptions of a biopsychosocial model of integrated care in the health center: the case of 4 health districts in South Kivu, Democratic Republic of Congo

Background Biopsychosocial care is one of the approaches recommended in the health system by the WHO. Although efforts are being made on the provider side to implement it and integrate it into the health system, the community dynamic also remains to be taken into account for its support. The objective of this study is to understand the community’s perceptions of the concept of integrated health care management according to the biopsychosocial approach (BPS) at the Health Center of a Health District and its evaluation in its implementation. Methods This cross-sectional study was done in six Health Areas belonging to four Health Districts in South Kivu, DRC. We conducted 15 semi-directive individual interviews with 9 respondents selected by convenience, including 6 members of the Development Committees of the Health Areas, with whom we conducted 12 interviews and 3 patients met in the health centers. The adapted Normalization MeAsure Development (NoMAD) tool, derived from the Theory of the Normalization Process of Complex Interventions, allowed us to collect data from November 2017 to February 2018, and then from November 2018 to February 2019. After data extraction and synthesis, we conducted a thematic analysis using the NoMAD tool to build a thematic framework. Six themes were grouped into three categories. Results Initially, community reports that the BPS approach of integrated care in the Health Centre is understood differently by providers; but then, through collective coordination and integrated leadership within the health care team, the approach becomes clearer. The community encouraged some practices identified as catalysts to help the approach, notably the development of financial autonomy and mutual support, to the detriment of those identified as barriers. According to the community, the BPS model has further strengthened the performance of health workers and should be expanded and sustained. Conclusions The results of our study show the importance of community dynamics in the care of biopsychosocial situations by providers. The barriers and catalysts to the mechanism, both community-based and professional, identified in our study should be considered in the process of integrating the biopsychosocial model of person-centered health car