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Background: Trilateral South‒South cooperation is envisioned as an equal and empowering partnership model but still faces certain challenges. This study addresses whether and how trilateral South‒South cooperation can transform traditional development assistance for health (DAH) and explores the opportunities and challenges of trilateral South‒South cooperation for transforming future DAH, in the theme of "the emerging development partner's DAH transformation facilitated by a multilateral organization". Methods: We evaluate a maternal, newborn, and child health (MNCH) project involving the Democratic Republic of Congo (DRC), the United Nations Children's Fund (UNICEF), and China (hereinafter referred to as the "DRC–UNICEF–China project"). We analyze data from project documents and seventeen semi-structured interviews using a pragmatic analytical framework based on the DAH program logic model and the OECD's trilateral cooperation framework. Results: Evidence from the DRC–UNICEF–China MNCH project suggests that trilateral South‒South cooperation facilitated by a multilateral organization can provide transformative opportunities for emerging development partners' DAH to generate and deliver context-based, demand-oriented solutions, harmonize rules and procedures, institutionalize mutual learning and knowledge sharing, and increase the visibility of emerging development partners as sources for South‒South development experience transfer. However, the project revealed some challenges, including the neglect of key stakeholders in the complex governance structure, the high transaction costs needed to ensure transparency, and the harm local absence of the emerging development partner poses to long-term DAH engagement. Conclusions: This study echoes some of the findings in trilateral SSC literature that claim power structures and philanthropic, normative justification for health equity are often juxtaposed in trilateral SSC partnerships. The opportunities offered by the DRC–UNICEF–China project align with China's cognitive learning process for strengthening international engagement and global image building. However, challenges may arise as a result of complex governance structures and the entrustment of facilitating partners, which can threaten the effectiveness of trilateral cooperation. We call for strengthening the beneficiary partner's ownership at all levels, engaging the emerging development partner to better understand the beneficiary partner's local context(s) and needs, and ensuring available resources to support programmatic activities and long-term partnerships for the health and well-being of the beneficiaries. [ABSTRACT FROM AUTHOR]

Background: The importance of medico-psychosocial conditions MPSCs at primary health care level is deemed high among people with chronic comorbidities and mother-infant pairs with history of child malnutrition in sub-Saharan Africa. In Eastern DR Congo where up to 8% of children younger than 5 years are acutely malnourished, more than 1 in very 2 children are stunted and nearly 60% of diabetic patients present with high blood pressure, the real burden of MPSCs is unknown. Besides, there is dearth of evidence-based stratification of such complex conditions in low- and middle-income countries. This hinders integrated care of different medico-psychosocial sub-populations particularly in resource-constrained countries. This study sets out to suggest a rigorous approach to stratifying complex MPSCs and understanding their natural history in adults with chronic diseases and mother-infant pairs with acute malnutrition in post-war rural eastern DR Congo settings. Method: This will be a community-based cohort study in adults with diabetes and hypertension and mother-infant pairs with acute malnutrition in four rural and two sub-urban health areas in South-Kivu Province, Eastern DR Congo. Participants will be identified through health centres record review and community health workers search. Pre-tested structured enrolment questionnaires, WHO Disability Assessment Schedule 2.0 WHODAS, Diabetes self-efficacy management scale, questionnaire and eight-item modified Medical Outcomes Study Social Support Survey mMOS-SS questionnaires will be administered by trained data collectors. Participants will be followed up as per 6 months scheduled visits. Principal component analyses with clustering will be run on social determinants of health, clinical factors, WHODAS and mMOS-SS scores to determine the CMPSCs levels at baseline. We shall use the R markovchain package for analyses and predictions of CMPCs trends over time. To identify the predictors of CMPSCs patterns, we shall fit multilevel mixed-effects regression models to account for repeated measurements in the same individual and possible variability in CMSPCs determinants by health areas. In addition to statistical predictions, we shall study the dynamic of CMPSCs in the six health zones through the 2 years follow-up period by agent-based modelling using NetLogo software. The agents under this study will comprise of mother-infant pairs with history of SAM, adults with multi-morbidities and health centres. We shall integrate the role of history and conditional if-then rules in ABM to account for the inherent contextual and human factors in development of CMPSCs. Discussion: Well-defined CMSCs categories could ease understanding of their evolution patterns and predictors, foster adequate and efficient integrated care and enhance quality of life at individual and community levels in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Introduction: In the Democratic Republic of Congo, the health care system remains essentially focused on the management of the disease. The health center, the first point of contact between the community and the health system, operates on the basis of standardized flow charts that do not take into account the other dimensions of the person. How to ensure at the level of the health centers a psychomedicosocial care, centered on the patient? The first stage of the study aims to analyze the organizational capacity of health centers. Methodology: A grid, inspired by the components of the Context and Capabilities for Integrating Care CCIC Framework has been developed, including the different components. The grid takes into account the importance of each of these components for the actors of the 6 study health centers. The pre-test of the grid at the level of a health center made it possible to improve it and to draw up a maintenance guide based on the management of a psychomedicosocial situation at the health center level. Results: Preliminary results shed light on the lack of evolution of health centre for key characteristics included in the framework for providing patient centred care. It concerns, amongst others, 1 information systems too much focused on reports writing for donors agencies and ignoring individual comprehensive patient file, 2 tools for decision making too much oriented towards single disease management; 3 disintegrated multiple leadership, structured amongst specific disease control programs. Opportunities exist, i.e., on partnership with community and large experience of nurse's in-charge as part of a multi-disciplinary team. Discussion and conclusion: The framework make it possible to identify emerging dynamics unconducive for the development of person centred care at health centre level. Through structured discussion, this framework helped the health centre staff to better understand how concretely reform health centre organisation for developing a psycho-medico-social approach called person centred care in 6 primary care facilities in Sud-Kivu in DRC. Future follow-up will assess the organisational changes implemented and the consequence on care provision in these facilities in DRC. [ABSTRACT FROM AUTHOR]

Introduction: Due to the Democratic Republic of the Congo’s (DRC) precarious health system that provides only limited access to health care, the European Union, via Memisa Belgium, implemented a program to strengthen provision of and access to health care (known as PRO DS) in the provinces of Kongo Central and Ituri. This program took a holistic approach, seeking to improve equitable access and combat malnutrition., Methods: To measure the program’s social return on investment and to estimate the cost per capita and effectiveness per euro invested (efficiency), a 61-month (1 July 2017 to 31 July 2022) cost-effectiveness evaluation with a societal perspective was carried out. The double-difference method was used to compare the results of PRO DS and non-PRO DS zones. The social return on investment was assessed via the ratio of effectiveness to costs., Results: Analyses revealed the program cost between 3.72 and 3.96 euros per capita per year (2022) in Kongo Central, and between 3.12 and 3.36 euros in Ituri. Importantly, it was cost-effective in the areas of reproductive health, nutrition, and the use of health and nutrition services., Conclusions: The program’s strong nutritional component and overall holistic vision may explain why it was so efficient. PRO DS stands out from other programs that focus solely on one specific problem or population. Although the program has some limitations, it would be worthwhile for the government to invest in it.

Background: The Eastern part of the Democratic Republic of Congo (DRC) has been affected by armed conflict for several years. Despite the growing interest in the impact of these conflicts on health service utilisation, few studies have addressed the coping mechanisms of the health system. The purpose of this study is to describe the traumatic events and coping mechanisms used by the health zones (HZs) in conflict settings to maintain good performance., Methods: This multiple case study took place from July to October 2022 in four HZs in the South Kivu Province of DRC. HZs were classified into "cases" according to their conflict profile: accessible and stable (Case 1), accessible but remote (Case 2), unstable (Case 3), and intermediate (Case 4). Eight performance indicators and the amount of funding provided to the HZs by non-governmental organizations (NGOs) were recorded. A graph was created to compare their evolution from 2013 to 2018. A thematic analysis of qualitative data from individual interviews with selected health workers was conducted., Results: Both battle-related events (war and its effects) and non-battle-related events (epidemics, disasters, strikes) were recorded according to the case conflict-profile. Although the cases (3 and 4) most affected by armed conflicts occasionally performed better than the stable ones (1 and 2), their operational action plan was poorly carried out. The coping mechanisms developed in cases 3 and 4 were the deployment of military nurses in preventive and supervisory activities, the solicitations of subsidies from NGOs, the relocation of health care facilities and the implementation of negotiation strategies with the belligerents., Conclusion: Armed conflict results in traumatic events that disrupt the execution of the operational action plan of HZs. The HZs' management team expertise, its strong leadership, and substantial financial support would enable this system to develop reliable and sustainable adaptive mechanisms., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Reform and Performance of the Provincial Health Inspectorate and the Provincial Division of Health of South Kivu in the Democratic Republic of Congo., Background: The intermediate level incorporated both the Provincial Health Inspectorate (IPS) and the Provincial Health Division (DPS) of Health. The new constitution of 2006 gave impetus to decentralisation, which became effective in 2015. The reform introduced at the intermediate level clearly separated the IPS and the DPS. This article assesses the effect of this reform on the performance of IPS and DPS in South Kivu, Democratic Republic of Congo., Methodology: The study is evaluative before and after and covers the period from 2012 to 2017. It uses mixed methods: three techniques were used to collect data including observation, document review and individual interviews. The analysis of the quantitative data concerned the evolution of the indicators; that of qualitative data was carried out by themes from two theoretical models: the ministerial functional framework and the 'Strengths, Weaknesses, Opportunities and Threats' analysis framework (SWOT analysis). Scores were assigned to each managerial function according to their level of performance for better comparison., Results: After the reform, a decline in the performance score of activities devolved to IPS is noted, mainly due to the low funding of activities. On the other hand, in the DPS, the evolution of the score is favorable, because of the strong support given to the reform at this level by the partners and the government. The alignment of partners to a single contract for funding DPS activities is observed. The weak financing of the health sector by the government remains a weak point, however, and the brain drain a threat to institutional sustainability. The introduction of the single financing contract constitutes an opportunity to improve the performance of the provincial management team., Discussion and Conclusion: The study shows the improvement in the performance of managerial functions of the DPS and the regression to the IPS. The low funding of IPS by the Congolese government could jeopardise the reform.

Introduction: This study highlights the determinants of the use of health services by adherents to the three mutual health insurances in the town of Bukavu in the Democratic Republic of the Congo., Methods: We conducted a descriptive cross-sectional study, based on a perception survey among users of healthcare services affiliated to the mutual health insurances in the Bukavu health zones. The encoding and statistical analysis were carried out using the Epi INFO version 2010 software., Results: The main determinants of the use of healthcare services by adherents to the mutual health insurances are: the member's place of residence, the level of education of the head of household, the previous experience of care in the healthcare structure partner of the mutual health insurances, the reputation of the structure partner of the mutual health insurances and the ability of households to pay the user fee., Conclusion: This study highlights that, beyond the financial barrier, the implementation of a mutual health organisation should promote a better regulation of the user fee and a good quality of care to meet the care needs of members. The factors emerging from the study as a major determinant of the use of health services by adherents to a mutual health insurance are often not taken into account in the implementation of mutual health insurance in contexts similar to those of Bukavu., Competing Interests: Les auteurs ne déclarent aucun conflit d'intérêts., (© Justine Bashi et al.)

Introduction: Prolonged waiting times for medical consultations become a factor in patient dissatisfaction. This study aimed to measure the waiting times for medical consultation and to identify the causes and the consequences from the perspective of improvement of the organisation of medical services., Methods: We conducted a cross-sectional descriptive study at the General Provincial Reference hospital in Bukavu and at the Biopharm Hospital Center. Data were collected using a literature review, the monitoring of the waiting times and individual interviews of patients and care providers. Quantitative data analysis was accomplished using Epi Info 7.2.0.1.software. Qualitative data were analyzed searching for themes., Results: More than 70% of patients in 3 major Departments at the General Provincial Reference Hospital in Bukavu waited more than 30 minutes before being seen. More than 40% of patients in the 4 major Departments at the Biopharm Hospital Center waited between 0 and 15 minutes. In the Department of Gynecology and Obstetrics at the General Provincial Reference hospital in Bukavu 56% of patients had shorter waiting times (0-15 minutes). The two main causes of prolonged wait times included administrative burden of medical services and physicians delay. Serious implications included a reduction in attendance, in medicinal recipes as well as patients' fatigue. The availability of qualified health staff, the computerization of hospital services and continuous staff training are priorities to reduce waiting times., Conclusion: Waiting times vary from one hospital to another and from one department to another within the same hospital, depending on several factors. This study describes possible measures for improvement of waiting times for medical consultations., Competing Interests: Les auteurs ne déclarent aucun conflit d'intérêts.

Introduction: Intermediate health care structures in the DRC were designed during the setting-up of primary health care in a perspective of health district support. This study was designed to describe stakeholder representations of the intermediate level of the DRC health system during the first 30 years of the primary health care system., Methods: This case study was based on inductive analysis of data from 27 key informant interviews.., Results: The intermediate level of the health system, lacking sufficient expertise and funding during the 1980s, was confined to inspection and control functions, answering to the central level of the Ministry of health and provincial authorities. Since the 1990s, faced with the pressing demand for support from health district teams, whose self-management had to deal with humanitarian emergencies, the need to integrate vertical programmes, and cope with the logistics of many different actors, the intermediate heath system developed methods and tools to support heath districts. This resulted in a subsidiary model of the intermediate level, the perceived efficacy of which varies according to the province over recent years., Conclusion: The "subsidiary" model of the intermediary health system level seems a good alternative to the "control" model in DRC.

As a result of the decentralization of health systems, some countries have introduced intermediate (provincial) levels in their public health system. This paper presents the results of a case study conducted in Kinshasa on health system decentralization. The study identified a shift from a focus on regulation compliance assessment to an emphasis on health system coordination and health district support. It also highlighted the emergence of a?managerial (as opposed to a bureaucratic) approach to health district support. The performance of health districts in terms of health care coverage and health service use were also found to have improved. The results highlight the importance of intermediate levels in?the health care system and the value of a more organic and managerial rationality in supporting health districts faced with the complexity of urban environments and the integration of specialized multi-partner programs and interventions.