Exploring the inherent resilience of health districts in a context of chronic armed conflict: a case study in Eastern Democratic Republic of the Congo.
Makali, Samuel Lwamushi; St Louis, Patricia; Karemere, Hermèset al.
2024 • In Health Research Policy and Systems, 22 (1), p. 175
Chronic armed conflict; DRC; Health district; Inherent resilience; South Kivu; Democratic Republic of the Congo; Humans; Delivery of Health Care; Surveys and Questionnaires; Adaptation, Psychological; Male; Armed Conflicts; Resilience, Psychological; Qualitative Research; Health Policy
Abstract :
[en] [en] BACKGROUND: In South Kivu (Eastern Democratic Republic of the Congo [DRC]), health districts (HDs) affected by chronic armed conflicts are devising coping mechanisms to continue offering healthcare services to the population. Nonetheless, this alone does not suffice to make them fully resilient to such conflicts. This study aims to explore the characteristics of these HDs' resilience.
METHODS: This study uses mixed methods (triangulation) and an extreme case study design to compare a HD with no history of armed conflict (Idjwi, Case 1) and another one experiencing armed conflict (Fizi, Case 2) in South Kivu. The Kruk et al. (BMJ 23:357, 2017) index was employed as a theoretical framework for exploring resilience characteristics. Qualitative data were collected through a document review using a pre-set review grid and semi-structured individual interviews with purposively sampled key stakeholders. They were subjected to deductive-inductive thematic analysis. Quantitative data were collected using a Likert scale questionnaire (administered to stakeholders in the selected HDs using non-probabilistic methods - purposive and snowball sampling). These data were subsequently analysed for comparative descriptive purposes.
RESULTS: Recurring short-term shocks as well as chronic stress factors whether or not linked to chronic armed conflicts were identified. According to most respondents (> 98%), essential components of a resilient HDs were prior knowledge of the strengths and weaknesses as well as the public health risk posed by the crisis (awareness), together with community and non-health actors' involvement during the crisis (Integration). Common resilience mechanisms (e.g. epidemic management plan, crisis management committee) were identified, and Case 2 implemented additional mechanisms, including DRC armed forces involvement, community healthcare sites and mobile clinics, specific warning system, and regular socio-demographic monitoring of displaced persons alongside promotion of activities for social cohesion strengthening.
CONCLUSIONS: For meaningful resilience to emerge, HDs must be better resourced in "normal" times. If this condition is fulfilled, quality of care could improve and spare capacity could be created to withstand disturbances.
Disciplines :
Public health, health care sciences & services
Author, co-author :
Makali, Samuel Lwamushi; Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo. samuelmakali11@gmail.com ; Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium. samuelmakali11@gmail.com ; Centre de Connaissance en Santé, Kinshasa, Democratic Republic of the Congo. samuelmakali11@gmail.com
St Louis, Patricia; Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
Karemere, Hermès; Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
Wautié, Alice; Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
Pavignani, Enrico; Independent Public Health Practitioner/Consultant, Maputo, Mozambique
Eboma, Christian Molima; Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
Bigirinama, Rosine; Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
Lembebu, Corneille; Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
Porignon, Denis ; Université de Liège - ULiège > Département des sciences de la santé publique > Santé publique : aspects spécifiques
Balaluka, Ghislain Bisimwa; Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo ; Centre de Connaissance en Santé, Kinshasa, Democratic Republic of the Congo ; Université de Cinquantenaire de Lwiro, Kavumu, Democratic Republic of the Congo ; Département de Nutrition, Centre de Recherche en Sciences Naturelles de Lwiro (CRSN-LWIRO), Kavumu, Democratic Republic of the Congo
Donnen, Philippe; Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
Paul, Elisabeth; Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
Language :
English
Title :
Exploring the inherent resilience of health districts in a context of chronic armed conflict: a case study in Eastern Democratic Republic of the Congo.
B. Walker C.S. Holling S.R. Carpenter A.P. Kinzig Resilience, adaptability and transformability in social-ecological systems Ecol Soc 9 2 ar5
J. Rodin The resilience dividend: being strong in a world where things go wrong Illustrated New York PublicAffairs 384
P. Allan M. Bryant Resilience as a framework for urbanism and recovery J Landsc Archit 6 2 34 45
I. Lussier J.L. Derevensky R. Gupta T. Bergevin S. Ellenbogen Youth gambling behaviors: an examination of the role of resilience Psychol Addict Behav J Soc Psychol Addict Behav 21 2 165 173
S. Abimbola S.M. Topp Adaptation with robustness: the case for clarity on the use of ‘resilience’ in health systems and global health BMJ Glob Health 3 1 29527354 5841517 e000758
A.G. Buseh P.E. Stevens M. Bromberg S.T. Kelber The Ebola epidemic in West Africa: challenges, opportunities, and policy priority areas Nurs Outlook 63 1 30 40 25645480 7111626
M.E. Kruk M. Myers S.T. Varpilah B.T. Dahn What is a resilient health system? Lessons from Ebola Lancet 385 9980 1910 1912 25987159
S. Burke S. Parker P. Fleming S. Barry S. Thomas Building health system resilience through policy development in response to COVID-19 in Ireland: from shock to reform Lancet Reg Health Eur 1 9 100223
T.J. Bollyky E. Castro A.Y. Aravkin K. Bhangdia J. Dalos E.N. Hulland et al. Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis Lancet 401 10385 1341 1360 36966780 10036128
S. Thomas C. Keegan S. Barry R. Layte M. Jowett C. Normand A framework for assessing health system resilience in an economic crisis: Ireland as a test case BMC Health Serv Res 13 1 450 24171814 3816300
S. Zhong M. Clarck Y. Zang X. Hou L. Wang G. FitzGerald Establishing healthcare resilience to cope with disasters: theory, definition and conceptual framework Emergencias 31 26
M. Moitinho de Almeida J.A.F. van Loenhout S. Singh Thapa K.C. Kumar D. Prakash Mahara D. Guha-Sapir et al. Hospital resilience after the 2015 earthquake in Nepal: results from semi-structured interviews with hospital staff Front Public Health 9 602509 33718318 7952522
C. Truppa S. Yaacoub M. Valente G. Celentano L. Ragazzoni D. Saulnier Health systems resilience in fragile and conflict-affected settings: a systematic scoping review Confl Health 18 1 2 38172918 10763433
A.K. Ager M. Lembani A. Mohammed G. Mohammed Ashir A. Abdulwahab H. de Pinho et al. Health service resilience in Yobe state, Nigeria in the context of the Boko Haram insurgency: a systems dynamics analysis using group model building Confl Health 9 30 26442129 4593224
A. Woodward E. Sondorp S. Witter T. Martineau Health systems research in fragile and conflict-affected states: a research agenda-setting exercise Health Res Policy Syst 14 1 51 27439611 4955129
S. Witter H. Wurie P. Chandiwana J. Namakula S. So A. Alonso-Garbayo et al. How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia Health Policy Plan 32 suppl_3 iii3 13 29149313
Ministère de la santé publique, RDC. Plan National de Développement Sanitaire (PNDS) recadré pour la période 2019–2022 : Vers la couverture sanitaire universelle. Kinshasa; 2018.
Ministère de la santé publique, RDC. Rapport des comptes nationaux de la Santé 2020. Matadi; 2021.
G. Bisimwa S.L. Makali H. Karemere C. Molima R. Nunga A. Iyeti et al. 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 Afr J Prim Health Care Fam Med 13 1 e1 9 34879695
Center for Preventive Action. Global conflict tracker. Instability in the Democratic Republic of Congo. 2022. https://www.cfr.org/global-conflict-tracker/conflict/violence-democratic-republic-congo. Accessed 26 Nov 2022.
S.L. Makali E.B. Malembaka A.S. Lambert H.B. Karemere C.M. Eboma A.T. Mwembo et al. Comparative analysis of the health status of the population in six health zones in South Kivu: a cross-sectional population study using the WHODAS Confl Health 15 1 52 34215304 8254209
C. Altare E.B. Malembaka M. Tosha C. Hook H. Ba S.M. Bikoro et al. Health services for women, children and adolescents in conflict affected settings: experience from North and South Kivu, Democratic Republic of Congo Confl Health 14 1 9
E.B. Malembaka H. Karemere G. Bisimwa Balaluka C. Altare M.A. Odikro S.M. Lwamushi et al. Are people most in need utilising health facilities in post-conflict settings? A cross-sectional study from South Kivu, eastern DR Congo Glob Health Action 13 1 1740419 32191159 7144215
N. Kenanewabo C. Molima H. Karemere Gestion adaptative des centres de santé dans un environnement changeant en République démocratique du Congo Sante Pub 32 4 359 370
C. Altare V. Castelgrande M. Tosha E.B. Malembaka P. Spiegel From insecurity to health service delivery: pathways and system response strategies in the Eastern Democratic Republic of the Congo Glob Health Sci Pract 9 4 915 927 34933986 8691875
L.S. Makali H. Karemere R. Banywesize C.M. Eboma P. Mwene-Batu C. Lembebu et al. Adaptive mechanisms of health zones to chronic traumatic events in eastern DRC: a multiple case study Int J Health Policy Manag 12 8001
K. Blanchet S.L. Nam B. Ramalingam F. Pozo-Martin Governance and capacity to manage resilience of health systems: towards a new conceptual framework Int J Health Policy Manag 6 8 431 28812842 5553211
M.E. Kruk L.P. Freedman G.A. Anglin R.J. Waldman Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: a theoretical framework and research agenda Soc Sci Med 70 1 89 97 19850390
P. Fleming C. O’Donoghue A. Almirall-Sanchez D. Mockler C. Keegan J. Cylus et al. Metrics and indicators used to assess health system resilience in response to shocks to health systems in high income countries—a systematic review Health Policy 126 12 1195 1205 36257867 9556803
S. Zhong M. Clark X.Y. Hou Y.L. Zang G. Fitzgerald Development of hospital disaster resilience: conceptual framework and potential measurement Emerg Med J 31 11 930 938 24028975
M.E. Kruk E.J. Ling A. Bitton M. Cammett K. Cavanaugh M. Chopra et al. Building resilient health systems: a proposal for a resilience index BMJ 23 357
C.C. Rios E.J. Ling R. Rivera-Gutierrez J. Gonzalez Sanchez S.B. Merrell J. Bruce et al. Puerto Rico health system resilience after Hurricane Maria: implications for disaster preparedness in the COVID-19 era Front Commun 5 593939
H.C. Karamagi R. Titi-Ofei H.K. Kipruto A.B.W. Seydi B. Droti A. Talisuna et al. On the resilience of health systems: a methodological exploration across countries in the WHO African Region PLoS ONE 17 2 35130289 8820618 e0261904
Kivu Security Tracker. The landscape of armed groups in Eastern Congo: missed opportunities, protracted insecurity and self-fulfilling prophecies. 2021. https://africacenter.org/security-article/the-landscape-of-armed-groups-in-eastern-congo-missed-opportunities-protracted-insecurity-and-self-fulfilling-prophecies/. Accessed 26 Nov 2022.
S. Witter S. Thomas S.M. Topp E. Barasa M. Chopra D. Cobos et al. Health system resilience: a critical review and reconceptualisation Lancet Glob Health 11 9 e1454 e1458 37591591
N. Kagwanja D. Waithaka J. Nzinga B. Tsofa M. Boga H. Leli et al. Shocks, stress and everyday health system resilience: experiences from the Kenyan coast Health Policy Plan 35 5 522 535 32101609 7225571
World Health Organization Regional Office for Africa. Framework for health systems development towards universal health coverage in the context of the sustainable development goals in the African Region. Congo Brazzaville; 2017. https://www.afro.who.int/sites/default/files/2018-01/AFR-RC67-10%20Framework%20for%20health%20systems%20development-Rev%2023.09.17.pdf. Accessed 26 Jan 2024.
J. Gerring Case study research: principles and practices 2 Cambridge Cambridge University Press 441
J.W. Creswell P.V.L. Clark Designing and conducting mixed methods research Aust N Z J Public Health 31 4 388 388
J. Gerring J.M. Box-Steffensmeier H.E. Brady D. Collier Case selection for case-study analysis: qualitative and quantitative techniques The Oxford handbook of political methodology Oxford Oxford University Press
R. Likert A technique for the measurement of attitudes Arch Psychol 22 140 55 55
V. Braun V. Clarke Thematic analysis: a practical guide Thousand Oaks Sage 371
L.J. Hoffer Clinical nutrition: 1. Protein–energy malnutrition in the inpatient CMAJ Can Med Assoc J 165 10 1345 1349
F. Chabrol P.M. David How resilience affected public health research during COVID-19 and why we should abandon it Glob Public Health 18 1 2212750 37196668
K. Accoe B. Criel M.A.A. Ahmed V.T. Buitrago B. Marchal Conditions for health system resilience in the response to the COVID-19 pandemic in Mauritania BMJ Glob Health 8 12 38050409 10693853 e013943
T. Lerosier L. Touré S. Diabaté Y. Diarra V. Ridde Minimal resilience and insurgent conflict: qualitative analysis of the resilience process in six primary health centres in central Mali BMJ Glob Health 7 Suppl 9 37185362 10580275 e010683
S.M. Topp Power and politics: the case for linking resilience to health system governance BMJ Glob Health 5 6 32546590 7299011 e002891
S. Bosongo Z. Belrhiti F. Chenge B. Criel Y. Coppieters B. Marchal The role of provincial health administration in supporting district health management teams in the Democratic Republic of Congo: eliciting an initial programme theory of a realist evaluation Health Res Policy Syst 22 1 29 38378688 10880215
D. Porignon Adéquation des systèmes de santé de district en situation critique: Expériences de la région des grands lacs africains Bruxelles Université Libre de Bruxelles
WHO. The role of community engagement in restoring trust and resilience in the after math of the COVID-19 pandemic and beyond. 2023. https://www.who.int/publications/m/item/the-role-of-community-engagement-in-restoring-trust-and-resilience-in-the-after-math-of-the-covid-19-pandemic-and-beyond. Accessed 23 Feb 2024.
Ministère de la Santé Publique. RDC. Recueil des normes d’organisation et de fonctionnement des structures sanitaires de la zone de santé en République Démocratique du Congo. Kinshasa; 2012.
E. Barasa R. Mbau L. Gilson What is resilience and how can it be nurtured? A systematic review of empirical literature on organizational resilience Int J Health Policy Manag 7 6 491 503 29935126 6015506
D.D. Saulnier S.M. Topp We need to talk about ‘bad’ resilience BMJ Glob Health 9 2 38320804 10859976 e014041
C. Béné A. Newsham M. Davies M. Ulrichs R. Godfrey-Wood Review article: resilience, poverty and development J Int Dev 26 5 598 623
S.L. Makali J.C. Lembebu R. Boroto C.C. Zalinga D. Bugugu E. Lurhangire et al. Violence against health care workers in a crisis context: a mixed cross-sectional study in Eastern Democratic Republic of Congo Confl Health 17 1 44 37789323 10546691
A. Lal N.A. Erondu D.L. Heymann G. Gitahi R. Yates Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage Lancet 397 10268 61 67 33275906
E. Seville D. Brunsdon A. Dantas J. Le Masurier S. Wilkinson J. Vargo Organisational resilience: researching the reality of New Zealand organisations J Bus Contin Emerg Plan 2 3 258 266
C. Béné R.G. Wood A. Newsham M. Davies Resilience: new utopia or new tyranny? reflection about the potentials and limits of the concept of resilience in relation to vulnerability reduction programmes IDS Work Pap 2012 405 1 61
