Bosongo Samuel, Belrhiti Zakaria, Chenge Faustin, Criel Bart, Marchal Bruno, Coppieters Yves
Faculté de Médecine et Pharmacie, Université de Kisangani, Kisangani 2012, Democratic Republic of the Congo.
École de Santé Publique, Université Libre de Bruxelles, 1070 Bruxelles, Belgium.
Int J Environ Res Public Health. 2024 Dec 10;21(12):1646. doi: 10.3390/ijerph21121646.
Since 2014, the health sector in the Democratic Republic of the Congo has been undergoing reforms aimed at strengthening the Provincial Health Administration (PHA) to better support health district development through technical support to district health management teams (DHMTs). However, there is limited understanding of how, for whom, and under what conditions this support works. Using a realist evaluation approach, this study aimed to test an initial program theory of technical support to DHMTs by PHA staff in Kasai Central Province. Data were collected from document reviews, interviews, questionnaires, and routine health information systems. After thematically analysing the implementation, context, actors, mechanisms, and outcomes, we applied retroductive reasoning to connect these elements using the Intervention-Context-Actors-Mechanisms-Outcomes configurations (ICAMOcs) heuristic. We identified nine ICAMOcs showing how resource constraints and political and organisational challenges hindered the effective delivery of technical support. These challenges triggered disabling mechanisms, such as low motivation, self-efficacy, a sense of accountability, psychological safety, reflexivity, the perceived relevance of support, the perceived credibility of PHA staff, and perceived autonomy, resulting in mixed outcomes. The performance-based financing scheme helped mitigate some issues by providing resources and boosting extrinsic motivation, but concerns persist about its sustainability due to reliance on external funding. These findings highlight the need for strong political commitment and coordinated efforts to address these challenges.
自2014年以来，刚果民主共和国的卫生部门一直在进行改革，旨在加强省级卫生管理局（PHA），通过向地区卫生管理团队（DHMTs）提供技术支持，更好地支持卫生区的发展。然而，对于这种支持如何发挥作用、针对谁以及在何种条件下发挥作用，人们的了解有限。本研究采用现实主义评估方法，旨在检验开赛中央省PHA工作人员对DHMTs技术支持的初步项目理论。数据收集自文件审查、访谈、问卷调查和常规卫生信息系统。在对实施情况、背景、行为者、机制和结果进行主题分析后，我们运用溯因推理，使用干预-背景-行为者-机制-结果配置（ICAMOcs）启发法将这些要素联系起来。我们确定了九个ICAMOcs，展示了资源限制以及政治和组织挑战如何阻碍技术支持的有效提供。这些挑战引发了一些使能机制失效的情况，比如积极性低落、自我效能感低、责任感缺失、心理安全感不足、缺乏反思能力、对支持的相关性认识不足、对PHA工作人员的可信度缺乏信心以及自主性缺失，从而导致了参差不齐的结果。基于绩效的融资计划通过提供资源和增强外部动机，帮助缓解了一些问题，但由于依赖外部资金，其可持续性仍令人担忧。这些发现凸显了需要坚定的政治承诺和协调一致的努力来应对这些挑战。
