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The provinces of North and South Kivu in eastern Democratic Republic of the Congo (DRC) have experienced insecurity since the 1990s. Without any solution to the conflict in sight, health actors have adapted their interventions to maintain some level of health service provision. We reflect on the health system resilience in the Kivu provinces in response to chronic levels of insecurity. Using qualitative interviews of health care providers from local government, United Nations agencies, and international nongovernmental organizations, we identify the mediating factors through which insecurity affects both service quality and delivery and investigate the strategies adopted to sustain service provision. Three main drivers linking insecurity and health service quality and delivery emerged: via violence, mobility restrictions, and resources availability. The effect of these drivers is mediated by several system or individual-level factors. Two factors were reported in each pathway: health care workforce availability and drug/equipment accessibility. Human resources were affected differently by each driver: in terms of willingness to be stationed in a certain area (violence), capacity to access the health facility (mobility), and sustainability and motivation of conducting duties (resources). Similarly, the presence of drugs/equipment varied in case of looting or damages (violence), delays in delivery (mobility), or delays in procurement (resources). While these mediators are not surprising, their identification allows the design of appropriate response strategies. The majority of the reported solutions attempt to address the lack of human resources and reflect absorptive capacity. Adaptive capacity characterizes the attempts to address lack of access (contingency plan, mobile clinics, maternity waiting homes, and security drugs). Finally, interventions to address insecurity can be classified as transformative. Health actors in eastern DRC have shown some capacity to adapt, adjust, and transform due to insecurity. Further research is needed to measure the effectiveness of such strategies to provide guidance to increasingly vulnerable health systems.
This analysis is embedded within a broader research project conducted by the BRANCH (Bridging Research and Action in Conflict settings for the Health of women and children) consortium in 10 conflict-affected countries to investigate factors that shape decision making and maternal and child health service delivery.17 In DRC, we conducted a mixed-methods case study, using both secondary quantitative and primary qualitative data. More details are provided in the article presenting the results of the case study.10 In this substudy, we use qualitative data to identify operational challenges and investigate strategies to maintain service delivery and quality. While service delivery is also influenced by decision making and policy making, we limited the scope of this article to operational aspects to allow for more detailed discussion. The case study was conducted in the North and South Kivu provinces in DRC in 2018. North Kivu has experienced higher intensity violence than South Kivu, both in terms of casualties and events. Few fatalities have occurred in South Kivu since 2012, despite numerous violent events throughout the years. Violence against civilians (33.2%) and battles with no change of territory (31.2%) were the most frequent forms of violent episodes in both provinces.18 Two health zones in each province were selected due to their history of conflict and insecurity (in terms of active armed clashes, population displacement, and accessibility) during the previous 5 years. The decision was taken in consultation between the research team and representatives of the provincial health offices. In North Kivu, the health zones of Mweso and Ruanguba were visited; in South Kivu, those of Minova and Walungu. Mweso experienced extensive violence, population displacement, and attacks on health facilities; Ruanguba was the center of the March 23 Movement (M23) offensive in 2012–2013; Minova and Walungu have experienced extensive conflict over land issues and customary power.19 We selected 2 health zones in each province due to their history of conflict and insecurity during the previous 5 years. Qualitative data were collected through individual or group interviews with representatives of private and public health care providers currently working in North and/or South Kivu. These included staff of the Ministry of Health, UN agencies, NGOs, faith-based organizations as well as health care workers (chief midwives, chief nurses, and community health workers). We visited 1 hospital, 1 health center, and 1 health post in each health zone to ensure health facilities of different sizes, services, and resources were included in the study. Two referral hospitals (1 per province) were visited as well. We conducted 51 in-depth interviews (IDI) and 4 focus group discussions (FGDs), with a total of 84 respondents (Table 1). Participation was voluntary. Oral informed consent was obtained from all participants, who needed to be aged 18 years or older and working in the position for more than 30 days. Participants in In-Depth Interviews and Focus Group Discussions in Analysis of Insecurity and Health Service Provision and Quality in North and South Kivu Provinces, Democratic Republic of the Congo Abbreviations: DPS, Division Provinciale de Santé (Provincial Health Division); MCZ, Médicin Chef de Zone (Chief Medical Officer of the health zone). We developed and piloted an interview guide for each respondent group to reflect their role and the mandate of their organizations. Questions aimed to inquire about availability and quality of provided maternal and child health services; factors affecting decision making and program implementation (including human resources, funding, information management, infrastructure, and coordination); challenges and opportunities; adaptations to programs to respond to population displacement and insecurity; and level and type of insecurity in the communities. All interview guides were developed in French; the interview guides for FGDs and facility health care workers were translated into Swahili by the research team members (native speakers). Translation into Swahili was tested during the pilot of the guides and fine-tuned until an agreed-upon formulation was found. A 4-day training of the interviewers was conducted in Bukavu to familiarize them with the project objectives and the data collection tools. The case study coordinator (CA) led the training together with the field research coordinator (MT). Interview guides were piloted in a health facility in Bukavu, which was not included in the sample. Data collection took place between August and September 2018. Interviews took place in French or Swahili according to the preference of the respondent. Recordings were transcribed in French. Data management and coding were done in NVivo.20 The codebook included both predefined codes addressing issues the study aimed to explore and additional ones that arose from the interviews. Two team members coded the transcripts after having tested and compared coding approaches to ensure harmonization. Thematic analysis methods were used, whereby data were compiled, disassembled, and then reassembled.21 Framework analysis was used to explore data. A matrix output (with cases as row and codes as column) was developed to systematically summarize data and facilitate constant comparison within and across cases and topics.22 The Johns Hopkins Bloomberg School of Public Health determined that this study was not human subjects research and therefore did not require institutional review board oversight (IRB 8652). In DRC, the study protocol was reviewed and approved by the Université Catholique de Bukavu’s Institution Review Board (UCB/CIES/NC/02/2018). Oral consent was obtained from all study participants before initiating data collection.
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