State of the world’s human resources for health
The crisis in human resources for health constitutes a worldwide concern. In its report on the World Health in 2006, the World Health Organization’s (WHO) has mentioned that crisis in Human Resources for Health (HRH) is observed worldwide and particularly in sub-Saharan Africa [
1]. This crisis is mainly characterized by staffing problem, training profile, supervision and motivation and non-standard working conditions as well [
1‐
4]. Developed countries also variously face problems of health workforce supply. In France, the number of health professionals in training is regulated by the health system. However, the existence of a plethora or shortage is rather linked to an unequal geographical distribution between urban and rural areas and a poor distribution between primary and secondary care specialties [
5].
In most countries, the training of health professionals benefits from fairly rigorous regulation involving both the academic organizations and the government (Ministry of Health and Ministry of Higher Education), so as to ensure monitoring and control during their work. This makes it possible both to regulate the number of doctors and other working health professionals. It also allows assessing the training quality and ensuring respect for the technical and ethical aspects of their job [
3].
Similarly, standards and procedures for recruiting staff in health structures exist and are generally applied by the regulation bodies: either the Ministry of the Public Service, the Ministry of Planning or the Ministry of Health itself [
6].
Human resource development in the DRC health system
In the Democratic Republic of Congo, human resource development is one of the six axes of the strategy for strengthening the health system adopted since 2006 and revised in 2010, and a document on staff standards in health districts has been drawn up [
7‐
9]. This strategy is operationalized by a health development plan. The sector diagnosis of the 1st and 2nd edition plans identified the main priority problems of human resources for health, in particular the imbalance in the production and inequitable distribution of Human Resources for Health, the low motivation and loyalty of health personnel, the insufficient quality of education for health professionals and the poor development of the skills of health personnel [
10,
11]. A national plan for the development of human resources for health has been drawn up in response to the problems identified. This plan aimed at “providing the health sector multidisciplinary, competent, high-performance health teams at all levels of the health pyramid, sufficient quantity and equitably distributed, contributing to the improvement of the state of health of the Congolese population through the provision of quality health care services”. One of the proposed solutions is the establishment of a health information system on HRH and the national observatory of HRH. The latter already exists, but is not documented [
12].
Human resources are an essential pillar of the health system especially for countries in crisis such as the DRC. They allow the health system to function at its best despite the crisis context. Several authors have shown how a staff could help reduce the adverse effects of the crisis on the health system [
2,
13‐
15].
As in most of African countries, the organization of the health system in the DRC is of the pyramidal type and includes three levels: the central level (National Ministry of Health), the intermediate level (Provincial Health Department) and the operational or peripheral level (the Health District) [
7‐
11].
Context of instability and its impact on the health system
Two billion people now live in situations of fragility and conflict [
16]. The share of people living in extreme poverty in conflict situations is expected to rise from 17% of the global total to nearly 60% by 2030. More than a third of maternal deaths occur in fragile states, and half of all children who die before the age of five live in situations of fragility and conflict [
17].
The WHO estimates that poor quality of care accounts for 15% of all deaths in low- and middle-income countries; and most likely even more in fragile, conflict-affected areas. The same source estimates that 60% of preventable maternal deaths, 53% of under-five deaths and 45% of neonatal deaths occur in fragile areas.
Many states classified as fragile are also in a post-conflict situation [
18], which means that these countries have had to endure the destruction of their service infrastructure, which has worsened their service delivery situation.
Witter and Pavignani [19] have demonstrated the extent of conflict and state fragility and their negative impact on the functioning of the health system. They highlighted, among other things, the inability to provide health services to a large proportion of the population, the lack of political mechanisms to develop, establish and implement national health policies, inadequate capacity and management systems (such as budgeting, accounting and human resource management systems) to mobilize and control resources [
19].
In the book on sustainability of health systems in crisis situations, Witter and Hunter argued that populations living in fragile, conflict-affected or vulnerable areas are at risk of worsening health conditions due to lack of access to even routine health care and the additional health risks associated with damaged infrastructure, physical and psychological trauma, and difficult living and economic conditions. Over 80% of major infectious disease outbreaks occur in these areas. Conflict areas, in particular, may face disruption of systems processes such as supply and health information, as well as the emigration or death of health workers.
There are also likely to be significant financial and resource constraints in these contexts that could impact on the quality of care in the health sector. The availability of an adequate workforce, both in terms of quantity and skills needed, is a common challenge [
20].
Governments are therefore expected to do more with less, and it is the health workers who suffer the consequences of these pressures. These problems are compounded when some social groups perceive government as inefficient or not meeting expectations and thereby undermine its legitimacy, [
20].
However, financing is only one of many important inputs in terms of health system sustainability. Yet human resources are also important and the targets for health systems to achieve Sustainable Development Goal 3 (SDG3) include one on recruitment, training and retention of staff [
20].
The literature also indicates that some countries have taken advantage of the experience of the crisis to try to reorganize their health systems. The experience of the response to the Ebola virus disease (EVD) epidemic in Guinea provided an opportunity to reorganize the health system by investing in the workforce. A post-Ebola study provided strategic guidance to support the retention of health workers in rural areas [
15].
Context of instability and its impact on the health system in eastern DRC
The DR Congo has just completed three decades of crisis and instability. Eastern DRC was the first part to be affected by the crisis with the first Rwanda war in 1994, which led to the Rwandan genocide and dumped 1 million of the refugees in the two Kivu provinces [
21]. Other crisis events have followed one another (the 1998 war, the Province crisis, the 2004 crisis in South Kivu, the Kasaï Oriental crisis and various movements of insecurity observed in various regions). Thus, Eastern DRC has been considered by some authors as the region at high risk of death, with the highest mortality rate since the Second World War. This crisis, whose number of deaths was initially estimated at 3 million in 2002 [
22], woke up various specialists in armed conflict situations. A second study estimated the number of deaths linked to this crisis at 5 million [
23]. The country is currently considered as an “unstable country” or “fragile state”, and some authors now speak of “mega crisis” [
24].
Eastern DRC is still considered as a red zone and some foreign countries do not allow their citizens to visit the region despite the presence of MONUSCO for more than 15 years [
25,
26]. The province of South Kivu is among the three most affected provinces, after North Kivu and Tanganyika. The displacement of populations due to the intensification of violent inter-community conflicts, combined with the looting of healthcare institutions, have contributed to creating a volatile situation that has led to the flight of qualified health workers from the concerned areas [
20].
A major feature of the province of South Kivu in this decade of war is the looting of health infrastructure, particularly hospitals and health centers, by armed gangs. This situation has put hospitals and health centers in very difficult conditions for their operation [
28].
This situation has plunged hospitals and health centers into very difficult conditions for their operation. Furthermore, the coordination structures (Provincial Health Inspectorate, Health District Offices and Central Health districts Offices) are only functioning at a minimum due to the lack of operating costs and logistical means to ensure their regulatory and supervisory role. The health personnel have become demotivated as a result of the non-payment of salaries and the lack of bonuses [
28].
During these various crises, the health system was supported by both international partners and local organizations. Support from the health system was sometimes directed towards the rehabilitation of infrastructure, the supply of equipment and other inputs. This support was sometimes as subsidization of health care for the indigent and displaced populations, or direct remuneration of staff in the form of bonuses [
10,
11,
23‐
25].
At the provincial level, the Provincial Health Department (PHD) of South Kivu has grouped health districts into three categories in 2010 and 2015, according to a number of criteria: developing health districts, health districts in transition and emergency health districts. This categorization included social, economic and political conditions; insecurity or armed conflict, geographical accessibility, etc. [
28].
The health institutions involved in the provision of care are either public or private, or they depend on faith-based networks. Two of these faith-based networks are predominant, namely the network of the Catholic Church through the Diocesan Office of Medical Works and the network of the Protestant Church. Although they have a monopoly on the management of health resources who are registered to the National Public services and enjoy the same benefits as those in the public sector in accordance with the memorandum of understanding signed by the Ministry of Public Health [7, 11, 24]. With the new reform of the intermediate level, six working groups have been set up within the PHD, including the human resources working group, which normally has to analyze all the problems related to HRH and propose solutions [
10,
28] but up to now this commission is not operational.
Current evidences and debates on HRH in South Kivu
The issue of human resources could only arise when people have to be assigned or decommissioned by the political authorities.
Some of the current debates in Human Resources of Health (HRH) are dominated by the relationship between HRH and the state-building, particularly in fragile settings and after conflict [12, 18, 27].
Studies conducted on fragile settings and after conflicts zones such as DR Congo has globally highlighted the fact agents that work in urban and semi-urban benefit from more advantages than those in rural areas [
38,
41]. None of them has deeply focused on fragile and post-conflicts Provinces such as South Kivu where armed conflicts have affected Health services settings.
Moreover, these studies have been conducted before the DR Congo to adopt the Human Resources Management as one of the strategic pillar of the Strengthening Strategy System for Health.
As long as debate on Human Resources for health and its role in state-building, many questions are possible. What is the case of rural zones commonly affected by conflicts after the DR Congo adopt that strategy? In a state-building point of view, did this strategy enhance the performance of Human Resources from recruitment to retirement especially in fragile and conflicts affected provinces such as South Kivu?
The context of fragility aggravates the underperformance of health systems as a whole, especially in low-income countries [
19,
20].
The area of human resources management for health is among those most affected by the non-application of the usual policies and practices related to its management; thus, there is often an unavailability of qualified and motivated personnel, especially in rural areas, which leads to the dysfunction of health services [
11,
38,
41].
According to WHO (2010), salaries are an important determinant of the quantity, distribution and performance of health workers. Low salaries for some categories of health workers can be a disincentive to enter the health professions or to accept a rural posting and do not motivate improved performance or quality.
Low salaries also affect several cross-cutting issues, including multiple job holding and migration to countries where salaries are much higher [
41].
In the DRC, although Human Resource Management for Health has been adopted as one of the strategic axes of the SRSS by the Ministry of Health, this area remains a very weak link in the health sector, particularly in the health zones of South Kivu province (East of the country), which are in a fragile context.
It remains essential to guarantee the quality of health services to the population, especially in situations of permanent fragility such as in the east of the DRC. It therefore seemed very important to us to analyze the capacity of the Ministry of Health to continue to exercise its leadership in the management of HRH through the availability in crisis districts of personnel with an acceptable profile, meeting the standards and enjoying the regalian advantages for their motivation. It is impossible to make the health system effective without the availability of qualified and motivated HRH.
Our study aimed to answer the following questions:
-
What is the profile of human resources for health in health districts in the context of conflict and ongoing fragility?
-
What are the human resources for health factors associated with poor performance of health districts in conflict situations?
So, we aimed to: (1) analyze certain socio-demographic and economic characteristics such as age, gender, level of education and monthly income of the staff; (2) evaluate the recruitment and hiring process of health personnel as well as their distribution in the health zones targeted by the study; (3) evaluate the system of remuneration, payment of social benefits as well as the mechanization of the civil service of the agents in the health zones in crisis targeted by the study. The analysis of the level of performance of each health district associated with the profiles of the available HRH allowed us to answer the second question.
These analyses are an essential way of identifying the strategies and adaptations needed to maintain the proper functioning of the health system in a crisis context.