Adaptive Mechanisms of Health Zones to Chronic Traumatic Events in Eastern DRC: A Multiple Case Study

Document Type : Original Article


1 Ecole Régionale de Santé Publique, Faculté de Médecine, Université Catholique de Buka-vu, Bukavu, Democratic Republic of the Congo

2 Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium

3 Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo

4 Division Provinciale de la santé du Sud-Kivu, Bukavu, Democratic Republic of the Congo

5 Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland


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.

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 organisations (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.

Both battle-related events (war and its effects) and non-battle-related events (epidemics, disasters, and 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 healthcare facilities and the implementation of negotiation strategies with the belligerents.

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.


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  • Receive Date: 02 March 2023
  • Revise Date: 25 July 2023
  • Accept Date: 30 September 2023
  • First Publish Date: 04 October 2023