Exploring the inherent resilience of health districts in a context of chronic armed conflict: a case study in Eastern Democratic Republic of the Congo.

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.