Using action research to promote reflective practice in the strengthening of the local health system Kisantu-DRC

General Hospital Technical Team Health District Administrative Team Problem identification Action Evaluation Action Conception and Planning Action Implementation The Action research Cycle and the Reinforcement of the District Medical Health Team Integrated Health District Team

Problem Identification Fee for Service Hospital Competing with First Level HR Plethora Hospital Efficiency Irrational Prescription Access to Care Quality of Care Low Hospitalization Rate Right to Free Direct Access to Care for Staff Low First Level Utilization rate Action Conception and Planning Action Implementation Irrational Prescription Action Evaluation HR Plethora Fee for Service Hospital Competing with First Level Right to Free Direct Access to Care for Staff Retirements and Redeployments Health Insurance Membership for all staff Conditional Subsidy on the flat fees Flat Fees Second levelSecond level 1stLevel1stLevel HR plethora or shortage Access to Care Quality of Care First Level Efficiency Low quality of training Access to Care Hospita- lization Rate First Level Utilization rate HR plethora or shortage Retirements and Redeployments Irrational Prescription Low quality of training Access to Care First Level Efficiency Quality of Care Hospital Efficiency Quality of Care Quality of Care Compe- tition between levels New Problem Identification Action Conception, Planning, Implementation Hospital Protocols First level protocols Improved supervision Adjusted Flat Fees Action Evaluation Treachery Quality of Care New Problem Identification… Treachery Staff’s strike

Problem identification Action Evaluation Action Conception and Planning Action Implementation The Action research Cycle and the Reinforcement of the District Medical Health Team Integrated Health District Team

Problem Identification Fee for Service Hospital Competing with First Level HR Plethora Hospital Efficiency Irrational Prescription Access to Care Quality of Care Low Hospitalization Rate Right to Free Direct Access to Care for Staff Low First Level Utilization rate Action Conception and Planning Action Implementation Irrational Prescription Action Evaluation HR Plethora Fee for Service Hospital Competing with First Level Right to Free Direct Access to Care for Staff Retirements and Redeployments Health Insurance Membership for all staff Conditional Subsidy on the flat fees Flat Fees Second levelSecond level 1stLevel1stLevel HR plethora or shortage Access to Care Quality of Care First Level Efficiency Low quality of training Access to Care Hospita- lization Rate First Level Utilization rate HR plethora or shortage Retirements and Redeployments Irrational Prescription Low quality of training Access to Care First Level Efficiency Quality of Care Hospital Efficiency Quality of Care Quality of Care Compe- tition between levels New Problem Identification Action Conception, Planning, Implementation Hospital Protocols First level protocols Improved supervision Adjusted Flat Fees Action Evaluation Treachery Quality of Care New Problem Identification… Treachery Staff’s strike Lack of Leadership Integrated Health District Team

In short… Systematic learning with gradual awareness of the complexity of the health system (capacity building) Action research as a mechanism of change. Progressive improvement in the reflexion, the analysis and the monitoring/evaluation Local embeddedness with emancipation of the local managers from a top-down system. Inclusion : multiple stakeholders within the system but also beyond the local level were partaking the process

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