TY - JOUR T1 - From Insecurity to Health Service Delivery: Pathways and System Response Strategies in the Eastern Democratic Republic of the Congo JF - Global Health: Science and Practice JO - GLOB HEALTH SCI PRACT SP - 915 LP - 927 DO - 10.9745/GHSP-D-21-00107 VL - 9 IS - 4 AU - Chiara Altare AU - Vito Castelgrande AU - Maphie Tosha AU - Espoir Bwenge Malembaka AU - Paul Spiegel Y1 - 2021/12/31 UR - http://www.ghspjournal.org/content/9/4/915.abstract N2 - Key FindingsInsecurity affects health service delivery and quality in eastern Democratic Republic of the Congo through 3 main pathways: violence, mobility restrictions, and resources availability.Of several mediating factors that play a role in service delivery and quality, the 2 most important are health care workforce availability and drug/equipment accessibility.Health care providers are implementing a variety of strategies to address such barriers, showing some capacity to adapt, adjust, and transform due to insecurity. Most of the response strategies reflect the absorptive capacity and address the lack of human resources. Adaptive solutions tried to address the lack of access, and transformative interventions address the challenges posed by insecurity.Key ImplicationsUnderstanding the mechanisms through which insecurity affects health service provision and quality is central to designing appropriate response strategies.The effectiveness and cost-effectiveness of response strategies to chronic insecurity should be assessed to provide guidance to increasingly fragile health systems.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. ER -