Reform of the intermediate level of the health system in the Democratic Republic of the Congo: Adaptations and limits in the stabilization of the personnel of the Provincial Health Division: A cohort study.

Background: Human resources are one of the pillars of health systems. Since the World Health Organization's report on human resources issues, several countries have integrated this component into the various reforms aimed at strengthening their health systems. This study aims to explore the effects of reforming the intermediate level of a health system operating in a fragile state context. Methodology Our study was conducted in the Democratic Republic of Congo (DRC). It was a cohort study of the staff of the 14 Provincial Health Divisions (PHD) out of the 26 existing in the DRC. We established a database of the staff of these 14 PHD from 2016, just after the implementation of the intermediate level reform and the allocation of this staff by the Ministry of Health. We did a recall in 2021, in each of these PHD to survey this staff through a structured questionnaire and supplemented by the files of the agents available in each PHD. Sociodemographic, economic and academic variables were collected and analyzed. Data were entered into an Excel 2016 database and processed with SPSS software version 25. The chi-square test was used for comparison of proportions with a statistical significance level of p < 0.05. Risk ratios ratios (RR) and their 95% confidence intervals were calculated as measures of association. The error threshold was set at 5%. Results A total of 657 agents with an average age of 45.2 years had been identified in 2016 at the start of the survey and in 2021, 118 or 18% of them were no longer part of the PHD agents. Among the causes of absence noted: 48% of agents placed on leave, 16% promoted to other functions within the health system, 16% desertion and dismissal and 11% cases of death. 19.8% of absentees are executives, 19.5% men against 10.3% women; 22.3% of absentees in unstable provinces against 16.6% in stable ones. The factors associated with the absence of agents in the PHD remain the reaching of retirement age [RR (95% CI) = 5.5 (1.2-24.9) ]and male agents [RR (95% CI) = 3.2 (1.3-7.9)]. Among the agents who remained, 92% kept their initial position, 6% were subject to an internal permutation accompanied by a promotion. The factors associated with the stability of human resources at the level of the Provincial Health Division are: female gender, manager with experience or seniority > 5 years, Age > 35 years, Stable province, Presence of a partner bonus. Conclusion Even in a crisis and fragile context, health system reform is possible. It is possible to organize staff recruitment through a selection process independent of the political authorities of the Ministry of Health and supported by the technical services of the Ministry and partners . Experience and the presence of a financial bonus are motivating factors for staff stability. The involvement of Technical and Financial Support Partners in the recruitment process helped the Ministry of Health to minimize political influence in the recruitment of middle-level executives.