title: Referral hospitals in the Democratic Republic of Congo as complex adaptive systems: similar program, different dynamics.
abstract: BACKGROUND
  In many African countries, first referral hospitals received little attention from development agencies until recently. We report the evolution of two of them in an unstable region like Eastern Democratic Republic of Congo when receiving the support from development aid program. Specifically, we aimed at studying how actors' network and institutional framework evolved over time and what could matter the most when looking at their performance in such an environment.
  
  
  METHODS
  We performed two cases studies between 2006 and 2010. We used multiple sources of data: reports to document events; health information system for hospital services production, and "key-informants" interviews to interpret the relation between interventions and services production. Our analysis was inspired from complex adaptive system theory. It started from the analysis of events implementation, to explore interaction process between the main agents in each hospital, and the consequence it could have on hospital health services production. This led to the development of new theoretical propositions.
  
  
  RESULTS
  Two events implemented in the frame of the development aid program were identified by most of the key-informants interviewed as having the greatest impact on hospital performance: the development of a hospital plan and the performance based financing. They resulted in contrasting interaction process between the main agents between the two hospitals. Two groups of services production were reviewed: consultation at outpatient department and admissions, and surgery. The evolution of both groups of services production were different between both hospitals.
  
  
  CONCLUSIONS
  By studying two first referral hospitals through the lens of a Complex Adaptive System, their performance in a context of development aid takes a different meaning. Success is not only measured through increased hospital production but through meaningful process of hospital agents'" network adaptation. Expected process is not necessarily a change; strengthened equilibrium and existing institutional arrangement may be a preferable result. Much more attention should be given in future international aid to the proper understanding of the hospital adaptation capacities.
authors.affiliation: Université Catholique de Bukavu, République Démocratique du Congo.
authors.forename: Hermès
authors.initials: H
authors.lastname: Karemere
authors.affiliation: Université Catholique de Louvain, IRSS (Institut de Recherche Santé et Société), Belgique.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Ribesse
authors.affiliation: Cemubac (Centre scientifique et médical de l'Université libre de Bruxelles pour ses activités de coopération), République Démocratique du Congo.
authors.forename: Jean-Bosco
authors.initials: JB
authors.lastname: Kahindo
authors.affiliation: Université Catholique de Louvain, IRSS (Institut de Recherche Santé et Société), Belgique.
authors.forename: Jean
authors.initials: J
authors.lastname: Macq
mesh_terms: D002391:Catchment Area, Health; D015023:Democratic Republic of the Congo; D003906:Developing Countries; D003953:Diagnosis-Related Groups; D004526:Efficiency; D005060:Europe; D005377:Financial Management, Hospital; D006740:Hospital Administrators; D006801:Humans; D007390:International Agencies; D007391:International Cooperation; D007400:Interprofessional Relations; D008962:Models, Theoretical; D016730:Program Development; D012017:Referral and Consultation; D062606:Tertiary Care Centers / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data / Q000639:trends
keywords: Complex adaptive system; Democratic Republic of Congo; aid development evaluation; district hospitals; governance