How Does the Context Shape the Technical Support from the Provincial Health Administration to District Health Management Teams in the Democratic Republic of Congo? A Realist Evaluation.

Since 2014, the health sector in the Democratic Republic of the Congo has been undergoing reforms aimed at strengthening the Provincial Health Administration (PHA) to better support health district development through technical support to district health management teams (DHMTs). However, there is limited understanding of how, for whom, and under what conditions this support works. Using a realist evaluation approach, this study aimed to test an initial program theory of technical support to DHMTs by PHA staff in Kasai Central Province. Data were collected from document reviews, interviews, questionnaires, and routine health information systems. After thematically analysing the implementation, context, actors, mechanisms, and outcomes, we applied retroductive reasoning to connect these elements using the Intervention-Context-Actors-Mechanisms-Outcomes configurations (ICAMOcs) heuristic. We identified nine ICAMOcs showing how resource constraints and political and organisational challenges hindered the effective delivery of technical support. These challenges triggered disabling mechanisms, such as low motivation, self-efficacy, a sense of accountability, psychological safety, reflexivity, the perceived relevance of support, the perceived credibility of PHA staff, and perceived autonomy, resulting in mixed outcomes. The performance-based financing scheme helped mitigate some issues by providing resources and boosting extrinsic motivation, but concerns persist about its sustainability due to reliance on external funding. These findings highlight the need for strong political commitment and coordinated efforts to address these challenges.