Unravelling the implementation of the technical support from the provincial health administration to district health management teams in the democratic Republic of Congo: a realist evaluation

The Ministry of Health of the Democratic Republic of Congo set out to revitalise health districts by strengthening the leadership and management capacities of the District Health Management Teams (DHMTs). This capacity strengthening, called technical support, was provided by staff from the reformed Provincial Health Administration (PHA) through supervision and coaching. We aimed to understand how, for whom, and under what conditions such technical support works (or not) in the Tshopo Province. Our study adopted a realist approach and a case study design. We collected data from document reviews, interviews, questionnaires, and routine data from the health information management system. Data analysis followed a two-step process: first, we identified key features of interventions, context, actors, mechanisms, and outcomes through thematic content analysis. Second, we formulated intervention–context–actor–mechanism–outcome (ICAMO) configurations using a retroductive approach. We found that challenging conditions, such as limited resources, hierarchical culture, poor leadership and narrow decision spaces, hinder the capacity building and motivation of PHA staff, resulting in mixed competencies. This adversely affected the quality of their technical support to DHMT members, failing to fully meet the criteria of being personalised and need-driven, problem-solving-centred, reflection-stimulating, comprehensive, and regular. This sub-optimal support undermined the perceived support’s relevance and the perceived credibility of PHA staff among DHMT members, hindering their active participation and learning and resulting in inconsistent management capacities. Consequently, DHMT members experienced low levels of motivation, self-efficacy and perceived autonomy to improve the performance of their health district. Our findings highlight the need for strong political will and leadership to address contextual challenges, a structured training programme to enhance the competencies of PHA staff, and participatory approaches to tailor technical support to the specific needs of DHMTs.