Measuring Hospital Performance Using the EGIPSS Model: Lessons Learned from Ten Hospitals in the Kadutu Health Zone in the Democratic Republic of Congo

Abstract

This study analyzes the comparative performance of ten hospitals in the Kadutu Health Zone in the Democratic Republic of Congo using the EGIPSS model. This study was carried out at the height of the COVID-19 pandemic in August and September 2021, in a changing global context where health systems were called upon to improve their resilience capacity while maintaining high levels of performance. This is a descriptive observational study using documentary review, interviews with 85 key informants, and participatory observation at ten hospitals selected based on several criteria, including the organization of a complete complementary package of activities assigned to a hospital in the DR Congo. This study mainly reveals three facts, namely that (i) university hospitals show the best performance, (ii) adaptive capacity considerably influences the other dimensions of the EGIPSS model and the overall performance of the hospital, and (iii) to adapt, hospitals need resources and good management and governance. Adapting hospitals in the Kadutu Health Zone to the changing context requires a holistic approach that combines clinical work with research, investments in infrastructure (often dilapidated and not modern), training, technology, and governance. It also involves learning from practices implemented in more efficient hospitals.

1. Introduction

Performance is a multidimensional concept that concerns health system managers. Faced with the changing global context of recent years and in particular with the advent of the COVID-19 pandemic, health systems have been called upon to improve their resilience while remaining efficient [1]. At the particular level of hospitals, which are complex adaptive systems [2,3], measuring hospital performance fulfills several objectives [4,5]. These include optimal cost management, improving internal hospital management, establishing benchmarking between hospital establishments, putting hospitals under control in order to have visibility on their achievements, putting hospitals in competition, and improving patient satisfaction [5]. On the other hand, evaluating performance within the hospital can encounter difficulties linked to the nature of hospital activity, the actors, but also to uncertainty about the tools for this measurement [3]. Also, in DRC, the healthcare environment is confronted with a serious problem of the medicalization of front-line healthcare structures (represented by health centers). Doctors, who are not supposed to work in this line of care, are turning health centers into “little hospitals” offering a package of care that is poorly controlled by the health authorities [6,7].

In practice, there are several performance measurement models [8,9], depending on the definition given to the latter. The literature describes several performance measurement models, some of which are unidimensional [10,11] and others which are multidimensional [10,12,13]. Studies on hospital performance have demonstrated the interest of considering the concept of performance from a multidimensional perspective [14,15]. However, the performance of the health system in the DRC is most often assessed on a unidimensional basis (often via the achievement of goals and through a comparison with the country’s standards) [16]. Unfortunately, this way of assessing the health system fails to establish the links between the different functions of the system and the objectives it is supposed to achieve. Moreover, the context of the eastern DRC presents a level of complexity that makes it difficult to assess the hospital performance based on a single dimension alone. This complexity includes the protracted crisis associated with armed conflict, which disrupts the organization of health services and frequently necessitates adaptive strategies to maintain essential care [16]. It also encompasses the urban health system landscape, which is heavily influenced by the proliferation of private for-profit facilities delivering poorly defined and inadequately regulated care packages [17,18]. Additionally, the increasing “medicalization” of primary care—reflected in the presence of general practitioners in health centers—has further blurred the delineation of care levels and disrupted hospital activities [6].

One of the integrative models groups the sub-dimensions of performance into four poles that define the four functions of a health system. This is the EGIPSS model (Global and Integrated Evaluation of the Performance of Health Systems) [12]. According to this model, to be efficient (maintain its existence and develop), the hospital, like any organized health system of action, must assume over time four major functions corresponding to four dimensions (or poles) of performance: adaptation to the environment, achievement of goals, production, and maintenance of culture and values. Adaptation to the environment is described in terms of the acquisition of resources (human, financial, and material, including drugs and laboratory reagents), response to the expectations of the population, mobilization of the community, the attraction of customers, and the capacity to innovate. The achievement of goals implies the provision of reference healthcare with effectiveness, efficiency, even equity to the overall satisfaction of the population. As for production, it is understood as a volume of acts, quality services that the hospital is called upon to provide. Finally, maintaining culture and values represents the organizational climate as well as the different values, including provider satisfaction, compliance with standards, and procedures. These four functions have close links called balances or alignments [12].

We were interested in this latter model to measure the performance of ten hospitals in South Kivu, in the East of the Democratic Republic of Congo (DRC), in the Kadutu Health Zone (HZ). This region has been the scene of armed violence for three decades. Ongoing armed conflict in Eastern DRC is having a profound impact on hospital performance, destroying infrastructure, driving staff to flee, and disrupting medical supplies. Health facilities are overloaded by the influx of wounded and displaced people, while access to care is becoming extremely difficult for the population. This situation, compounded by unstable funding and heavy dependence on humanitarian aid, is seriously weakening the health system and contributing to the vulnerability of local communities. In that context, the objective of this study was to measure the comparative performance of hospital structures in the Kadutu HZ using the EGIPSS model and to draw lessons for managers.

2. Materials and Methods

2.1. Description of the Study Environment

This study was conducted in August and September 2021—coinciding with the COVID-19 pandemic period, providing an unusual opportunity to study the hospitals during a time of great challenges—in the urban health zone of Kadutu. The health zone is the operational level of the DRC health system, subdivided into two levels of healthcare. The hospital constitutes the second level of healthcare and is closely linked to the first level made up of health centers. The hospital thus offers a complementary package of care provided at the health center. In 2020, the Kadutu HZ had 89 health facilities offering hospital care, for a total population estimated at 392,298 inhabitants [19]. It had 549 beds, 38% of which were at the general referral hospital of the health zone (Ciriri Hospital) and only 39.5% were used in 2020, compared to 67.1% in 2019, before the pandemic [19]. This low use appears to be linked not only to the proliferation of private structures which do not report their data [19] but also to the effects of the COVID-19 pandemic [20,21] including the resistance of the population to using health structures.

2.2. Operational Framework of the EGIPSS Model, Its Components, and Their Relationship with the Hospital

EGIPSS is a model developed by Sicotte and his collaborators [12], inspired by Parsons’ theory of social action [22] that integrates the essential functions of an organization. It is composed of four main dimensions separated into two axes. A first axis includes the relationship between an open system and its environment (external–internal). On the other side, a second axis takes into account the balance between incoming resources, the use process, transformation, and results (means–goals)

In the EGIPSS model, the functions described by Parsons form the basis of the four functions of performance. The interactions between these four dimensions are called “balances” or “alignments” and are also a fundamental factor to monitor according to the model to maintain a high-performance system. Based on the EGIPSS model, Guisset [4] defined what constitutes a high-performing hospital in a European context. This study draws on the work of Guisset and colleagues to measure the performance of hospitals in the Kadutu HZ. Below, we define the components of the model (dimensions and sub-dimensions) and their relationship with a “high-performing” hospital:

Adaptation

• Acquisition of resources (6 items): hospital that obtains public and/or private (NGO) funds, has highly qualified staff (specialists), is associated with groups/associations/mergers, obtains research funds or does research with its funds, has managed to obtain a substantial increase in its total budget, and collaborates with other institutions in order to expand its services.
• Local community support (5 items): hospital whose board members are active, whose doctors and other professionals appear in the media, have many volunteers, serve as a reference, and whose services are highly regarded by the public.
• Consistency with social values (6 items): hospital whose board of directors demonstrates accountability, is trusted by other healthcare providers, consults extensively with the local population, operates within its budget, has board members that are aware of their responsibilities to payers, and actively seeks to include representatives of the local population.
• Response to population needs (5 items): hospital that adapts its activities in response to the needs of the population, takes sociodemographic data into account, informs the population of changes, has opened certain services and closed others in response to changes in the needs of the population and regularly monitors the evolution of the demographic characteristics of the population it serves.
• Market presence (4 items): hospital that treats a large portion of the population, is considered a reference center (local, provincial, national or international), treats many more patients than competing hospitals, and provides services not available elsewhere.
• Innovation and learning (5 items): hospital that has changed its management practices in response to new knowledge, is able to identify the opportune moment to change strategic direction, rewards learning and innovation, demonstrates an interest in research and the production of new technologies, and staff members apply research results in their practice.

Achieving goals

• Patient satisfaction (5 items): hospital with loyal patients, where patients are very satisfied with the reception and the results of care, that treats patients referred by other patients (word of mouth), where the patient satisfaction rate is high, and that receives few complaints from patients about the results of care.
• Effectiveness (5 items): hospital that works with other organizations to develop databases to evaluate and monitor performance, has a low rate of unplanned readmissions, has a low percentage of patients who develop complications, evaluates the impact of its care and services, and consistently produces the best possible health outcomes.
• Efficiency (4 items): hospital that presents an excellent cost/quality ratio, systematically produces the best possible health results while controlling costs, reduces its costs by improving the adequacy of care and allocates budgets between services on the basis of their relative cost-effectiveness.

Production

• Productivity (3 items): hospital that manages to reduce costs while maintaining the range of services offered, shares certain services with others in order to achieve economies of scale and whose length of stay is low compared to other similar hospitals.
• Volume of activity (5 items): hospital that treats a large number of patients, has expanded its outpatient services, has increased the range of services offered, has a large number of emergency admissions and allocates new resources to services with increasing patient numbers.
• Quality (5 items): hospital that constantly tries to improve the quality of care, maintains contacts with other institutions to ensure excellent follow-up, where the waiting time for scheduled surgery is short, which makes its services easily accessible to those who need them and which provides excellent care from a technical point of view.
• Coordination of production (5 items): hospital that continually tries to coordinate care with other organizations, has a high degree of coordination between clinical staff and logistics staff, where there is great coordination among professionals, where there is great coordination between care units, and where there is good coordination with other care producers.

Culture

• Organizational values (5 items): hospital that regularly reviews and updates its missions and objectives, whose philosophy of care is common to all staff members, which consults its staff, whose organizational objectives have been integrated by everyone, and which has established formal mechanisms for discussing and resolving ethical problems.
• Organizational climate (5 items): A hospital whose staff members feel they have the necessary expertise, provides opportunities for managers and staff to improve their leadership skills, is able to create a sense of trust among staff members, whose staff members are aware of the importance of their work, and in which formal channels for conflict resolution have been established and are used by staff members.

2.3. Hospital Selection

The mapping of hospital structures in the Kadutu HZ carried out between August 2021 and October 2021 counted a total of 30 structures [17]. The selection of hospitals was guided by criteria aligned with the organizational standards for health facilities in the DRC [23]. Facilities were included if they met the following conditions: (i) the provision of a comprehensive hospital-level care package, encompassing the four essential medical services—gynecology and obstetrics, internal medicine, pediatrics, and surgery—and the capacity to deliver additional specialized services such as medical imaging, physiotherapy, dentistry, and ophthalmology; (ii) employment of at least one full-time general practitioner; and (iii) formal integration into the provincial health system, demonstrated by official recognition from the provincial health division. Only 10 of the 30 hospital facilities identified within the Kadutu Health Zone met the inclusion criteria and were therefore selected for this study (

Table 1. Selected hospitals across the different health areas of the Kadutu health zone.

No.	HA *	HA Population	Selected Hospitals
1	BINAME	32,361
2	BUHOLO2	28,197
3	CECA MWEZE	29,030
4	CIMPUNDA	29,904
5	CIRIRI 1	59,628	Ciriri GRH
6	CIRIRI2	14,786
7	UNEF	23,515	Kadutu GRH
			Red Cross MC
8	LURHUMA	19,068	ISTM HC
9	MARIA	71,543	UOB Clinic
			HPGRB
			Maroy Foundation MC
10	NEEMA	20,932	Saint-Vincent HC
11	NYAMUGO	26,059	CBCA Nyamugo HC
12	NYAMULAGIRA	22,736	Berna Polyclinic
13	UZIMA	14,537
TOTAL HZ		392,296

* HA = Health area (geographic subdivisions of the HZ which include at least one functional health center). GRH = General reference hospital; HC = Hospital center; MC = Medical center; UOB = Official University of Bukavu; HPGRB = Provincial General Reference Hospital of Bukavu; CBCA = Baptist Community of Central Africa; ISTM = Higher Institute of Medical Techniques, CECA= Evangelical Community in Central Africa.

). The 20 hospitals excluded also had specific deficiencies in the care package, staff, equipment, and drug supply.

2.4. Study Design

This is a descriptive observational study using documentary review, interviews with key informants, and participatory observation to the organizational performance of urban hospitals. This study is part of a series on the urban hospital environment in South Kivu province (DRC) [17].

2.5. Data Collection

A bespoke data collection instrument was developed, drawing on the dimensions of performance defined by the EGIPSS model and the conceptualization of a high-performing hospital as outlined by Guisset [4], and adapted to the context of the Kadutu health zone. The tool included a total of 73 qualitative indicators, distributed across four performance dimensions: adaptability (31 items), goal attainment (14 items), preservation of values and culture (10 items), and production (18 items). To strengthen the internal validity of our study, we triangulated several data collection techniques (see

Table 2. Data collection technique for each item of the EGIPSS framework.

Items	Number of Items	Data Collection Technique
Adaptation
Adaptation of resources	6	Document review, interviews, observation
Local community support	5	Interviews
Consistency with social values	6	Interviews
Responses to the needs of the population	5	Document review, interviews
Market presence	4	Document review, interviews
Innovation and learning	5	Document review, interviews, observation
Achieving goals
Patient satisfaction	5	Interviews
Efficiency	5	Document review, interviews
Efficiency	4	Document review, interviews
Culture (maintaining values)
Organizational values	5	Document review, interviews, observation
Organizational climate	5	Interviews
Production
Productivity	3	Document review, interviews
Volume of activity	5	Document review, interviews
Quality	5	Interviews, observation
Production coordination	5	Interviews, observation

): First, the document review which concerned several parameters, using national and provincial texts on the provision of hospital care in urban areas (essentially the health development plan of the Kadutu health zone and the collection of national standards on the health zone), various reports from the Provincial Health Division (DPS) on the performance of health facilities and the annual reports of the various hospitals and the Kadutu health zone for the years between 2019 and 2021. This document review made it possible, on the one hand, to identify the hospital structures of the health zone, and on the other hand, to describe their characteristics. Second semi-structured individual interviews used a pre-established guide with key informants. Participants were selected using a purposive sampling approach [24]. This strategy was guided by the direct involvement of the selected individuals in the establishment and functioning of hospitals within the Kadutu Health Zone. These included members of the health zone management team, healthcare providers, hospital directors, and administrative managers. To ensure a diversity of viewpoints, community leaders and patients were also included in the sample, in order to capture the perspectives and experiences of service users. In total, 85 key informants were interviewed across the ten hospital facilities, with an average of eight participants per facility—including two patients per hospital, selected at random during the site visit—and five members of the Kadutu Health Zone management team, including the Chief Medical Officer. The interviews were conducted by 4 trained investigators who were supervised in the field by one of the researchers in order to ensure the quality of the data collected. Third, the non-participant observations of the ten hospitals, using a structured collection grid.

The interviews and observation focused mainly on the acquisition of resources (in particular the availability of qualified human resources), innovation, and learning (in this case, the new technologies implemented in the hospital and the application of research results in hospital practices), organizational values (mechanisms put in place to implement the missions and achieve the hospital’s objectives), quality (in the dimensions of human reception, waiting time before surgery and patient hospitalization conditions), and finally the coordination of production (the continuous coordination of care with other structures including referral and counter-referral, the level of coordination between clinical staff and logistics staff, coordination within professionals, and coordination between care units).

2.6. Data Analysis

To assess hospital performance, each of the 73 items from the evaluation questionnaire was scored on a scale from 0 (not present) to 100 (fully present), following the methodology of Guisset et al. (2002) [4]. This scoring was based on a triangulation of data sources, including the views of the hospital’s medical director, documentary analysis, and direct observation within the facility. Sub-dimension scores (e.g., resource acquisition) were calculated by averaging the scores of the corresponding items. The overall performance score was computed as the mean of all dimension scores derived from the average of related sub-dimensions. For visual comparison, a performance level was classified as poor (<50%, red), acceptable (50–74%, yellow), or satisfactory (≥75%, green). In parallel, qualitative data obtained through interviews were analyzed thematically using the EGIPSS framework, and structured according to its four key organizational functions. For its validation, the 0–100 scoring scale was pre-tested in two functional hospital facilities in the neighboring health zone of Bagira.

2.7. Ethical Considerations

The research protocol was approved by the Kadutu HZ management team, which authorized data collection. A prior informed consent form, guaranteeing anonymity and free participation, was completed by each of the identified structures and key informants.

3. Results

Table 3. Overview of hospital performance based on the EGIPSS model’s dimensions.

Performance Level		Satisfying			Acceptable			Worrying
STRUCTURES	HPGRB	Ciriri GRH	UOB	Kadutu GRH	Nyamugo HC	Croix Rouge Polyclinic	Berana Polyclinci	ISTM HC	Saint-Vincent HC	Maroy Fondation MC
ADAPTATION	78	61	59	53	47	42	41	40	40	36
Resource acquisition (%)	60	43	45	32	28	27	30	28	22	18
Local community support (%)	78	66	68	56	48	42	36	40	46	40
Consistency with social values (%)	85	67	68	67	65	62	62	62	58	48
Response to population needs (%)	78	50	58	46	50	28	38	26	24	26
Market presence (%)	88	75	35	55	48	55	38	45	48	48
Innovation and learning (%)	80	64	82	62	40	40	40	38	40	34
ACHIEVEMENT OF OBJECTIVES	78	69	65	64	63	60	60	59	60	56
Patient satisfaction (%)	82	80	72	72	68	70	76	62	66	62
Efficiency (%)	74	68	58	66	60	62	56	70	60	52
Efficiency (%)	78	60	65	55	60	48	48	45	53	55
PRODUCTION	85	75	73	66	57	55	55	54	53	48
Activity volume (%)	86	76	70	76	54	46	46	46	50	42
Quality (%)	83	78	80	68	60	65	64	67	62	50
Production coordination (%)	86	72	70	54	58	54	54	48	48	52
CULTURE/VALUES	85	82	71	67	62	61	57	55	54	53
Organizational values (%)	86	82	76	74	64	60	62	62	56	56
Organizational climate (%)	84	82	66	60	60	62	52	48	52	50
OVERALL AVERAGE	82	72	67	63	57	55	53	52	52	48

gives the overall performance score of the different hospitals considering the rating made for the four dimensions of the EGIPSS model.

3.1. Adaptation

Only one hospital structure (HPGRB) out of ten, or 10%, has a satisfactory level of performance in adaptation to the urban context. Three others (30%) have an adaptation performance level considered acceptable (Ciriri GRH, UOB clinic and Kadutu GRH). On the other hand, 60% of the structures display a worrying performance (CBCA Nyamugo HC, Red Cross Polyclinic, Berna Polyclinic, ISTM HC, Saint-Vincent HC and Maroy Fondation MC).

The HPGRB naturally stands out from other hospital structures in the Kadutu HZ due to the specificities conferred on it by its status as a tertiary level structure with an acquisition of considerable resources supported by other partner organizations (including the International Committee of the Red Cross or Doctors Without Borders), specific equipment, and highly qualified personnel engaged in operational research and regularly appearing in the media. It organizes services not available elsewhere (MRI, Hemodialysis, Neonatology).

The University Clinics of the Official University of BUKAVU (UOB), a public structure supposed to be of tertiary level, has a team of highly qualified and diversified professionals (professors, specialists, general practitioners, nurses, and other paramedical professions). The structure is specialized and demonstrates an interest in research, organizes the continuous training of staff, facilitates providers to access scholarships, and rewards research and innovation by promotion.

The Ciriri GRH is a denominational structure managed by the Diocesan Bureau of Medical Works (BDOM) Bukavu. It has sufficiently qualified staff, including specialists, general practitioners, caregivers, and paramedical staff. Following the arrival of specialists and new services, it has increased its budget. It is a reference structure within the Kadutu HZ and takes care of the patients from other HZ, with good attendance in outpatient and hospitalization, whose services are highly regarded by the public.

Hospital structures in the last category generally have problems with the resources needed to meet the needs and demands for services and healthcare. They do not organize operational research but apply therapeutic protocols for care resulting from research by other institutions or the Ministry of Health. They operate with a low budget and do not benefit sufficiently from funds from donations from the public and organizations to support their operations. The medical staff of most of these structures have little or no involvement in the media. They do not take into account demographic data in their planning or the involvement of the community in decision making.

3.2. Achieving Goals

Only one structure, the HPGRB, has a satisfactory performance for this dimension. All other structures have an acceptable performance.

The HPGRB periodically conducts satisfaction surveys, with an average patient satisfaction rate of 80% in 2020 and 2021. It receives support from performance evaluation organizations such as the ICRC, WHO, and MSF and enjoys autonomy in diagnostic equipment and materials.

UOB University Clinics, in addition to satisfaction surveys, collect data from suggestion boxes to assess the level of appreciation of services and benefits by clients. They work with partner organizations to develop databases to assess and monitor performance. Ciriri GRH also receives technical support from BDOM to periodically assess the performance of services and operations in general.

Furthermore, the other structures do not benefit from permanent technical support from partner organizations to evaluate and support the performance of the services and care offered to clients. This generally limits the effectiveness and efficiency of the service in achieving the objectives of each of them. These structures record the low use of services, the vast majority of whose clients come from the health areas in which they are implemented. They even request certain paraclinical examinations elsewhere to confirm the diagnosis and schedule interventions, and this prolongs the waiting time of clients. The patient satisfaction study is not conducted in the majority of these structures.

3.3. Production

The study shows that 30% of the hospital structures in the urban HZ of Kadutu have a satisfactory performance for the “Production” dimension (HPGRB, UOB Clinic and Ciriri GRH); 60% have an acceptable performance (CBCA Nyamugo HC, Saint-Vincent HC, Kadutu GRH, ISTM HC, the Red Cross and Berna Polyclincs); and 10% have a worrying performance, the Maroy Fondation MC.

The structures with satisfactory performance are those that admit a large number of patients in the emergency and intensive care departments, are a reference structure, have a short length of hospital stay (except HPGRB and UOB clinics, which record more reference cases with chronic pathologies or having dragged on in the therapeutic itinerary). They organize services that are not available elsewhere such as neonatology and maintain contacts with other institutions, allocating additional resources to the services according to their use to maximize revenue. They regularly strengthen the capacities of the staff through in-service training, specialization, and operational research. These structures have developed different services and have a short waiting time for scheduled surgery.

Furthermore, the underperformance in the other category of structures (acceptable production) is due to the lack of certain services such as emergency and intensive care, the lack or obsolescence of diagnostic equipment, and the fact that they do not share services with other institutions. Relatively high healthcare costs were also noted in structures with underperformance. At Maroy Foundation MC, for example, most patients are followed up on an outpatient basis by general practitioners, and the waiting time for scheduled surgery is long due to the lack of a permanent surgeon.

3.4. Culture/Values

For this dimension, 30% of hospital structures have a satisfactory performance (HPGR, UOB Clinic, and Ciriri GRH) and the other structures have an acceptable performance. The performances are recorded in the structures where formal mechanisms for the discussion and resolution of conflicts, the management of ethical problems (ethics committee, complaints management committee, the union, etc.) have been set up and are functioning. The integration of organizational objectives by the members, the common philosophy of care for all staff members (the protocols of care displayed, applied, and discussed in medical staff meetings), and the consultation of staff by the steering committee (the maintenance of good communication between managers and providers) before any decision were also assessed.

Poor performance was noted in structures that do not provide staff training or opportunities to improve the management team members’ skills in leadership, conflict management, and ethical issues.

4. Discussion

The present study aimed to measure the comparative performance of hospital structures in the Kadutu HZ using the EGIPSS model, to draw lessons for their improvement. Unlike models that are purely quantitative or focus exclusively on financial or clinical indicators (such as the Balanced Scorecard model or ISO audit approaches), EGIPSS takes into account contextual, social and human aspects, which are essential for analyzing performance in a conflict zone. It takes into account not only medical outcomes, but also the system’s ability to adapt to instability, manage human resources under stress, maintain access to care despite logistical obstacles, and guarantee a minimum level of quality and equity in the delivery of services. One of the strengths of EGIPSS in this context is its qualitative dimension, which makes it possible to assess the resilience of hospitals in the face of challenges such as insecurity, mass population movements, chronic shortages and lack of regular funding. While other models struggle to integrate these realities in a coherent way, EGIPSS offers an adaptable and participatory framework, incorporating the perceptions of local stakeholders, in particular healthcare professionals, patients, and humanitarian partners. This collaborative approach is particularly valuable in areas where data is incomplete or unreliable.

The study highlights three key observations: (i) university-affiliated hospitals tend to demonstrate higher levels of performance; (ii) the various dimensions of the EGIPSS model within the hospitals studied are strongly interconnected and may influence one another; and (iii) limited capacity for resource acquisition (adaptation dimension) appears to be the component that poses the greatest challenge to hospital performance.

4.1. Combining Clinical Care with Research and Teaching Improves Hospital Performance

This study found that hospitals affiliated with academic institutions, such as the HPGRB and the Bukavu Clinic, demonstrated stronger performance across EGIPSS dimensions. These findings echo evidence from other low- and middle-income countries where teaching hospitals often benefit from greater access to specialized staff, continuous medical education, and advanced technologies [25,26,27]. Another fundamental aspect of university hospitals is their role in medical education. The integration of research and teaching enhances clinical care by promoting the uptake of evidence-based practices and fostering innovation in diagnostics and treatment pathways. In line with the findings from studies in sub-Saharan Africa and Latin America [28,29], academic hospitals in the Kadutu Health Zone were more likely to attract external funding, meet quality standards, and maintain structured feedback systems.

In addition, university hospitals often benefit from greater public and/or private funding than other types of hospitals, particularly for research, education, and the acquisition of cutting-edge technologies [27,29]. Adequate budget and institutional support help maintain a high level of quality of care and invest in innovation.

The culture of university hospitals generally encourages the continuous improvement of processes, integrating feedback from patients, healthcare professionals, and researchers [27]. This allows weaknesses to be identified and solutions to be implemented to improve the efficiency and quality of care. Finally, the organization of care in a university hospital often places particular emphasis on patient-centered care, thanks to diverse teams that collaborate to provide holistic and personalized care. Taking into account the psychological, social, and medical needs of patients, such as those with HIV [30] or chronic diseases [31], as well as communication with them, can improve their experience and, ultimately, their health outcomes [31].

4.2. Adaptability Significantly Influences Other Dimensions of the EGIPSS Model and Along the Way the Overall Performance of the Hospital

Our analysis suggests that adaptability is not only a standalone dimension but also a cross-cutting enabler influencing other EGIPSS domains. Hospitals that demonstrated stronger adaptability were more capable of addressing changes in patient needs, managing health crises, and navigating technological and regulatory transitions [18,32]. Regarding technological advances, they are essential in the hospital sector to improve the accuracy of diagnoses, the effectiveness of treatments, and the management of medical data through the electronic medical records [18]. Similarly to findings from evaluations using the WHO Health System Framework and the Balanced Scorecard in fragile settings [33] adaptability was associated with greater performance across human resources management, care quality, and patient satisfaction. The inability of Kadutu hospitals to integrate advanced technologies reflects broader digital disparities in African health systems. This technological gap hinders both clinical efficiency and institutional responsiveness. As for human resources management, it is a key dimension of hospital performance. In a context of shortage of qualified labor as it is in the DR Congo [34,35], hospitals must demonstrate a great capacity for adaptation to maintain a motivated and efficient team. This requires the effective management of recruitment, continuing training, and retention strategies. Furthermore, managing health workforce challenges—notably retention and motivation in a context of scarcity—requires adaptive leadership and governance. As highlighted in studies from post-conflict health systems [36,37,38], successful facilities invest in flexible HR strategies, including task-shifting, decentralized decision making, and locally adapted incentive schemes.

Kadutu HZ hospitals present unique challenges due to the socio-economic, cultural and environmental context, as well as resource limitations. However, these challenges can become levers for innovation and performance. By leveraging strong governance, effective human resource management, adapted technologies, resilient infrastructure, and close collaboration with the community and partners, hospitals can not only overcome challenges but also excel in a complex and dynamic environment. This also requires a long-term commitment to ensure the sustainability and performance of the health system [39,40].

4.3. To Adapt, Hospitals Need Resources and Good Management and Governance

Hospitals in the Kadutu Health Zone operate in a constrained resource environment, where outdated infrastructure, limited access to utilities, and fragmented supply chains pose significant barriers to performance. This aligns with regional studies showing that resource scarcity undermines both service delivery and strategic planning [41,42]. However, our findings also indicate that strong governance and targeted resource mobilization can mitigate some of these constraints. Hospitals with more transparent management and stronger linkages with external partners (including faith-based networks, NGOs, and local government) displayed better adaptability and more consistent performance.

Resources are also needed to support the universal health coverage system advocated in the DR Congo and equity of access to care. To move towards sustainable and equitable hospital performance, policy approaches must go beyond ad hoc investments. Strategic public–private partnerships, aligned with national health priorities and responsive to local needs, are essential. Our findings support the view that governance reforms—including decentralized planning, regular performance audits, and improved accountability—can enhance institutional resilience [3,43].

4.4. Limitations of This Study

This study has some limitations that warrant consideration. First, the assessment of hospital performance relied in part on subjective perceptions gathered through interviews with hospital managers and medical directors. While triangulation with document reviews and direct observations helped to mitigate this bias, the interpretation of questionnaire items and scoring may still reflect respondent subjectivity. Second, it was impossible to measure the variation of balances between the dimensions of the EGIPSS model because the data were collected, not in a recurring manner over several years but in a transversal manner, at a given moment in the life of the hospitals.

5. Conclusions

This study assessed hospital performance in the Kadutu Health Zone using the EGIPSS model, focusing on attributes across its four organizational dimensions. While the lack of longitudinal data limited the analysis of interdimensional alignments, key findings emerged. Hospitals that integrate clinical care with research and teaching tend to perform better overall. Crucially, adaptability strongly influences other dimensions and is closely linked to resource availability and governance quality. Improving adaptability in Kadutu hospitals requires a holistic approach—investing in infrastructure, training, technology, and governance. Learning from higher-performing hospitals may offer practical insights for improvement. Future research should explore these interconnections through longitudinal designs to capture performance dynamics over time and comparative studies across regions to contextualize findings more broadly.