Measuring Hospital Performance Using the EGIPSS Model: Lessons Learned from Ten Hospitals in the Kadutu Health Zone in the Democratic Republic of Congo
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe paper offers a very clear reading. It addresses a critical issue (hospital performance measurement) in a challenging, resource-limited, and conflict-affected environment. This focus, especially during the COVID-19 pandemic, increases the study’s practical and academic relevance.
A. Introduction
We suggest expanding the background on the healthcare environment in DR Congo and the unique challenges faced by hospitals in the Kadutu Health Zone. This will help set the stage for why the EGIPSS model is particularly relevant. Also, we suggest to clearly articulate the gap in the literature that the study aims to address. Explain how the current study differs from previous performance evaluations in similar contexts.
B. Methodology
Please provide a more detailed explanation of the selection criteria for the ten hospitals (sampling). For instance, explain the rationale behind choosing hospitals with a “complete complementary package of activities” and clarify the exclusion process. Also, we believe that describing the process of sampling key informants (e.g., criteria for “reasoned choice”) and how the diversity of perspectives was ensured might enhance the paper's quality.
Please revise this section by providing a detailed description or an appendix containing the full list of 73 items used for the assessment. This will aid in reproducibility and allow readers to better understand the operationalization of the EGIPSS dimensions.
We suggest explaining how the rating scale (0 to 100) was validated. Also, consider including information on any software or statistical methods used.
C. Results
If applicable, include measures of variability (standard deviations, confidence intervals) and consider whether statistical comparisons between hospitals or dimensions can be made.
D. Discussion
We suggest deepening the discussion by comparing the findings with those from similar studies or other performance evaluation models. How do the challenges and strengths identified here relate to global trends in hospital performance?
E: Conclusion
We believe that reinforcing the main lessons learned, emphasizing how adaptability, resource availability, and governance are interlinked with performance would increase the quality of this section. Also, please suggest areas for further research, such as longitudinal studies to capture dynamic changes over time or comparative studies with other regions.
Comments on the Quality of English LanguageRevise some of the lengthy sentences for clarity. Ensure that technical terms are defined when first introduced.
Author Response
ANSWERS TO REVIEWER #1
The paper offers a very clear reading. It addresses a critical issue (hospital performance measurement) in a challenging, resource-limited, and conflict-affected environment. This focus, especially during the COVID-19 pandemic, increases the study’s practical and academic relevance.
a) Introduction
Comments 1: We suggest expanding the background on the healthcare environment in DR Congo and the unique challenges faced by hospitals in the Kadutu Health Zone. This will help set the stage for why the EGIPSS model is particularly relevant.
Response 1: Thank you for pointing this out. I/We agree with this comment. Therefore, we have added a paragraph in introduction in accordance of this comment as follow (Page 2, lines 43-47): “Also, in DRC, the healthcare environment is confronted with a serious problem of 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”
Comments 2: Also, we suggest to clearly articulate the gap in the literature that the study aims to address. Explain how the current study differs from previous performance evaluations in similar contexts.
Response 2: We agree with this. We have, accordingly, revised the paper to emphasize this point. Here is a paragraph that we have added at page 2, lines 52-56: “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 comparison with the country's standards). 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”.
b) Methodology
Comments 3: Please provide a more detailed explanation of the selection criteria for the ten hospitals (sampling). For instance, explain the rationale behind choosing hospitals with a “complete complementary package of activities” and clarify the exclusion process. Also, we believe that describing the process of sampling key informants (e.g., criteria for “reasoned choice”) and how the diversity of perspectives was ensured might enhance the paper's quality.
Response 3: Thank you again for this suggestion. We have improved the explanation regarding the selection criteria like this (page 5, lines 218-228) : “The selection of hospitals was guided by criteria aligned with the organizational standards for health facilities in the DRC. Facilities were included if they met the following conditions: (i) 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. Of the 30 hospital facilities identified within the Kadutu Health Zone, only 10 met the inclusion criteria and were therefore selected for this study (Table 1).”
For key informants sampling, we have added this paragraph to make the process more comprehensive (page 7, lines 279-286): “Participants were selected using a purposive sampling approach Different key informants were solicited by reasoned choice. 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.”
Comments 4: Please revise this section by providing a detailed description or an appendix containing the full list of 73 items used for the assessment. This will aid in reproducibility and allow readers to better understand the operationalization of the EGIPSS dimensions.
Response 4: Thank you for pointing this out. We have revised this section and add un appendix of the 73 items. Please found the revisions as follow (page 8, lines 320-327 and page 9, lines 328-330): “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 Gusset et al (2002) methodology. 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 analysed thematically using the EGIPSS framework, structured according to its four key organizational functions.”
Comments 5: We suggest explaining how the rating scale (0 to 100) was validated. Also, consider including information on any software or statistical methods used.
Response 5: Thank you again for this constructive comment. We clarified the scale in the above revised section. We added also a reference to Gusset and al (2002) paper which explain the methodology behind this scale.
c) Results
Comments 6: If applicable, include measures of variability (standard deviations, confidence intervals) and consider whether statistical comparisons between hospitals or dimensions can be made.
Response 6: Thank you for your comment. However, this is not applicable to our study. The aim was to see in which areas of the EGIPSS model hospitals performed better, and why.
d) Discussion
Comments 7: We suggest deepening the discussion by comparing the findings with those from similar studies or other performance evaluation models. How do the challenges and strengths identified here relate to global trends in hospital performance?
Response 7: In the revised paper, we have rephrased some sections of the discussion in line with your comment, thank you very much.
e) Conclusion
Comments 8: We believe that reinforcing the main lessons learned, emphasizing how adaptability, resource availability, and governance are interlinked with performance would increase the quality of this section. Also, please suggest areas for further research, such as longitudinal studies to capture dynamic changes over time or comparative studies with other regions.
Response 7: Thank you. Here is the revised conclusion based on your valuable comment: “This study assessed hospital performance in the Kadutu Health Zone using the EGIPSS model, focusing on attributes across its four organisational 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 contextualise findings more broadly.”
Reviewer 2 Report
Comments and Suggestions for AuthorsI enjoyed reading this paper and find the insights quite interesting. The paper is very well written in an engaging style.
There are a few improvements that will help to solidify the contribution of the paper to a broad reading audience. I number my comments here, but some are more important than others.
- The EGIPSS dimensions are presented somewhat differently at different points in the paper. In the introduction section and in section 2.2, the four main dimensions and some of the sub-dimensions are listed. However, the two sets of information are at odds with regard to patient satisfaction which is under the "goals" dimension in one place and under the "culture/values" dimension in another. Please double check the details here.
- Around lines 65-70, the authors state why the study is important and worthy of publication. The authors should expand on what they have here. There are broader reasons and broader explanations that can be provided to strengthen the foundation for why the paper is worthy of publication and why readers should continue reading. Setting this foundation early in the paper will significantly improve the paper.
- In section 2.1, the authors do not explain why the study was undertaken during the pandemic. Perhaps it was coincidence and perhaps there were other reasons, but this is not explained. Even if it was coincidence, it seems that the timing provides an unusual opportunity to study the hospitals during a time of great challenges and this can be brought into this section.
- Figure 1 is not in English. I am not sure if this is a publication requirement but something to be considered.
- In line 229, "3" should be "iii"
- The hospital names differ across Tables 1 and 2. These should be reconciled and a single set of names should be used.
- I have several comments related to lines 410-412 in the first paragraph of section 4 where the authors are summarizing the results of their analysis. I suggest several improvements to be made. First, the authors should not use the word "facts" since their qualitative analysis and their interpretation of results are at play here. These are not facts, and yet, the authors' interpretation of the data are the value here. The value is not facts but rather is the nuanced insights from the analysis. Second, under point (ii), the authors state a causal ("influences") relationship. Their analysis does not support this. They should simply state that these various dimensions are related, rather than that one may influence another. Third, under point (iii), the authors should only present their findings - that hospitals lack in certain areas - resources, etc. and not that some dimensions drive other dimensions. This is again written as if there is a causal relationship, while the analysis does not support the causal inference.
Finally, I congratulate the authors on their work and hope that my comments are helpful for improving their paper.
Author Response
I enjoyed reading this paper and find the insights quite interesting. The paper is very well written in an engaging style.
There are a few improvements that will help to solidify the contribution of the paper to a broad reading audience. I number my comments here, but some are more important than others.
Comments 1: The EGIPSS dimensions are presented somewhat differently at different points in the paper. In the introduction section and in section 2.2, the four main dimensions and some of the sub-dimensions are listed. However, the two sets of information are at odds with regard to patient satisfaction which is under the "goals" dimension in one place and under the "culture/values" dimension in another. Please double check the details here.
Response 1: Thank you for your comment. Patient satisfaction is addressed under the ‘goal attainment’ dimension. We have clarified this in the revised version.
Comments 2: Around lines 65-70, the authors state why the study is important and worthy of publication. The authors should expand on what they have here. There are broader reasons and broader explanations that can be provided to strengthen the foundation for why the paper is worthy of publication and why readers should continue reading. Setting this foundation early in the paper will significantly improve the paper.
Response 2: Thank you for this comment. We added this paragraph in the introduction section accordingly (Page 2, lines 57-65): “Moreover, the context of Eastern DRC presents a level of complexity that makes it difficult to assess hospital performance based on a single dimension alone. This complexity in-cludes the protracted crisis associated with armed conflict, which disrupts the organisation of health services and frequently necessitates adaptive strategies to maintain essential care. 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 [15, 16]. Additionally, the increasing “medicali-sation” of primary care—reflected in the presence of general practitioners in health centres—has further blurred the delineation of care levels and disrupted hospital activities.”
Comments 3: In section 2.1, the authors do not explain why the study was undertaken during the pandemic. Perhaps it was coincidence and perhaps there were other reasons, but this is not explained. Even if it was coincidence, it seems that the timing provides an unusual opportunity to study the hospitals during a time of great challenges and this can be brought into this section.
Response 3: That was just a coincidence. Thanks for your suggestion. Here's how we reformulated that sentence (Page 3, lines 92-94): “The 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.”
Comments 4: Figure 1 is not in English. I am not sure if this is a publication requirement but something to be considered.
Response 4: Thank you for this remark. The figure is in english in the revised paper.
Comments 5: In line 229, "3" should be "iii"
Response 5: Done, thanks.
Comments 6: The hospital names differ across Tables 1 and 2. These should be reconciled and a single set of names should be used.
Response 6: We reconciled them, thank you.
Comments 7: I have several comments related to lines 410-412 in the first paragraph of section 4 where the authors are summarizing the results of their analysis. I suggest several improvements to be made. First, the authors should not use the word "facts" since their qualitative analysis and their interpretation of results are at play here. These are not facts, and yet, the authors' interpretation of the data are the value here. The value is not facts but rather is the nuanced insights from the analysis. Second, under point (ii), the authors state a causal ("influences") relationship. Their analysis does not support this. They should simply state that these various dimensions are related, rather than that one may influence another. Third, under point (iii), the authors should only present their findings - that hospitals lack in certain areas - resources, etc. and not that some dimensions drive other dimensions. This is again written as if there is a causal relationship, while the analysis does not support the causal inference.
Response 7: Thank you very much for these observations. We totally agree with them. Here is a reformulation of this paragraph (page 14, lines 494-501): “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. 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 hos-pitals 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.”
3. Response to Comments on the Quality of English Language
Point 1: Revise some of the lengthy sentences for clarity. Ensure that technical terms are defined when first introduced.
Response 1: Thank you for this remark. We have clarified sentences and revised our English.
4. Additional clarifications concerning academic Editor Notes
We thank editorial team for his comments, which are intended to improve the quality of our paper. We have considered all the major recommndations that were addressed to us. Most of them match those mentioned by the reviewers. Here are the answers to them:
Point 1: Strengthen methodological rigor by justifying the scoring system, detailing the validation of tools, and clarifying how qualitative data were triangulated.
Response 1: Thanks again for this constructive comment. We have revised this section, providing further methodological clarification.
Point 2: Improve data analysis by incorporating more analytical comparisons across hospitals and using the EGIPSS dimensions more critically.
Response 2: Thank you for this comment. The aim of this study was not to conduct a statistical comparison of hospital performance, but rather to assess their performance levels using the EGIPSS model, through the triangulation of several predominantly qualitative data sources, including interviews, document reviews, and direct observations
Point 3: Tighten the discussion and conclusions, ensuring they are more directly connected to the findings rather than reiterating generic claims about hospital performance.
Response 3: Done, thanks
Point 4: Add a reflection on biases and limitations, especially regarding the subjectivity of data and the implications of the sample selection.
Response 4: Done, thanks
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThe authors have addressed our comments, significantly strengthening the paper’s clarity, methodological rigor, and contextual relevance. Many thanks for that.
Introduction: While the added context is valuable, a brief mention of how conflict dynamics in Eastern DRC exacerbate these challenges (beyond COVID-19) could further contextualize the study.
Methodology: The rationale for excluding 20/30 hospitals could be elaborated (for example, specific deficiencies in care packages or staffing). While the 0–100 scoring scale is referenced, a brief validation note (e.g., pilot testing) would strengthen rigor.
Discussion: The discussion could explicitly contrast EGIPSS with other models (e.g., Balanced Scorecard) to highlight its suitability for conflict settings.
Comments on the Quality of English LanguageMinor proofing necessary.
Author Response
The authors have addressed our comments, significantly strengthening the paper’s clarity, methodological rigor, and contextual relevance. Many thanks for that.
R/ Many thanks !
Introduction: While the added context is valuable, a brief mention of how conflict dynamics in Eastern DRC exacerbate these challenges (beyond COVID-19) could further contextualize the study.
R/ Thanks for the commentarie. A paragraph has been added to the introduction and highlighted in green(L84-L91): 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.
Methodology: The rationale for excluding 20/30 hospitals could be elaborated (for example, specific deficiencies in care packages or staffing). While the 0–100 scoring scale is referenced, a brief validation note (e.g., pilot testing) would strengthen rigor.
R/ Thank you for your review . The following sentences highlighted in green have been added:
L204 – 206 : The 20 hospitals excluded also had specific deficiencies in the care package, staff, equipment and drug supply.
L271 – L273 : For its validation, the 0–100 scoring scale was pre-tested in two functional hospital facilities in the neighboring Health Zone of Bagira.
Discussion: The discussion could explicitly contrast EGIPSS with other models (e.g., Balanced Scorecard) to highlight its suitability for conflict settings.
R/ Thank you for your review. We have added the following paragraph highlighted in green to the discussion section(L373-L386):
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 analysing 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.
Author Response File: 
Author Response.pdf
