Sustaining health system progress in fragile settings: Lessons from South Kivu
Improving health outcomes in fragile and conflict-affected settings requires sustained commitment, resilient systems, and alignment between programmes and broader contextual realities.
A recent assessment led by hera examined the impact of the fifth round of the Programme d’Appui au Système de Santé du Sud Kivu (PASS V) on the health system and population outcomes in South Kivu in the Democratic Republic of Congo. The programme was supported by the Swiss Agency for Development and Cooperation (DDC) through its office in Bukavu. The evaluation aimed to assess programme performance, capture lessons learned and inform future investments—including the ongoing Programme Santé Maternelle et Infantile (PSaMI).
Assessing the impact of PASS V
The evaluation followed a rigorous mixed-methods approach, where 119 stakeholders were consulted across 25 organisations, combining:
A literature and documentation review
Analysis of secondary quantitative data
35 key informant interviews and 6 focus group discussions
Participants included implementing partners, donors, government authorities, and other key actors involved in health system strengthening initiatives in the province. Quantitative data were analysed using structured datasets, while qualitative information was transcribed, anonymised, and thematically analysed. Findings were triangulated and validated during a restitution meeting with provincial health authorities.
The final report provided a detailed assessment of PASS V results, strategic guidance for the ongoing PSaMI programme, and an advocacy note focused on sustaining maternal and child health services in the province.
A rights-based focus on Primary Health Care
The evaluation placed the right to health at the centre of the analysis, with particular attention to access to and utilisation of primary health care services for mothers and children.
The mission also examined how programmes addressed the needs of particularly vulnerable groups, including women and children in remote and underserved communities, sex workers in mining areas and survivors of gender-based violence.
By considering these populations, the assessment sought to understand whether programme interventions were reaching those most at risk of exclusion from essential health services.
When progress meets fragility: External pressures on health systems
While the evaluation confirmed that PASS V contributed to important improvements within the provincial health system, it also highlighted significant external factors that threaten the sustainability of these gains.
South Kivu continues to face complex structural challenges typical of fragile and conflict-affected contexts. These include:
Persistent security instability in certain areas
Economic vulnerability affecting households’ ability to access care
Structural weaknesses in health system financing
Dependence on donor-funded programmes for key services
Such factors create an environment where progress achieved through targeted programmes can quickly erode if broader systemic conditions are not addressed.
The evaluation emphasised that health system strengthening efforts must account for these contextual realities to ensure that programme gains can endure beyond the lifespan of specific interventions.
Another important finding concerned programmatic coherence between successive and parallel health initiatives. As PASS V transitioned toward the implementation of the Programme Santé Maternelle et Infantile (PSaMI), the evaluation highlighted the importance of maintaining continuity of essential services and avoiding fragmentation between different donor-supported interventions, thus ensuring alignment between programme objectives and health system priorities
To address this risk, the evaluation included an advocacy note aimed at preserving the legacy of PASS V and supporting the effective implementation of PSaMI, with specific recommendations to sustain maternal and child health services in the province.
Partnering for stronger health systems
The experience in South Kivu highlights an important lesson for global health programmes: achieving progress is only the first step—ensuring that gains are resilient to external pressures is equally critical.
Strengthening health systems in complex environments requires rigorous analysis, strategic planning, and close collaboration with governments and development partners. Drawing on experience in programme evaluation, health systems strengthening, and stakeholder engagement, hera supports organisations in assessing impact, identifying systemic risks, and designing strategies that sustain health gains over time.
If your organisation is seeking support to evaluate health programmes, strengthen policy coherence, or develop evidence-based strategies in challenging contexts, the hera team would welcome the opportunity to collaborate. Contact us at hera@hera.eu.