Analysis of hospital performance from the point of view of sanitary standards: study of Bagira General Referral Hospital in DR Congo
Original Article

Analysis of hospital performance from the point of view of sanitary standards: study of Bagira General Referral Hospital in DR Congo

Hermès Karemere1,2, Joseph Mukwege3, Christian Molima1, Samuel Makali1

1Université Catholique de Bukavu, Ecole Régionale de Santé Publique, DR Congo; 2Université du Cinquantenaire de Lwiro, DR Congo; 3Bagira General Referral Hospital, DR Congo

Contributions: (I) Conception and design: H Karemere, J Mukwege; (II) Administrative support: H Karemere; (III) Provision of study materials or patients: J Mukwege; (IV) Collection and assembly of data: J Mukwege, H Karemere, C Molima; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Hermès Karemere, MD, MPH, PhD. Université Catholique de Bukavu, Ecole Régionale de Santé Publique, DR Congo. Email:

Background: This study determines hospital performance in terms of the operating standards of a General Referral Hospital (GRH) established by the Democratic Republic of the Congo (DRC) Ministry of Health in relation to the organization of a hospital, its package of activities, the resources available, its architectural structure and its environment.

Methods: A descriptive, cross-sectional study conducted in 2017 at Bagira Reference General Hospital in the city of Bukavu, in DRC. Data collection used the literature review, observation and interviews. The data were compiled using Excel spreadsheets, analyzed using Word and Excel, and presented as proportions and qualitative observations. All results were compared to the standards of the Ministry of Health of the DRC for the GRH functioning.

Results: Based on the 5 components analyzed relating to the operating standards of an GRH, the level of performance is variable depending on each component. Standards are sometimes completely achieved, sometimes partially, sometimes not reached. Gaps hampering the operation of the hospital were identified using this standards-based performance assessment model.

Conclusions: Measuring hospital performance according to standards is one of the perspectives that can guide managers to improve the quality of the care provided. The operating standards of the Bagira GRH are on average reached partially, jeopardizing the quality of patient care. While local efforts can be made to raise the hospital’s organizational level, improving the quality of the hospital activity package requires significant funding from the government.

Keywords: General Referral Hospital (GRH); health standard; performance; governance; Bagira; South Kivu; Democratic Republic of the Congo (DRC)

Received: 14 October 2019; Accepted: 05 March 2020; Published: 25 March 2020.

doi: 10.21037/jhmhp.2020.03.02


The hospital structure is part of a health system and as such it constitutes a system of care. It includes people and all activities and interventions whose primary purpose is to prevent, diagnose and treat health problems (1,2). The hospital will thus have to guarantee that each patient receives the combination of preventive, diagnostic and therapeutic acts which will assure him the best result in term of health, according to the current state of the medical science, at the best cost for the same result (efficiency), at the least iatrogenic risk (efficacy), and for its greater satisfaction in terms of procedures, results and human contacts within this system of care.

In the Democratic Republic of the Congo (DRC), a country that has adhered to the Alma Ata declaration on primary health care, the analysis of the provision of hospital care is generally only considered in the context of functionality of a health zone (HZ). The role of the hospital and in particular the General Referral Hospital (GRH) and its importance for the development of a HZ are reaffirmed (3-5). In addition to the provision of health care as a complementary package of activities (CPA) to the package of activities of the front line structures, the hospital in the DRC also has the mission to provide education and training, retraining of health professionals, operational research, quality control and supervision of first-level health structures namely health centers (HC) (6).

The DRC hospitalis no longer able to fulfill its mission for various reasons, the main ones being: poor governance, under-financing of the health system as a whole and the hospital in particular, weaknesses in the development of human resources, the living conditions of the patient in hospital, the deteriorated infrastructure, medical and non-medical equipment and materials, and inaccessibility to good quality drugs. These issues were carefully analyzed during the development of the strategic plan of the hospital reform in DR Congo initiated by the Ministry of Public Health in 2010 (7). The central problem identified for the entire hospital system of the Democratic Republic of Congo was the poor access of populations to quality health care. Four major direct causes were criminalized, namely: unsatisfactory governance in hospitals, unfair access of populations to health care, inadequate training of health personnel and health research to the needs of the sector, the poor quality of services and care provided to the population (7).

There seems to be a consensus on the importance of a hospital performing well and measuring its performance in order to improve it, but consensus on the approach to measure this performance does not seem to be established (8,9). The Bagira GRH organizes activities in a concrete context (South Kivu in eastern DRC), unstable (post-conflict armed situations) and changing (unstable human resources, casual partners). In such a context, measuring hospital performance in a conventional manner and then evaluating it can be difficult, costly and even controversial, mainly because of a lack of necessary, reliable and accurate data (1,10).

Through studies conducted in the context of developing countries, several concepts have been used in turn to designate hospital performance, including the operation of hospitals according to standards (6,11), patient satisfaction (12,13), quality of care (14), service delivery (10), service effectiveness (15) or profitability (16,17).

Taking into account all these concepts, dimensions and sub-dimensions that they entail, the performance of a hospital structure can be defined as its ability to establish and maintain a dynamic tension between the achievement of its mission (achievement of goals), the acquisition and control of resources, human resource development (well-being of workers and human development),integration and predictability of its production activities (18).

We have taken the perspective to analyze the Bagira GRH according to the standards set by the Ministry of Health of Congo.The operating standards of a hospital (6) are indeed a modality of regulation of a system of care and have constituted the main analytical framework of the Bagira GRH. The Ministry of Health of the DRC defines the operating standards of a GRH in relation to the organization of a hospital, its package of activities,the resources available, its structure and its environment. In this work, the performance of Bagira GRH is analyzed according to these five components of the standards, in a multidimensional approach. This model is closer to the normative model of Donabedian's rational action system (19). The objective of this study is to measure the hospital performance of Bagira GRH in terms of the operating standards established by the DRC Ministry of Health.


Presentation of the BAGIRA GRH

BAGIRA GRH serves an estimated population of 131,102 inhabitants (2016). The services it organizes are: Pediatrics, Surgery, Obstetrics of Gynecology, Internal Medicine, Laboratory, Ultrasound, Radiology, Reception, Pharmacy, Consultation, Voluntary Testing and Taking Center in charge of HIV patients, the family planning service, Maternal and Child care service, Administrative Services and Emergencies.

General methodological approach

Type of study

A descriptive, cross-sectional study using document review, participant observation and individual interviews.

Data collection

Document review

The study used the existing data at the hospital, collected as part of the national health information system (NHIS) between 2013 and 2016. Data collected relates to the patient's situation (rights, satisfaction), organization of the GRH (organized services, organized activities), the resources available at the hospital and the internal and external environment of the GRH. In order to extract this type of information, the documents consulted were: patient cards and various registers of services (consultations, laboratory, reception, transfer, presence, finance, accounting, personnel management, NHIS periodic templates, slip registration, input management sheets, etc.).

Participant observation

It focused on the organization of the hospital, the package of activities offered, the resources available, the structure and the environment. The principal investigator has meticulously reported all his observations weekly in a notebook. He was then medical director at Bagira GRH. The information has then been encoded using Word software by the secretary of the hospital initially formed on the study. The information mentioned in the reports of the services and validated during the meetings of the management committee of the hospital were compared to those collected by the principal investigator for their validation.

Interviews with key players

The interview consisted of oral questions to caregivers and patients during the study period about their perception of hospital benefits. Semi-closed questions were used during the interviews, addressed in particular to 200 patients who had been cared for in the BAGIRA GRH between 2013–2016 and 45 targeted care providers at random. They focused on the status of patients (rights and satisfaction especially), the organization (services and activities), the available resources and the environment of the GRH. A patient was considered to be satisfied with the care when he claimed to know his rights, that these rights were respected and that he could recommend relatives to this hospital.

Data analysis

Data on the status of patients’ rights were grouped and described according to the prevailing trend. The information about the activities, the resources and management tools, the architectural structure and the hospital environment were compared to the Health’s standards of functionality of a GRH in DR Congo to assess the level of Bagira GRH’ performance.

Ethical considerations

The study protocol was approved by the ethics committee of the Catholic University of Bukavu. Data collection was carried out in strict compliance with law and order and the moral integrity of the people interviewed. Informed, free and verbal consent was obtained prior to administering the questionnaire. Data was collected anonymously and confidentially, protecting the privacy of each respondent during encoding and data analysis.


Situation of patients’ rights at Bagira Hospital

The proportion of patients satisfied with care is 69% during our study. The patient rights situation is summarized in Table 1.

Table 1
Table 1 Status of patients’ rights at Bagira GRH
Full table

Organization of GRH Bagira

The organization and functioning of the Bagira GRH do not always meet the standards (Table 2).

Table 2
Table 2 Organization of services at GRH Bagira
Full table

Activities of CPA

Degree of achievement of activities of the CPA at GRH Bagira (Table 3).

Table 3
Table 3 Degree of achievement of activities of the complementary package of activities at GRH Bagira
Full table


Human resources

Human resources at Bagira GRH (Table 4).

Table 4
Table 4 Human resources at Bagira GRH
Full table

Financial resources

Elements of financial resources (Table 5).

Table 5
Table 5 Elements of financial resources
Full table

Material ressouces and equipment

Material resources and equipment are insufficient. In each service as shown in Table 6, equipment and materials planned areincomplete.

Table 6
Table 6 Availability of basic equipment
Full table

Among the material resources management tools, the hospital does not have title deeds or cadastral documents (Table 7).

Table 7
Table 7 Availability of material resource management tools and drugs
Full table

Drug management

Essential drugs are often available even though there have been some ruptures as shown in Table 8 in 2016.

Table 8
Table 8 Availability of drugs at the Bagira GRH in 2016
Full table

Architectural structure of Bagira GRH

The dimensions of the buildings proposed by the Ministry of Health to a hospital with the capacity of 100 beds per 100,000 inhabitants are not satisfied. The hospital had originally been designed as a health post before to be transformed into a hospital center and then a GRH in the Bagira HZ without the possibility of compliance with standards. The hospital has kept the old laboratory, maternity, laundry and other services that do not currently meet the standards in every respect.

These dimensions concern the administrative department, the outpatient department, the internal medicine department, the pediatric service, the surgery department, the operating theater, the gynecological obstetric department, the maternity ward, the laboratory, the central office of the health area (if included in the GRH), pharmacy, radiology, laundry room, central kitchen, both incinerators and garage.

The radiology room is not far enough away from busy areas. The electrical installation does not allow to have a three-phase electric current of 240–380 V + neutral + earth 30 to minimum. A 20 KVA breakdown generator and a solar panel are available but often out of order or not functional.

The site where the hospital is located is not polluted, but is close to traffic. The terrain is not spacious enough to allow for possible extension. The site is well connected to the existing road network, the terrain is slightly hilly. Aseptic areas are separated from septic areas.

Hospital environment

Situation of the environment within GRH Bagira (Table 9).

Table 9
Table 9 Situation of the environment within GRH Bagira
Full table

Only 14 out of 21 standards of the environment within GRH Bagira are fully met.


This chapter is devoted mainly to the discussion of the main results concerning the characteristic of the hospital, the organization of the services, the activities of the CPA, the resources, the structures of the hospital, the internal and external environment of the hospital and the evolution of hospital indicators. Standards are not reached at Bagira GRH.

Patient Satisfaction at Bagira GRH

The proportion of satisfied patients care offered at the GRH Bagira is 69% in our study. The measure of satisfaction is generally based on multiple means, complaints, exit questionnaires, but also specific or general surveys (20,21). One of the limitations of our study is the impossibility of determining the aspects of care on which patient dissatisfaction is observed due to the absence of a complaint committee at the GRH or a specific satisfaction questionnaire. The suggestion box is not used by patients and misses the hospital’s innovative ideas (22) that patients would bring to improve the quality of care.

Regarding the rights of patients, they are welcomed and treated without any discrimination related to sex (gender), race, religion, membership of a political group, tribal or other specific. Patients consider that their right to information is respected, albeit to varying degrees. The right to confidentiality has not been analyzed. However, patients can not protest when their rights are violated because they do not know them. The most effective way to protect the rights of patients is either the existence of a person with specialized knowledge of patients’ rights or the creation of an internal committee of the hospital (23). The GRH has not developed a policy to strengthen respect for patients’ rights. In fact, 50% of the interventions are based on verbal consent and in 50% of the other cases, the consent of the patients is not formalized before surgery.

Organization of services

Standards are not reached in the organization of hospital services. The capacity is 1 bed for 2007 inhabitants but in reality it would be 1 bed per 1,004 inhabitants in view of the low use of the hospital by the inhabitants of Bagira (56% in 2016). The standard defined by the Ministry of Health is disconnected from the reality of hospitals in urban areas and thus requires a revision due to the creation of new structures providing hospital care in the Bagira HZ but also the facility for patients to go to nearby areas seeking non-existent care at Bagira Hospital. Several services planned and useful to the population are not organized; this is the case of the emergency and resuscitation service, as well as so-called specialized services (including ophthalmology, otorhinolaryngology, orthopedic or physiotherapy). General services are also lacking (laundry, maintenance, carpentry, electrification, logistic, morgue...). The use of an hospital can thus be influenced by the organized services and the care offered (24)

CPA activities

The analysis of activities of the supplementary package of activities (CPA) at GRH Bagira demonstrates some deficiencies that would hinder the quality of care and ultimately the performance of the hospital (2). Among these shortcomings are noted, the low equipment (almost 46% of the required equipment is not available), the lack of intensive care and emergency for lack of resuscitation service, the partograph badly held at the maternity, the non-organization of rehabilitation activities (kinesiology, physiotherapy, equipment) or lack of psychosocial support for lack of psychologist.

Resources of the Bagira Hospital

Overall, the resources at Bagira Hospital do not support the standards. The total number of staff is 61 in 2017 instead of 43, which is 42% more. Some human resources are missing (anesthesiologist, physiotherapist), others are more numerous (nurses). Caregivers represent 75% of all staff compared to 25% of administrative and support staff. The levels of competence and motivation of staff can influence the performance of a hospital (25); they do not were measured in this study.

The payment of care by the population is the main source of funding for the hospital (78% in 2016). The State budget allocation is non-existent, cost recovery is 63% mainly due to the poverty of the population in DR Congo (26,27). The flat rate is applied to the Bagira hospital offering an advantage of access to care for the poorest and a disadvantage for the managers to measure the real cost of the acts of care.

Material resources and equipment are insufficient. In each service, equipment and materials planned are incomplete.

This negatively interferes with the quality of care provided and the use of the hospital (2). The availability of drugs is an important factor in the quality of care. Despite a few days of stock-outs observed at Bagira Hospital, the latter has worked well in recent years.

Hospital structures at the architectural level

The building does not meet the standards in terms of dimensions. The Hospital was before designed as a health post and has become a GRH with the same facilities that do not meet the structuring standards. In such buildings and premises, some services are difficult to operate with an impact on the quality of patient reception and care. The hospital architecture must be the factor and the instrument of the hospital cure (28).

Environment (Water-Hygiene and Sanitation) at Bagira Hospital

At the Bagira hospital, 67% of hygiene standards are fully respected, 29% partially respected and 4% not respected. The non-permanence of water in the hospital is the most crucial problem. The analysis of knowledge of healthy practices in relation to hygiene was not carried out as part of this study.

Limitations of the study

The main limitations of this study primarily concern the methodological approach based on standards. Indeed, the study could not explore the other dimensions of performance (29,30) due to limited data collection from the start. Secondly, the tools used to measure patient satisfaction (23) as well as those used to assess their rights could not be representative of all aspects.


The objective of the study was to contribute to the performance and the good functioning of the BAGIRA GRH by identifying the information on the current operation of the BAGIRA GRH against the standards; the main factors that can reduce performance and to identify interventions adapted to the context may improve performance.

The study shows that the standards are not met and describes the limitations of the study, essentially from a methodological point of view. The study also questions the relevance of certain standards such as hospital capacity or the number of employees by occupational category, particularly in urban areas.

Efforts should be made at different levels to improve the performance of the Bagira Hospital in relation to the organization of services, the organization of activities of the CPA, the availability of resources, the development of structures at the architectural level and the internal and external environment of the hospital. The approach used can be improved in another hospital to produce a hospital performance assessment tool.




Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study protocol was approved by the ethics committee of the Catholic University of Bukavu. Data collection was carried out in strict compliance with law and order and the moral integrity of the people interviewed. Informed, free and verbal consent was obtained prior to administering the questionnaire. Data was collected anonymously and confidentially, protecting the privacy of each respondent during encoding and data analysis.


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doi: 10.21037/jhmhp.2020.03.02
Cite this article as: Karemere H, Mukwege J, Molima C, Makali S. Analysis of hospital performance from the point of view of sanitary standards: study of Bagira General Referral Hospital in DR Congo. J Hosp Manag Health Policy 2020;4:5.