The health and well - being of the world's populations are closely linked to the performance of their health systems . This performance in turn depends largely on sufficient, high quality and motivated human resources. These are essential for providing users with quality health care that meets their individual and collective health status [2, 3]. Therefore, adequate human resource development is an important element in terms of planning, training, management and support for the professional development of health workers at all levels of the health system [3, 4, 5].
In its report on the World Health in 2006, the World Health Organization's (WHO) has mentioned that crisis in Human Resources for Health (HRH) is observed worldwide and particularly in sub-Saharan Africa . This crisis is mainly characterized by staffing problem, training profile, supervision and motivation and non-standard working conditions as well [3, 5, 6, 7]. Developed countries also variously face problems of health workforce supply. In France, the number of health professionals in training is regulated by the health system. However, the existence of a plethora or shortage is rather linked to an unequal geographical distribution between urban and rural areas and a poor distribution between primary and secondary care specialties .
In most countries, the training of health professionals benefits from fairly rigorous regulation involving both the academic organizations and the government (Ministry of Health and Ministry of Higher Education), so as to ensure monitoring and control during their work. This makes it possible both to regulate the number of doctors and other working health professionals. It also allows assessing the training quality and ensuring respect for the technical and ethical aspects of their job. .
Similarly, standards and procedures for recruiting staff in health structures exist and are generally applied by the regulation bodies: either the Ministry of the Public Service, the Ministry of Planning or the Ministry of Health itself .
In the Democratic Republic of Congo, human resource development is one of the six axes of the strategy for strengthening the health system adopted since 2006 and revised in 2010, and a document on staff standards in health zones (districts) has been drawn up [10, 11, 12]. This strategy is operationalized by a health development plan. The sector diagnosis of the 1st and 2nd edition plans identified the main priority problems of human resources for health, in particular the imbalance in the production and inequitable distribution of Human Resources for Health, the low motivation and loyalty of health personnel, the insufficient quality of education for health professionals and the poor development of the skills of health personnel [13, 14]. A national plan for the development of human resources for health has been drawn up in response to the problems identified. This plan aimed at «providing the health sector multidisciplinary, competent, high-performance health teams at all levels of the health pyramid, sufficient quantity and equitably distributed, contributing to the improvement of the state of health of the Congolese population through the provision of quality health care services". One of the proposed solutions is the establishment of a health information system on HRH and the national observatory of HRH. The latter already exists but is not documented .
Inside countries in crisis such as the DRC, human resources are an essential pillar of the health system because they are already part of the system and they also allow the health system to function at its best despite the crisis context. Several authors have shown how a staff could help reduce the adverse effects of the crisis on the health system [5, 16, 17, 18]. Some countries have used the crisis experience to try to reorganize their health systems. The experience of the Ebola Virus Disease (EVD) response, epidemic in Guinea, provided an opportunity to reorganize the health system by investing in the workforce. A post-Ebola study provided strategic guidelines for promoting the retention of health workers in rural areas (18).
As in most of African countries, the organization of the health system in the DRC is of the pyramidal type and includes three levels: the central level (National Ministry of Health), the intermediate level (Provincial Health Department) and the operational or peripheral level (the Health Zone) [10–14].
The DR Congo has just completed three decades of crisis and instability. Eastern DRC was the first part to be affected by the crisis with the first Rwanda war in 1994, which led to the Rwandan genocide and dumped 1 million of the refugees in the two Kivu provinces . Other crisis events have followed one another (the 1998 war, the Province crisis, the 2004 crisis in South Kivu, the Kasaï Oriental crisis and various movements of insecurity observed in various regions). Thus, Eastern DRC has been considered by some authors as the region at high risk of death, with the highest mortality rate since the Second World War. This crisis, whose number of deaths was initially estimated at 3 million in 2002 , woke up various specialists in armed conflict situations. A second study estimated the number of deaths linked to this crisis at 5 million . The country is currently considered as an "unstable country" or "fragile state", and some authors now speak of "mega crisis" .
Eastern DRC is still considered as a red zone and some foreign countries do not allow their citizens to visit the region despite the presence of MONUSCO for more than fifteen years [24, 25]. The province of South Kivu is among the three most affected provinces, after North Kivu and Tanganyika. The displacement of populations due to the intensification of violent inter-community conflicts, combined with the looting of healthcare institutions, have contributed to creating a volatile situation that has led to the flight of qualified health workers from the concerned areas .
During these various crises, the health system was supported by both international partners and local organizations. Support from the health system was sometimes directed towards the rehabilitation of infrastructure, the supply of equipment and other inputs. This support was sometimes as subsidization of health care for the indigent and displaced populations, or direct remuneration of staff in the form of bonuses [13, 14, 26].
At the provincial level, the Provincial Health Department (PHD) of South Kivu has grouped health zones into three categories in 2010 and 2015, according to a number of criteria: developing health zones, health zones in transition and emergency health zones. This categorization included social, economic and political conditions; insecurity or armed conflict, geographical accessibility, etc. .
The health institutions involved in the provision of care are either public or private, or they depend on faith-based networks. Two of these faith-based networks are predominant, namely the network of the Catholic Church through the Diocesan Office of Medical Works and the network of the Protestant Church. Although they have a monopoly on the management of health resources who are registered to the National Public services and enjoy the same benefits as those in the public sector in accordance with the memorandum of understanding signed by the Ministry of Public Health [10, 14, and 27]. With the new reform of the intermediate level, six working groups have been set up within the PHD, including the human resources working group, which normally has to analyze all the problems related to HHR and propose solutions [11, 28] but up to now this commission is not operational.
The issue of human resources only arises when people have to be assigned or decommissioned by the political authorities.
The general objective of this study is to analyze the level of application of regulations in terms of planning and management of human resources for health in the 3 health zones in the context of a crisis in order to enable policy makers to provide appropriate solutions.
Specifically, this study aims to:
assess the process of recruitment of healthcare workers and its impact to the performance of the studied health districts
compare some socio-demographic and economic characteristics such as age, gender, level of education, and average monthly income in the stable and crisis health zones;
Assess the treatment of health zone staff in terms of social benefits such as mechanization to the civil service, remuneration, in-service trainingThen better control of human resources in the health system would allow decision-makers to better plan and deploy human resources appropriately.