Abstract
Free maternal healthcare is a key strategy for accelerating progress toward Universal Health Coverage (UHC) in low- and middle-income countries. However, evidence from sub-Saharan Africa indicates that removing user fees alone does not ensure continuity and quality of maternal health services when health systems continue to face persistent financing, supply chain and governance constraints. Although the effects of these policies on service utilization have been widely documented, the organizational mechanisms explaining why some health facilities sustain service delivery while others struggle under the same policy remain poorly understood. To analyze and compare the organizational resilience mechanisms mobilized by health facilities to sustain maternal healthcare services during implementation of the national free maternal healthcare policy in the Democratic Republic of the Congo. This secondary qualitative analysis was conducted using data generated from an implementation fidelity evaluation of the free maternal healthcare policy. A multiple case study design was applied across three health facilities representing different levels of the Congolese health system: Renaissance University Hospital, Kintambo Maternity Hospital and Kenge General Referral Hospital. Data were obtained from semi-structured interviews, direct observations, document review and provider questionnaires used exclusively for triangulation. Thematic analysis, guided by the Health System Resilience Framework, explored the absorptive and adaptive capacities mobilized by health facilities. Comparative analysis identified three organizational resilience profiles. Renaissance University Hospital demonstrated adaptive resilience, maintaining service delivery through sustained organizational adjustments. Kintambo Maternity Hospital exhibited resilience under strain, relying on increasingly intensive adaptations to preserve continuity of care. In contrast, Kenge General Referral Hospital showed fragile resilience, where persistent reimbursement delays, shortages of essential medical supplies and weak institutional support ultimately resulted in interruption of the programme. Despite facing similar constraints, the three facilities developed distinct organizational responses, including internal service reorganization, prioritization of essential activities, alternative procurement strategies and adaptation of referral pathways. The sustainability of free maternal healthcare policies depends not only on removing financial barriers but also on health facilities' capacity to absorb disruptions and adapt their organization to sustain service delivery. Identifying differentiated organizational resilience profiles highlights the value of incorporating organizational resilience into the evaluation of Universal Health Coverage policies to strengthen their long-term sustainability in fragile health systems.