Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam

Responsive health systems improve utilisation of services and improve health outcomes. Yet, it is a least studied health systems goal, especially in low- and middle-income countries (LMICs).

Despite significant progress, maternal health remains an international and national priority, and is highly inequitable in Ghana and Vietnam. However, mental health in pregnancy and postpartum are often neglected alongside the more mainstream maternal health priorities; this represents a challenge which responsive health systems should effectively address.

This study seeks to improve health systems responsiveness to neglected health needs of vulnerable groups in LMICs. We will explore interpretations of responsiveness by key actors (people, healthcare providers, managers) to inform the design, implementation and pilot-testing of health systems interventions to make systems more responsive to the maternal, including neglected mental, health needs of women from vulnerable groups.

We will work in Ghana and Vietnam, which were selected because their different commonalities and differences provide excellent cases for cross-country comparisons and developing transferable best practices, there is high interest from policymakers and our strong collaborations which will enhance South-South exchange and learning.

In each country, we will select two districts. Within each district, we will intervene at district hospital, 2-4 primary health care facilities and communities. However, we will also engage with key decision-makers at the regional/province and national levels to maximise the interventions' sustainability, replication and scaling up.

This 42-months study will be theory-driven, utilising our expertise in the realist approach and will include three Phases: In Phase 1 we will understand actors' expectations of responsive health systems, drawing on literature from realist synthesis will develop an initial working theory, will identify key priorities for the interventions and generate a baseline. We will review relevant documents and analyse facility records, conduct in-depth interviews, focus groups and community survey. Data will be analysed using a retroductive approach.

In Phase 2, we will co-produce the context-sensitive interventions. We will consolidate, adapt and extend our experiences in Ghana and Vietnam to address key priority areas from Phase 1, relating these to responsiveness and our initial theory. These will inform meetings in each district with key actors to co-produce the interventions, to be led by the district health leadership and facilitated and documented by researchers. The interventions will focus on improving internal and external interactions from our framework, using low-cost participatory and interactive workshops with staff and communities.

In Phase 3, we will implement and evaluate the interventions within local contexts. The implementation will be conducted through existing structures and processes. In the evaluation, we will test our theory through comparing the planned to the actual performance of the interventions through adapting and extending Phase 1 methods.

Local, regional and national decision-makers will be engaged throughout, using the embedded approach to research and development. The key study's outcomes and impact will be two-fold: (1) improved health systems responsiveness to the complex health needs of vulnerable groups and therefore contribution to improved health equity in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex relations between the contexts, mechanisms and outcomes of the interventions, along with transferable best practices for scalability (i.e. expansion within similar contexts) and generalisability (i.e. expansion to different contexts, such as other health areas and other countries) for future health systems strengthening.

The socio-economic growth in many LMICs has improved availability of healthcare, where people increasingly demand health systems to be more responsive to their needs. Yet of all health systems goals, responsiveness is the least studied particularly in LMICs.

This study seeks to contribute to improving health systems responsiveness in LMICs through the case studies from Ghana and Vietnam. We will co-produce, implement and evaluate context-sensitive interventions to improve health system responsiveness to neglected mental health needs of vulnerable pregnant women.

We interpret systems responsiveness as socially-constructed interactions between the people and their health systems. We will use a mixed-methods theory-driven case study design, combining qualitative and quantitative methods.

In each country, we will focus on two district health systems as our case studies. In each, we will intervene in the district hospital and 2-4 public and private primary health care facilities. However, we will also engage with relevant decision-makers at the province and national levels to ensure longer-term sustainability, replication and scaling up.

This 42-months study will include three Phases. In Phase 1, we will review theories of how responsiveness works and explore actors' expectations of responsive systems. In Phase 2, we will co-produce the context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups. In Phase 3, we will implement and evaluate the interventions within the local contexts to inform their integration within routine practices.

Decision-makers will be engaged through embedding research in policy and practice. The study outcomes will be: 1)improved health systems responsiveness to health needs of vulnerable groups and 2)a model of complex relations between the contexts, mechanisms and outcomes of the interventions, along with transferable best practices for scalability and generalisability.

We expect our research to have policy impact in Ghana and Vietnam and beyond, through:
i. consolidation and extension of expertise in how to advise policymakers on development and implementation of effective health policies
ii. utilisation of a rigorous multi-disciplinary approach to inform co-design, implementation and evaluation of interventions to improve health systems responsiveness
iii. extending our robust academic collaborations into strong South-South collaborations, exchange and learning, including links amongst policymakers and practitioners from Ghana and Vietnam
iv. capacity strengthening and use of an innovative research approach in politically stable African and Asian countries with steady socio-economic growth
v. advancement of theories on how to strengthen health systems in low- and middle- income countries

The key beneficiaries are:
a. Policy-makers and implementers at facility, district, province/regional, country, African/Asian and global levels responsible for development and implementation of policies related to maternal health, mental health and health systems strengthening
b. Local, national and international civil society organisations and user associations with interest in improving health systems' accountability to health needs of local people
c. Academic institutions interested in health systems and policy research and strengthening
d. Local, national and international media with a focus on health and social issues.

The economic and societal impact will be generated through the following:

1) Improved health policies
The national and local decision-makers will be provided with evidence of effectiveness of the interventions to improve health systems responsiveness. This will enable them to make informed decisions about the future health systems strengthening, ultimately contributing to health equity.

The comparative analysis will equip policymakers in the two countries and beyond, with an understanding of what works for whom and under what circumstances, to allow future health systems strengthening and development of accompanying legislation at different levels.

2) Improved policy implementation and health service provision
Ghanaian and Vietnamese policy implementers and practitioners at different levels will improve their understanding of how to best identify and address health needs of vulnerable groups.

The research will inform the need and possible paths, for a change in culture and practices within health facilities to improve their responsiveness to health needs of vulnerable groups.

The results will also increase public awareness and advocacy by the civil society organisations in these two countries, on how to strengthen provision of maternal and mental healthcare to vulnerable groups.

3) Improved health systems
Improved policymaking and service provision will inform improvements to responsiveness of national health systems, thereby contributing to health systems strengthening in Ghana and Vietnam.

The documented transferable best practices best practices for scalability and generalisability of the pilot-tested interventions will contribute to improvements in national health systems in these two countries and beyond.

International policymakers (e.g. WHO) will be able to use the evidence from this study to inform future guidance and frameworks for assessments and strengthening of national health systems.

4) Improved health outcomes and equity
Ghanaian and Vietnamese women with compounded effects of vulnerability at intersection of income, gender and other characteristics and their societies, will benefit from improved insights into how to make health systems more responsive to their circumstances.

In the long-term, improved health outcomes of vulnerable groups will ultimately contribute to better health equity in each context.