Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam
Lead Research Organisation:
London School of Hygiene & Tropical Medicine
Department Name: Public Health and Policy
Abstract
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.
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.
Technical Summary
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.
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.
Planned Impact
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.
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.
Publications
Do TTH
(2023)
Using the WHO Self-Reporting Questionnaire-20 (SRQ-20) to Detect Symptoms of Common Mental Disorders among Pregnant Women in Vietnam: a Validation Study.
in International journal of women's health
Lakin K
(2023)
A critical interpretive synthesis of migrants' experiences of the Australian health system.
in International journal for equity in health
Lakin K
(2022)
Peoples' expectations of healthcare: A conceptual review and proposed analytical framework.
in Social science & medicine (1982)
Lakin K
(2024)
"We can't expect much": Childbearing women's 'horizon of expectations' of the health system in rural Vietnam
in Health & Place
Mirzoev T
(2021)
Protocol for a realist synthesis of health systems responsiveness in low-income and middle-income countries
in BMJ Open
| Description | Conference presentation at international symposium |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Policymakers/politicians |
| Results and Impact | An in-person poster presentation at the 7th Global Symposium on Health Systems Research, Bogota Colombia, 31st October-4th November 2022, 'Navigating complex realist methods to meet real world challenges of improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam' by first author Anna Cronin de Chavez and co-authors Kimberly Lakin, Ana Manzano, Sumit Kane, Trang Thi Do, Irene Agyepong, Tolib Mirzoev. There were 1800 participants, some attending in person, some online. Participants spoke to us in person at the event and contacts us via Twitter to enquire more about the study and methods used |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://healthsystemsresearch.org/hsr2022/ |
| Description | Inputs to a webinar from the Pan American Health Organization on "Making Evaluations Matter to Address Inequities" |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | In November 2021 Dr Ana Manzano presented in an online webinar on how a realist evaluation approach has the potential to better understand the contexts and mechanisms that are critical to enhancing equities. Using real world examples, including the example of the RESPONSE project this webinar covered how to conduct a realist evaluation while evaluating interventions that have the aspiration of reducing health inequities. This included theory-driven approaches in evaluation; conceptualizing and measuring contexts, mechanisms and outcomes for health equity interventions; testing theories of changes; understanding heterogenous mechanisms in addressing inequities: what works for whom, under what conditions?; the role of power in generating and addressing inequities; systems, contexts and inequities. The webinar had simultaneous interpretation in Spanish, English and Portuguese. Impact: Around 300 registrees Central and South American made up of policy makers, WHO staff, evaluation leaders and practitioners. Networking with of the Evaluation Centre for Complex Health Interventions at the University of Toronto and Country Lead, Learning Systems and Systems Evaluation at the Bill and Melinda Gates Foundation who were co-organizers. Impact: Colleagues and audience reported views on change and opinion. The webinar was recorded and it is on the PAHO /WHO Americas Website reaching thousands of potential audience attracted daily to their website which maximizes search engine results. |
| Year(s) Of Engagement Activity | 2021 |
| URL | https://www.paho.org/en/events/incorporating-contexts-and-mechanisms-addressing-inequities-how-condu... |
| Description | International conference presentation |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | An in-person oral presentation on 'How to Deal with National Contexts in Cross-Country Comparisons Using Realist Evaluation and Synthesis' at the 14th European Evaluation Society Biennial Conference: Evaluation in an Uncertain World: Complexity, Legitimacy and Ethics in Copenhagan, Denmark 6-10 June 2022. There were 600 delegates from over 60 countries. Manzano shared her session with Carlos Tarazona (senior evaluator at FAO, Food and Agriculture Organization of the UN; Andrew Fife (Head of Evaluation at the United Nations); and Dr. Bianca Montrosse-Moorhead, University of Connecticut and former American Evaluation Association board member. Around 50 people attended the talk with many sat on the floor as space was tight and interest higher than expected by organisers. The topic of methodological challenges of cross-country comparisons using the example of RESPONSE was very well received by an audience of transnational professional evaluators who saw the benefits of comparing through extremely different countries; instead of seeing differences as an inherently negative methodological problem. Manzano's LinkedIn post about her presentation was liked by many professional evaluators, it received 844 impressions and Dr Montrosse-Moorhead wrote: "It was an honor and a pleasure to be in a session with you. Fantastic work you shared today!" |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://europeanevaluation.org/events/13th-ees-biennial-conference-evaluation-for-more-resilient-soc... |
| Description | International conference presentation |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Policymakers/politicians |
| Results and Impact | An in-person poster presentation at the 7th Global Symposium on Health Systems Research, Bogota Colombia, 31st October-4th November 2022, 'Maternal mental health care in Vietnam: system level gaps and opportunities for change' by first author Bui Thi Thu Ha and co-authors Do Thi Hanh Trang, Le Minh Thi, Nguyen Thai Quynh Chi, Le Thi Vui, Tolib Mirzoev and Sumit Kane. There were 1800 participants, some attending in person, some online. |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://healthsystemsresearch.org/hsr2022/ |
| Description | Presentation at an international symposium |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Other audiences |
| Results and Impact | An in-person poster presentation at the 7th Global Symposium on Health Systems Research, Bogota Colombia, 31st October-4th November 2022, 'Understanding and improving health system responsiveness to needs of vulnerable populations - emerging lessons from Ghana and Vietnam' by first author Tolib Mirzoev and co-authors Bui Thi Thu Ha; Irene Akua Agyepong; Ana Manzano; Do Thi Hanh Trang; Anthony Danso-Appiah; Le Minh Thi; Mary Eyram Ashinyo; Le Thi Vui; Leveana Gyimah; Nguyen Thai Quynh Chi; Lucy Yevoo; Thi Thuy Duong Doan; Joseph Paul Hicks; Anna Cronin de Chavez; Sumit Kane. There were 1800 participants, some attending in person, some online. |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://healthsystemsresearch.org/hsr2022/ |
| Description | Stakeholder engagements to co-produce interventions to improve health service responsiveness in Ghana |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Fifty-eight stakeholders in maternal mental health in Ghana attended a meeting over two sessions. The participants included maternal health clients, frontline health providers, district health managers, a representative of the mental health authority and a representative of local government. The purpose of the stakeholders meeting was to discuss the baseline findings from the RESPONSE project, and to co-produce the interventions to improve health systems responsiveness for pregnant women with mental health problems. Stakeholders were put into groups of five to discuss the findings and the series of Health Workers for Change workshops discussed. The interaction with the stakeholders revealed several ways by which findings from the baseline could contribute to co-designing the interventions over the subsequent workshops planned over the following weeks. |
| Year(s) Of Engagement Activity | 2023 |
| Description | Stakeholder engagements to co-produce interventions to improve health service responsiveness in Vietnam |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Professional Practitioners |
| Results and Impact | A total of 16 meetings were held in Vietnam with different stakeholders (policymakers, frontline health providers, patients) to discuss needs and feasible plans of integrating maternal and mental health services at PHC level, as part of the co-production of interventions to improve health systems responsiveness to the needs of pregnant women with mental health problems in Ghana. The purpose of the stakeholders meeting was to discuss the baseline findings from the RESPONSE project, and to co-produce the interventions to improve health systems responsiveness for pregnant women with mental health problems. The intervention will be implemented in 2 district hospitals, 3 commune health centres and 1 private clinic over the coming year. |
| Year(s) Of Engagement Activity | 2022,2023 |