Strengthening health system responsiveness to citizen feedback in South Africa and Kenya

Citizens in LMICs experience a range of problems with public and private health services: from poor quality of services to rights violations. In spite of numerous calls and interventions for increased community participation in health, service users and citizens often do not have adequate opportunities to engage with the system about their problems and induce appropriate responses and remedies. Responsiveness to citizens' rights and needs is an essential quality of health systems, and is necessary in order to provide inclusive and accountable services, ensure the social rights of citizens and improve the quality of services. Mechanisms for feedback and response are varied and result in dispersed and sometimes conflicting feedback. These range from conventional facility-based complaints boxes and exit surveys to strategies such as community report cards, social audits, and hotlines. Citizen feedback at community-level has also been sought by implementing health facility committees, intersectoral forums, and community monitoring systems. Growing access to information technology in LMICs has often empowered citizens to raise their concerns through social media, the mainstream press, and even through social protest.

Health system responsiveness is gaining global currency as an intrinsic goal of health systems alongside service delivery outcomes, financial fairness and equity. However our current understanding of health system responsiveness is extremely limited, and there is a significant evidence gap about the structure, implementation and effectiveness of citizen feedback and the related response mechanisms about health services currently in place in LMICs. In this study, we aim to address these knowledge gaps by asking: What policies and mechanisms (formal and informal) work for receiving and responding to citizen feedback on health systems in South Africa and Kenya? How can health systems responsiveness be strengthened towards the development of learning, equitable health systems?

The proposed study is an interdisciplinary mixed methods study, running from 2018 to 2020. The study will be conducted in three phases, and we will apply several, primarily qualitative methods and tools. The first phase will consist of 'mapping' of policies, feedback mechanisms and pathways for system responsiveness in the study provinces (as well as theoretical and methodological framing relating to responsiveness). Many governments in LMICs are recognising the pressing need to improve health system responsiveness, and both countries in this study have recently implemented significant policy reforms aimed at improving responsiveness to citizen feedback on health services. We will capitalise on this window of opportunity, with the second in-depth phase consisting of case studies in each country, tracking the implementation experience of a particular innovation in this area. The third phase will focus on knowledge translation and cross-country comparison.

This project will contribute to a deeper and more systematic understanding of health system responsiveness in South Africa and Kenya, with relevance for other comparable LMICs. By applying an embedded approach to HPSR, it is intended that the research will also have a health system strengthening effect: creating space for reflective practice, strengthening feedback and response within the system, and improving decision-making opportunities for HS leaders. Therefore, this study on responsiveness to citizen feedback should also improve the responsiveness of the health systems in which it is implemented. In each country, we have partnered with policy decision-makers engaged in implementing reforms for greater health system responsiveness, and this study will directly help bring about improvements in these policies. We will also engage with other health system and civil society leaders to identify strategies to strengthen health system responsiveness.

The World Health Organisation's (2000) Health Report framed responsiveness as a critical issue in health system (HS) strengthening - as critical as financing. However, between the two, financing has dominated HS research and practice agendas, with responsiveness largely something mentioned in policies but rarely addressed in practice. A review of the focus of HS research attests to this, with several thousand more publications on health financing against a small handful of studies assessing HS responsiveness.

In health system development and research, there is growing attention on HS resilience and responsiveness (as evidenced by the focus of the 2016 HSG 4th Health Systems Research Symposium). However, the concept of 'health system responsiveness' remains poorly developed and experience vary greatly. In addition, the tools for measurement remain focused on patient experience (such as satisfaction), whilst the approaches for strengthening HS responsiveness are inadequately understood. These issues are especially important in LMIC settings given their historic inequities and the perceived value of HS responsiveness in addressing these.

It is therefore urgent to investigate and strengthen HS responsiveness in LMIC systems. We need to identify and evaluate the mechanisms already in place that are intended to improve HS responsiveness. We need to build the knowledge-base on how to improve these, strengthen HS responsiveness to issues raised, and ultimately strengthen health systems. On a technical level, this means pushing the current framing of HS responsiveness beyond the narrow understanding of responsiveness as the 'non-health' aspects of the patient contact experience. It requires a movement towards a conceptualisation of responsiveness as a characteristic and function of a 'complex adaptive health system', influenced by the decisions and actions of an array of HS actors who draw on varied streams of feedback for decision-making.

The primary beneficiaries are:
Health system decision-makers (mainly public sector): This research should provide them with new information about the responsiveness of their HS, including the effectiveness of existing feedback mechanisms. This should also inform strategies for HS strengthening interventions, informing policy formulation and implementation. Those who are drawn in more fully should also see benefits from reflective practice and co-production of knowledge, in support of decision-making. These benefits should be realised within the project life-span.

Civil society organisations and representatives: In both countries civil society is active in the HS at all levels, usually seeking to strengthen health systems by providing feedback, but very often this feedback does not reach decision-makers. We seek to strengthen the feedback loop between community, civil society and the health system, and in some cases improve the relationship between civil society and the HS (to be realised within the project life-span).

Health workers: Health workers often get blamed for poor feedback. However, it is our intention to understand what the systemic barriers to feedback and response are. This should facilitate better communication, provide some health workers with an opportunity to give insight into policy-level decisions, and possibly lead to improved community engagement and better working conditions. These benefits should be realised within the project life-span (although some are longer-term).

Established health systems researchers: the researchers (and their institutions) will benefit from engagement in this project by strengthening their HPSR experience and capacity, and especially by engaging in S-S collaboration (the sharing of experiences and skills). Added benefits include a strengthened relationship with the local health system, which might result in future research opportunities. These benefits will be realised immediately (in fact, some have already emerged).

Emerging HPS researchers and leaders: As a result of the linked research and teaching elements, students (who in our contexts are usually emerging HPS leaders) will benefit by being exposed to these HS contexts, by gaining experience in engaged research; and by being exposed to the cross-country engagement. They will be given opportunities to utilise HPSR methods and develop relationships with the HS and with HPS researchers in other countries. These benefits should be realised within the project life-span.

Policy makers and decision-makers in other LMIC settings: This research has the potential to impact on other LMIC HS decision-makers, as well as international agencies who engage in HSS interventions with these. This research will highlight key areas and strategies for HSS intervention and implementation, in particular because of the cross-country comparison that should provide added generalisability to other LMIC systems. This should be realised within the 3-year time-span.

HPSR Researchers: This research should have relevance to other HPSR researchers for whom HS responsiveness is an interest. These would benefit not only from the results, but also from the theoretical and methodological developments (communicated in peer-reviewed and informal publications during the project life-span as well as afterwards).
Health-seeking citizens: We seek to strengthen response to citizen feedback, by ensuring that feedback is taken into account in decision-making, and possibly to highlight feedback loops that are not functioning as intended. This seeks to increase the accountability of the system to citizen feedback. Ultimately, this research has the potential to strengthen feedback mechanisms, which should make the system more responsive and more robust, and therefore better equipped to serve the citizens utilising the system - enhancing quality of life and health outcomes. This is a longer-term benefit, observable after the research has ended.