Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol

Abstract

Background Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam. Methods We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors’ expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions’ actual performance. Discussion The study’s key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

Protocol for a realist synthesis of health systems responsiveness in low-income and middle-income countries

“…Initial stakeholder consultations will be in the form of in-depth interviews with purposefully identified key health systems actors (service users, communities, service providers and managers). These interviews are planned during the baseline data collection within RESPONSE to understand what responsiveness means to different health systems actors including its importance, underlying principles, components, mechanisms and intended outcomes, 22 and analysis of interview data will contribute to formulation of initial programme theories. The main output from this step will be a (longer) list of programme theories of how health systems responsiveness works in LMICs.…”

“…We will carefully document stakeholder views of causal pathways of how the interventions are intended to work to inform theory refinement, and through participant observations will also reflect on the coproduction processes. 22 The interventions to improve health system responsiveness will not be targeting individual elements of responsiveness in the WHO framework 1 but will seek to improve internal interactions (ie, within health system) and external interaction (ie, people systems), through series of participatory workshops with health workers and communities. 12 22 The main output from this step will be a (shorter) list of selected programme theories for subsequent testing.…”

“…We will draw on an approach used by Cooper et al where interview data were integrated with evidence from the literature in testing programme theories. 33 We already plan to evaluate effectiveness of interventions within the RESPONSE, 22 and we will use this primary data set for testing our programme theories. In each country, data collection will include combinations of about 60 in-depth interviews and 4–6 focus groups with purposefully identified key health systems actors (communities and service users, service providers), a multistage clustered household community survey with sample size estimated at 562 and review of relevant policy and facility documentation.…”

“…RESPONSE seeks to contribute to improving health systems responsiveness in LMICs through case studies of addressing neglected health needs of vulnerable groups in Ghana and Vietnam. As described in the RESPONSE protocol available elsewhere, 22 in Ghana, the study will be implemented in Greater Accra Region and in Vietnam, we will work in Bắc Giang Province. The study is being implemented jointly by the London School of Hygiene and Tropical Medicine, University of Ghana, Ghana Health Service, Mental Health Authority of Ghana, Hanoi University of Public Health, University of Leeds and University of Melbourne.…”

Perception of the primary health care response capacity by patients with and without mental health problems, and health professionals: qualitative study

“…People, especially the most vulnerable (and people with mental disorders are among this vulnerable population), are more likely to use services if health systems are responsive to their expectations. Conversely, people are unlikely to use services within unresponsive systems [18]. Yet, of the four intrinsic goals of health systems, that is, improving health, ensuring fairness in financing, efficiency, and responsiveness, it is responsiveness that is the least studied [17].…”