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.