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


The socio-economic growth in many low and middle-income countries (LMICs) 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 health needs. Responsiveness, a key goal of any national health system is “…when institutions… are cognisant and respond appropriately to the universally legitimate expectations of individuals... safeguarding of rights of patients to adequate… care” (de Silva, 2000; p.3) and its improvement is the focus of our study.

This study 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. We will co-produce, implement and evaluate context-sensitive interventions to improve systems responsiveness to the needs and expectations of pregnant women, particularly those with neglected mental health problems.

Project objectives

Our core question is: “In what way can health systems become more responsive to neglected health needs of vulnerable groups within the contexts of lower-middle-income countries? The project objectives are to:

  1. Conduct in-depth analyses of how health systems responsiveness is understood and enacted by key health systems actors, and to what degree the local health systems are responsive to these expectations;
  2. Co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to neglected health needs of vulnerable groups;
  3. Develop an empirically based and theoretically grounded model of complex relations between the contexts, the mechanisms and the outcomes of the interventions to improve health systems responsiveness;
  4. Develop transferable best practices for scalability and generalisability of the pilot-tested interventions;
  1. Strengthen research capacity through extending existing collaborations into strong South-South and South-North exchange and learning within and between Ghana, Vietnam and UK.

Theoretical framework

We approach health systems responsiveness as a dynamic social action which is produced via relationships between different actors within contexts of particular socio-economic arrangements as they negotiate experiences of professional, citizen, consumer and patient rights and responsibilities

Framework for health systems responsiveness (Adapted from: Mirzoev T and Kane S, BMJ Global Health 2017; 2(4): e000486, Figure 1)

Health systems responsiveness involves two socially constructed interactions:

  • internal (i.e. between policymakers, managers and service providers, for example in resource allocation, target-setting, staff supervision and performance appraisal)
  • external (i.e. between people and the system, typically during service provision)

Experiences of these interactions shape degree of health systems responsiveness across its eight domains: dignity, autonomy, confidentiality, attention, access to networks, quality of amenities, choice of service provider and trust. People’s engagements with health systems (e.g. to seek healthcare) and system’s responses to these engagements (e.g. service delivery) are shaped by their initial expectations from each side.


This theory-driven and mixed methods study will use Realist Evaluation as an overarching methodological framework. Realist researchers develop, test and refine middle-range theories which show causal pathways of how interventions work, for whom and under which conditions. Our initial theory, to be further tested and refined is:

Context-sensitive interventions for better recognition of initial expectations of key actors, if co-produced by these actors to target internal and external interactions and implemented within favourable policy contexts, will improve health systems responsiveness to neglected health needs of vulnerable groups, ultimately contributing to their better health outcomes.

The study comprises three Phases. In Phase 1, we will understand actors’ expectations of responsive health systems, identify key priorities for systems responsiveness, using evidence from the realist synthesis will develop initial programme theory. We will also generate a baseline through reviewing relevant documents and analyse facility records, conduct in-depth interviews, focus groups and community survey.

In Phase 2, we will co-produce the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. within health system) and external (i.e. people-systems) interactions through participatory workshops with health workers and communities, addressing priorities from Phase 1. The co-production will be through meetings with key local, district, regional and national actors, to be led by relevant health authorities and carefully documented by researchers.

In Phase 3, we will implement and evaluate the interventions. The implementation will be through existing structures and processes. In the evaluation, we will test and refine our initial theory through comparing the intended design to the interventions’ actual performance. We will also assess interventions’ feasibility, acceptability and processes.


Decision-makers from facility, district, regional and national levels in both Ghana and Vietnam will be continuously engaged through embedding research into policy and practice.

Key study outcomes and impacts will be: (1) improved health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex relationships 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. to different contexts, such as other health areas and countries) for future health systems strengthening.

Project Team

University of Leeds (Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences; School of Sociology and Social Policy)

Ghana Health Service

University of Ghana

Hanoi University of Public Health

University of Melbourne (Nossal Institute for Global Health, , Melbourne School of Population and Global Health)

If you are a researcher, practitioner or policy-maker interested in enhancing responsive health systems, we welcome and invite you to reach out to us