Introduction
Responsiveness, nowadays a well-recognised key objective of national health systems,1 2 was explicitly introduced in the World Health Report 2000.3 In the discussion paper which set the background for conceptualisation of health systems responsiveness by the WHO, it was defined as ‘…when institutions and institutional relationships are designed in such a way that they are cognisant and respond appropriately to the universally legitimate expectations of individuals…[including] safeguarding of rights of patients to adequate and timely care’ 4 (p. 3). Better understanding health systems responsiveness is particularly important for many low-income and middle-income countries which are experiencing fast-paced economic and social development. Responsive health systems anticipate and adapt to changing needs, harness opportunities to promote access to effective interventions and improve quality of health services,5–7 ultimately leading to better health outcomes.8 9
There is a growing body of literature on health systems responsiveness, though much of it refers to responsiveness as part of other concepts. For example, responsiveness has been described as a principle of wider governance10 and an outcome of relationship between the people and the state11 or service providers.12 Substantial literature on accountability13 and acceptability and trust14–16 also touches on the different aspects of health systems responsiveness. Responsiveness has also been used alongside the concept of health systems resilience, for example, in the 2016 Global Health Systems Research Symposiumi and in the current research.ii Although both responsiveness and resilience emphasise common systems characteristics such as its adaptive and transformative nature4 17–19 and addressing people’s needs is a key aspect of systems capacity to withstand everyday shocks and major crises,18 20 these are typically explored either discretely or in conjunction with broader concepts such as governance.9 17 18 20 21
Health systems responsiveness is a distinct, complex and not yet sufficiently explored concept.10–15 This perhaps explains lack of comprehensive frameworks that go beyond the normative characteristics of responsiveness of health services and also justifies the examination of responsiveness as a distinct phenomenon.
Conceptually, it includes two aspects. First is initial expectations from the people (ie, human rights bearing individuals, encompassing users and non-users of services and legal citizens and non-citizens) and the other health systems actors (most obviously, service providers and others such as managers and policy-makers) of how the individuals should be treated and within which environment.22 23 These expectations are likely to be shaped by social perceptions of what constitutes (ill-)health, needs, appropriate care and appropriate conduct during the care process. These expectations are shaped by characteristics of what services are available, their perceived quality and trust16 and the sociopolitical societal views on health as a human right.9 24
Second, shaped by the initial expectations, is the act of interaction itself—entailing the enactment of the multiple moments and processes of interaction between the people and the health system—shaping people’s experiences of these interactions. The most obvious point of interaction is the utilisation of health services9; this determines the experience of, for example, dignity, promptness or attention. Beyond the healthcare, the experiences of interaction are shaped by broader institutional arrangements, relations and interactions thereof, within the health system. These refer to, for example, the processes for people’s involvement in setting priorities or arrangements for oversight over healthcare and relations between various actors within the health system.4 25–27 Thus, health systems responsiveness includes a more proximal end encompassing the health services’ responsiveness (ie, how the individuals are treated) and a more distal end which is about wider system’s responsiveness (ie, the environment within which the individuals are treated).21 22
The most widely used framework for understanding health systems responsiveness was proposed by the WHO. It comprises seven elements against which responsiveness is measured: dignity, autonomy, confidentiality, prompt attention, quality of amenities, access to social support networks and choice of service provider.4 25–27 It covers different aspects of individual’s satisfaction with medical and non-medical aspects of healthcare3 28 and focuses on self-assessment within each element. Other frameworks represent either an extension of the WHO framework9 21 or focus on a specific aspect of responsiveness such as patient-provider interaction24 or provider accountability.29
In this paper, we draw on the understanding of responsiveness of public services,21 30–34 to add to and extend the growing, yet still limited and fragmented, knowledge on health systems responsiveness. The objective is to review, build on and extend the existing published knowledge on health systems responsiveness. More specifically, we: (1) review the current frameworks for understanding and assessing health systems responsiveness and (2) drawing on results of our review, and on key insights from the public services literature, propose a comprehensive conceptual framework for health systems responsiveness. In doing so, we also show how different concepts (satisfaction, perceived quality, rights, accountability and trust) are used, either interchangeably with or in relation to the concept of responsiveness. While we hope to trigger further thinking on the conceptualisation of health systems responsiveness, the proposed framework itself can inform future assessments, and strengthening, of health systems.
Our interest in health systems responsiveness stems from our previous analyses of policy, governance and regulation in different Asian and African contexts. We believe that this integrative piece will be of interest and relevance to different constituencies, including policy-makers and practitioners who may be interested in improving responsiveness of their health systems and academics who may be engaged in conceptualising and assessing health systems responsiveness.
The paper is structured as follows. After describing the methodology, we summarise the key frameworks for health systems responsiveness and identify the corresponding empirical work. We then reflect on key frameworks from beyond the health systems literature, to help identify the areas in which the current health systems literature can be usefully extended. Finally, we propose a comprehensive conceptual framework for understanding health systems responsiveness, building on both health systems literature and draws on key insights on service responsiveness from the public services literature.