Health systems responsiveness in low and middle-income countries (L&MICs): revisiting its scope

Health systems responsiveness (HSR) addresses the legitimate non-health expectations of the population and plays a vital role in strengthening health systems and enhancing population health. Identifying specific constructs or domains within HSR is particularly important in the context of low and middle-income countries (L&MICs) to facilitate targeted improvement. Following a comprehensive systematic review of the literature, we developed a conceptual framework for HSR. This study was designed to validate our proposed framework through a Delphi process.

Global HSR experts were contacted via email to participate in the study, and a copy of the proposed framework (12 domains, 53 subdomains) was shared with them. Participants were asked to rate each subdomain on a scale of 1-5, with 5 being the highest score; based on scientific strength, relevance and feasibility. They also provided suggestions to merge, omit or add domains and subdomains. A subdomain was retained if it received a rating of 4 or 5 from at least 70% of participants for scientific strength and relevance, and 50% or more for feasibility. The final version of the framework was shared with all participants for approval.

Thirteen global health experts participated in the Delphi process. Final version of the HSR framework consisted of 10 domains: respect for dignity, autonomy and confidentiality of information; quality of basic amenities; access to social support networks during care; choice of provider; prompt access to care; attention, clarity of communication and guidance; consideration of financial protection; coordination and continuity of care and 31 subdomains. The overall Cronbach's alpha values were 0.94, 0.93 and 0.96 for the categories of scientific strength, relevance and feasibility of assessment, respectively, indicating very high internal consistency among the Delphi participants.

We recommend using this framework to elaborate on HSR across L&MICs, after pretesting within specific contexts.