Examining health system responsiveness policy in Kenya and South Africa: A content and framing analysis of policy documents 1994-2024

Examining health system responsiveness policy in Kenya and South Africa: A content and framing analysis of policy documents 1994-2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Examining health system responsiveness policy in Kenya and South Africa: A content and framing analysis of policy documents 1994-2024 Nancy Kagwanja, Sassy Molyneux, Lucy Gilson, Benjamin Tsofa, Gadija Khan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8624444/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Health system responsiveness is regarded as a core goal of health systems, both for its intrinsic value and its potential to contribute to inclusive, participatory, and accountable health systems. Although responsiveness is frequently mentioned in health policy documents, the public experience challenges in engaging with and eliciting responses from health systems. There is also limited receptivity to public concerns by policymakers and health providers. We analysed national policy documents for responsiveness content and framing with the aim of identifying how to strengthen policy proposals towards more responsive health systems. Methods We conducted a three-stage qualitative analysis of Kenyan and South African policy documents: ( 1 ) policy document retrieval; ( 2 ) data extraction and coding; and ( 3 ) content and framing analysis. We analysed purposively selected public sector plans, legislative instruments and health-sector specific plans and policies released between 1994 and 2024 (n = 28 [Kenya]; n = 26 [South Africa]). Documents were identified from government and Ministry of Health websites. Results Responsiveness was framed differently across the analysed texts. Public sector and legislative instruments primarily adopted public participation frames, while health sector documents predominantly framed responsiveness as ‘health service feedback’. Within health sector policy documents, the measurement of responsiveness was underdeveloped, with no clear overarching strategy to support the achievement of system responsiveness. There was also little evidence of intention to integrate feedback from multiple channels and limited description of monitoring and evaluation of feedback mechanisms. There was almost no attention to how public feedback could be used to shape a responsive health system. Conclusion In Kenya and South Africa, while legislative and public policy documents had a broad and inclusive remit for responsiveness, health policy documents had a narrow focus with a dominant ‘health service feedback’ framing. This framing undermines a systemic approach to responsiveness by inadequately addressing equity challenges and power and knowledge differentials between the public and health system actors. Integrating the broader frames identified in public sector and legislative instruments (public participation, accountability) into health policy documents can re-define health system responsiveness to include a focus beyond service delivery, attention to the wider public, including varied population segments and vulnerable groups. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Health system responsiveness is regarded as one of the core health system goals alongside health outcomes, fairness in financing and efficiency (1). As framed by the World Health Report (WHR) 2000, responsiveness comprises two main categories (respect for persons and client orientation), with seven underlying elements related to dignity, confidentiality, autonomy, prompt attention, quality of amenities, choice of provider, and access to social support networks (for those receiving in-patient care) (1, 2) . Responsiveness also has an equity dimension, focusing on distribution and level of responsiveness in the WHR 2000 (1). However, Khan et al illustrated that the experiences of minorities and vulnerable groups are rarely explored in the responsiveness literature (3). Literature also suggests that for many members of the public, access to feedback channels and the ability to leverage responses is often inequitable and determined by citizens’ social and educational status and their social capital (1, 4-7). Two recent reviews described responsiveness as a complex, and multi-dimensional health system goal but for which most research evidence has focused on service delivery encounters (3, 8). Such a focus is perhaps driven by the use of the WHO framing of responsiveness which tends to focus on individual service users and providers’ interactions (3). In this paper, we adopt and apply the definition of health system responsiveness as how the health system reacts/responds to the needs and concerns of citizens (9). This conceptualisation of responsiveness contains some overlap with the concept of accountability, and has been described elsewhere in a related paper(10). This conceptualisation of responsiveness identifies three processes as important for developing a health system that is responsive to public feedback: receiving feedback from the public, processing (such as integration, analysis and/or prioritisation of feedback from multiple sources), and systemic response (9, 10) (Figure 1). The term ‘feedback’ then refers to the views, concerns, priorities, and information provided by the public, while feedback channel/feedback mechanism refers to the avenues through which these might be shared with health system actors. Figure 1: Authors’ conceptualisation of responsiveness(10). Concerning the practice of health system responsiveness, the literature contains mention of interventions aimed at developing responsiveness such as the introduction of feedback mechanisms. These include community level feedback mechanisms such as clinic committees, intersectoral health forums, or community monitoring (11-14) and individual level feedback mechanisms such as complaints boxes, exit surveys, and incident reports. Other mechanisms include score/report cards, social audits, toll-free hotlines and web-based portals (15, 16). However, within the responsiveness literature little attention has been paid to how functional such mechanisms are towards building responsive health systems (3). Generally, responsiveness is often treated as a ‘nice to have’ that is prioritized below service provision; and while it is frequently mentioned in health system policies, guidelines and value-statements – especially in low--and-middle-income countries (LMICs) – there is limited evidence on whether such references change practice. There is therefore value in examining how responsiveness has been conceptualised in national policy documents. Such an examination (of policy documents as products of the policy process), is one way to understand an issue and uncover the assumptions embedded in written policy, that could have implications for practice (17, 18). We conducted a content and framing analysis of policy documents from two sub-Saharan countries - Kenya and South Africa - to determine, i) what is the content on health system responsiveness in policy documents, and to whom is responsiveness targeted? ii) how is responsiveness framed within policy documents and iii) what mechanisms, processes and actors are described in policy for enhancing health system responsiveness. This work was part of a larger study in both Kenya and South Africa whose overall goal was to examine health system responsiveness to public feedback. The review of policy documents was therefore part of the contextual analysis to understand responsiveness in these two countries. Background: Kenyan and South African Health Systems and Health System Responsiveness Kenya and South Africa are comparable (Table 1 ), both having plural health systems, with similar low ranking in the 2000 health system assessments, and a similar value-base (such as a public sector oriented towards Universal Health Coverage (UHC) and equity). Both countries’ health systems simultaneously display similar challenges: for example, geographical ( 19 – 21 ) and wealth disparities ( 22 , 23 ) in access, and cultural differences that frequently flare up into social protest or unrest ( 24 – 26 ). Both countries have devolved government structures. County and sub-county (Kenya) and provincial and district (South Africa) managers play a pivotal role in the development, management and delivery of public health services ( 27 ). Table 1 Key policy initiatives and specific feedback mechanisms in Kenya and South Africa Political Economy and Health System Context South Africa Kenya LMIC: Middle-income classification ( 28 ) Political Independence:1994 WHO HS ranking (2000):175/190 ( 1 ) LMIC: Lower middle-income classification ( 28 ) Political Independence: 1963 WHO HS ranking (2000): 140/190 ( 1 ) Key HS Characteristics • Legislated national health system incorporating public & private ( 29 ) • Provision of equitable health-care services and a rights-based approach (especially for children and pregnant women) ( 29 ) • District health system in place to implement the PHC approach ( 30 , 31 ) • HS moving towards UHC (piloting NHIS)( 32 , 33 ) • Vibrant civil society (advocacy and service provider, local and international actors ( 34 – 36 ) Key HS Characteristics • Legislated national health system incorporating public & private ( 37 ) • Provision of equitable health-care services (especially for children and women) ( 38 ) • A history of a (district HS) PHC approach ( 39 , 40 ) • Moving towards UHC ( 41 , 42 ) • A civil society that is acknowledged in health policy and studies as a critical or key stakeholder in the HS ( 43 , 44 ) Health System Responsiveness • Studies report responsiveness challenges and inequalities for certain vulnerable populations for example, inequalities in responsiveness among vulnerable groups such as the poor( 45 ), women with disability( 46 ), the elderly ( 47 ) and among street-connected youth( 48 ) • Health System actors consider responsiveness (and equity) to be a core value of the HS( 49 , 50 ), but also a continued challenge (for example, feedback mechanisms experience multiple constraints in their functioning) ( 51 – 54 ) Through the introduction of local government (which had some health service responsibilities) in 1977 and the district health system in the 1980s, Kenya experienced health system reform characterised by re-orientation of a centralised health system to a decentralised one with structures aimed at enhancing public participation at district, and community level ( 39 ). These reforms were intended to promote the health status of all Kenyans by improving accessibility, affordability and effectiveness of health services ( 37 , 40 ). However, even though the ‘‘people’’ (communities, households, and individuals) were identified as key policy actors in these health sector reform processes, they were functionally excluded and had little or no voice in policy development and implementation processes ( 39 ). In 2010, Kenya adopted a new constitution, ushering in devolution in 2013, which featured broad political reform aimed at enhancing equitable resource allocation across regions and communities, and public involvement across all phases of the policy process and resource management ( 55 , 56 ). Devolution significantly impacted the health system including introducing new actors, structures and processes that influenced the governance and organisation of the health system ( 56 – 58 ). Similarly, within the devolved governance structure enshrined in the 1996 constitution, the South African health system has experienced reforms aimed at improving health inequity in the post-apartheid period (since 1996) – including the establishment of a ‘district health system approach’ and an emphasis of community participation in policy decisions ( 59 ). However, the early efforts of the Reconstruction and Development Programme of 1994 ( 60 ) to develop ‘people-driven’ policies and plans were constrained by lack of clarity around powers and responsibilities, and challenges in co-ordinating peoples’ participation in policy formulation. Subsequent policy documents such as the White Paper for the Transformation of the Public Sector ( 61 ) and the White Paper for the Transformation of the Health System ( 62 ) continued to emphasise community participation in improving communication between the public and the health system, respectively, across the policy process. Despite these efforts, across countries there continues to be uncertainty about the extent to which continuing health system reforms support effective engagement with the public, and inclusion of their voice in policy making ( 10 , 59 , 63 ). Methods We conducted a qualitative analysis of policy documents - an approach that has been widely used in health policy and systems research (HPSR) ( 64 – 67 ). The analysis was conducted in three phases: ( 1 ) policy document retrieval, ( 2 ) data extraction and coding, and ( 3 ) content and framing analysis. All the policy documents included were analysed using a two-step deductive and inductive process namely data extraction and coding and framing analysis. A related systematic mapping and review of literature (reported elsewhere)( 3 ) was useful for identifying terms related to health system responsiveness (Table 2 ). Table 2 Summary of words and phrases searched and coded for in policy documents Words and phrases searched for in the policy and legislative document Responsiveness Health system responsiveness Public service responsiveness Accountability Social accountability Public participation Community participation Community involvement Community engagement Citizen participation Citizen involvement Citizen engagement Social good Social rights Citizen Rights Patient’s rights Needs of minority groups Needs of marginalized groups Citizen views Community views Population views Citizen voice Community voice Population voice (Legitimate) Expectations of users Expectations of clients Expectations of the population User satisfaction patient satisfaction Citizen satisfaction The primary policy document selection process was conducted in an iterative manner searching across policy materials from the last three decades (1994–2024). Four researchers (NK, GK, NS, JO) searched the websites of the National ministries of health of South Africa and Kenya for health sector specific policies. The health sector specific policies included national health sector strategic plans and policies as well as health sub-system (such as community health, mental health, primary healthcare) policy documents (Supplementary material_1). A secondary search of broader national level public sector documents was also conducted. We found it necessary to include broader public sector policy documents because often, governance principles adopted for the wider public sector will apply in some ways to the health sector. Where documents were not available online, hard copy documents were sourced. Initial primary document selection was conducted as a team and guided by senior researchers with long-term experience in the respective health systems. For the South African documents, we considered documents published or released from 1994 onwards (the end of apartheid rule). Kenyan documents were also limited to those published or released from 1994 (when Kenya released its first health policy framework) onwards. Once the selection process was complete, we read and re-read documents to establish their main content. We then developed a content coding sheet in Microsoft Excel for each document and coded for the items summarised in Box 1 below. • The purpose of the document and influences in the development of the document • Specific reference to the term responsiveness • Use of other terms linked to responsiveness (Table 2 ) • To whom responsiveness is directed (public, patients/clients, community) • Mention of vulnerable groups and which vulnerable groups are mentioned • Feedback mechanisms mentioned or established within the legislative or policy documents • Actors identified as responsible for responsiveness or functioning of feedback mechanisms • Measurement of responsiveness (indicators for tracking responsiveness) Box 1: Items coded for within policy and legislative documents To understand how responsiveness policy is constructed in both countries, we employed framing analysis which is a form of interpretive policy analysis ( 17 ). Framing analysis is concerned with how problem definition is linked to policy solutions. Frames highlight certain aspects of a problem, diagnose causes, and propose solutions ( 17 , 18 ). By asking how responsiveness is ‘framed as a policy issue’ we sought to understand how policy documents articulate or describe responsiveness and what arguments are used to support varied views of responsiveness. To elicit frames from the policy documents, we considered to whom responsiveness is targeted, which methods are proposed to enhance responsiveness, and with what objectives. Results Overall, 54 primary policy documents were included in this policy analysis (28 Kenyan and 26 South African) – a full list of these is provided in Supplementary Material 1. In this section we present our findings in three parts. First, we present policy content on whether and how responsiveness was mentioned within policy documents, to whom responsiveness was targeted, and proposed evaluation of responsiveness; next we present findings related to how responsiveness was framed, and finally we consider the functioning of feedback mechanisms proposed to enhance responsiveness. Content of responsiveness within policy documents and legislative instruments Frequent mention of responsiveness, but lacking an overarching strategy Across the two countries, twenty-seven documents explicitly mentioned the term ‘responsiveness’. Box 2 below illustrates the different ways in which responsiveness was referred to in these documents. Kenya South Africa • A value and principle of public service ( 68 – 73 ) or principle to guide implementation of the policy ( 74 – 76 ) • An objective, goal or broad aim of the health system ( 77 – 83 ) • A value or guiding principle for public service provision ( 61 , 62 , 84 – 86 ) • An outcome of effectively functioning health systems ( 87 ) • An outcome of well-functioning feedback mechanisms ( 88 ) • A requirement to meet the needs of the community ( 89 ) ( 62 ) and health service users ( 90 , 91 ) Box 2: How responsiveness is referred to in legislative instruments and policy documents in Kenya and South Africa Despite these broad references to responsiveness, closer inspection of the content in the policy documents revealed little continuity across documents or emerging trends over time, and few specific directives that could guide action on building a responsive health system. In both countries, responsiveness was often mentioned in the prefaces and opening statements of the analysed policy texts. For example, in the foreword of the Kenya Health Policy (KHP) [1994–2010], the then Minister for Health states: ‘Throughout [the implementation of health sector reforms proposed in the KHP (1994–2010)], the locus for the executive control of resources will undergo further, functional decentralisation. This will ensure that local health authorities become both more autonomous and more responsive to local needs’ (pg 4). Following this introduction, responsiveness was not referred to again in the KHP (1994–2010). Notably, since responsiveness was first referred to in the KHP (1994–2010),and later highlighted as a broad goal of the health system by the KHP (2014–2030), there has not been a single overarching strategy for enhancing health system responsiveness. Similarly, in South Africa, responsiveness was stressed in the 2017 White Paper for National Health Insurance (the defining focus of the South African policy environment at this time), which noted that NHI will seek to: ‘…ensure a more responsive and accountable health system that takes into account socio-cultural factors whilst prioritising vulnerable communities. Such a people-centred integrated healthcare service platform should also improve user satisfaction, lead to a better quality of life of the citizens and improved health outcomes across all socioeconomic groups. This will contribute towards improved human capital, labour productivity, economic growth, social stability and social cohesion.’ ( 92 ) However, in the later NHI Act 20 of 2023, the word or concept does not appear at all. There is brief mention of how PHC Outreach Teams will “facilitate community involvement and participation in identifying health problems and behaviours” and that there is a need to “promote community participation in the planning, provision and evaluation of health care services" ( 93 )– but nothing on how NHI would make the South African health system more responsive, per se. Varying breadth of responsiveness across policy and legislative documents There was also variation in the breadth of responsiveness across the documents reviewed, in the sense of ‘to whom’ policy documents propose responsiveness should be directed. Figure 2 below illustrates the different populations identified in the analysed documents to whom responsiveness should be directed. Overall, across both countries there was a predominance of attention to patients (in health sector policies) as the population for whom the health system should be responsive to. Across the reviewed Kenyan health sector texts, four health sector policies focused on responsiveness to patients or clients ( 37 , 76 , 94 , 95 ) and five documents indicated that responsiveness be directed to patients but also included local communities ( 77 – 81 ). The legislative instruments and public sector documents had a broader scope and referred to responsiveness to “the public” ( 69 – 73 , 83 , 96 , 97 ). Similarly, among the South African documents analysed, legislative instruments and public sector texts referred to responsiveness to the public ( 29 , 84 , 88 , 89 , 98 ). The majority of health sector specific documents ( 85 – 87 , 91 , 99 – 103 ) and two legal instruments focused on the health sector ( 104 , 105 ) referred to responsiveness to patients/ service users. Seven texts from the public sector and the health sector referred to responsiveness to both patients/service users and communities ( 61 , 62 , 90 , 106 – 109 ). None of the documents from either country clearly defined ‘the community/public’ in terms of legal status (that is, responsive to legal citizenry or ‘all’ [the whole population] – this becomes particularly relevant when issues such as responsiveness to migrant populations is raised). Most of the policy documents across both countries referred to responsiveness to vulnerable populations. Similar categories of vulnerable populations were mentioned as shown in Fig. 3 below. Among the frequently mentioned vulnerable populations were youth, children, orphans, women, the elderly, people from indigenous communities and people living with disability. Figure 3 a: Vulnerable populations identified in legislation and policy documents, Kenya, n = 24 Key: PLWHA-People Living with HIV and AIDs; PLWD-People Living with Disability, PLWHIV-People Living With HIV Figure 3 : Vulnerable populations identified in Kenyan and South African legislation and policy documents Despite describing the need for responsiveness to vulnerable groups, few of the analysed texts explicitly described the presence of vulnerable groups in participatory feedback mechanisms or how their voices would be included in shaping health system views or functions. In Kenya, exceptions to these observations included the legislative supplements for health facility committees (HFCs) which recommended the presence of women as HFC members; the Urban Areas and Cities Act (UACA, 2012) and County Government Act (CGA, 2012) which required inclusion of the vulnerable groups in making city plans (UACA, 2012) and in all areas of county economic, political, and cultural life (CGA, 2012); and the County Public Participation and Community Score Card Guidelines which offered specific suggestions to proactively target members of vulnerable groups to get their feedback. In South Africa, the 2013 Framework for Citizen-Government partnership highlights that vulnerable groups may fail to provide feedback on their experiences with the health system due to cultural, social and physical barriers ( 88 ) but does not provide detail about how to overcome these barriers. The second Presidential Compact on Health (2024), however, identified a Community Liaison Officer and specified their role in facilitating outreach and engagement with vulnerable groups such as hard-to-reach populations, people living with disabilities, people living with mental health disorders and their families, and older citizens ( 90 ). Underdeveloped assessment of responsiveness Part of the implementation process of policies involves monitoring and periodic evaluation ( 110 ). We therefore explored the documents for proposals on how responsiveness could be measured or assessed and found that the assessment of health system responsiveness was rarely discussed in the reviewed policy documents. In the Kenyan documents, a satisfaction index (tracked annually) was adopted as a measure for health system responsiveness in three documents, the KHP (2014–2030) and its subsequent strategic five-year plans KHSSP (2013–2017) and KHSSP (2018–2022). In the KHSPP (2013–2017), the satisfaction index was reported at 65% in 2012, 78% in 2015 and a target for 2017 set at 85%( 82 ). The KHP (2014–2030) set the client satisfaction target at 95% in 2030 ( 79 ). The adoption of a satisfaction index as a measure of responsiveness raises questions. It was unclear from the documents reviewed whether the reported satisfaction rates in the policy documents were a measure of satisfaction with the health facility, the services provided by the HCW, the health system in general or a combination of all three. Further, there was no description of the populations that these statistics represented, nor comment on variations across population segments. In more recent documents, the measures of responsiveness appear to vary in breadth, as various dimensions are introduced. For example, in the more recent Kenya UHC policy 2020–2030, indicators to track responsiveness of the health system include general facility service readiness; and International Health Regulations (IHR) capacity and health emergency preparedness ( 74 ), while the Community score-card guidelines present responsiveness as an indicator with three related sub-indicators: facility staff participation in community dialogue meetings, how promptly facility staff respond to community grievances including those arising from the community score card exercise ( 111 ). While no single measure for health system responsiveness was identified in the South African health policy documents, we identified mainly quantifiable service-related indicators, illustrated by a focus on meeting service standards ( 106 ), and other measures such as patient waiting times ( 87 ) and findings from patient experience surveys ( 102 ). The framing of health system responsiveness across policy documents and legislative instruments In this section, we present five framings of responsiveness identified from the analysed policy documents. Although presented separately there are overlapping elements across the framings. We attempted to include all the documents that we found to be relevant to a particular framing, resulting in some documents appearing more than once in the various framings (Supplementary Material 2). The most dominant framing was responsiveness as feedback on health service, identified in fourteen Kenyan and fifteen South African health policy health policy documents. Responsiveness as feedback on health service In the Kenyan documents, within 14 health sector specific policies ( 37 , 76 – 80 , 82 , 83 , 94 , 111 – 114 ) that framed responsiveness as feedback on quality of health services, most of the proposed feedback mechanisms targeted patients or service users with the aim of gauging client or patient satisfaction. For example, the Kenya Health Policy Framework (KHPF) I 1994–2010 and Kenya Health Sector Strategic Plan (KHSSP) II 1999–2004 noted the need to establish a multi-professional inspectorate to ensure professional conduct and institution of proper regulatory mechanisms in the interests of the public in order ‘ to better respond to the needs of patients…,’ (pg 15) ( 94 ). The KHSSP II 2005–2010 included responsiveness to client needs and quality of care as one of its objectives. Among the actions intended to enhance responsiveness were: ‘ ensuring complaint procedures are in place , and ‘training health workers on client handling and patient centred accountability’ (pg 26)( 77 ). Within the KHSSP III strategic objectives, health services were expected to be ‘ responsive’ to client needs (pg 39) ( 82 ). Specific actions to achieve these objectives were mainly service related and the ways to track them included, ‘conducting regular client satisfaction surveys to continually ensure clients expectations are informing intervention provision, and ensuring patient safety is ensured in provision of services’ (pg 33) ( 82 ). This framing of responsiveness as service-feedback, was also predominant in South African health sector specific policies. For example in a cluster of documents whose focus was to track and improve service delivery experiences related to patient safety ( 85 ), waiting time ( 87 ), complaints about service delivery ( 101 , 103 ), and patients’ experiences of receiving care ( 102 ). These documents focused on collecting information from patients and their families with a view to increase user satisfaction or make health services more responsive to the concerns and needs of users. The documents outlined three broad processes involved in service feed-back to facilitate responsiveness: 1) creating an enabling environment for users and/or public to complain about services and to receive information about their care; 2) action on feedback provided by service users (for example investigation of complaints made by patients or their relatives); and 3) provision of a response back to the source of feedback/ complainant or to patients/families affected by a safety incident or to service users who participated in patient experience surveys ( 85 , 101 – 103 ). Responsiveness as non-clinical dimensions of care (the WHO framing) Across both countries, there was little explicit reference to the WHO framing of responsiveness (with its seven dimensions) and only a few of its dimensions were identified in the analysed texts. Within Kenyan documents, only three documents used the language of the WHO framing of responsiveness ( 77 ) ( 75 , 79 ). The terms identified in these documents were ‘legitimate expectations of the population’ and ‘dignified care’. The KHP II 2012–2030, included a people-centred approach to health and health interventions as one of its principles and stated that health interventions should be ‘premised on people’s legitimate needs and expectations’ (pg 25)( 79 ). There was no further elaboration of these ‘legitimate expectations’. Dignified, human and compassionate care was mentioned in the context of service provision to vulnerable groups (women, children, people with mental and physical disabilities) who experienced socio-cultural barriers when accessing care ( 77 ). However, there were no other details regarding dignified care, for example, how it might be measured or what other interventions might contribute to dignified care beyond providing privacy for women during service delivery. Similarly, in the South African policy documents there was limited reference to the WHO framing of responsiveness. For example, the guidelines on patient waiting times, identified ‘ patient waiting time as a reflection of the responsiveness of the health system to the needs and demands for health services’ (pg 5) ( 87 ). This timely provision of care is encapsulated in the ‘prompt attention’ domain of the WHO framing of responsiveness. Another dimension of the WHO framing, respect for persons, which includes autonomy, confidentiality, dignity and respect was included within the National Core Standards under the domain of Patient Rights ( 106 ). Responsiveness as public participation Across the two countries responsiveness was presented as constituting public participation in several of the analysed texts. Within the Kenyan texts, this frame of responsiveness was identified predominantly within legal instruments and public sector documents (n = 5). The texts described public participation as being required for policy formulation and implementation including service delivery. For example, the Urban Areas and Cities Act required that ‘ community needs are reflected in Urban Areas and Cities' plans especially for access to services’ (section 40(d)); and identified that residents had ‘ a right to participate in decision-making, and a right to prompt responses ‘(pg 28–29) ( 97 ). The documents required not just the collection of public views, but also that government plans reflect community needs and input. Besides inviting public and community views, state actors were required to facilitate the participation of local communities in governance and build the capacities of communities to participate (Constitution of Kenya, Section 196; 201) ( 68 ). Public Participation Guidelines developed in 2016 identified various ways that county governments could receive feedback from the public. The methods proposed to get public input were varied representing a mix of quantitative and qualitative approaches to gathering public views. In the public participation guidelines, responsiveness was described as ‘ when the implemented process shall envisage a response from a decision maker or institutional representative, in order to ensure that participants’ inputs are taken seriously and properly considered’ (pg 38) ( 73 ). Within the South African documents, we identified a ‘responsiveness as public participation’ frame in nine legislative instruments and public and health sector policy documents ( 29 , 62 , 84 , 88 , 98 , 106 , 107 , 109 , 115 ). These documents emphasised the need for incorporation of public views through varied participation mechanisms. For example, the National Health Act (2003) proposed promotion of ‘ community participation in the planning, provision and evaluation of health services’ (pg, 30) at different levels of the health system ( 29 ), while the 2007 Policy on Quality on Healthcare proposed engagement with the public in non-technical language and through varied formats to ensure their contributions were included in quality improvement efforts ( 109 ). Participatory mechanisms mentioned within this frame included clinic committees/hospital boards, citizen-based monitoring in which the public was actively involved in policy formulation, ward committees, and implementation primary health care outreach teams inclusive of CHWs ( 29 , 88 , 98 , 108 ). All these mechanisms sought to enhance responding to the needs and concerns of the public. Within the 2013 Framework for Community Based Monitoring, there was an acknowledgement that ‘c itizens cannot be passive recipients if government is to deliver services that address real needs. The process of citizens working jointly with government to produce information on service delivery fosters active citizenry and contributes to building a capable and developmental state’ (pg 25) ( 88 ). Responsiveness as internal and/or external accountability We identified responsiveness framed as accountability mainly in health sector policy documents across both countries. Two forms of accountability framing were identified within the reviewed documents: external accountability was more dominant in Kenyan texts, and internal accountability more dominant in South African texts. The Kenyan documents that adopted this frame included the Kenyan Health Sector Strategic Plan II (2005–2010, its related Community Strategy policy documents ( 77 , 78 , 80 , 81 , 111 )) and recent legislation for Primary Health Care ( 116 ). Within the Kenyan Community Strategy (CS) policy and implementation guidelines, CS was described as a way for communities to ‘ seek accountability from the formal system for the efficiency and effectiveness of health and other services’ (pg 2) ( 78 ) through ‘ participation in meetings to discuss trends in coverage, morbidity, resources and client satisfaction, and giving feedback to the service system’ (pg 4) ( 80 ). The CS implementation guidelines presented participatory mechanisms such as Community Health Committees (CHCs) and HFCs as channels where feedback from the community could be shared with health system actors. These mechanisms were described as linked across system levels, with a suggestion that where there was failure to resolve/address issues, they could be escalated to a higher health system level. Among the responsiveness related roles for CHCs were ‘ providing a channel of communication with levels 2 and 3 management committees (HFCs), divisional health forum and the district health stakeholder forum (pg 6) ( 80 ). Responsiveness related roles for HFCs included ‘ providing feedback on services at level one [the community] … advocacy for community issues to be taken up to higher levels of the system…and review of client satisfaction records’ (pg10-11) ( 80 ). The South African texts identified in this category referred to responsiveness in terms of accountability to people’s rights and needs. We described this frame ‘responsiveness as internal accountability’ because the cluster of documents identified here were focused on answerability between actors within the health system for delivery of a pre-determined standard of service or care. These standard of care documents referred to the need to improve patient safety, medical accountability, and clinical governance ( 85 , 90 , 101 – 103 , 105 ). In these documents, the establishment and improvement of specific accountability mechanisms such as the patient safety incident reporting procedures were thought to be important to hold providers accountable. The guidelines on patient safety and complaints management for example addressed users concerns and promoted access to safe and good quality services ( 85 , 103 ). Other mechanisms described within this cluster of documents for service users (and their relatives) to provide feedback and therefore provide a means for holding service providers accountable included the ombudsperson, and the Office of Health Standards Compliance ( 105 ). Responsiveness as the realisation of a right to health Responsiveness was also framed as the realisation of the provisions and entitlements to uphold and promote fundamental rights such as access to health for all communities and public. This framing was elicited across legislative documents, public and health sector specific documents. In the South African texts, we elicited a more direct link, between a responsive health system and the right to health. For example, the National Health Act (2003) indicated that adequate information on the rights and duties of users, communities and public are critical to ensure responsiveness and preserve the rights of users ( 29 ). The National Core Standards (Domain 1: Patient Rights) and Patients’ Rights Charter specified these rights as access to adequate and appropriate services, respectful and dignified treatment; participation, and the right to complain ( 99 , 106 ). The National Health Insurance Bill (2019) recognised ‘ the need to heal the divisions of the past and to establish a society based on democratic values, social justice, and fundamental human rights; and the need to improve the quality of life of all citizens and to free the potential of each person. The Bill therefore sought to ‘ achieve the progressive realisation of the right of access to quality personal health care services' and ‘make progress towards achieving Universal Health Coverage’ (pg.3) ( 104 ). Within the Kenyan texts, several legal instruments ( 68 – 70 , 97 ) and health sector policy documents ( 77 , 78 , 80 ) considered the state and service providers as having a responsibility to provide the right to health, with the public as rights claimants. To facilitate access to other rights (including the right to health) the Constitution included a right to ‘ information held by the state and state actors’ (Article 35) ( 68 ). The County Government Act also reiterated this right to information by requiring governments to establish mechanisms to ‘ facilitate public communication and access to information in form of media that has the widest public outreach’ (section, 95:2) ( 70 ). The Health Act 2017 reiterated the constitutionally guaranteed right to health, the duty of the state for provision and the responsibility of the county governments to facilitate participatory governance. Within the health sector specific policy documents, the KHSSP II 2005–2010 included a human rights approach to service delivery, in which the health sector had a duty to ‘respond to the aspirations and expectations of communities’ (pg 41) ( 77 ). This is referred to again in the CS policy document and implementation guidelines which sought to empower communities to ‘ claim their right to accessible and quality care and seek accountability from the formal system ’ ( 78 , 80 ). Feedback mechanisms supporting health system responsiveness In this section, we describe the various feedback mechanisms which we judged had the potential to enhance responsiveness. Our description includes a summary of the mechanisms, the range of actors mentioned with responsibility for responsiveness, and considers the level of detail concerning the functioning of the identified feedback channels. Multiple Channels through which the public could provide feedback to the health system Most of the mechanisms identified had broad functions related to public participation and community engagement beyond the health sector. Receiving feedback from the public was therefore one among other functions carried out by these mechanisms. Supplementary Material 3 summarises their roles in supporting responsiveness to public feedback across both countries in multiple sectors including the health sector and includes a section for mechanisms identified specifically for the health sector. In both countries, within the health sector, feedback mechanisms could be broadly classified into those that supported feedback on service after a provider-client interaction, for example client satisfaction surveys in Kenya ( 77 , 82 ) and patient experience surveys in South Africa ( 102 ), suggestion boxes at facility level, and patient rights charters and complaint management systems ( 77 , 80 , 95 , 99 , 101 , 103 ) across both countries. The participatory mechanisms included health facility committees ( 29 , 77 , 80 ) in both countries, community health committees and district/county health boards ( 77 , 82 , 111 ) in Kenya; and ward committees ( 98 ) and primary health outreach teams ( 108 ) in South Africa. These mechanisms were proposed to function at various levels of the health system from community level, through peripheral facility and district/subcounty level, and upwards to county/provincial and national levels. Varied range of actors with responsibility for supporting health system responsiveness We identified actors ranging from health managers, public administrators and elected representatives at sub-national and national level who had roles in enhancing responsiveness. In Kenyan policy texts these roles varied, ranging from national and county elected representatives receiving petitions from the public ( 68 , 70 ), public-sector administrators ensuring public views were considered in strategic policy, budgeting, planning activities and evaluation of county performance ( 70 , 96 ) and hospital heads, health facility in-charges receiving complaints and compliments from service users ( 69 , 80 , 95 ). The roles of county and sub-county health managers in enhancing responsiveness were more implicit given their participation in various participatory mechanisms such as County Health Stakeholder Forums, and cunty and sub-county Primary Health Committees as secretaries to these participatory mechanisms that comprised health managers and community members ( 82 , 112 ). Within the South African texts, the role of local-level elected representatives with respect to health system responsiveness was not explicitly stated. However, the health minister at the national level and the Member of Executive Council (MEC) for health at provincial level both had a responsibility for approval of service standards set by provincial and district health managers ( 106 ), suggesting an oversight role. Other actors identified within the South African texts included the Health Ombudsman and Quality assurance managers, respectively responsible for receiving complaints and conducting patient experience surveys ( 103 , 106 ). This clarity was absent in the Kenyan documents, where an Ombudsman was mentioned in one policy document ( 82 ) without description of their roles. Hospital heads and health facility-in-charges in South African texts were expected to receive and respond to complaints ( 103 ) while provincial and district health managers had a responsibility to review complaints resolved at facility level and provide information to lower health system level actors on the procedure for receiving and responding to complaints ( 103 ). Scant detail on expected functioning of feedback mechanisms for system response For several mechanisms, the policy documents analysed gave little detail on how they would be operationalised to receive information and what would happen to the collected information. For example, in Kenya for mechanisms such as hotlines, suggestion boxes, health ombudsmen and patient satisfaction surveys there was little information on who would be assigned to run hotlines and conduct satisfaction surveys, and whether the information collected would be integrated to enhance health system responsiveness. Several health sector policy documents in both countries focused primarily on collecting feedback and provided little description of whether and how a response would be provided to the public after feedback was received. For example, Kenyan Community Strategy documents, and the Kenya Community Health Policy 2020–2030 described escalation of public feedback through participatory structures at community and facility level to higher health system levels ( 78 , 80 , 113 ), but rarely mentioned responses back down to the public. In the South African documents, the Policy framework and Strategy for Ward-based Public Health Outreach Teams described that it ‘will collectively facilitate community involvement and participation in identifying health threats, vulnerable groups and individuals and appropriate interventions for addressing these ’ ( 108 ). However, there was no further elaboration within the document of how information from the public would be utilised to enact responses or develop appropriate interventions. Despite these gaps, there were two clusters of documents that provided some detail on potential responses from the health system and communication back to the public (including service users) after sharing feedback. These are summarised in Table 3 below, which highlights that the included documents mentioned varying potential responses depending on the form of public feedback. For example, the Patient Safety Guidelines recommended that service use complaints be responded to at the individual-level by clear communication with the affected users ( 100 ), the Patient Experience Survey Guideline recommended patient experience survey findings be reported in public media in summary form and drawn on to initiate quality improvement cycles to enhance service delivery ( 102 ), while Community Score-Card and Public Participation and Guidelines recommended provision of up-dates to the public about which of their input had been incorporated (or not) into the planning cycle at community and higher levels( 111 ) Table 3 Details of functioning of feedback mechanisms in relation to receiving, processing and responding to public feedback Functioning of feedback mechanism Cluster one: Health sector specific policies (mainly from South Africa) Cluster two: legal instruments and public sector documents from Kenya and South Africa Receiving feedback from service users/public • Community-level collection of information during community score card (CSC) exercise ( 111 ) • Facility level collection of information through surveys, safety walk arounds, review of medical records, incident reports, and via standardised complaint/compliment form, email, fax, suggestion boxes ( 85 , 87 , 102 , 103 ) • Setting up enabling conditions for meaningful public participation by sending out invitations to attend meetings, conferences, ensuring representation of marginalised groups ( 73 , 98 ) • Collection of community/public views on proposed projects or plans ( 70 , 73 , 97 , 98 ) and budgetary preparation ( 96 ) from lowest administrative levels and upwards levels through surveys, FGDs, public meetings ( 73 , 98 ), oral/written submissions ( 73 , 97 ) and ward committees( 98 ) Processing and utilisation of feedback • Analysis and reviewing information to determine trends ( 87 ) and for immediate response at facility level or escalation to higher system levels ( 85 , 87 , 102 , 103 ) • At facility level, proposed actions in response to the data generated from patient experience surveys, safety incident reporting, complaints and patient waiting times informed preparation of facility improvement plans ( 85 , 87 , 102 , 103 ) • In Kenya: Up-ward sharing of actions generated at community dialogue, to facility and sub-county teams, inclusion of scores in Health Information System ( 111 ) • Upward submission of public views from the wards, to the sub-counties/districts and synthesis at county /province level ( 73 , 98 ) Response to users/the public • Communication to the patient regarding resolution of their complaint within 25 days ( 103 ) • Sharing of findings with users who participated in patient experience surveys and with the public through mass media (e.g. radio and televisions) ( 102 ) • Communicating to patients and/or their families what went wrong and why in the case of safety incidents ( 85 ) • Monthly follow-up on implementation of community action plan during community action days, with facility in-charge, Community Health focal person at sub-county and county levels ( 111 ) • Feedback to the public on whether their input was included in planning and policy formulation ( 73 , 98 ) Across both countries, there was little mention of tracking or monitoring how well the feedback mechanisms functioned, save for the public participation guidelines which proposed evaluation of public participation initiatives and processes to determine i) whether the participation activities had achieved their objectives; ii) implementation challenges; and to draw lessons for future initiatives ( 73 , 98 ). The Kenyan public participation guidelines included indicators for evaluation such as civic education on the process and content of participation, resources allocated to the public participation process/initiative, access to information by members of the public, diversity of participants, timely communication and the extent to which public feedback was incorporated into decision-making ( 73 ). While there were many similarities, there were several differences across Kenya and South Africa in the feedback mechanisms outlined in the analysed texts. First, there seemed to be institutionalization of Civil Society Organisations (CSOs) as a mechanism for voicing public concerns within the framework of citizen-based monitoring of service delivery in the South African context ( 88 ). In the Kenyan texts analysed, CSOs were included as stakeholders in the health sector, but more attention was paid to their role in complementing service delivery than in voicing community concerns. Second, there was variation in the level of development of certain feedback mechanisms. For example, in the Kenyan documents, the Health Ombudsman was mentioned with scant detail on their functioning ( 82 ), whereas the South African documents includes details of the role of the health Ombudsman as a recipient of public complaints about health service delivery, their powers to investigate and linkages to a tribunal that adjudicates on cases brought by the health Ombudsman ( 101 , 103 ). Third, within the South African documents there were more detailed guidelines for the collection of various forms of feedback from patients ( 85 , 87 , 102 , 103 ). In contrast, across the Kenyan documents analysed, there were few guidelines. For example, it was expected that satisfaction surveys would be done annually, but there was no direction as to how they would be carried out, who would be responsible for conducting them (for example whether by facility level staff or an independent body). The South African complaint management system also made provision for data generated from complaints to inform proposed actions in facility improvement plans ( 85 , 87 , 102 , 103 ). This was absent in the complaint management system proposed in Kenyan documents ( 69 , 73 , 95 ) where there was little to suggest that information from complaints informed facility quality improvement plans. However, in Kenya a more recent guideline, the Community Score Card Guideline provides some details on who would be involved in collecting information from community members (the Community Health Committee), where this could be done, and how frequently, including procedures for how this information would be shared up-wards with healthcare workers and health managers ( 111 ). Discussion In this study, we conducted a content and framing analysis to establish the policy framing of responsiveness in Kenya and South Africa. We found that there was provision for responsiveness in national policy and legislation, and support for the institutionalization of mechanisms for receiving and responding to public feedback. However, we also found a lack of coherence in how responsiveness was described across the reviewed documents. Drawing on our understanding of responsiveness as comprising processes of receiving, processing, and responding to public feedback, we identified inattention to certain elements that could support the development of responsive health systems across policy documents in both countries. First, despite frequent mention of ‘system responsiveness’ we found little attention to system-wide processes for responsiveness. Feedback mechanisms were presented in isolation especially within health sector policy documents, where a single feedback mechanism often handled a specific type of information. For example, complaints management systems were extensively described in both countries but there was little to suggest that for instance, patient satisfaction survey results were considered together with complaints data or any other form of public feedback. Where provision for upward escalation of public feedback was recommended, it was not clear that there was integration to identify patterns, across facilities or health system levels. Our findings are consistent with other literature that reported similar siloed functioning of feedback mechanisms in Kenya ( 117 ) and South Africa ( 118 ). This inattention to integration of data from multiple feedback channels in the health sector policy documents of both countries, is a missed opportunity to strengthen health system responsiveness since integration could provide a more holistic picture of health system experience. Second, there was limited attention to how the health system would generate responses once feedback was received. These findings are consistent with a review of responsiveness literature that found that few studies reported health system responses to public feedback ( 3 ), and a report on public participation where the authors observed that many health systems in LMICs have a poor record in feeding information back to communities ( 119 ). Inattention to responses and failure to communicate back to the public could undermine responsiveness. Literature demonstrates that if the public do not feel that their input has value, they stop providing it ( 120 , 121 ). Indeed, in both Kenya and South Africa, studies have reported the public’s perception of perfunctory participation processes that do not attain objectives of being responsive to local needs (122–124). Our study findings included a dominant framing of responsiveness as ‘health service feedback’ within the health sector documents. This predominant focus on service feedback within health sector policy documents draws attention to the different problem definitions addressed by the varying frames identified in the policy texts. Bacchi argues that policy is often a governance tool intended to redress a problem in society ( 125 ). Drawing on this argument, the participation and rights-based frames within legislative, public sector and a few health sector documents present responsiveness as an opportunity to enhance equity. This is implied by the frames’ attention to inclusivity of various segments of the population, particularly the vulnerable whose representation in participatory mechanisms is explicitly expected. In contrast the policy responses proposed by the ‘responsiveness as feedback on health service’ frame suggest that responsiveness is viewed as an opportunity to address clinical service delivery problems. This is important because, what is determined to be the problem influences decision-making around resources and governance arrangements. A narrow focus on clinical service delivery within health sector policy documents could translate to meagre resources being allocated to the feedback mechanisms required to enable health system responsiveness. Frames also legitimise which actors can participate in policy processes ( 64 ). In this study, the participation and rights-based frames in both countries include multiple actors within and outside the health system. However, the ‘responsiveness as feedback on clinical service delivery’ and ‘responsiveness as internal accountability’ frames narrow the focus on actors to providers (and their managers) and patients. As a result, it is unclear, for example, how state actors with responsibilities for ensuring functioning of feedback mechanisms (as described in Kenyan legal instruments ( 68 , 70 , 96 )) facilitate health system responsiveness. In addition, and particularly in the Kenyan health sector policy documents, much more attention was paid to the role of civil society in service provision than in enhancing responsiveness. Yet literature demonstrates that civil society can engage in others ways in policy processes; for example by putting issues on the government’s agenda leading to improvements in access to services for marginalised populations or scale up of services not prioritised in the public health sector ( 126 – 128 ). This study also revealed the influence of frames on how the goal of health system responsiveness is measured. The Kenyan Health Policy 2014–2030 and KHSSP III 2018–2022 reported a satisfaction index as a measure for tracking health system responsiveness ( 129 , 130 ) linked to the ‘responsiveness as feedback on health service’ frame. In other documents, client satisfaction was implicitly identified as measure given the attention to satisfaction in the descriptions of responsiveness ( 77 , 80 ). In South African texts, more attention was paid to quantifiable indicators of health service quality, again linked to the ‘responsiveness as feedback on health service’ frame. While these quantifiable indicators can provide varied information about the health system, they do not fully capture the multi-dimensional nature of responsiveness. Notably, whether an overall health system responsiveness index was adopted, or multiple service-related quantifiable indicators were used, there was a clear ‘silence’ on the experiences of vulnerable groups. For example, the Kenyan health policy documents that adopted a satisfaction index to measure health system responsiveness did not provide disaggregated data across different population segments. In South African health policy documents and guidelines for the quantifiable processes such as patient waiting times, patient experience surveys and complaints management hardly mentioned different population segments, and how views of vulnerable groups could be captured in the data collection. The health service feedback frame predominant in most health sector documents largely neglects phases of the policy process (other than implementation), equity challenges, and power and knowledge differentials between population groups and between the public and health system actors. Yet, these are important considerations given that Kenya and South Africa have histories of inequalities in health service access and distribution ( 39 , 60 ). Further, literature from other LMICs suggest that structural challenges such as poverty and low education levels, power dynamics and knowledge asymmetry influence whether the public can voice concerns or leverage responses from the health system. For example, in Nigeria and Nepal, low usage of suggestion boxes and service charters was linked to low awareness of their existence and how to use them, low literacy levels, fear of reprisal from health providers, and perceptions that the communities suggestion would be viewed as irrelevant or that it would take long to get a response ( 5 , 131 ). In Zambia and Tanzania, elite community members with vested interests such as political and personal gain often formed the membership of HFCs, raising concerns about the degree of representativeness in these participatory mechanisms (132). This analysis also illustrates that the broader public sector documents were more holistic and inclusive in their conceptualisation of responsiveness and provided more detail on the proposed functioning of feedback mechanisms. While health sector-specific documents referred to the values in the Constitutions of both countries and legislative documents, they did not maintain the broad and inclusive intentions in their framing of responsiveness. Figure 4 below illustrates the thinning down of policy intent moving from broad public sector and legislation to health sector-specific policy documents which had a narrower focus. In seeking to strengthen health sector policies, we propose adopting a broader framing based on integrating the frames from different policy document types and moving beyond ‘responsiveness as feedback on health service’. A broader framing would re-define health system responsiveness to include a focus on the wider public (irrespective of whether they have had a service delivery encounter) and provide more attention to varied population segments, including vulnerable groups. A focus beyond patients/service users would also allow for collection and synthesis of multiple types of data and at different phases of the policy process, as suggested in in several public sector documents but currently absent from health sector documents. There is potential to learn from a few policy documents which seemed to achieve this level of integration – such as the South African Framework for Citizen-Based Monitoring ( 88 ), and public participation guidelines from both countries ( 73 , 98 ). These texts include consideration of an environment that enables citizen/public feedback (suggesting attention to structural and power issues that might hinder the public from voicing their needs and concerns), collection of various data forms (both quantitative and qualitative) depending on the issue for which participation is required, communication of findings following data collection back to the public, incorporation of feedback for service improvement, and monitoring of the feedback mechanisms. These considerations capture the interlinked framings of participation, accountability, rights-based and feedback on clinical service potentially providing a more holistic approach to building responsive health systems. This study which examined the content and framing of responsiveness in two LMIC countries, demonstrates that combining content and framing analyses can uncover valuable insights. Applying framing analysis to the content of policy documents enabled critical reflection and deepened the analyses of the content of responsiveness policy in terms of what was ‘problematised’ in health sector policy documents and what was left out. This analysis also shows that, particularly in health sector policies, power and system-wide issues were not adequately addressed. This underscores the importance of paying greater attention to power relations and adopting a broader health system approach to responsiveness in future research – considering, for example, how multiple forms of feedback mechanisms work together to enhance health system responsiveness. We therefore support the call for greater theoretical distinction between health system responsiveness and health service responsiveness ( 3 ), and the need to consider the historical, political, cultural and socioeconomic contexts of health systems and how these shape health system responsiveness ( 8 ). Response to these calls would trigger further research on how responsiveness from a broader system perspective might look, in line with the systemic lens applied in the HPSR field ( 133 , 134 ). There is also need for research around the population to whom responsiveness is targeted. While all clusters of analysed texts (legislative instruments, public sector & health sector specific policy documents) mentioned vulnerable groups, attention to them in terms of inclusion in feedback mechanisms was more notable in the participation and rights-based frames within legislative instruments and public sector documents. Consideration of how they could leverage responses was hardly referred to particularly within the health sector specific documents. In the wider LMIC literature, there is little empirical evidence on responsiveness amongst vulnerable groups ( 4 , 9 ). This is an important research gap to address given that equity in responsiveness is a key dimension of responsiveness ( 1 ), and that vulnerable groups are likely to experience even worse responsiveness from the health system when there are periods of health system shock as has happened more recently in LMICs that experienced the Ebola outbreaks of 2014/2015 ( 135 ), and more recently with the COVID-19 pandemic ( 136 ). Notably, in our analysis of Kenyan and South African policy texts, there was little direct mention of the different domains of the non-clinical WHO framing within the policy texts from both countries. Yet two literature reviews on health system responsiveness ( 3 , 8 ) found that the WHO framing (considering most or all of the seven domains) was the most commonly used approach to assess health system responsiveness. Overall, similarities between the evidence mapping findings ( 3 ) and our policy analysis, suggests, that there has been little global guidance since the WHR2000 on how responsiveness should be operationalised, or that policymakers disagree with the WHO non-clinical framing of responsiveness. Overall, there is need to have more direct and coherent statements about health system responsiveness in policy documents. Limitations This work primarily analysed policy documents which provide an opportunity for in-depth analysis but also have significant limitations when used alone. These include understanding the dynamic interaction between actors and policy processes, because the voices of actors are absent. These have been included in separate empirical work ( 10 , 137 ). Nonetheless, the work is strengthened by the combination of content and framing analysis that allowed a balanced examination of included policy documents. Conclusion Our analysis of policy documents from two LMICs demonstrates the limited attention given to the ‘system’ in policy content on the goal of health system responsiveness. Feedback mechanisms appear to function in isolation with little potential for integration to enable system wide responses, while attention is focused not on all people that the health system serves but on service users. Our analysis also contributes to the framing analysis literature and demonstrates that multiple frames are employed within policy documents to define responsiveness and offer policy responses on how a responsive health system might be built. The framing of responsiveness as feedback on health service is dominant particularly within health sector specific documents. Other frames such as accountability, the realisation of the right to health and participation appear although in a less cohesive manner. The equity dimension of health system responsiveness and potential for health system strengthening have thus been less commonly presented within health sector specific documents. Given the dominance of the frame of responsiveness as feedback on health service we observed a narrowing of policy options to address how a responsive health system might be achieved. This dominance has implications for resource allocation and decision-making and potentially undermines a systems approach and efforts to achieve equity in responsiveness. How responsiveness is framed matters both for practice and analysis of policy, and there is value in integrating existing frames to achieve a broader frame of and a systems approach to responsiveness. Declarations Ethics approval and consent to participate As this paper was based on a review of policy documents, no ethical approval was obtained. Consent for publication We thank the Director of the Kenya Medical Research Institute (KEMRI), Kenya for granting permission to publish this work. Competing interest The authors declare that they have no competing interests. Funding NK was funded in part by the Health Policy Analysis Fellowship programme supported by the Alliance for Health Policy and Systems Research, Switzerland. This paper is also linked to a broader study funded by the United Kingdom Medical Research Council ‘Strengthening health system responsiveness to community and citizen feedback in SA and Kenya’ (UKRI: MR/R013365/1). B.T. and S.M. are members of the KEMRI-Wellcome Trust Research Programme in Kenya that is supported by a core grant [# 203077/Z/16/Z] from the Wellcome Trust. N.K. was a PhD student supported by the Initiative to Develop African Research Leaders, DELTAS Africa Initiative [DEL-15-003]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [107769/Z/10/Z] and the UK government. The views expressed in this publication are those of the authors and not necessarily those of AAS, NEPAD Agency, Wellcome Trust, or the UK government. Author Contribution NK, GK, NS, JO searched for and identified relevant policy documents, with input from SM, BT and LG. NK, GK, NS and JO extracted data from the agreed upon policy documents. NK, GK, NS and JO were involved in formal analysis, methodology and validation. NK drafted the original manuscript. All authors were involved in reviewing and editing it. BT, SM and LG reviewed drafts and gave final approval of the version to be published. Acknowledgement We would like to acknowledge the research and health systems partners involved in the broader Health Systems Responsiveness study for their inputs during conceptualisation of this article. Data Availability The data supporting the findings and conclusions of this article are included within the article and its supplementary files. References WHO. World Health Report 2000. Geneva: World Health Organisation; 2000 2000. Valentine N, Prasad A, Rice N, Robone S, Chatterji S. Health systems responsiveness – a measure of the acceptability of health care processes and systems from the users' perspective. In: Smith P, Mossialos E, Leatherman S, Papanicolas I, editors. Performance measurement for health system improvement: Experiences, challenges and prospects. Geneva: World Health Organisation; 2010. pp. 138–72. Khan G, Kagwanja N, Whyle E, Gilson L, Molyneux S, Schaay N, et al. Health system responsiveness: a systematic evidence mapping review of the global literature. Int J Equity Health. 2021;20(1):112. Malhotra C, Do YK. Socio-economic disparities in health system responsiveness in India. Health Policy Plann. 2012;28:197–205. Gurung G, Derrett S, Gauld R, Hill PC. Why service users do not complain or have ‘voice’: a mixed-methods study from Nepal’s rural primary health care system. BMC Health Serv Res. 2017;17(1):81. Golooba-Mutebi F. When popular participation won't improve service provision: primary health care in Uganda. Dev Policy Rev. 2005;23(2):165–82. Scott K, George AS, Harvey SA, Mondal S, Patel G, Sheikh K. Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India? Int J Equity Health. 2017;16(1):84. Mirzoev T, Kane S. What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework. BMJ Global Health. 2017;2(4):e000486. Whyle E, Olivier J. Health Service Responsiveness versus health system responsiveness: a systematic conceptual review. Cape Town: CHESAI Report; 2017. Kagwanja N, Gilson L, Tsofa B, Olivier J, Leli H, Molyneux S. Understanding health system responsiveness to public feedback at the sub-national level: Insights from Kilifi County, Kenya. PLOS Glob Public Health. 2024;4(12):e0002814. Cleary S, Molyneux S, Gilson L. Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary healthcare settings. BMC Health Serv. 2013;13:320. Kenny A, Hyett N, Sawtell J, Dickinson-Swift V, Famer J, O'Meara P. Community participation in rural health: a scoping review. BMC Health Serv Res. 2013;13:64. Loewensen R, Tibazarwa K. Annotated Bibliography: Social power, participation and accountability in health. Harare: TARSC, EQUINET with COPASAH; 2013. Mahapatra P. Quality health care in private and public health care institutions. Health Policy Research in South Asia. Washington DC: World Bank; 2003. Garg S, Laskar AR. Community-Based Monitoring: Key to Success of National Health Programs. Indian J Community Med. 2010;35(2):214–6. McNamara P. Provider specific report cards: a tool for health sector accountability in developing countires. Health Policy Plann. 2006;21(2):101–9. Koon AD, Hawkins B, Mayhew SH. Framing and the health policy process: a scoping review. Health Policy Plann. 2016;31(6):801–16. Entman RM, Framing. Toward clarification of a fractured paradigm. J communication. 1993;43(4):51–8. Kapwata T, Manda S. Geographic assessment of access to health care in patients with cardiovascular disease in South Africa. BMC Health Serv Res. 2018;18(1):197. McLaren Z, Ardington C, Leibbrandt M. Distance as a barrier to health care access in South Africa2013. Keats EC, Akseer N, Bhatti Z, Macharia W, Ngugi A, Rizvi A, et al. Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya. JAMA Netw Open. 2018;1(8):e185152. Ilinca S, Di Giorgio L, Salari P, Chuma J. Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey. Int J Equity Health. 2019;18(1):196. Gordon T, Booysen F, Mbonigaba J. Socio-economic inequalities in the multiple dimensions of access to healthcare: the case of South Africa. BMC Public Health. 2020;20(1):289. Express K. Clinic, vehicles torched during overnight protest action in Tembisa. Kempton Express [Internet]. 2015 03 May 2021 [cited 2015 18 March]. Available from: https://kemptonexpress.co.za/65444/clinics-vehicles-torched-during-overnight-protest-action-in-tembisa Waithaka D, Kagwanja N, Nzinga J, Tsofa B, Leli H, Mataza C, et al. Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County. Int J Equity Health. 2020;19(1):23. ANA. Covid-19 facility in Khayelitsha set on fire by illegal land invaders2020 15 May 2021 [cited 2020 July 19]. Available from: https://www.iol.co.za/news/watch-covid-19-facility-in-khayelitsha-set-on-fire-by-illegal-land-invaders-51177583 Gilson L, Barasa E, Nxumalo N, Cleary S, Goudge J, Molyneux S, et al. Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa. BMJ Glob Health. 2017;2(2):e000224. WB. World Bank Country and Lending Groups. The World Bank Group; 2021 [. National HA. 2003, (2003). McKenzie A, Schneider H, Schaay N, Scott V, Sanders D. Primary Health Care Systems (PRIMASYS) Case study from South Africa. Geneva: World Health Organisation; 2017. White Paper for National Health Insurance For South Africa. Towards Universal Health Coverage. White Paper. Pretoria: Government Gazette; 2015. Report No. Baleta A. South Africa Rolls out Pilot Health Scheme. Lancet. 2012;379(9822). National Health. Insurance In South Africa, Policy Paper. Pretoria; 2011. Heywood M. South Africa's Treatment Action Campaign: Combining Law and Social Mobilization to Realize the Right to Health. J Hum Rights Pract. 2009;1(1):14–36. Habib A. State-Civil Society Relations in Post-Apartheid South Africa. Soc Res. 2005;72(3):671–92. Ndinda C, Mokomane Z, Mokhele T, Gqamane V, Chilwane D. Civil Society Activism in Accessing Healthcare in South Africa. A Technical Report for CODESRIA. Human Sciences Research Council; 2013. MOH. Kenya Health Policy Framework 1994–2010 Nairobi. Kenya: Ministry of Health; 1994. Health A. 2017. Nairobi: Government of Kenya; 2017. Anangwe A. Health Sector Reforms in Kenya. Governing Health Systems in Africa. African Books Collective; 2008. Oyaya CO, Rifkin SB. Health sector reforms in Kenya: an examination of district level planning. Health Policy. 2003;64(1):113–27. Kenyatta U. Delivering health care for all in Kenya. Financial Times. 2019 October 16. President Uhuru launches Universal Health Coverage Pilot Program Nairobi, (KENYA) December 13, 2018 Nairiobi: Ministry of Health. 2018 [. Wamai RG. Reforming health systems: the role of NGOs in decentralisation-lessons from Kenya and Ethiopia. Working Paper. The Elephant; 2018. Wamai RG. NGOs and Public Health Systems: Comparative Trends in Transforming Health Care Systems in Kenya and Finland. Helsinki; 2004. Peltzer K. Patient experiences and health system responsiveness in South Africa. BMC Health Serv Res. 2009;9(117). Kabia E, Mbau R, Muraya K, Morgan R, Molyneux S, Barasa E. How do gender and disability influence the ability of the poor to benefit from pro-poor health financing policies in Kenya? An intersectional analysis. Int J Equity Health. 2018;17:149. Peltzer K, Phaswana-Mafuya N. Patient experiences and health system responsiveness among older adults in South Africa. Global Health Action. 2012;5(1). Embleton L, Pooja S, Gayapersad A, Kiptui R, Ayuku D, Wachira J et al. Exploring patient-provider interactions and health system resposiveness to street connected youth and children in Kenya. BMC Health Serv Res. 2021;21(363). White Paper for the. transformation of the health system in South Africa. Pretoria, South Africa: Department of Health; 1997. Kenya Health. Policy 2012–2030. Nairobi: Government of Kenya; 2012. Atela M, Bakibinga P, Ettarh R, Kyobutungi C, Cohn S. Strengthening health system governance using health facility service charters: a mixed methods assessment of community experiences and perceptions in a district in Kenya. BMC Health Services Research; 2015. O'Meara W, Tsofa B, Molyneux S, Goodman C, McKenzie EF. Community and facility-level engagement in planning and budgeting for the government health sector – A district perspective from Kenya. Health Policy. 2011;99(3):234–43. Cleary S, Schaay N, Botes E, Ntombizanele F, Uta L, Gilson L. Re-imagining community participation at the district level: Lessons from the DIALHS collaboration. South African Health Review 2014/2015. Cape Town, South Africa2014. pp. 151 – 60. Boulle T, Makhamandela N, Goremucheche R, Loewensen R. Promoting Partnership between Communities and Frontline Health Workers: Strengthening Community Health Committees in South Africa,. EQUINET PRA Paper. Harare: EQUINET; 2008. O’Loughlin EA. Kenya’s Constitution in a global context. Int J Const Law. 2017;15(3):839–48. Kramon E, Posner D. Kenya's new constitution. J Democracy. 2011;22(2):89–103. Tsofa B, Goodman C, Gilson L, Molyneux S. Devolution and its effects on health workforce and commodities management –early implementation experiences in Kilifi County, Kenya. Int J Equity Health. 2017;16(69). Tsofa B, Molyneux S, Gilson L, Goodman C. How does decentralisation affect health sector planning and financial management? A case study of early effects of devolution in Kilifi County, Kenya. J Equity Health. 2017;16(151). Meier BM, Pardue C, London L. Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa. BMC Int Health Hum Rights. 2012;12(1):15. ANC. The Reconstruction and Development Programme (RDP). Government Gazette; 1994. Administration NDoPSa. Batho Pele-People First White Paper on Transforming Public Service Delivery. Pretoria, South Africa: National Department of Public Service and Administration; 1997. Health NDo. White Paper for the Transformation of the Health System in South Africa. Pretoria, South Africa: Ministry of Health; 1997. Maritim B, Koon AD, Kimaina A, Goudge J. Citizen engagement in national health insurance in rural western Kenya. Health Policy Plann. 2024;39(4):387–99. Okeyo I, Lehmann U, Schneider H. The impact of differing frames on early stages of intersectoral collaboration: the case of the First 1000 Days Initiative in the Western Cape Province. Health Res Policy Syst. 2020;18(1):3. Pinto AD, Manson H, Pauly B, Thanos J, Parks A, Cox A. Equity in public health standards: a qualitative document analysis of policies from two Canadian provinces. Int J Equity Health. 2012;11(1):28. Phillips C, Fisher M, Baum F, MacDougall C, Newman L, McDermot D. To what extent do Australian child and youth health policies address the social determinants of health and health equity? a document analysis study. BMC Public Health. 2016;16(512). 10.1186/s12889-016-3187-6 . Jacobs T, George A, De Jong M. Policy foundations for transformation: a gender analysis of adolescent health policy documents in South Africa. Health Policy Plann. 2021;36(5):684–94. Government of Kenya. The Constitution of Kenya 2010. 2010. Health, Act. (2017). County Government Act. (2012). GoK. Kenya Vision 2030: A Globally Competitive and Prosperous Kenya. Nairobi Kenya: National Economic & Social Council of Kenya, Government of Kenya; 2007. PSC. Human Resources Policies and Procedure Manual for the Public Service. Nairobi, Kenya: Public Service Commission. 2016 1 May 2016. Planning MD. Governors Co. County Public Participation Guidelines. Nairobi, Kenya: Ministry of Devolution and Planning Council of Governors; 2016. MoH. Kenya Universal Health Coverage Policy. Nairobi, Kenya: Ministry of Health; 2020. MoH. Kenya Mental Health Policy 2015–2030. Nairobi, Kenya: Ministry of Health; 2014. MoH. Kenya Palliative Care Policy 2021–2030. Nairobi, Kenya: Ministry of Health; 2021. MOH. Reversing the trends: The second national health sector strategic plan NHSSP II 2005–2010. Nairobi, Kenya: Ministry of Health; 2005. MOH. Taking the Kenya Essential Package of Health to the Community: A strategy for the delivery of Level One services. Nariobi, Kenya: Ministry of Health; 2006. MoH. The Kenya Health Policy 2014–2030. Nairobi, Kenya: Ministry of Health; 2014. MOH. Community Strategy Implementation Guidelines for Managers of the Kenya Essential Package for Health at the Community Level. Nairobi, Kenya: Ministry of Health; 2007. MOH. Strategy for Community Health 2014–2019. Nairobi, Kenya: Ministry of Health; 2014. MOMS MOPH, Transforming Health. Accelerating Attainment of Universal Health Coverage. Nairobi: Ministry of Medical Services and Ministry of Public Health; 2012. MoH. Kenya Health Sector Strategic Plan 2018–2022. Nairobi, Kenya: Ministry of Health; 2018. Constitution of the Republic of South Africa. (1996). NDoH. National Guideline for Patient Safety Incident Reporting and Learning in the Public Health Sector of South Africa. Pretoria, South Africa: National Department of Health; 2017. NDoH. In: Health, NDo, editors. National Cancer Strategic Framework 2017–2022. South Africa: National Department of Health; 2017. NDoH. National Policy for the management of patient waiting times at health facilities. Pretoria, South Africa: National Department of Health; 2019. DPME. Framework for Strengthening Citizen-Government Partnerships for Monitoring Frontline Service Delivery. Pretoria, South Africa: National Department of Performance, Monitoring and Evaluation, Evaluation DoPM; 2013. NPC. National Development Plan 2030-Our future make it work. Pretoria, South Africa: National Planninc Commission; 1997. NDoH. The Presidential Health Compact. 2024: Accelerating Health System Strengthening and National Health Insurance (NHI) Implementation. In: Health, editor. South Africa: National Department of Health; 2024. NDoH. National Policy Framework and Strategy on Palliative Care. In. Health, editor South Africa: National Department of Health; 2017. NDoH. White Paper on National Health Insurance. In. National Department of Health SA, editor. Pretoria, South Africa: NDoH; 2017. RoSA. National Health Insurance Act of 2023. In: Republic of South Africa ANo, editor. Cape Town2023. MoH. The National Health Sector Strategic Plan: 1999–2004. Nairobi, Kenya: Ministry of Health. MoH. Patient Rights Charter. Nairobi, Kenya: Ministry of Health; 2013. Public Finance Management Act, PFMA 2012, (2012). Urban Areas and Cities Act, 2011, (2011). DPSA. Guide on Public Participation in the Public Service. Pretoria, South Africa,Administration NDoPSa; Undated. NDoH. National Patients Rights Charter. Pretoria, South Africa, Health NDo; 1999. NDoH. Human Resources for Health – South Africa (HRH Strategy for the Health Sector: 2012/13–2016/17) Pretoria, South Africa, Health NDo; 2012. NDoH. Medico-Legal Declaration Implementation Plan. Pretoria, South Africa, Health NDo; 2016. NDoH. National guideline on conducting patient experience of care surveys in public health establishments. Pretoria, South Africa, Health NDo; 2017. NDoH. National guideline to manage complaints, compliments and suggestions in the health sector of South Africa. Pretoria, South Africa: National Department of Health 2017. National Health Insurance Bill (2019). National Health Act Amendment of 2013, (2013). NDoH. Towards Quality Care for Patients, National Core Standards for Health Establishments in South Africa. Pretoria, South Africa: National Department of Health: Republic of South South Africa; 2011. NDoH. Re-engineering Primary Health Care in South Africa. Pretoria, South Africa,Health NDo; 2010. NDoH. Policy framework and strategy for Ward-based Primary Healthcare Outreach Teams (2018/19–2023/24) Pretoria, South Africa, Health NDo; 2018. NDoH. Policy on Quality Healthcare in South Africa. In: Health, editor. South Africa: Department of Health; 2007. Wu X, Ramesh M, Howlett M, Fritzen SA. The public policy primer: managing the policy process: Routledge; 2017. MoH. Kenya Community Score Card Guidelines for Social Accountability in Primary Health Care. In: Health C, editor.: Ministry of Health; 2022. MoH. Kenya Primary Healthcare Strategic Framework 2019–2024. Nairobi, Kenya:Ministry of Health; 2019. MoH. Kenya Community Health Policy. Nairobi, Kenya, Health Mo; 2020. MoH. Kenya Community Health Policy 2020–2030. Nairobi: Ministry of Health; 2020. NDoH. National Health Insurance Bill. In: Health, editor. South Africa: National Department of Health; 2024. GoK. Primary Healthcare Act 2023. Kenya Gazette Supplements No 190; 2023. Atela M. Health System Accountability and Primary Health Care Delivery in Rural Kenya, An Analysis of the Structures, Process and Outcomes. Peterhouse, Cambridge:University of Cambridge; 2013. Sutherns T, Olivier J. Mapping the Multiple Health System Responsiveness Mechanisms in One Local Health System: A Scoping Review of the Western Cape Provincial Health System of South Africa. Int J Health Policy Manag. 2022;11(1):67–79. Loewensen R. Public participation in health: making people matter. Brighton:Institute of Development Studies; 1999. Mahmoud s. Citizen participation in the health sector in Rural Bangladesh. Brighton:Institute of Development Studies; 2004. Fluck VL, Barter D. Jumping Hurdles: Key Barriers to Feedback mechanisms. Humanitarian Practice Network. 2019. Williams JJ. Community participation: Lessons from post-apartheid South Africa.Policy studies. 2006;27(3):197–217. McCollum R, Taegtmeyer M, Otiso L, Muturi N, Barasa E, Molyneux S, et al. "Sometimes it is difficult for us to stand up and change this": an analysis of power within priority-setting for health following devolution in Kenya. BMC Health Serv Res. 2018;18(1):906. Haricharan HJ, Stuttaford M, London L. Effective and meaningful participation or limited participation? A study of South African health committee legislation. Primary Health Care Research & Development. 2021;22:e28. Bacchi C. Problematizations in Health Policy: Questioning How “Problems” Are Constituted in Policies. SAGE Open. 2016;6(2):2158244016653986. Gómez-Jauregui J. Participation in reproductive health policies in the context of health system reform in Mexico. IDS bulletin. 2008;38(6):81 – 7. Lodenstein E, Dieleman M, Gerretsen B, Broerse JE. Health provider responsiveness to social accountability initiatives in low- and middle-income countries: a realist review. Health Policy Plan. 2017;32(1):125 – 40. Evensen J, Stokke K. United agains HIV/AIDs? Politics of local governance in HIV/AIDS treatment in Lusikisiki, South Africa. Journal of Southern African Studies.2010;36:151 – 67. MoH. The Kenya Health Policy 2012–2030. Nairobi, Kenya: Ministry of Health; 2012. MOMS, MOPH. Transforming Health: Accelerating Attainment of Universal Health Coverage. Nairobi: Ministry of Medical Services and Ministry of Public Health; 2012. Ogbuabor DC, Onwujekwe OE. The community is just a small circle: citizen participation in the free maternal and child healthcare programme of Enugu State, Nigeria. Glob Health Action. 2018;11(1):1421002. Few R, Harpham T, Atkinson S. Urban primary health care in Africa: a comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam. Health &Place. 2003;9(1):45–53. Sheikh K, Gilson L, Agyepong I, Hanson K, Ssengoba F, Bennett S. Building the Field of Health Policy and Systems Research: framing the questions. Plos Med. 2011;8(8). de Savigny D, Adam T. Systems Thinking for Health Systems Strengthening. Geneva:Alliance for Health Policy and Systems Research, World Health Organisation; 2009. Wilkinson A, Parker M, Martineau F, Leach M. Engaging ‘communities’: anthropological insights from the West African Ebola epidemic. Philosophical Transactions of the Royal Society B: Biological Sciences. 2017;372(1721):20160305. Tindana PO, De Vries J, Kamuya D. Ethical challenges in community engagement practices in research during the COVID-19 pandemic in Africa. AAS Open Research. 2020;3(23):23. Kagwanja N, Molyneux S, Whyle E, Tsofa B, Leli H, Gilson L. Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast. International Journal for Equity in Health. 2024;23(1):177. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial2ResponsivenessFraminginpolicydocumentsfromKenyaandSouthAfrica.docx SupplementaryMaterial1Listofanalysedpolicydocuments.docx SupplementaryMaterial3Feedbackmechanismsinpublicsectorandhealthsector.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviewers invited by journal 16 Feb, 2026 Editor invited by journal 20 Jan, 2026 Editor assigned by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 17 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8624444","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592559919,"identity":"25c496e5-0396-4ca4-b100-0698816c6294","order_by":0,"name":"Nancy Kagwanja","email":"data:image/png;base64,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","orcid":"","institution":"KEMRI Wellcome Trust Research Programme","correspondingAuthor":true,"prefix":"","firstName":"Nancy","middleName":"","lastName":"Kagwanja","suffix":""},{"id":592559921,"identity":"23e391d3-046a-41bc-b88e-499307e9e253","order_by":1,"name":"Sassy Molyneux","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Sassy","middleName":"","lastName":"Molyneux","suffix":""},{"id":592559922,"identity":"2fadc364-9c55-430a-9877-c28d1100da47","order_by":2,"name":"Lucy Gilson","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Lucy","middleName":"","lastName":"Gilson","suffix":""},{"id":592559923,"identity":"aa648d17-805b-4dee-a387-04ee774ebbfe","order_by":3,"name":"Benjamin Tsofa","email":"","orcid":"","institution":"KEMRI Wellcome Trust Research Programme","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Tsofa","suffix":""},{"id":592559925,"identity":"8a6079a0-34dc-42c7-9925-83500ee2d1d2","order_by":4,"name":"Gadija Khan","email":"","orcid":"","institution":"Human Sciences Research Council","correspondingAuthor":false,"prefix":"","firstName":"Gadija","middleName":"","lastName":"Khan","suffix":""},{"id":592559926,"identity":"d80be13c-7233-48a3-998e-51009192a0fb","order_by":5,"name":"Nikki Schaay","email":"","orcid":"","institution":"University of the Western Cape","correspondingAuthor":false,"prefix":"","firstName":"Nikki","middleName":"","lastName":"Schaay","suffix":""},{"id":592559927,"identity":"2365206b-cca1-4de3-ba4c-2f10806658f7","order_by":6,"name":"Jill Olivier","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Jill","middleName":"","lastName":"Olivier","suffix":""}],"badges":[],"createdAt":"2026-01-17 08:08:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8624444/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8624444/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103234972,"identity":"5ad4909e-a256-432c-a9d5-38decf856a45","added_by":"auto","created_at":"2026-02-23 12:57:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76357,"visible":true,"origin":"","legend":"\u003cp\u003eAuthors’ conceptualisation of responsiveness(10).\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/7b038b39105cf99d8866eb83.jpg"},{"id":103234980,"identity":"11e43901-da1c-4e0d-ae7e-2a5daae6fff5","added_by":"auto","created_at":"2026-02-23 12:57:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":106721,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of documents that indicated to whom responsiveness should be directed\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/f1152bcb9e2827663f446018.jpg"},{"id":103234981,"identity":"fe14cf50-67a5-477f-b02b-77459f498f51","added_by":"auto","created_at":"2026-02-23 12:57:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":75150,"visible":true,"origin":"","legend":"\u003cp\u003eVulnerable populations identified in Kenyan and South African legislation and policy documents\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/43a38d16d80b322e974e06d6.png"},{"id":103234940,"identity":"3e6dd218-0942-4522-8eb2-fe101a98b217","added_by":"auto","created_at":"2026-02-23 12:57:30","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32382,"visible":true,"origin":"","legend":"\u003cp\u003eNarrowing of the focus of responsiveness across different clusters of policy documents\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/83c3695c14aed6dfca1b822d.jpg"},{"id":103235030,"identity":"893e480e-4bee-430c-894c-085367c2d585","added_by":"auto","created_at":"2026-02-23 12:58:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2043192,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/ab781f7f-8d05-4392-9226-1bfc208ad33d.pdf"},{"id":103234983,"identity":"9490959a-d044-4d61-96eb-6a6832df64ea","added_by":"auto","created_at":"2026-02-23 12:57:53","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":22342,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial2ResponsivenessFraminginpolicydocumentsfromKenyaandSouthAfrica.docx","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/b92b4e6dd5107ee070d19fb5.docx"},{"id":103234942,"identity":"9ae30216-2663-4d52-92ba-56e8238b2930","added_by":"auto","created_at":"2026-02-23 12:57:31","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17098,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial1Listofanalysedpolicydocuments.docx","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/6ab492398e4d1c66398b3031.docx"},{"id":103234945,"identity":"446f3ce0-1867-44e6-ae32-f40f7f8a1ba3","added_by":"auto","created_at":"2026-02-23 12:57:32","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25411,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial3Feedbackmechanismsinpublicsectorandhealthsector.docx","url":"https://assets-eu.researchsquare.com/files/rs-8624444/v1/fc8e8aef3b89f5f3b38e2a27.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Examining health system responsiveness policy in Kenya and South Africa: A content and framing analysis of policy documents 1994-2024","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth system responsiveness is regarded as one of the core health system goals alongside health outcomes, fairness in financing and efficiency (1). As framed by the World Health Report (WHR) 2000, responsiveness comprises two main categories (respect for persons and client orientation), with seven underlying elements related to dignity, confidentiality, autonomy, prompt attention, quality of \u0026nbsp;amenities, choice of provider, and access to social support networks (for those receiving in-patient care) (1, 2)\u003cem\u003e.\u0026nbsp;\u003c/em\u003eResponsiveness also has an equity dimension, focusing on distribution and level of responsiveness in the WHR 2000\u0026nbsp;(1). However, Khan et al illustrated that the experiences of minorities and vulnerable groups are rarely explored in the responsiveness literature\u0026nbsp;(3). Literature also suggests that for many members of the public, access to feedback channels and the ability to leverage responses is often inequitable and determined by citizens\u0026rsquo; social and educational status and their social capital\u0026nbsp;(1, 4-7).\u0026nbsp;Two recent reviews described responsiveness as a complex, and multi-dimensional health system goal but for which most research evidence has focused on service delivery encounters\u0026nbsp;(3, 8). Such a focus is perhaps driven by the use of the\u0026nbsp;WHO framing of responsiveness which tends to focus on individual service users and providers\u0026rsquo; interactions\u0026nbsp;(3).\u003c/p\u003e\n\u003cp\u003eIn this paper, we adopt and apply the definition of health system responsiveness as how the health system reacts/responds to the needs and concerns of citizens (9). This conceptualisation of responsiveness contains some overlap with the concept of accountability, and has been described elsewhere in a related paper(10). This conceptualisation of responsiveness identifies three processes as important for developing \u0026nbsp;a health system that is responsive to public feedback: receiving feedback from the public, processing (such as integration, analysis and/or prioritisation of feedback from multiple sources), and systemic response (9, 10) (Figure 1). The term \u0026lsquo;feedback\u0026rsquo; then refers to the views, concerns, priorities, and information provided by the public, while feedback channel/feedback mechanism refers to the avenues through which these might be shared with health system actors. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 1: Authors\u0026rsquo; conceptualisation of responsiveness(10). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConcerning the practice of health system responsiveness, the literature contains mention of interventions aimed at developing responsiveness such as the introduction of feedback mechanisms. These include \u003cem\u003ecommunity level\u003c/em\u003e feedback mechanisms such as clinic committees, intersectoral health forums, or community monitoring (11-14) and \u003cem\u003eindividual level\u003c/em\u003e feedback mechanisms such as complaints boxes, exit surveys, and incident reports. Other mechanisms include score/report cards, social audits, toll-free hotlines and web-based portals (15, 16). However, within the responsiveness literature little attention has been paid to how functional such mechanisms are towards building responsive health systems (3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGenerally, responsiveness is often treated as a \u0026lsquo;nice to have\u0026rsquo; that is prioritized below service provision; and while it is\u0026nbsp;frequently mentioned in health system policies, guidelines and value-statements \u0026ndash; especially in low--and-middle-income countries (LMICs) \u0026ndash; there is limited evidence on whether such references change practice. There is therefore value in examining \u003cem\u003ehow\u003c/em\u003e responsiveness has been conceptualised in national policy documents. Such an\u0026nbsp;examination (of policy\u003cem\u003e\u0026nbsp;\u003c/em\u003edocuments as products of the policy process),\u0026nbsp;is one way to understand an issue and uncover the assumptions embedded in written policy, that could have implications for practice\u0026nbsp;(17, 18).\u003c/p\u003e\n\u003cp\u003eWe conducted a content and framing analysis of policy documents from two sub-Saharan countries - Kenya and South Africa -\u0026nbsp;to determine, i)\u0026nbsp;what is the content on health system responsiveness in policy documents, and to whom is responsiveness targeted? ii) how is responsiveness framed within policy documents and iii)\u0026nbsp;what mechanisms, processes and actors are described in policy for enhancing health system responsiveness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis work was part of a larger study in both Kenya and South Africa whose overall goal was to examine health system responsiveness to public feedback. The review of policy documents was therefore part of the contextual analysis to understand responsiveness in these two countries.\u0026nbsp;\u003c/p\u003e"},{"header":"Background: Kenyan and South African Health Systems and Health System Responsiveness","content":"\u003cp\u003eKenya and South Africa are comparable (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), both having plural health systems, with similar low ranking in the 2000 health system assessments, and a similar value-base (such as a public sector oriented towards Universal Health Coverage (UHC) and equity). Both countries\u0026rsquo; health systems simultaneously display similar challenges: for example, geographical (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and wealth disparities (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) in access, and cultural differences that frequently flare up into social protest or unrest (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Both countries have devolved government structures. County and sub-county (Kenya) and provincial and district (South Africa) managers play a pivotal role in the development, management and delivery of public health services (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey policy initiatives and specific feedback mechanisms in Kenya and South Africa\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePolitical Economy and Health System Context\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLMIC: Middle-income classification (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePolitical Independence:1994\u003c/p\u003e \u003cp\u003eWHO HS ranking (2000):175/190 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLMIC: Lower middle-income classification (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePolitical Independence: 1963\u003c/p\u003e \u003cp\u003eWHO HS ranking (2000): 140/190 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey HS Characteristics\u003c/p\u003e \u003cp\u003e\u0026bull; Legislated national health system incorporating public \u0026amp; private (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Provision of equitable health-care services and a rights-based approach (especially for children and pregnant women) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; District health system in place to implement the PHC approach (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; HS moving towards UHC (piloting NHIS)(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Vibrant civil society (advocacy and service provider, local and international actors (\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey HS Characteristics\u003c/p\u003e \u003cp\u003e\u0026bull; Legislated national health system incorporating public \u0026amp; private (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Provision of equitable health-care services (especially for children and women) (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; A history of a (district HS) PHC approach (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Moving towards UHC (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; A civil society that is acknowledged in health policy and studies as a critical or key stakeholder in the HS (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth System Responsiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026bull; Studies report responsiveness challenges and inequalities for certain vulnerable populations for example, inequalities in responsiveness among vulnerable groups such as the poor(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), women with disability(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), the elderly (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) and among street-connected youth(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Health System actors consider responsiveness (and equity) to be a core value of the HS(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), but also a continued challenge (for example, feedback mechanisms experience multiple constraints in their functioning) (\u003cspan additionalcitationids=\"CR52 CR53\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThrough the introduction of local government (which had some health service responsibilities) in 1977 and the district health system in the 1980s, Kenya experienced health system reform characterised by re-orientation of a centralised health system to a decentralised one with structures aimed at enhancing public participation at district, and community level (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). These reforms were intended to promote the health status of all Kenyans by improving accessibility, affordability and effectiveness of health services (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). However, even though the \u0026lsquo;\u0026lsquo;people\u0026rsquo;\u0026rsquo; (communities, households, and individuals) were identified as key policy actors in these health sector reform processes, they were functionally excluded and had little or no voice in policy development and implementation processes (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In 2010, Kenya adopted a new constitution, ushering in devolution in 2013, which featured broad political reform aimed at enhancing equitable resource allocation across regions and communities, and public involvement across all phases of the policy process and resource management (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Devolution significantly impacted the health system including introducing new actors, structures and processes that influenced the governance and organisation of the health system (\u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimilarly, within the devolved governance structure enshrined in the 1996 constitution, the South African health system has experienced reforms aimed at improving health inequity in the post-apartheid period (since 1996) \u0026ndash; including the establishment of a \u0026lsquo;district health system approach\u0026rsquo; and an emphasis of community participation in policy decisions (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). However, the early efforts of the Reconstruction and Development Programme of 1994 (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) to develop \u0026lsquo;people-driven\u0026rsquo; policies and plans were constrained by lack of clarity around powers and responsibilities, and challenges in co-ordinating peoples\u0026rsquo; participation in policy formulation. Subsequent policy documents such as the White Paper for the Transformation of the Public Sector (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e) and the White Paper for the Transformation of the Health System (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e) continued to emphasise community participation in improving communication between the public and the health system, respectively, across the policy process.\u003c/p\u003e \u003cp\u003eDespite these efforts, across countries there continues to be uncertainty about the extent to which continuing health system reforms support effective engagement with the public, and inclusion of their voice in policy making (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMethods\u003c/p\u003e \u003cp\u003eWe conducted a qualitative analysis of policy documents - an approach that has been widely used in health policy and systems research (HPSR) (\u003cspan additionalcitationids=\"CR65 CR66\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). The analysis was conducted in three phases: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) policy document retrieval, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) data extraction and coding, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) content and framing analysis. All the policy documents included were analysed using a two-step deductive and inductive process namely data extraction and coding and framing analysis.\u003c/p\u003e \u003cp\u003eA related systematic mapping and review of literature (reported elsewhere)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) was useful for identifying terms related to health system responsiveness (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of words and phrases searched and coded for in policy documents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWords and phrases searched for in the policy and legislative document\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponsiveness\u003c/p\u003e \u003cp\u003eHealth system responsiveness\u003c/p\u003e \u003cp\u003ePublic service responsiveness\u003c/p\u003e \u003cp\u003eAccountability\u003c/p\u003e \u003cp\u003eSocial accountability\u003c/p\u003e \u003cp\u003ePublic participation\u003c/p\u003e \u003cp\u003eCommunity participation\u003c/p\u003e \u003cp\u003eCommunity involvement\u003c/p\u003e \u003cp\u003eCommunity engagement\u003c/p\u003e \u003cp\u003eCitizen participation\u003c/p\u003e \u003cp\u003eCitizen involvement\u003c/p\u003e \u003cp\u003eCitizen engagement\u003c/p\u003e \u003cp\u003eSocial good\u003c/p\u003e \u003cp\u003eSocial rights\u003c/p\u003e \u003cp\u003eCitizen Rights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient\u0026rsquo;s rights\u003c/p\u003e \u003cp\u003eNeeds of minority groups\u003c/p\u003e \u003cp\u003eNeeds of marginalized groups\u003c/p\u003e \u003cp\u003eCitizen views\u003c/p\u003e \u003cp\u003eCommunity views\u003c/p\u003e \u003cp\u003ePopulation views\u003c/p\u003e \u003cp\u003eCitizen voice\u003c/p\u003e \u003cp\u003eCommunity voice\u003c/p\u003e \u003cp\u003ePopulation voice\u003c/p\u003e \u003cp\u003e(Legitimate) Expectations of users\u003c/p\u003e \u003cp\u003eExpectations of clients\u003c/p\u003e \u003cp\u003eExpectations of the population\u003c/p\u003e \u003cp\u003eUser satisfaction\u003c/p\u003e \u003cp\u003epatient satisfaction\u003c/p\u003e \u003cp\u003eCitizen satisfaction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe primary policy document selection process was conducted in an iterative manner searching across policy materials from the last three decades (1994\u0026ndash;2024). Four researchers (NK, GK, NS, JO) searched the websites of the National ministries of health of South Africa and Kenya for health sector specific policies. The health sector specific policies included national health sector strategic plans and policies as well as health sub-system (such as community health, mental health, primary healthcare) policy documents (Supplementary material_1). A secondary search of broader national level public sector documents was also conducted. We found it necessary to include broader public sector policy documents because often, governance principles adopted for the wider public sector will apply in some ways to the health sector.\u003c/p\u003e \u003cp\u003eWhere documents were not available online, hard copy documents were sourced. Initial primary document selection was conducted as a team and guided by senior researchers with long-term experience in the respective health systems. For the South African documents, we considered documents published or released from 1994 onwards (the end of apartheid rule). Kenyan documents were also limited to those published or released from 1994 (when Kenya released its first health policy framework) onwards. Once the selection process was complete, we read and re-read documents to establish their main content. We then developed a content coding sheet in Microsoft Excel for each document and coded for the items summarised in Box 1 below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; The purpose of the document and influences in the development of the document\u003c/p\u003e \u003cp\u003e\u0026bull; Specific reference to the term responsiveness\u003c/p\u003e \u003cp\u003e\u0026bull; Use of other terms linked to responsiveness (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; To whom responsiveness is directed (public, patients/clients, community)\u003c/p\u003e \u003cp\u003e\u0026bull; Mention of vulnerable groups and which vulnerable groups are mentioned\u003c/p\u003e \u003cp\u003e\u0026bull; Feedback mechanisms mentioned or established within the legislative or policy documents\u003c/p\u003e \u003cp\u003e\u0026bull; Actors identified as responsible for responsiveness or functioning of feedback mechanisms\u003c/p\u003e \u003cp\u003e\u0026bull; Measurement of responsiveness (indicators for tracking responsiveness)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBox 1: Items coded for within policy and legislative documents\u003c/p\u003e \u003cp\u003eTo understand how responsiveness policy is constructed in both countries, we employed framing analysis which is a form of interpretive policy analysis (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Framing analysis is concerned with how problem definition is linked to policy solutions. Frames highlight certain aspects of a problem, diagnose causes, and propose solutions (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). By asking how responsiveness is \u0026lsquo;framed as a policy issue\u0026rsquo; we sought to understand how policy documents articulate or describe responsiveness and what arguments are used to support varied views of responsiveness. To elicit frames from the policy documents, we considered to whom responsiveness is targeted, which methods are proposed to enhance responsiveness, and with what objectives.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, 54 primary policy documents were included in this policy analysis (28 Kenyan and 26 South African) \u0026ndash; a full list of these is provided in Supplementary Material 1. In this section we present our findings in three parts. First, we present policy content on whether and how responsiveness was mentioned within policy documents, to whom responsiveness was targeted, and proposed evaluation of responsiveness; next we present findings related to how responsiveness was framed, and finally we consider the functioning of feedback mechanisms proposed to enhance responsiveness.\u003c/p\u003e \u003cp\u003eContent of responsiveness within policy documents and legislative instruments\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eFrequent mention of responsiveness, but lacking an overarching strategy\u003c/h2\u003e \u003cp\u003eAcross the two countries, twenty-seven documents explicitly mentioned the term \u0026lsquo;responsiveness\u0026rsquo;. Box 2 below illustrates the different ways in which responsiveness was referred to in these documents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; A value and principle of public service (\u003cspan additionalcitationids=\"CR69 CR70 CR71 CR72\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) or principle to guide implementation of the policy (\u003cspan additionalcitationids=\"CR75\" citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; An objective, goal or broad aim of the health system (\u003cspan additionalcitationids=\"CR78 CR79 CR80 CR81 CR82\" citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; A value or guiding principle for public service provision (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; An outcome of effectively functioning health systems (\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; An outcome of well-functioning feedback mechanisms (\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; A requirement to meet the needs of the community (\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e) (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e) and health service users (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e, \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBox 2: How responsiveness is referred to in legislative instruments and policy documents in Kenya and South Africa\u003c/p\u003e \u003cp\u003eDespite these broad references to responsiveness, closer inspection of the content in the policy documents revealed little continuity across documents or emerging trends over time, and few specific directives that could guide action on building a responsive health system. In both countries, responsiveness was often mentioned in the prefaces and opening statements of the analysed policy texts. For example, in the foreword of the Kenya Health Policy (KHP) [1994\u0026ndash;2010], the then Minister for Health states:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Throughout [the implementation of health sector reforms proposed in the KHP (1994\u0026ndash;2010)], the locus for the executive control of resources will undergo further, functional decentralisation. This will ensure that local health authorities become both more autonomous and more responsive to local needs\u0026rsquo; (pg 4).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFollowing this introduction, responsiveness was not referred to again in the KHP (1994\u0026ndash;2010). Notably, since responsiveness was first referred to in the KHP (1994\u0026ndash;2010),and later highlighted as a broad goal of the health system by the KHP (2014\u0026ndash;2030), there has not been a single overarching strategy for enhancing health system responsiveness.\u003c/p\u003e \u003cp\u003eSimilarly, in South Africa, responsiveness was stressed in the 2017 White Paper for National Health Insurance (the defining focus of the South African policy environment at this time), which noted that NHI will seek to:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;ensure a more responsive and accountable health system that takes into account socio-cultural factors whilst prioritising vulnerable communities. Such a people-centred integrated healthcare service platform should also improve user satisfaction, lead to a better quality of life of the citizens and improved health outcomes across all socioeconomic groups. This will contribute towards improved human capital, labour productivity, economic growth, social stability and social cohesion.\u0026rsquo;\u003c/em\u003e(\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, in the later NHI Act 20 of 2023, the word or concept does not appear at all. There is brief mention of how PHC Outreach Teams will \u0026ldquo;facilitate community involvement and participation in identifying health problems and behaviours\u0026rdquo; and that there is a need to \u0026ldquo;promote community participation in the planning, provision and evaluation of health care services\" (\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e)\u0026ndash; but nothing on how NHI would make the South African health system more responsive, per se.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVarying breadth of responsiveness across policy and legislative documents\u003c/h3\u003e\n\u003cp\u003eThere was also variation in the breadth of responsiveness across the documents reviewed, in the sense of \u0026lsquo;to whom\u0026rsquo; policy documents propose responsiveness should be directed. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below illustrates the different populations identified in the analysed documents to whom responsiveness should be directed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOverall, across both countries there was a predominance of attention to patients (in health sector policies) as the population for whom the health system should be responsive to. Across the reviewed Kenyan health sector texts, four health sector policies focused on responsiveness to patients or clients (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e, \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e95\u003c/span\u003e) and five documents indicated that responsiveness be directed to patients but also included local communities (\u003cspan additionalcitationids=\"CR78 CR79 CR80\" citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e). The legislative instruments and public sector documents had a broader scope and referred to responsiveness to \u0026ldquo;the public\u0026rdquo; (\u003cspan additionalcitationids=\"CR70 CR71 CR72\" citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e96\u003c/span\u003e, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e97\u003c/span\u003e). Similarly, among the South African documents analysed, legislative instruments and public sector texts referred to responsiveness to the public (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e). The majority of health sector specific documents (\u003cspan additionalcitationids=\"CR86\" citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e, \u003cspan additionalcitationids=\"CR100 CR101 CR102\" citationid=\"CR100\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e) and two legal instruments focused on the health sector (\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e104\u003c/span\u003e, \u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e105\u003c/span\u003e) referred to responsiveness to patients/ service users. Seven texts from the public sector and the health sector referred to responsiveness to both patients/service users and communities (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e, \u003cspan additionalcitationids=\"CR107 CR108\" citationid=\"CR107\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e109\u003c/span\u003e). None of the documents from either country clearly defined \u0026lsquo;the community/public\u0026rsquo; in terms of legal status (that is, responsive to legal citizenry or \u0026lsquo;all\u0026rsquo; [the whole population] \u0026ndash; this becomes particularly relevant when issues such as responsiveness to migrant populations is raised).\u003c/p\u003e \u003cp\u003eMost of the policy documents across both countries referred to responsiveness to vulnerable populations. Similar categories of vulnerable populations were mentioned as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below. Among the frequently mentioned vulnerable populations were youth, children, orphans, women, the elderly, people from indigenous communities and people living with disability.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea: Vulnerable populations identified in legislation and policy documents, Kenya, n\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eKey: PLWHA-People Living with HIV and AIDs; PLWD-People Living with Disability, PLWHIV-People Living With HIV\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e: Vulnerable populations identified in Kenyan and South African legislation and policy documents\u003c/p\u003e \u003cp\u003eDespite describing the need for responsiveness to vulnerable groups, few of the analysed texts explicitly described the presence of vulnerable groups in participatory feedback mechanisms or how their voices would be included in shaping health system views or functions. In Kenya, exceptions to these observations included the legislative supplements for health facility committees (HFCs) which recommended the presence of women as HFC members; the Urban Areas and Cities Act (UACA, 2012) and County Government Act (CGA, 2012) which required inclusion of the vulnerable groups in making city plans (UACA, 2012) and in all areas of county economic, political, and cultural life (CGA, 2012); and the County Public Participation and Community Score Card Guidelines which offered specific suggestions to proactively target members of vulnerable groups to get their feedback. In South Africa, the 2013 Framework for Citizen-Government partnership highlights that vulnerable groups may fail to provide feedback on their experiences with the health system due to cultural, social and physical barriers (\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e) but does not provide detail about how to overcome these barriers. The second Presidential Compact on Health (2024), however, identified a Community Liaison Officer and specified their role in facilitating outreach and engagement with vulnerable groups such as hard-to-reach populations, people living with disabilities, people living with mental health disorders and their families, and older citizens (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eUnderdeveloped assessment of responsiveness\u003c/h3\u003e\n\u003cp\u003ePart of the implementation process of policies involves monitoring and periodic evaluation (\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e110\u003c/span\u003e). We therefore explored the documents for proposals on how responsiveness could be measured or assessed and found that the assessment of health system responsiveness was rarely discussed in the reviewed policy documents. In the Kenyan documents, a satisfaction index (tracked annually) was adopted as a measure for health system responsiveness in three documents, the KHP (2014\u0026ndash;2030) and its subsequent strategic five-year plans KHSSP (2013\u0026ndash;2017) and KHSSP (2018\u0026ndash;2022). In the KHSPP (2013\u0026ndash;2017), the satisfaction index was reported at 65% in 2012, 78% in 2015 and a target for 2017 set at 85%(\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e). The KHP (2014\u0026ndash;2030) set the client satisfaction target at 95% in 2030 (\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe adoption of a satisfaction index as a measure of responsiveness raises questions. It was unclear from the documents reviewed whether the reported satisfaction rates in the policy documents were a measure of satisfaction with the health facility, the services provided by the HCW, the health system in general or a combination of all three. Further, there was no description of the populations that these statistics represented, nor comment on variations across population segments.\u003c/p\u003e \u003cp\u003eIn more recent documents, the measures of responsiveness appear to vary in breadth, as various dimensions are introduced. For example, in the more recent Kenya UHC policy 2020\u0026ndash;2030, indicators to track responsiveness of the health system include general facility service readiness; and International Health Regulations (IHR) capacity and health emergency preparedness (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e), while the Community score-card guidelines present responsiveness as an indicator with three related sub-indicators: facility staff participation in community dialogue meetings, how promptly facility staff respond to community grievances including those arising from the community score card exercise (\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile no single measure for health system responsiveness was identified in the South African health policy documents, we identified mainly quantifiable service-related indicators, illustrated by a focus on meeting service standards (\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e106\u003c/span\u003e), and other measures such as patient waiting times (\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e) and findings from patient experience surveys (\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe framing of health system responsiveness across policy documents and legislative instruments\u003c/p\u003e \u003cp\u003eIn this section, we present five framings of responsiveness identified from the analysed policy documents. Although presented separately there are overlapping elements across the framings. We attempted to include all the documents that we found to be relevant to a particular framing, resulting in some documents appearing more than once in the various framings (Supplementary Material 2). The most dominant framing was responsiveness as feedback on health service, identified in fourteen Kenyan and fifteen South African health policy health policy documents.\u003c/p\u003e\n\u003ch3\u003eResponsiveness as feedback on health service\u003c/h3\u003e\n\u003cp\u003eIn the Kenyan documents, within 14 health sector specific policies (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan additionalcitationids=\"CR77 CR78 CR79\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e, \u003cspan additionalcitationids=\"CR112 CR113\" citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e114\u003c/span\u003e) that framed responsiveness as feedback on quality of health services, most of the proposed feedback mechanisms targeted patients or service users with the aim of gauging client or patient satisfaction. For example, the Kenya Health Policy Framework (KHPF) I 1994\u0026ndash;2010 and Kenya Health Sector Strategic Plan (KHSSP) II 1999\u0026ndash;2004 noted the need to establish a multi-professional inspectorate to ensure professional conduct and institution of proper regulatory mechanisms in the interests of the public in order \u0026lsquo;\u003cem\u003eto better respond to the needs of patients\u0026hellip;,\u0026rsquo;\u003c/em\u003e(pg 15) (\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e). The KHSSP II 2005\u0026ndash;2010 included responsiveness to \u003cem\u003eclient needs and quality of care\u003c/em\u003e as one of its objectives. Among the actions intended to enhance responsiveness were: \u0026lsquo;\u003cem\u003eensuring complaint procedures are in place\u003c/em\u003e, and \u003cem\u003e\u0026lsquo;training health workers on client handling and patient centred accountability\u0026rsquo;\u003c/em\u003e (pg 26)(\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). Within the KHSSP III strategic objectives, health services were expected to be \u0026lsquo;\u003cem\u003eresponsive\u0026rsquo; to client needs (pg 39)\u003c/em\u003e(\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e). Specific actions to achieve these objectives were mainly service related and the ways to track them included, \u003cem\u003e\u0026lsquo;conducting regular client satisfaction surveys to continually ensure clients expectations are informing intervention provision, and ensuring patient safety is ensured in provision of services\u0026rsquo; (pg 33)\u003c/em\u003e(\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis framing of responsiveness as service-feedback, was also predominant in South African health sector specific policies. For example in a cluster of documents whose focus was to track and improve service delivery experiences related to patient safety (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e), waiting time (\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e), complaints about service delivery (\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e101\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e), and patients\u0026rsquo; experiences of receiving care (\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e). These documents focused on collecting information from patients and their families with a view to increase user satisfaction or make \u003cem\u003ehealth services\u003c/em\u003e more responsive to the concerns and needs of users. The documents outlined three broad processes involved in service feed-back to facilitate responsiveness: 1) creating an enabling environment for users and/or public to complain about services and to receive information about their care; 2) action on feedback provided by service users (for example investigation of complaints made by patients or their relatives); and 3) provision of a response back to the source of feedback/ complainant or to patients/families affected by a safety incident or to service users who participated in patient experience surveys (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan additionalcitationids=\"CR102\" citationid=\"CR102\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eResponsiveness as non-clinical dimensions of care (the WHO framing)\u003c/h3\u003e\n\u003cp\u003eAcross both countries, there was little explicit reference to the WHO framing of responsiveness (with its seven dimensions) and only a few of its dimensions were identified in the analysed texts. Within Kenyan documents, only three documents used the language of the WHO framing of responsiveness (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e). The terms identified in these documents were \u0026lsquo;legitimate expectations of the population\u0026rsquo; and \u0026lsquo;dignified care\u0026rsquo;. The KHP II 2012\u0026ndash;2030, included a people-centred approach to health and health interventions as one of its principles and stated that health interventions should be \u003cem\u003e\u0026lsquo;premised on people\u0026rsquo;s legitimate needs and expectations\u0026rsquo;\u003c/em\u003e (pg 25)(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e). There was no further elaboration of these \u0026lsquo;legitimate expectations\u0026rsquo;. Dignified, human and compassionate care was mentioned in the context of service provision to vulnerable groups (women, children, people with mental and physical disabilities) who experienced socio-cultural barriers when accessing care (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). However, there were no other details regarding dignified care, for example, how it might be measured or what other interventions might contribute to dignified care beyond providing privacy for women during service delivery.\u003c/p\u003e \u003cp\u003eSimilarly, in the South African policy documents there was limited reference to the WHO framing of responsiveness. For example, the guidelines on patient waiting times, identified \u0026lsquo;\u003cem\u003epatient waiting time as a reflection of the responsiveness of the health system to the needs and demands for health services\u0026rsquo; (pg 5)\u003c/em\u003e (\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e). This timely provision of care is encapsulated in the \u0026lsquo;prompt attention\u0026rsquo; domain of the WHO framing of responsiveness. Another dimension of the WHO framing, respect for persons, which includes autonomy, confidentiality, dignity and respect was included within the National Core Standards under the domain of Patient Rights (\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e106\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResponsiveness as public participation\u003c/h2\u003e \u003cp\u003eAcross the two countries responsiveness was presented as constituting public participation in several of the analysed texts. Within the Kenyan texts, this frame of responsiveness was identified predominantly within legal instruments and public sector documents (n\u0026thinsp;=\u0026thinsp;5). The texts described public participation as being required for policy formulation and implementation including service delivery. For example, the Urban Areas and Cities Act required that \u0026lsquo;\u003cem\u003ecommunity needs are reflected in Urban Areas and Cities' plans especially for access to services\u0026rsquo;\u003c/em\u003e (section 40(d)); and identified that residents had \u0026lsquo;\u003cem\u003ea right to participate in decision-making, and a right to prompt responses\u003c/em\u003e \u0026lsquo;(pg 28\u0026ndash;29) (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e97\u003c/span\u003e). The documents required not just the collection of public views, but also that government plans reflect community needs and input. Besides inviting public and community views, state actors were required to facilitate the participation of local communities in governance and build the capacities of communities to participate (Constitution of Kenya, Section 196; 201) (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Public Participation Guidelines developed in 2016 identified various ways that county governments could receive feedback from the public. The methods proposed to get public input were varied representing a mix of quantitative and qualitative approaches to gathering public views. In the public participation guidelines, responsiveness was described as \u0026lsquo;\u003cem\u003ewhen the implemented process shall envisage a response from a decision maker or institutional representative, in order to ensure that participants\u0026rsquo; inputs are taken seriously and properly considered\u0026rsquo; (pg 38)\u003c/em\u003e(\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin the South African documents, we identified a \u0026lsquo;responsiveness as public participation\u0026rsquo; frame in nine legislative instruments and public and health sector policy documents (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e, \u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e106\u003c/span\u003e, \u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e107\u003c/span\u003e, \u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e109\u003c/span\u003e, \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e115\u003c/span\u003e). These documents emphasised the need for incorporation of public views through varied participation mechanisms. For example, the National Health Act (2003) proposed promotion of \u0026lsquo;\u003cem\u003ecommunity participation in the planning, provision and evaluation of health services\u0026rsquo; (pg, 30)\u003c/em\u003e at different levels of the health system (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), while the 2007 Policy on Quality on Healthcare proposed engagement with the public in non-technical language and through varied formats to ensure their contributions were included in quality improvement efforts (\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e109\u003c/span\u003e). Participatory mechanisms mentioned within this frame included clinic committees/hospital boards, citizen-based monitoring in which the public was actively involved in policy formulation, ward committees, and implementation primary health care outreach teams inclusive of CHWs (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e, \u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e108\u003c/span\u003e). All these mechanisms sought to enhance responding to the needs and concerns of the public. Within the 2013 Framework for Community Based Monitoring, there was an acknowledgement that \u0026lsquo;c\u003cem\u003eitizens cannot be passive recipients if government is to deliver services that address real needs. The process of citizens working jointly with government to produce information on service delivery fosters active citizenry and contributes to building a capable and developmental state\u0026rsquo; (pg 25)\u003c/em\u003e (\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResponsiveness as internal and/or external accountability\u003c/h3\u003e\n\u003cp\u003eWe identified responsiveness framed as accountability mainly in health sector policy documents across both countries. Two forms of accountability framing were identified within the reviewed documents: external accountability was more dominant in Kenyan texts, and internal accountability more dominant in South African texts. The Kenyan documents that adopted this frame included the Kenyan Health Sector Strategic Plan II (2005\u0026ndash;2010, its related Community Strategy policy documents (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e)) and recent legislation for Primary Health Care (\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e116\u003c/span\u003e). Within the Kenyan Community Strategy (CS) policy and implementation guidelines, CS was described as a way for communities to \u0026lsquo;\u003cem\u003eseek accountability from the formal system for the efficiency and effectiveness of health and other services\u0026rsquo; (pg 2)\u003c/em\u003e(\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e) through \u0026lsquo;\u003cem\u003eparticipation in meetings to discuss trends in coverage, morbidity, resources and client satisfaction, and giving feedback to the service system\u0026rsquo; (pg 4)\u003c/em\u003e (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e). The CS implementation guidelines presented participatory mechanisms such as Community Health Committees (CHCs) and HFCs as channels where feedback from the community could be shared with health system actors. These mechanisms were described as linked across system levels, with a suggestion that where there was failure to resolve/address issues, they could be escalated to a higher health system level. Among the responsiveness related roles for CHCs were \u0026lsquo;\u003cem\u003eproviding a channel of communication with levels 2 and 3 management committees (HFCs), divisional health forum and the district health stakeholder forum (pg 6)\u003c/em\u003e (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e). Responsiveness related roles for HFCs included \u0026lsquo;\u003cem\u003eproviding feedback on services at level one [the community]\u003c/em\u003e\u0026hellip;\u003cem\u003eadvocacy for community issues to be taken up to higher levels of the system\u0026hellip;and review of client satisfaction records\u0026rsquo; (pg10-11)\u003c/em\u003e (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe South African texts identified in this category referred to responsiveness in terms of accountability to people\u0026rsquo;s rights and needs. We described this frame \u0026lsquo;responsiveness as internal accountability\u0026rsquo; because the cluster of documents identified here were focused on answerability between actors within the health system for delivery of a pre-determined standard of service or care. These standard of care documents referred to the need to improve patient safety, medical accountability, and clinical governance (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e, \u003cspan additionalcitationids=\"CR102\" citationid=\"CR102\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e, \u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e105\u003c/span\u003e). In these documents, the establishment and improvement of specific accountability mechanisms such as the patient safety incident reporting procedures were thought to be important to hold providers accountable. The guidelines on patient safety and complaints management for example addressed users concerns and promoted access to safe and good quality services (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e). Other mechanisms described within this cluster of documents for service users (and their relatives) to provide feedback and therefore provide a means for holding service providers accountable included the ombudsperson, and the Office of Health Standards Compliance (\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e105\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eResponsiveness as the realisation of a right to health\u003c/h3\u003e\n\u003cp\u003eResponsiveness was also framed as the realisation of the provisions and entitlements to uphold and promote fundamental rights such as access to health for all communities and public. This framing was elicited across legislative documents, public and health sector specific documents. In the South African texts, we elicited a more direct link, between a responsive health system and the right to health. For example, the National Health Act (2003) indicated that adequate information on the rights and duties of users, communities and public are critical to ensure responsiveness and preserve the rights of users (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The National Core Standards (Domain 1: Patient Rights) and Patients\u0026rsquo; Rights Charter specified these rights as access to adequate and appropriate services, respectful and dignified treatment; participation, and the right to complain (\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e99\u003c/span\u003e, \u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e106\u003c/span\u003e). The National Health Insurance Bill (2019) recognised \u0026lsquo;\u003cem\u003ethe need to heal the divisions of the past and to establish a society based on democratic values, social justice, and fundamental human rights; and the need to improve the quality of life of all citizens and to free the potential of each person.\u003c/em\u003e The Bill therefore sought to \u0026lsquo;\u003cem\u003eachieve the progressive realisation of the right of access to quality personal health care services' and \u0026lsquo;make progress towards achieving Universal Health Coverage\u0026rsquo; (pg.3)\u003c/em\u003e(\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e104\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin the Kenyan texts, several legal instruments (\u003cspan additionalcitationids=\"CR69\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e97\u003c/span\u003e) and health sector policy documents (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e) considered the state and service providers as having a responsibility to provide the right to health, with the public as rights claimants. To facilitate access to other rights (including the right to health) the Constitution included a right to \u0026lsquo;\u003cem\u003einformation held by the state and state\u003c/em\u003e actors\u0026rsquo; (Article 35) (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). The County Government Act also reiterated this right to information by requiring governments to establish mechanisms to \u0026lsquo;\u003cem\u003efacilitate public communication and access to information in form of media that has the widest public outreach\u0026rsquo; (section, 95:2)\u003c/em\u003e (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). The Health Act 2017 reiterated the constitutionally guaranteed right to health, the duty of the state for provision and the responsibility of the county governments to facilitate participatory governance. Within the health sector specific policy documents, the KHSSP II 2005\u0026ndash;2010 included a human rights approach to service delivery, in which the health sector had a duty to \u003cem\u003e\u0026lsquo;respond to the aspirations and expectations of communities\u0026rsquo;\u003c/em\u003e(pg 41) (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). This is referred to again in the CS policy document and implementation guidelines which sought to empower communities to \u0026lsquo;\u003cem\u003eclaim their right to accessible and quality care and seek accountability from the formal system\u003c/em\u003e\u0026rsquo; (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFeedback mechanisms supporting health system responsiveness\u003c/p\u003e \u003cp\u003eIn this section, we describe the various feedback mechanisms which we judged had the potential to enhance responsiveness. Our description includes a summary of the mechanisms, the range of actors mentioned with responsibility for responsiveness, and considers the level of detail concerning the functioning of the identified feedback channels.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMultiple Channels through which the public could provide feedback to the health system\u003c/h2\u003e \u003cp\u003eMost of the mechanisms identified had broad functions related to public participation and community engagement beyond the health sector. Receiving feedback from the public was therefore one among other functions carried out by these mechanisms. Supplementary Material 3 summarises their roles in supporting responsiveness to public feedback across both countries in multiple sectors including the health sector and includes a section for mechanisms identified specifically for the health sector. In both countries, within the health sector, feedback mechanisms could be broadly classified into those that supported feedback on service after a provider-client interaction, for example client satisfaction surveys in Kenya (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e) and patient experience surveys in South Africa (\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e), suggestion boxes at facility level, and patient rights charters and complaint management systems (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e95\u003c/span\u003e, \u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e99\u003c/span\u003e, \u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e101\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e) across both countries. The participatory mechanisms included health facility committees (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e) in both countries, community health committees and district/county health boards (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e) in Kenya; and ward committees (\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e) and primary health outreach teams (\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e108\u003c/span\u003e) in South Africa. These mechanisms were proposed to function at various levels of the health system from community level, through peripheral facility and district/subcounty level, and upwards to county/provincial and national levels.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eVaried range of actors with responsibility for supporting health system responsiveness\u003c/h2\u003e \u003cp\u003eWe identified actors ranging from health managers, public administrators and elected representatives at sub-national and national level who had roles in enhancing responsiveness. In Kenyan policy texts these roles varied, ranging from national and county elected representatives receiving petitions from the public (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e), public-sector administrators ensuring public views were considered in strategic policy, budgeting, planning activities and evaluation of county performance (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e96\u003c/span\u003e) and hospital heads, health facility in-charges receiving complaints and compliments from service users (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e95\u003c/span\u003e). The roles of county and sub-county health managers in enhancing responsiveness were more implicit given their participation in various participatory mechanisms such as County Health Stakeholder Forums, and cunty and sub-county Primary Health Committees as secretaries to these participatory mechanisms that comprised health managers and community members (\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR113\" class=\"CitationRef\"\u003e112\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin the South African texts, the role of local-level elected representatives with respect to health system responsiveness was not explicitly stated. However, the health minister at the national level and the Member of Executive Council (MEC) for health at provincial level both had a responsibility for approval of service standards set by provincial and district health managers (\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e106\u003c/span\u003e), suggesting an oversight role. Other actors identified within the South African texts included the Health Ombudsman and Quality assurance managers, respectively responsible for receiving complaints and conducting patient experience surveys (\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e, \u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e106\u003c/span\u003e). This clarity was absent in the Kenyan documents, where an Ombudsman was mentioned in one policy document (\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e) without description of their roles. Hospital heads and health facility-in-charges in South African texts were expected to receive and respond to complaints (\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e) while provincial and district health managers had a responsibility to review complaints resolved at facility level and provide information to lower health system level actors on the procedure for receiving and responding to complaints (\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eScant detail on expected functioning of feedback mechanisms for system response\u003c/h2\u003e \u003cp\u003eFor several mechanisms, the policy documents analysed gave little detail on how they would be operationalised to receive information and what would happen to the collected information. For example, in Kenya for mechanisms such as hotlines, suggestion boxes, health ombudsmen and patient satisfaction surveys there was little information on who would be assigned to run hotlines and conduct satisfaction surveys, and whether the information collected would be integrated to enhance health system responsiveness.\u003c/p\u003e \u003cp\u003eSeveral health sector policy documents in both countries focused primarily on collecting feedback and provided little description of whether and how a response would be provided to the public after feedback was received. For example, Kenyan Community Strategy documents, and the Kenya Community Health Policy 2020\u0026ndash;2030 described escalation of public feedback through participatory structures at community and facility level to higher health system levels (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e113\u003c/span\u003e), but rarely mentioned responses back down to the public. In the South African documents, the Policy framework and Strategy for Ward-based Public Health Outreach Teams described that it \u003cem\u003e\u0026lsquo;will collectively facilitate community involvement and participation in identifying health threats, vulnerable groups and individuals and appropriate interventions for addressing these\u003c/em\u003e\u0026rsquo; (\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e108\u003c/span\u003e). However, there was no further elaboration within the document of how information from the public would be utilised to enact responses or develop appropriate interventions. Despite these gaps, there were two clusters of documents that provided some detail on potential responses from the health system and communication back to the public (including service users) after sharing feedback. These are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below, which highlights that the included documents mentioned varying potential responses depending on the form of public feedback. For example, the Patient Safety Guidelines recommended that service use complaints be responded to at the individual-level by clear communication with the affected users (\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e100\u003c/span\u003e), the Patient Experience Survey Guideline recommended patient experience survey findings be reported in public media in summary form and drawn on to initiate quality improvement cycles to enhance service delivery (\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e), while Community Score-Card and Public Participation and Guidelines recommended provision of up-dates to the public about which of their input had been incorporated (or not) into the planning cycle at community and higher levels(\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetails of functioning of feedback mechanisms in relation to receiving, processing and responding to public feedback\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctioning of feedback mechanism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCluster one: Health sector specific policies (mainly from South Africa)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCluster two: legal instruments and public sector documents from Kenya and South Africa\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceiving feedback from service users/public\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Community-level collection of information during community score card (CSC) exercise (\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Facility level collection of information through surveys, safety walk arounds, review of medical records, incident reports, and via standardised complaint/compliment form, email, fax, suggestion boxes (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Setting up enabling conditions for meaningful public participation by sending out invitations to attend meetings, conferences, ensuring representation of marginalised groups (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Collection of community/public views on proposed projects or plans (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e97\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e) and budgetary preparation (\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e96\u003c/span\u003e) from lowest administrative levels and upwards levels through surveys, FGDs, public meetings (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e), oral/written submissions (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e97\u003c/span\u003e) and ward committees(\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcessing and utilisation of feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Analysis and reviewing information to determine trends (\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e) and for immediate response at facility level or escalation to higher system levels (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; At facility level, proposed actions in response to the data generated from patient experience surveys, safety incident reporting, complaints and patient waiting times informed preparation of facility improvement plans (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; In Kenya: Up-ward sharing of actions generated at community dialogue, to facility and sub-county teams, inclusion of scores in Health Information System (\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Upward submission of public views from the wards, to the sub-counties/districts and synthesis at county /province level (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse to users/the public\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Communication to the patient regarding resolution of their complaint within 25 days (\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Sharing of findings with users who participated in patient experience surveys and with the public through mass media (e.g. radio and televisions) (\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Communicating to patients and/or their families what went wrong and why in the case of safety incidents (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Monthly follow-up on implementation of community action plan during community action days, with facility in-charge, Community Health focal person at sub-county and county levels (\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Feedback to the public on whether their input was included in planning and policy formulation (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAcross both countries, there was little mention of tracking or monitoring how well the feedback mechanisms functioned, save for the public participation guidelines which proposed evaluation of public participation initiatives and processes to determine i) whether the participation activities had achieved their objectives; ii) implementation challenges; and to draw lessons for future initiatives (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e). The Kenyan public participation guidelines included indicators for evaluation such as civic education on the process and content of participation, resources allocated to the public participation process/initiative, access to information by members of the public, diversity of participants, timely communication and the extent to which public feedback was incorporated into decision-making (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile there were many similarities, there were several differences across Kenya and South Africa in the feedback mechanisms outlined in the analysed texts. First, there seemed to be institutionalization of Civil Society Organisations (CSOs) as a mechanism for voicing public concerns within the framework of citizen-based monitoring of service delivery in the South African context (\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e). In the Kenyan texts analysed, CSOs were included as stakeholders in the health sector, but more attention was paid to their role in complementing service delivery than in voicing community concerns. Second, there was variation in the level of development of certain feedback mechanisms. For example, in the Kenyan documents, the Health Ombudsman was mentioned with scant detail on their functioning (\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e), whereas the South African documents includes details of the role of the health Ombudsman as a recipient of public complaints about health service delivery, their powers to investigate and linkages to a tribunal that adjudicates on cases brought by the health Ombudsman (\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e101\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThird, within the South African documents there were more detailed guidelines for the collection of various forms of feedback from patients (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e). In contrast, across the Kenyan documents analysed, there were few guidelines. For example, it was expected that satisfaction surveys would be done annually, but there was no direction as to how they would be carried out, who would be responsible for conducting them (for example whether by facility level staff or an independent body). The South African complaint management system also made provision for data generated from complaints to inform proposed actions in facility improvement plans (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e102\u003c/span\u003e, \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e103\u003c/span\u003e). This was absent in the complaint management system proposed in Kenyan documents (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e95\u003c/span\u003e) where there was little to suggest that information from complaints informed facility quality improvement plans. However, in Kenya a more recent guideline, the Community Score Card Guideline provides some details on who would be involved in collecting information from community members (the Community Health Committee), where this could be done, and how frequently, including procedures for how this information would be shared up-wards with healthcare workers and health managers (\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e111\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we conducted a content and framing analysis to establish the policy framing of responsiveness in Kenya and South Africa. We found that there was provision for responsiveness in national policy and legislation, and support for the institutionalization of mechanisms for receiving and responding to public feedback. However, we also found a lack of coherence in how responsiveness was described across the reviewed documents. Drawing on our understanding of responsiveness as comprising processes of receiving, processing, and responding to public feedback, we identified inattention to certain elements that could support the development of responsive health systems across policy documents in both countries.\u003c/p\u003e \u003cp\u003eFirst, despite frequent mention of \u0026lsquo;system responsiveness\u0026rsquo; we found little attention to system-wide processes for responsiveness. Feedback mechanisms were presented in isolation especially within health sector policy documents, where a single feedback mechanism often handled a specific type of information. For example, complaints management systems were extensively described in both countries but there was little to suggest that for instance, patient satisfaction survey results were considered together with complaints data or any other form of public feedback. Where provision for upward escalation of public feedback was recommended, it was not clear that there was integration to identify patterns, across facilities or health system levels. Our findings are consistent with other literature that reported similar siloed functioning of feedback mechanisms in Kenya (\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e117\u003c/span\u003e) and South Africa (\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e118\u003c/span\u003e). This inattention to integration of data from multiple feedback channels in the health sector policy documents of both countries, is a missed opportunity to strengthen health system responsiveness since integration could provide a more holistic picture of health system experience.\u003c/p\u003e \u003cp\u003eSecond, there was limited attention to how the health system would generate responses once feedback was received. These findings are consistent with a review of responsiveness literature that found that few studies reported health system responses to public feedback (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and a report on public participation where the authors observed that many health systems in LMICs have a poor record in feeding information back to communities (\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e119\u003c/span\u003e). Inattention to responses and failure to communicate back to the public could undermine responsiveness. Literature demonstrates that if the public do not feel that their input has value, they stop providing it (\u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e120\u003c/span\u003e, \u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e121\u003c/span\u003e). Indeed, in both Kenya and South Africa, studies have reported the public\u0026rsquo;s perception of perfunctory participation processes that do not attain objectives of being responsive to local needs (122\u0026ndash;124).\u003c/p\u003e \u003cp\u003eOur study findings included a dominant framing of responsiveness as \u0026lsquo;health service feedback\u0026rsquo; within the health sector documents. This predominant focus on service feedback within health sector policy documents draws attention to the different problem definitions addressed by the varying frames identified in the policy texts. Bacchi argues that policy is often a governance tool intended to redress a problem in society (\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e). Drawing on this argument, the participation and rights-based frames within legislative, public sector and a few health sector documents present responsiveness as an opportunity to enhance equity. This is implied by the frames\u0026rsquo; attention to inclusivity of various segments of the population, particularly the vulnerable whose representation in participatory mechanisms is explicitly expected. In contrast the policy responses proposed by the \u0026lsquo;responsiveness as feedback on health service\u0026rsquo; frame suggest that responsiveness is viewed as an opportunity to address clinical service delivery problems. This is important because, what is determined to be the problem influences decision-making around resources and governance arrangements. A narrow focus on clinical service delivery within health sector policy documents could translate to meagre resources being allocated to the feedback mechanisms required to enable health system responsiveness.\u003c/p\u003e \u003cp\u003eFrames also legitimise which actors can participate in policy processes (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). In this study, the participation and rights-based frames in both countries include multiple actors within and outside the health system. However, the \u0026lsquo;responsiveness as feedback on clinical service delivery\u0026rsquo; and \u0026lsquo;responsiveness as internal accountability\u0026rsquo; frames narrow the focus on actors to providers (and their managers) and patients. As a result, it is unclear, for example, how state actors with responsibilities for ensuring functioning of feedback mechanisms (as described in Kenyan legal instruments (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e96\u003c/span\u003e)) facilitate health system responsiveness. In addition, and particularly in the Kenyan health sector policy documents, much more attention was paid to the role of civil society in service provision than in enhancing responsiveness. Yet literature demonstrates that civil society can engage in others ways in policy processes; for example by putting issues on the government\u0026rsquo;s agenda leading to improvements in access to services for marginalised populations or scale up of services not prioritised in the public health sector (\u003cspan additionalcitationids=\"CR127\" citationid=\"CR127\" class=\"CitationRef\"\u003e126\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e128\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study also revealed the influence of frames on how the goal of health system responsiveness is measured. The Kenyan Health Policy 2014\u0026ndash;2030 and KHSSP III 2018\u0026ndash;2022 reported a satisfaction index as a measure for tracking health system responsiveness (\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e129\u003c/span\u003e, \u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e130\u003c/span\u003e) linked to the \u0026lsquo;responsiveness as feedback on health service\u0026rsquo; frame. In other documents, client satisfaction was implicitly identified as measure given the attention to satisfaction in the descriptions of responsiveness (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e). In South African texts, more attention was paid to quantifiable indicators of health service quality, again linked to the \u0026lsquo;responsiveness as feedback on health service\u0026rsquo; frame. While these quantifiable indicators can provide varied information about the health system, they do not fully capture the multi-dimensional nature of responsiveness. Notably, whether an overall health system responsiveness index was adopted, or multiple service-related quantifiable indicators were used, there was a clear \u0026lsquo;silence\u0026rsquo; on the experiences of vulnerable groups. For example, the Kenyan health policy documents that adopted a satisfaction index to measure health system responsiveness did not provide disaggregated data across different population segments. In South African health policy documents and guidelines for the quantifiable processes such as patient waiting times, patient experience surveys and complaints management hardly mentioned different population segments, and how views of vulnerable groups could be captured in the data collection.\u003c/p\u003e \u003cp\u003eThe health service feedback frame predominant in most health sector documents largely neglects phases of the policy process (other than implementation), equity challenges, and power and knowledge differentials between population groups and between the public and health system actors. Yet, these are important considerations given that Kenya and South Africa have histories of inequalities in health service access and distribution (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Further, literature from other LMICs suggest that structural challenges such as poverty and low education levels, power dynamics and knowledge asymmetry influence whether the public can voice concerns or leverage responses from the health system. For example, in Nigeria and Nepal, low usage of suggestion boxes and service charters was linked to low awareness of their existence and how to use them, low literacy levels, fear of reprisal from health providers, and perceptions that the communities suggestion would be viewed as irrelevant or that it would take long to get a response (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e131\u003c/span\u003e). In Zambia and Tanzania, elite community members with vested interests such as political and personal gain often formed the membership of HFCs, raising concerns about the degree of representativeness in these participatory mechanisms (132).\u003c/p\u003e \u003cp\u003eThis analysis also illustrates that the broader public sector documents were more holistic and inclusive in their conceptualisation of responsiveness and provided more detail on the proposed functioning of feedback mechanisms. While health sector-specific documents referred to the values in the Constitutions of both countries and legislative documents, they did not maintain the broad and inclusive intentions in their framing of responsiveness. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e below illustrates the thinning down of policy intent moving from broad public sector and legislation to health sector-specific policy documents which had a narrower focus.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn seeking to strengthen health sector policies, we propose adopting a broader framing based on integrating the frames from different policy document types and moving beyond \u0026lsquo;responsiveness as feedback on health service\u0026rsquo;. A broader framing would re-define health system responsiveness to include a focus on the wider public (irrespective of whether they have had a service delivery encounter) and provide more attention to varied population segments, including vulnerable groups. A focus beyond patients/service users would also allow for collection and synthesis of multiple types of data and at different phases of the policy process, as suggested in in several public sector documents but currently absent from health sector documents. There is potential to learn from a few policy documents which seemed to achieve this level of integration \u0026ndash; such as the South African Framework for Citizen-Based Monitoring (\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e), and public participation guidelines from both countries (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e98\u003c/span\u003e). These texts include consideration of an environment that enables citizen/public feedback (suggesting attention to structural and power issues that might hinder the public from voicing their needs and concerns), collection of various data forms (both quantitative and qualitative) depending on the issue for which participation is required, communication of findings following data collection back to the public, incorporation of feedback for service improvement, and monitoring of the feedback mechanisms. These considerations capture the interlinked framings of participation, accountability, rights-based and feedback on clinical service potentially providing a more holistic approach to building responsive health systems.\u003c/p\u003e \u003cp\u003eThis study which examined the content and framing of responsiveness in two LMIC countries, demonstrates that combining content and framing analyses can uncover valuable insights. Applying framing analysis to the content of policy documents enabled critical reflection and deepened the analyses of the content of responsiveness policy in terms of what was \u0026lsquo;problematised\u0026rsquo; in health sector policy documents and what was left out. This analysis also shows that, particularly in health sector policies, power and system-wide issues were not adequately addressed. This underscores the importance of paying greater attention to power relations and adopting a broader health system approach to responsiveness in future research \u0026ndash; considering, for example, how multiple forms of feedback mechanisms work together to enhance health system responsiveness. We therefore support the call for greater theoretical distinction between health system responsiveness and health service responsiveness (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and the need to consider the historical, political, cultural and socioeconomic contexts of health systems and how these shape health system responsiveness (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Response to these calls would trigger further research on how responsiveness from a broader system perspective might look, in line with the systemic lens applied in the HPSR field (\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e, \u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e134\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is also need for research around the population to whom responsiveness is targeted. While all clusters of analysed texts (legislative instruments, public sector \u0026amp; health sector specific policy documents) mentioned vulnerable groups, attention to them in terms of inclusion in feedback mechanisms was more notable in the participation and rights-based frames within legislative instruments and public sector documents. Consideration of how they could leverage responses was hardly referred to particularly within the health sector specific documents. In the wider LMIC literature, there is little empirical evidence on responsiveness amongst vulnerable groups (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This is an important research gap to address given that equity in responsiveness is a key dimension of responsiveness (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), and that vulnerable groups are likely to experience even worse responsiveness from the health system when there are periods of health system shock as has happened more recently in LMICs that experienced the Ebola outbreaks of 2014/2015 (\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e135\u003c/span\u003e), and more recently with the COVID-19 pandemic (\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e136\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNotably, in our analysis of Kenyan and South African policy texts, there was little direct mention of the different domains of the non-clinical WHO framing within the policy texts from both countries. Yet two literature reviews on health system responsiveness (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) found that the WHO framing (considering most or all of the seven domains) was the most commonly used approach to assess health system responsiveness. Overall, similarities between the evidence mapping findings (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and our policy analysis, suggests, that there has been little global guidance since the WHR2000 on how responsiveness should be operationalised, or that policymakers disagree with the WHO non-clinical framing of responsiveness. Overall, there is need to have more direct and coherent statements about health system responsiveness in policy documents.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis work primarily analysed policy documents which provide an opportunity for in-depth analysis but also have significant limitations when used alone. These include understanding the dynamic interaction between actors and policy processes, because the voices of actors are absent. These have been included in separate empirical work (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e137\u003c/span\u003e). Nonetheless, the work is strengthened by the combination of content and framing analysis that allowed a balanced examination of included policy documents.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur analysis of policy documents from two LMICs demonstrates the limited attention given to the \u0026lsquo;system\u0026rsquo; in policy content on the goal of health system responsiveness. Feedback mechanisms appear to function in isolation with little potential for integration to enable system wide responses, while attention is focused not on all people that the health system serves but on service users. Our analysis also contributes to the framing analysis literature and demonstrates that multiple frames are employed within policy documents to define responsiveness and offer policy responses on how a responsive health system might be built. The framing of responsiveness as feedback on health service is dominant particularly within health sector specific documents. Other frames such as accountability, the realisation of the right to health and participation appear although in a less cohesive manner. The equity dimension of health system responsiveness and potential for health system strengthening have thus been less commonly presented within health sector specific documents.\u003c/p\u003e \u003cp\u003eGiven the dominance of the frame of responsiveness as feedback on health service we observed a narrowing of policy options to address how a responsive health system might be achieved. This dominance has implications for resource allocation and decision-making and potentially undermines a systems approach and efforts to achieve equity in responsiveness. How responsiveness is framed matters both for practice and analysis of policy, and there is value in integrating existing frames to achieve a broader frame of and a systems approach to responsiveness.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e As this paper was based on a review of policy documents, no ethical approval was obtained.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eWe thank the Director of the Kenya Medical Research Institute (KEMRI), Kenya for granting permission to publish this work.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interest\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNK was funded in part by the Health Policy Analysis Fellowship programme supported by the Alliance for Health Policy and Systems Research, Switzerland. This paper is also linked to a broader study funded by the United Kingdom Medical Research Council \u0026lsquo;Strengthening health system responsiveness to community and citizen feedback in SA and Kenya\u0026rsquo; (UKRI: MR/R013365/1). B.T. and S.M. are members of the KEMRI-Wellcome Trust Research Programme in Kenya that is supported by a core grant [# 203077/Z/16/Z] from the Wellcome Trust. N.K. was a PhD student supported by the Initiative to Develop African Research Leaders, DELTAS Africa Initiative [DEL-15-003]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)\u0026rsquo;s Alliance for Accelerating Excellence in Science in Africa and supported by the New Partnership for Africa\u0026rsquo;s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [107769/Z/10/Z] and the UK government. The views expressed in this publication are those of the authors and not necessarily those of AAS, NEPAD Agency, Wellcome Trust, or the UK government.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNK, GK, NS, JO searched for and identified relevant policy documents, with input from SM, BT and LG. NK, GK, NS and JO extracted data from the agreed upon policy documents. NK, GK, NS and JO were involved in formal analysis, methodology and validation. NK drafted the original manuscript. All authors were involved in reviewing and editing it. BT, SM and LG reviewed drafts and gave final approval of the version to be published.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge the research and health systems partners involved in the broader Health Systems Responsiveness study for their inputs during conceptualisation of this article.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the findings and conclusions of this article are included within the article and its supplementary files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. World Health Report 2000. Geneva: World Health Organisation; 2000 2000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValentine N, Prasad A, Rice N, Robone S, Chatterji S. Health systems responsiveness \u0026ndash; a measure of the acceptability of health care processes and systems from the users' perspective. In: Smith P, Mossialos E, Leatherman S, Papanicolas I, editors. Performance measurement for health system improvement: Experiences, challenges and prospects. Geneva: World Health Organisation; 2010. pp. 138\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan G, Kagwanja N, Whyle E, Gilson L, Molyneux S, Schaay N, et al. Health system responsiveness: a systematic evidence mapping review of the global literature. Int J Equity Health. 2021;20(1):112.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalhotra C, Do YK. Socio-economic disparities in health system responsiveness in India. Health Policy Plann. 2012;28:197\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurung G, Derrett S, Gauld R, Hill PC. Why service users do not complain or have \u0026lsquo;voice\u0026rsquo;: a mixed-methods study from Nepal\u0026rsquo;s rural primary health care system. BMC Health Serv Res. 2017;17(1):81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolooba-Mutebi F. When popular participation won't improve service provision: primary health care in Uganda. Dev Policy Rev. 2005;23(2):165\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott K, George AS, Harvey SA, Mondal S, Patel G, Sheikh K. Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India? Int J Equity Health. 2017;16(1):84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirzoev T, Kane S. What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework. BMJ Global Health. 2017;2(4):e000486.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhyle E, Olivier J. Health Service Responsiveness versus health system responsiveness: a systematic conceptual review. Cape Town: CHESAI Report; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKagwanja N, Gilson L, Tsofa B, Olivier J, Leli H, Molyneux S. Understanding health system responsiveness to public feedback at the sub-national level: Insights from Kilifi County, Kenya. PLOS Glob Public Health. 2024;4(12):e0002814.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCleary S, Molyneux S, Gilson L. Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary healthcare settings. BMC Health Serv. 2013;13:320.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenny A, Hyett N, Sawtell J, Dickinson-Swift V, Famer J, O'Meara P. Community participation in rural health: a scoping review. BMC Health Serv Res. 2013;13:64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoewensen R, Tibazarwa K. Annotated Bibliography: Social power, participation and accountability in health. Harare: TARSC, EQUINET with COPASAH; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahapatra P. Quality health care in private and public health care institutions. Health Policy Research in South Asia. Washington DC: World Bank; 2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg S, Laskar AR. Community-Based Monitoring: Key to Success of National Health Programs. Indian J Community Med. 2010;35(2):214\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcNamara P. Provider specific report cards: a tool for health sector accountability in developing countires. Health Policy Plann. 2006;21(2):101\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoon AD, Hawkins B, Mayhew SH. Framing and the health policy process: a scoping review. Health Policy Plann. 2016;31(6):801\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEntman RM, Framing. Toward clarification of a fractured paradigm. J communication. 1993;43(4):51\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapwata T, Manda S. Geographic assessment of access to health care in patients with cardiovascular disease in South Africa. BMC Health Serv Res. 2018;18(1):197.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcLaren Z, Ardington C, Leibbrandt M. Distance as a barrier to health care access in South Africa2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeats EC, Akseer N, Bhatti Z, Macharia W, Ngugi A, Rizvi A, et al. Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya. JAMA Netw Open. 2018;1(8):e185152.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIlinca S, Di Giorgio L, Salari P, Chuma J. Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey. Int J Equity Health. 2019;18(1):196.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGordon T, Booysen F, Mbonigaba J. Socio-economic inequalities in the multiple dimensions of access to healthcare: the case of South Africa. BMC Public Health. 2020;20(1):289.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eExpress K. Clinic, vehicles torched during overnight protest action in Tembisa. Kempton Express [Internet]. 2015 03 May 2021 [cited 2015 18 March]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://kemptonexpress.co.za/65444/clinics-vehicles-torched-during-overnight-protest-action-in-tembisa\u003c/span\u003e\u003cspan address=\"https://kemptonexpress.co.za/65444/clinics-vehicles-torched-during-overnight-protest-action-in-tembisa\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaithaka D, Kagwanja N, Nzinga J, Tsofa B, Leli H, Mataza C, et al. Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County. Int J Equity Health. 2020;19(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eANA. Covid-19 facility in Khayelitsha set on fire by illegal land invaders2020 15 May 2021 [cited 2020 July 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.iol.co.za/news/watch-covid-19-facility-in-khayelitsha-set-on-fire-by-illegal-land-invaders-51177583\u003c/span\u003e\u003cspan address=\"https://www.iol.co.za/news/watch-covid-19-facility-in-khayelitsha-set-on-fire-by-illegal-land-invaders-51177583\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilson L, Barasa E, Nxumalo N, Cleary S, Goudge J, Molyneux S, et al. Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa. BMJ Glob Health. 2017;2(2):e000224.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWB. World Bank Country and Lending Groups. The World Bank Group; 2021 [.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational HA. 2003, (2003).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKenzie A, Schneider H, Schaay N, Scott V, Sanders D. Primary Health Care Systems (PRIMASYS) Case study from South Africa. Geneva: World Health Organisation; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite Paper for National Health Insurance For South Africa. Towards Universal Health Coverage. White Paper. Pretoria: Government Gazette; 2015. Report No.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaleta A. South Africa Rolls out Pilot Health Scheme. Lancet. 2012;379(9822).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Health. Insurance In South Africa, Policy Paper. Pretoria; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeywood M. South Africa's Treatment Action Campaign: Combining Law and Social Mobilization to Realize the Right to Health. J Hum Rights Pract. 2009;1(1):14\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHabib A. State-Civil Society Relations in Post-Apartheid South Africa. Soc Res. 2005;72(3):671\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNdinda C, Mokomane Z, Mokhele T, Gqamane V, Chilwane D. Civil Society Activism in Accessing Healthcare in South Africa. A Technical Report for CODESRIA. Human Sciences Research Council; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOH. Kenya Health Policy Framework 1994\u0026ndash;2010 Nairobi. Kenya: Ministry of Health; 1994.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHealth A. 2017. Nairobi: Government of Kenya; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnangwe A. Health Sector Reforms in Kenya. Governing Health Systems in Africa. African Books Collective; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOyaya CO, Rifkin SB. Health sector reforms in Kenya: an examination of district level planning. Health Policy. 2003;64(1):113\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenyatta U. Delivering health care for all in Kenya. Financial Times. 2019 October 16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePresident Uhuru launches Universal Health Coverage Pilot Program Nairobi, (KENYA) December 13, 2018 Nairiobi: Ministry of Health. 2018 [.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWamai RG. Reforming health systems: the role of NGOs in decentralisation-lessons from Kenya and Ethiopia. Working Paper. The Elephant; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWamai RG. NGOs and Public Health Systems: Comparative Trends in Transforming Health Care Systems in Kenya and Finland. Helsinki; 2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeltzer K. Patient experiences and health system responsiveness in South Africa. BMC Health Serv Res. 2009;9(117).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabia E, Mbau R, Muraya K, Morgan R, Molyneux S, Barasa E. How do gender and disability influence the ability of the poor to benefit from pro-poor health financing policies in Kenya? An intersectional analysis. Int J Equity Health. 2018;17:149.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeltzer K, Phaswana-Mafuya N. Patient experiences and health system responsiveness among older adults in South Africa. Global Health Action. 2012;5(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmbleton L, Pooja S, Gayapersad A, Kiptui R, Ayuku D, Wachira J et al. Exploring patient-provider interactions and health system resposiveness to street connected youth and children in Kenya. BMC Health Serv Res. 2021;21(363).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite Paper for the. transformation of the health system in South Africa. Pretoria, South Africa: Department of Health; 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenya Health. Policy 2012\u0026ndash;2030. Nairobi: Government of Kenya; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtela M, Bakibinga P, Ettarh R, Kyobutungi C, Cohn S. Strengthening health system governance using health facility service charters: a mixed methods assessment of community experiences and perceptions in a district in Kenya. BMC Health Services Research; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Meara W, Tsofa B, Molyneux S, Goodman C, McKenzie EF. Community and facility-level engagement in planning and budgeting for the government health sector \u0026ndash; A district perspective from Kenya. Health Policy. 2011;99(3):234\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCleary S, Schaay N, Botes E, Ntombizanele F, Uta L, Gilson L. Re-imagining community participation at the district level: Lessons from the DIALHS collaboration. South African Health Review 2014/2015. Cape Town, South Africa2014. pp. 151\u0026thinsp;\u0026ndash;\u0026thinsp;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoulle T, Makhamandela N, Goremucheche R, Loewensen R. Promoting Partnership between Communities and Frontline Health Workers: Strengthening Community Health Committees in South Africa,. EQUINET PRA Paper. Harare: EQUINET; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Loughlin EA. Kenya\u0026rsquo;s Constitution in a global context. Int J Const Law. 2017;15(3):839\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKramon E, Posner D. Kenya's new constitution. J Democracy. 2011;22(2):89\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsofa B, Goodman C, Gilson L, Molyneux S. Devolution and its effects on health workforce and commodities management \u0026ndash;early implementation experiences in Kilifi County, Kenya. Int J Equity Health. 2017;16(69).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsofa B, Molyneux S, Gilson L, Goodman C. How does decentralisation affect health sector planning and financial management? A case study of early effects of devolution in Kilifi County, Kenya. J Equity Health. 2017;16(151).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeier BM, Pardue C, London L. Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa. BMC Int Health Hum Rights. 2012;12(1):15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eANC. The Reconstruction and Development Programme (RDP). Government Gazette; 1994.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdministration NDoPSa. Batho Pele-People First White Paper on Transforming Public Service Delivery. Pretoria, South Africa: National Department of Public Service and Administration; 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHealth NDo. White Paper for the Transformation of the Health System in South Africa. Pretoria, South Africa: Ministry of Health; 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaritim B, Koon AD, Kimaina A, Goudge J. Citizen engagement in national health insurance in rural western Kenya. Health Policy Plann. 2024;39(4):387\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkeyo I, Lehmann U, Schneider H. The impact of differing frames on early stages of intersectoral collaboration: the case of the First 1000 Days Initiative in the Western Cape Province. Health Res Policy Syst. 2020;18(1):3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinto AD, Manson H, Pauly B, Thanos J, Parks A, Cox A. Equity in public health standards: a qualitative document analysis of policies from two Canadian provinces. Int J Equity Health. 2012;11(1):28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips C, Fisher M, Baum F, MacDougall C, Newman L, McDermot D. To what extent do Australian child and youth health policies address the social determinants of health and health equity? a document analysis study. BMC Public Health. 2016;16(512). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-016-3187-6\u003c/span\u003e\u003cspan address=\"10.1186/s12889-016-3187-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobs T, George A, De Jong M. Policy foundations for transformation: a gender analysis of adolescent health policy documents in South Africa. Health Policy Plann. 2021;36(5):684\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovernment of Kenya. The Constitution of Kenya 2010. 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHealth, Act. (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCounty Government Act. (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoK. Kenya Vision 2030: A Globally Competitive and Prosperous Kenya. Nairobi Kenya: National Economic \u0026amp; Social Council of Kenya, Government of Kenya; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePSC. Human Resources Policies and Procedure Manual for the Public Service. Nairobi, Kenya: Public Service Commission. 2016 1 May 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlanning MD. Governors Co. County Public Participation Guidelines. Nairobi, Kenya: Ministry of Devolution and Planning Council of Governors; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Universal Health Coverage Policy. Nairobi, Kenya: Ministry of Health; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Mental Health Policy 2015\u0026ndash;2030. Nairobi, Kenya: Ministry of Health; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Palliative Care Policy 2021\u0026ndash;2030. Nairobi, Kenya: Ministry of Health; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOH. Reversing the trends: The second national health sector strategic plan NHSSP II 2005\u0026ndash;2010. Nairobi, Kenya: Ministry of Health; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOH. Taking the Kenya Essential Package of Health to the Community: A strategy for the delivery of Level One services. Nariobi, Kenya: Ministry of Health; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. The Kenya Health Policy 2014\u0026ndash;2030. Nairobi, Kenya: Ministry of Health; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOH. Community Strategy Implementation Guidelines for Managers of the Kenya Essential Package for Health at the Community Level. Nairobi, Kenya: Ministry of Health; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOH. Strategy for Community Health 2014\u0026ndash;2019. Nairobi, Kenya: Ministry of Health; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOMS MOPH, Transforming Health. Accelerating Attainment of Universal Health Coverage. Nairobi: Ministry of Medical Services and Ministry of Public Health; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Health Sector Strategic Plan 2018\u0026ndash;2022. Nairobi, Kenya: Ministry of Health; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConstitution of the Republic of South Africa. (1996).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. National Guideline for Patient Safety Incident Reporting and Learning in the Public Health Sector of South Africa. Pretoria, South Africa: National Department of Health; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. In: Health, NDo, editors. National Cancer Strategic Framework 2017\u0026ndash;2022. South Africa: National Department of Health; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. National Policy for the management of patient waiting times at health facilities. Pretoria, South Africa: National Department of Health; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDPME. Framework for Strengthening Citizen-Government Partnerships for Monitoring Frontline Service Delivery. Pretoria, South Africa: National Department of Performance, Monitoring and Evaluation, Evaluation DoPM; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNPC. National Development Plan 2030-Our future make it work. Pretoria, South Africa: National Planninc Commission; 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. The Presidential Health Compact. 2024: Accelerating Health System Strengthening and National Health Insurance (NHI) Implementation. In: Health, editor. South Africa: National Department of Health; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. National Policy Framework and Strategy on Palliative Care. In. Health, editor South Africa: National Department of Health; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. White Paper on National Health Insurance. In. National Department of Health SA, editor. Pretoria, South Africa: NDoH; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoSA. National Health Insurance Act of 2023. In: Republic of South Africa ANo, editor. Cape Town2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. The National Health Sector Strategic Plan: 1999\u0026ndash;2004. Nairobi, Kenya: Ministry of Health.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Patient Rights Charter. Nairobi, Kenya: Ministry of Health; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePublic Finance Management Act, PFMA 2012, (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrban Areas and Cities Act, 2011, (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDPSA. Guide on Public Participation in the Public Service. Pretoria, South Africa,Administration NDoPSa; Undated.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. National Patients Rights Charter. Pretoria, South Africa, Health NDo; 1999.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. Human Resources for Health \u0026ndash; South Africa (HRH Strategy for the Health Sector: 2012/13\u0026ndash;2016/17) Pretoria, South Africa, Health NDo; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. Medico-Legal Declaration Implementation Plan. Pretoria, South Africa, Health NDo; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. National guideline on conducting patient experience of care surveys in public health establishments. Pretoria, South Africa, Health NDo; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. National guideline to manage complaints, compliments and suggestions in the health sector of South Africa. Pretoria, South Africa: National Department of Health 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Health Insurance Bill (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Health Act Amendment of 2013, (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. Towards Quality Care for Patients, National Core Standards for Health Establishments in South Africa. Pretoria, South Africa: National Department of Health: Republic of South South Africa; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. Re-engineering Primary Health Care in South Africa. Pretoria, South Africa,Health NDo; 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. Policy framework and strategy for Ward-based Primary Healthcare Outreach Teams (2018/19\u0026ndash;2023/24) Pretoria, South Africa, Health NDo; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. Policy on Quality Healthcare in South Africa. In: Health, editor. South Africa: Department of Health; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu X, Ramesh M, Howlett M, Fritzen SA. The public policy primer: managing the policy process: Routledge; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Community Score Card Guidelines for Social Accountability in Primary Health Care. In: Health C, editor.: Ministry of Health; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Primary Healthcare Strategic Framework 2019\u0026ndash;2024. Nairobi, Kenya:Ministry of Health; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Community Health Policy. Nairobi, Kenya, Health Mo; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. Kenya Community Health Policy 2020\u0026ndash;2030. Nairobi: Ministry of Health; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNDoH. National Health Insurance Bill. In: Health, editor. South Africa: National Department of Health; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoK. Primary Healthcare Act 2023. Kenya Gazette Supplements No 190; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtela M. Health System Accountability and Primary Health Care Delivery in Rural Kenya, An Analysis of the Structures, Process and Outcomes. Peterhouse, Cambridge:University of Cambridge; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutherns T, Olivier J. Mapping the Multiple Health System Responsiveness Mechanisms in One Local Health System: A Scoping Review of the Western Cape Provincial Health System of South Africa. Int J Health Policy Manag. 2022;11(1):67\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoewensen R. Public participation in health: making people matter. Brighton:Institute of Development Studies; 1999.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmoud s. Citizen participation in the health sector in Rural Bangladesh. Brighton:Institute of Development Studies; 2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFluck VL, Barter D. Jumping Hurdles: Key Barriers to Feedback mechanisms. Humanitarian Practice Network. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams JJ. Community participation: Lessons from post-apartheid South Africa.Policy studies. 2006;27(3):197\u0026ndash;217.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCollum R, Taegtmeyer M, Otiso L, Muturi N, Barasa E, Molyneux S, et al. \"Sometimes it is difficult for us to stand up and change this\": an analysis of power within priority-setting for health following devolution in Kenya. BMC Health Serv Res. 2018;18(1):906.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaricharan HJ, Stuttaford M, London L. Effective and meaningful participation or limited participation? A study of South African health committee legislation. Primary Health Care Research \u0026amp; Development. 2021;22:e28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBacchi C. Problematizations in Health Policy: Questioning How \u0026ldquo;Problems\u0026rdquo; Are Constituted in Policies. SAGE Open. 2016;6(2):2158244016653986.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026oacute;mez-Jauregui J. Participation in reproductive health policies in the context of health system reform in Mexico. IDS bulletin. 2008;38(6):81\u0026thinsp;\u0026ndash;\u0026thinsp;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLodenstein E, Dieleman M, Gerretsen B, Broerse JE. Health provider responsiveness to social accountability initiatives in low- and middle-income countries: a realist review. Health Policy Plan. 2017;32(1):125\u0026thinsp;\u0026ndash;\u0026thinsp;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvensen J, Stokke K. United agains HIV/AIDs? Politics of local governance in HIV/AIDS treatment in Lusikisiki, South Africa. Journal of Southern African Studies.2010;36:151\u0026thinsp;\u0026ndash;\u0026thinsp;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. The Kenya Health Policy 2012\u0026ndash;2030. Nairobi, Kenya: Ministry of Health; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOMS, MOPH. Transforming Health: Accelerating Attainment of Universal Health Coverage. Nairobi: Ministry of Medical Services and Ministry of Public Health; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgbuabor DC, Onwujekwe OE. The community is just a small circle: citizen participation in the free maternal and child healthcare programme of Enugu State, Nigeria. Glob Health Action. 2018;11(1):1421002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFew R, Harpham T, Atkinson S. Urban primary health care in Africa: a comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam. Health \u0026amp;Place. 2003;9(1):45\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheikh K, Gilson L, Agyepong I, Hanson K, Ssengoba F, Bennett S. Building the Field of Health Policy and Systems Research: framing the questions. Plos Med. 2011;8(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Savigny D, Adam T. Systems Thinking for Health Systems Strengthening. Geneva:Alliance for Health Policy and Systems Research, World Health Organisation; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilkinson A, Parker M, Martineau F, Leach M. Engaging \u0026lsquo;communities\u0026rsquo;: anthropological insights from the West African Ebola epidemic. Philosophical Transactions of the Royal Society B: Biological Sciences. 2017;372(1721):20160305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTindana PO, De Vries J, Kamuya D. Ethical challenges in community engagement practices in research during the COVID-19 pandemic in Africa. AAS Open Research. 2020;3(23):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKagwanja N, Molyneux S, Whyle E, Tsofa B, Leli H, Gilson L. Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast. International Journal for Equity in Health. 2024;23(1):177.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8624444/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8624444/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth system responsiveness is regarded as a core goal of health systems, both for its intrinsic value and its potential to contribute to inclusive, participatory, and accountable health systems. Although responsiveness is frequently mentioned in health policy documents, the public experience challenges in engaging with and eliciting responses from health systems. There is also limited receptivity to public concerns by policymakers and health providers. We analysed national policy documents for responsiveness content and framing with the aim of identifying how to strengthen policy proposals towards more responsive health systems.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a three-stage qualitative analysis of Kenyan and South African policy documents: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) policy document retrieval; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) data extraction and coding; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) content and framing analysis. We analysed purposively selected public sector plans, legislative instruments and health-sector specific plans and policies released between 1994 and 2024 (n\u0026thinsp;=\u0026thinsp;28 [Kenya]; n\u0026thinsp;=\u0026thinsp;26 [South Africa]). Documents were identified from government and Ministry of Health websites.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eResponsiveness was framed differently across the analysed texts. Public sector and legislative instruments primarily adopted public participation frames, while health sector documents predominantly framed responsiveness as \u0026lsquo;health service feedback\u0026rsquo;. Within health sector policy documents, the measurement of responsiveness was underdeveloped, with no clear overarching strategy to support the achievement of system responsiveness. There was also little evidence of intention to integrate feedback from multiple channels and limited description of monitoring and evaluation of feedback mechanisms. There was almost no attention to how public feedback could be used to shape a responsive health system.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn Kenya and South Africa, while legislative and public policy documents had a broad and inclusive remit for responsiveness, health policy documents had a narrow focus with a dominant \u0026lsquo;health service feedback\u0026rsquo; framing. This framing undermines a systemic approach to responsiveness by inadequately addressing equity challenges and power and knowledge differentials between the public and health system actors. Integrating the broader frames identified in public sector and legislative instruments (public participation, accountability) into health policy documents can re-define health system responsiveness to include a focus beyond service delivery, attention to the wider public, including varied population segments and vulnerable groups.\u003c/p\u003e","manuscriptTitle":"Examining health system responsiveness policy in Kenya and South Africa: A content and framing analysis of policy documents 1994-2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-23 12:56:51","doi":"10.21203/rs.3.rs-8624444/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-16T16:22:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134111527479904925508810085360368461822","date":"2026-05-04T18:06:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-16T22:12:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-20T10:51:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T12:07:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T12:07:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-17T07:59:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2d1ee25-fe5d-416d-ad31-55ca803d412e","owner":[],"postedDate":"February 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T16:22:40+00:00","index":56,"fulltext":""},{"type":"reviewerAgreed","content":"134111527479904925508810085360368461822","date":"2026-05-04T18:06:31+00:00","index":52,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T12:56:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-23 12:56:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8624444","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8624444","identity":"rs-8624444","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}