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

响应性卫生系统可改善服务的利用并改善健康结果。然而，这是一个研究最少的卫生系统目标，特别是在低收入和中等收入国家。尽管取得了重大进展，但孕产妇保健仍然是国际和国家的优先事项，在加纳和越南非常不公平。然而，怀孕和产后的心理健康与更主流的孕产妇保健优先事项一样，往往被忽视；这是应对性卫生系统应有效应对的挑战。本研究旨在提高卫生系统对低收入和中等收入国家弱势群体被忽视的卫生需求的响应能力。我们将探讨关键行为者（人、卫生保健提供者、管理人员）对响应性的解释，为卫生系统干预措施的设计、实施和试点测试提供信息，使系统更能响应弱势群体妇女的孕产妇需求，包括被忽视的精神卫生需求。我们将在加纳和越南开展工作，这两个国家之所以被选中，是因为它们的不同共性和差异为跨国比较和制定可转让的最佳做法提供了极好的案例，政策制定者对此非常感兴趣，我们的强有力合作将加强南南交流和学习。在每个国家，我们将选择两个区。在每个地区，我们将在地区医院、2-4个初级卫生保健设施和社区进行干预。然而，我们也将与地区/省和国家层面的关键决策者接触，以最大限度地提高干预措施的可持续性、可复制性和规模。这项为期42个月的研究将以理论为导向，利用我们在现实主义方法方面的专业知识，包括三个阶段：在第一阶段，我们将了解行为者对反应性卫生系统的期望，借鉴现实主义综合的文献，制定初步工作理论，确定干预措施的关键优先事项，并制定基线。我们会检视相关文件和分析设施纪录，并进行深入访谈、焦点小组和社区调查。数据将采用回溯法进行分析。在第二阶段，我们将共同生产环境敏感干预措施。我们将巩固、调整和扩展我们在加纳和越南的经验，以解决第一阶段的关键优先领域，并将这些领域与响应能力和我们的初步理论联系起来。这些报告将为各区与关键行为者共同制定干预措施的会议提供信息，这些干预措施将由地区卫生领导领导，并由研究人员提供便利和记录。干预措施将侧重于改善我们框架内的内部和外部互动，利用与工作人员和社区的低成本参与式互动讲习班。在第三阶段，我们将根据当地情况实施和评估干预措施。执行工作将通过现有的结构和进程进行。在评估中，我们将通过调整和扩展第一阶段方法，将计划的干预措施与实际效果进行比较，从而检验我们的理论。地方、区域和国家的决策者将全程参与，使用嵌入式方法进行研究和开发。关键研究的结果和影响将是双重的：(1)提高卫生系统对弱势群体复杂卫生需求的响应能力，从而有助于改善加纳和越南的卫生公平；(2)基于经验和理论的干预措施背景、机制和结果之间复杂关系模型，以及可转移的可扩展性（即在类似背景下扩展）和可推广性（即扩展到不同背景）的最佳实践；（如其他卫生领域和其他国家），以加强未来的卫生系统。

Responsive health systems improve utilisation of services and improve health outcomes. Yet, it is a least studied health systems goal, especially in low- and middle-income countries (LMICs).Despite significant progress, maternal health remains an international and national priority, and is highly inequitable in Ghana and Vietnam. However, mental health in pregnancy and postpartum are often neglected alongside the more mainstream maternal health priorities; this represents a challenge which responsive health systems should effectively address.This study seeks to improve health systems responsiveness to neglected health needs of vulnerable groups in LMICs. We will explore interpretations of responsiveness by key actors (people, healthcare providers, managers) to inform the design, implementation and pilot-testing of health systems interventions to make systems more responsive to the maternal, including neglected mental, health needs of women from vulnerable groups. We will work in Ghana and Vietnam, which were selected because their different commonalities and differences provide excellent cases for cross-country comparisons and developing transferable best practices, there is high interest from policymakers and our strong collaborations which will enhance South-South exchange and learning. In each country, we will select two districts. Within each district, we will intervene at district hospital, 2-4 primary health care facilities and communities. However, we will also engage with key decision-makers at the regional/province and national levels to maximise the interventions' sustainability, replication and scaling up.This 42-months study will be theory-driven, utilising our expertise in the realist approach and will include three Phases: In Phase 1 we will understand actors' expectations of responsive health systems, drawing on literature from realist synthesis will develop an initial working theory, will identify key priorities for the interventions and generate a baseline. We will review relevant documents and analyse facility records, conduct in-depth interviews, focus groups and community survey. Data will be analysed using a retroductive approach.In Phase 2, we will co-produce the context-sensitive interventions. We will consolidate, adapt and extend our experiences in Ghana and Vietnam to address key priority areas from Phase 1, relating these to responsiveness and our initial theory. These will inform meetings in each district with key actors to co-produce the interventions, to be led by the district health leadership and facilitated and documented by researchers. The interventions will focus on improving internal and external interactions from our framework, using low-cost participatory and interactive workshops with staff and communities. In Phase 3, we will implement and evaluate the interventions within local contexts. The implementation will be conducted through existing structures and processes. In the evaluation, we will test our theory through comparing the planned to the actual performance of the interventions through adapting and extending Phase 1 methods.Local, regional and national decision-makers will be engaged throughout, using the embedded approach to research and development. The key study's outcomes and impact will be two-fold: (1) improved health systems responsiveness to the complex health needs of vulnerable groups and therefore contribution to improved health equity in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex relations between the contexts, mechanisms and outcomes of the interventions, along with transferable best practices for scalability (i.e. expansion within similar contexts) and generalisability (i.e. expansion to different contexts, such as other health areas and other countries) for future health systems strengthening.