Health Systems and Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK.
Int J Equity Health. 2024 Sep 2;23(1):177. doi: 10.1186/s12939-024-02258-5.
Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal.
Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis.
We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents.
Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required.
卫生系统对公众优先事项和需求的反应能力是一个广泛的、多方面的和复杂的卫生系统目标，被认为在促进包容性和减少参与方面的系统不平等方面很重要。权力动态是反应能力的复杂性的基础，但很少被考虑。本文分析了肯尼亚在国家以下各级运作的卫生设施委员会（HFC）和次级县卫生管理小组（SCHMT）的反应能力实践中的各种权力表现形式。肯尼亚政策文件将反应能力确定为一个重要的政策目标。
我们的分析借鉴了肯尼亚海岸进行的一项研究中的定性数据（35 名卫生管理人员和地方政治家的访谈、4 次 HFC 成员焦点小组讨论、SCHMT 会议观察和文件审查）。我们应用了两种权力框架的组合来解释我们的发现：加文塔的权力立方体和朗的行为界面分析。
我们观察到一个反应迟钝的卫生系统，在这个系统中，系统范围内和反应能力的公平性经常受到各种形式和实践的权力的破坏。公众在与其他卫生系统行为体的互动中经常处于主导地位：看不见和隐藏的权力相互作用，限制了他们分享反馈的能力；而组织层次结构的可见权力则限制了 HFC 和 SCHMT 的能力，既无法支持公众反馈机制，也无法对提出的关切作出回应。这些权力实践是由职位权力关系、个人特征和世界观支撑的。尽管如此，HFC、SCHMT 和公众还是创造性地行使了一些权力来影响反应能力，例如与政治行为体合作。然而，大多数由此产生的反应是不可持续的，有时还会破坏公平性，因为政治家们为他们的选民寻求不公平的优势。
我们的研究结果阐明了即使在政策文件中优先考虑的情况下，导致卫生系统反应迟钝的结构和机制。支持公众在反馈机制中参与和参与可以加强对公众反馈的接收；然而，也需要采取措施增强公众参与的机构能力。此外，还需要建立一个赋予卫生管理人员回应公众投入能力的组织环境和文化。
