Supporting inclusive and accountable health systems decisions in Ghana and Kenya for universal health coverage (SUPPORT-SYSTEMS)

SUPPORT-SYSTEMS is based on three central questions for understanding how countries can progress towards stronger, more accessible, and equitable health systems. First, how are various sources of knowledge weighed – from global organizations to local healthcare professionals, patients, civil society, and vulnerable groups – when adapting global recommendations to local conditions during health policy processes? Second, how can such health policy processes be designed to be more inclusive and accountable? Finally, what role does knowledge from civil society play in achieving these goals? To explore this question, the project conducts a systematic review of qualitative studies (“qualitative evidence synthesis”) and conducts primary studies of health policy processes in Ghana and Kenya—two countries where universal health coverage is a political priority. The project is jointly led by the Norwegian Institute of Public Health, the University of Ghana, and KEMRI Wellcome Trust Research Programme. Key partners are NTNU, Western Norway University of Applied Sciences, the University of Oslo, Health Information for All (hifa.org), and People’s Health Movement (PHM)-Kenya. The qualitative evidence synthesis (QES) explores how civil society knowledge has been used in health policy processes, identifies the factors influencing its use and explores the value of such knowledge in promoting inclusive and accountable decision-making (WP1). Initial analyses of included research articles reveal examples of how civil society, through participation in local community meetings or national public hearings, collecting and systematizing field experiences, or engaging with participatory action research, has shared knowledge contributing to more responsive and inclusive health systems. Important factors influencing the use of civil society knowledge include political, legal, power structures, diverse perspectives on the value of civil society knowledge, government capacity to gather and apply this knowledge, and resource constraints among civil society actors. The QES is expected to be completed and submitted for publication in spring 2024. Two approaches have been used to discuss the scope of the synthesis, research questions, and initial findings with individuals active in civil society organizations, aiming to enhance the relevance and applicability of the results. The first is a 4-week thematic discussion on the Health Information for All (hifa.org) forum, which has 20,000 members with various health backgrounds, including representation from both patients and civil society. During this discussion, held in June 2021, 14 individuals from 11 countries made 80 written contributions shedding light on the role of civil society in providing knowledge for health policy processes. A summary of this discussion is planned for submission to a scientific journal in spring 2024. Additionally, a new 4-week discussion will be conducted to explore the main findings of the QES and discuss how these findings can be utilized to strengthen the role of civil society in health policy processes. The second approach involves regular dialogues with PHM-Kenya, a network of health activists, civil society organizations, and academics with civil society engagement. In November 2023, a 2-hour workshop entitled "The use of evidence from civil society in health policy making: Critical discussion of concepts, assumptions, and examples" was conducted during the PHM course International People’s Health University (IPHU). In Ghana and Kenya, decision processes for new vaccines in vaccination programs, as well as decisions on primary health care (PHC) strengthening in Ghana, will be case studies to explore the research questions (WP2). Decisions to implement new vaccines are largely dominated by national expert groups and health authorities, but the effectiveness of vaccination programs is also influenced by how vaccines are perceived by different population groups. Therefore, how various sources of knowledge are applied and the role of civil society are central to understanding how vaccine decisions can become more inclusive and responsive. In Ghana, how evidence is used during vaccine decision-making will be compared with evidence use during processes about PHC. In Kenya, primary data collection (interviews, observations) has been completed, while in Ghana, data collection formally started in November 2023. In WP3, informed by the QES and empirical studies in Ghana and Kenya, the project aims to develop new tools to support health policy processes. These tools will facilitate the consideration of global sources of knowledge (such as synthesized knowledge or global recommendations from WHO) alongside local sources of knowledge (such as from qualitative studies of the experiences of healthcare workers, patients, and civil society organizations). The goal is that these tools can support health system decisions that are evidence-informed, inclusive and accountable.

The overall goal of this project is to explore how decision-making processes for health systems strengthening and universal health coverage (UHC) can be made more inclusive, responsive and accountable. We will focus on the extent to which giving greater prominence to the voices of civil society groups and other stakeholders, both directly and through the wider use of qualitative and local evidence, can humanise decision-making processes and promote equity. As a major sub-goal of United Nations (UN) Sustainable Development Goal (SDG) 3 on ‘Good health and well-being’, UHC is now a global political priority. How countries pursue UHC depend on their approaches to strengthening health systems. But for all countries, this should ideally include the use of evidence to inform decisions about the financing, governance and delivery of health services, and the inclusive involvement of stakeholders in these processes.The ongoing COVID-19 pandemic has reinforced the value of assessing a wide range of evidence and listening to a wide range of stakeholders when health systems decisions are made. Our proposal will advance a research agenda at the intersection of two key ambitions: evidence-informed health systems decisions and inclusive and accountable decision-making. We will explore and compare national and subnational decision-making processes in Ghana and Kenya—two low- and middle-income countries (LMICs) with a political commitment to UHC. As these countries strive to deliver health care services for their populations, we will examine how they are using evidence to, firstly, help policymakers contextualize global guidance by integrating local stakeholder views and, secondly, foster agency among civil society stakeholders.