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

Background: Despite governments striving for responsive health systems and the implementation of mechanisms to foster better citizen feedback and strengthen accountability and stewardship, these mechanisms do not always function in effective, equitable, or efficient ways. There is also limited evidence that maps the diverse array of responsiveness mechanisms coherently across a particular health system, especially in low- and middle-income country (LMIC) contexts. Methods: This scoping review presents a cross-sectional ‘map’ of types of health system responsiveness mechanisms; the regulatory environment; and evidence available about these; and assesses what is known about their functionality in a particular local South African health system; the Western Cape (WC) province. Multiple forms of indexed and grey literature were synthesized to provide a contextualized understanding of current ‘formal’ responsiveness mechanisms mandated in national and provincial policies and guidelines (n = 379). Various forms of secondary analysis were applied across quantitative and qualitative data, including thematic and time-series analyses. An expert checking process was conducted, with three local field experts, as a final step to check the veracity of the analytics and conclusions made. Results: National, provincial and district policies make provision for health system responsiveness, including varied mechanisms intended to foster public feedback. However, while some are shown to be functioning and effective, there are major barriers faced by all, such as resource and capacity constraints, and a lack of clarity about roles and responsibilities. Most mechanisms exist in isolation, failing to feed into an overarching strategy for improved responsiveness. Conclusion: The lack of synergy between mechanisms or analysis of varied forms of feedback is a missed opportunity. Decision-makers are unable to see trends or gaps in the flow of feedback, check whether all voices are heard or fully understand whether/how systemic response occurs. Urgent health system work lies in the research of macro ‘whole’ systems responsiveness (levels, development, trends).