Dissertations and Theses (Open Access)

Date of Award

Summer 8-2025

Degree Name

Doctor of Philosophy (PhD)

Advisor(s)

CECILIA GANDUGLIA CAZABAN, MD, DR.P.H.

Second Advisor

CICI X. BAUR, PhD

Third Advisor

ROBERT MORGAN, PhD

Abstract

Health systems responsiveness (HSR) refers to a health system’s ability to meet legitimate non-health expectations of the population. Traditionally, HSR has been conceptualized across eight domains: respect for dignity, autonomy, confidentiality, prompt attention to health needs, availability of basic amenities, choice of provider, access to social support networks, and clarity of communication. However, as the expectations of populations in high-income countries (HICs) and low- and middle-income countries (L&MICs) differ significantly due to diverse social and cultural contexts, the conceptualization of HSR also varies. We conducted a systematic review of literature to adapt and contextualize the HSR framework for L&MICs based on available evidence. The modified HSR framework was further refined and validated through a Delphi process involving 13 global health experts specializing in HSR. Our proposed framework for L&MICs is based on ten domains viz; (1) respect for dignity, (2) autonomy, (3) confidentiality of information, (4) quality of basic amenities, (5) access to social support networks, (6) choice of provider, (7) prompt access to care, (8) attention, clarity of communication and guidance, (9) consideration of financial protection, and (10) coordination and continuity of care; and 32 sub-domains. We translated this conceptual framework into qualitative and quantitative measurement tools to assess HSR in L&MICs from the perspectives of patients, community leaders, service providers (doctors, nurses, paramedics), hospital managers, and policymakers, ensuring a comprehensive evaluation. The methodology and tools were pilot tested in district Rawalpindi, Pakistan. The overall HSR score for primary, secondary, and tertiary care hospitals in Rawalpindi was estimated at 4.0 on a 0 to 10 scale, with 10 representing the highest level of responsiveness. The health system performed well in respect for dignity, autonomy and confidentiality; was moderate for choice of provider, prompt access to care, attention, clarity of communication and guidance and access to social support networks; and performed poorly for quality of basic amenities, consideration of financial protection and coordination and continuity of care. The psychometric analysis of the tool demonstrated strong feasibility, reliability (Cronbach’s alpha = 0.69), and validity, confirming its suitability for use in L&MICs. We encourage researchers to apply our tools and methodology to assess HSR across L&MICs, with pilot testing in their specific contexts before broader implementation.

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