Examining health system responsiveness policy in Kenya and South Africa: A content and framing analysis of policy documents 1994-2024

Background Health system responsiveness is regarded as a core goal of health systems, both for its intrinsic value and its potential to contribute to inclusive, participatory, and accountable health systems. Although responsiveness is frequently mentioned in health policy documents, the public experience challenges in engaging with and eliciting responses from health systems. There is also limited receptivity to public concerns by policymakers and health providers. We analysed national policy documents for responsiveness content and framing with the aim of identifying how to strengthen policy proposals towards more responsive health systems. Methods We conducted a three-stage qualitative analysis of Kenyan and South African policy documents: (1) policy document retrieval; (2) data extraction and coding; and (3) content and framing analysis. We analysed purposively selected public sector plans, legislative instruments and health-sector specific plans and policies released between 1994 and 2024 (n = 28 [Kenya]; n = 26 [South Africa]). Documents were identified from government and Ministry of Health websites. Results Responsiveness was framed differently across the analysed texts. Public sector and legislative instruments primarily adopted public participation frames, while health sector documents predominantly framed responsiveness as ‘health service feedback’. Within health sector policy documents, the measurement of responsiveness was underdeveloped, with no clear overarching strategy to support the achievement of system responsiveness. There was also little evidence of intention to integrate feedback from multiple channels and limited description of monitoring and evaluation of feedback mechanisms. There was almost no attention to how public feedback could be used to shape a responsive health system. Conclusion In Kenya and South Africa, while legislative and public policy documents had a broad and inclusive remit for responsiveness, health policy documents had a narrow focus with a dominant ‘health service feedback’ framing. This framing undermines a systemic approach to responsiveness by inadequately addressing equity challenges and power and knowledge differentials between the public and health system actors. Integrating the broader frames identified in public sector and legislative instruments (public participation, accountability) into health policy documents can re-define health system responsiveness to include a focus beyond service delivery, attention to the wider public, including varied population segments and vulnerable groups.