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Health policy and systems research (HPSR) is vital to guiding global institutions, funders, policymakers, activists and implementers in developing and enacting strategies to achieve the Sustainable Development Goals. We undertook a multi-stage participatory process to identify priority research questions relevant to improving accountability within health systems. We conducted interviews (n = 54) and focus group discussions (n = 2) with policymakers from international and national bodies (ministries of health, other government agencies and technical support institutions) across the WHO regions. Respondents were asked to reflect on challenges and current policy discussions related to health systems accountability, and to identify their pressing research needs. We also conducted an overview of reviews (n = 34) to determine the current status of knowledge on health systems accountability and to identify any gaps. We extracted research questions from the policymaker interviews and focus groups (70 questions) and from the overview of reviews (112 questions), and synthesized these into 36 overarching questions. Using the online platform Co-Digital, we invited researchers from around the world to refine and then rank the questions according to research importance. The questions that emerged amongst the top priorities focused on political factors that mediate the adoption or effectiveness of accountability initiatives, processes and incentives that facilitate the acceptability of accountability mechanisms among frontline healthcare providers, and the national governance reforms and contexts that enhance provider accountability. The process revealed different underlying conceptions of social accountability and how best to promote it, with some researchers and policymakers focusing on specific interventions and others embracing a more systems-oriented approach to understanding accountability, the multiple forms that it can take, how these interact with each other and the importance of power and underlying social relations. The findings from this exercise identify HPSR funding priorities and future areas for evidence production and policy engagement.

Quantitative survey findings are important in measuring health-related phenomena, including on sensitive topics such as respectful maternity care (RMC). But how well do survey results truly capture respondent experiences and opinions? Quantitative tool development and piloting often involve translating questions from other settings and assessing the mechanics of implementation, which fails to deeply explore how respondents understand survey questions and response options. To address this gap, we conducted cognitive interviews on survey questions (n = 88) adapted from validated RMC instruments used in Ethiopia, Kenya and elsewhere in India. Cognitive interviews with rural women (n = 21) in Madhya Pradesh, India involved asking the respondent the survey question, recording her response, then interviewing her about what the question and response options meant to her. We analysed the interviews to revise the tool and identify question failures, which we grouped into six areas: issues with sequencing, length and sensitivity; problematic response options; inappropriate vocabulary; temporal and spatial confusion; accessing different cognitive domains; and failure to resonate with the respondent’s worldview and reality. Although women tended to provide initial answers to the survey questions, cognitive interviews revealed widespread mismatch between respondent interpretation and question intent. Likert scale response options were generally incomprehensible and questions involving hypothetical scenarios could be interpreted in unexpected ways. Many key terms and concepts from the international RMC literature did not translate well and showed low resonance with respondents, including consent and being involved in decisions about one’s care. This study highlights the threat to data quality and the validity of findings when translating quantitative surveys between languages and cultures and showcases the value of cognitive interviews in identifying question failures. While survey tool revision can address many of these issues, further critical discussion is needed on the use of standardized questions to assess the same domains across contexts.

Power is a critical concept to understand and transform health policy and systems. Power manifests implicitly or explicitly at multiple levels-local, national and global-and is present at each actor interface, therefore shaping all actions, processes and outcomes. Analysing and engaging with power has important potential for improving our understanding of the underlying causes of inequity, and our ability to promote transparency, accountability and fairness. However, the study and analysis of the role of power in health policy and systems, particularly in the context of low- and middle-income countries, has been lacking. In order to facilitate greater engagement with the concept of power among researchers and practitioners in the health systems and policy realm, we share a broad overview of the concept of power, and list 10 excellent resources on power in health policy and systems in low- and middle-income countries, covering exemplary frameworks, commentaries and empirical work. We undertook a two-stage process to identify these resources. First, we conducted a collaborative exercise involving crowdsourcing and participatory validation, resulting in 24 proposed articles. Second, we conducted a structured literature review in four phases, resulting in 38 articles reviewed. We present the 10 selected resources in the following categories to bring out key facets of the literature on power and health policy and systems-(1) Resources that provide an overarching conceptual exploration into how power shapes health policy and systems, and how to investigate it; and (2) examples of strong empirical work on power and health policy and systems research representing various levels of analyses, geographic regions and conceptual understandings of power. We conclude with a brief discussion of key gaps in the literature, and suggestions for additional methodological approaches to study power.

Background Sierra Leone has emerged from civil war but remains in the lowest tier of the human development index. While significant health reforms, such as the removal of user fees, aim to increase access to services, little is known about how families navigate a plural health system in seeking health care for sick children. This research aims to build on recent care-seeking literature that emphasizes a shift from static supply-and-demand paradigms towards more nuanced understandings, which account for the role of household agency and social support in navigating a landscape of options. Methods A rapid ethnographic assessment was conducted in villages near and far from facilities across four districts: Kambia, Kailahun, Pujehun and Tonkolili. In total, 36 focus group discussions and 64 in-depth interviews were completed in 12 villages. Structured observation in each village detailed sources of health care. Results When a child becomes sick, households work within their geographic, social and financial context to seek care from sources including home treatment, herbalists, religious healers, drug peddlers and facility-based providers. Pathways vary, but respondents living closer to facilities emphasized facility care compared with those living further away, who take multi-pronged approaches. Beyond factors linked to the location and type of healthcare provision, social networks and collaboration within and across families determine how best to care for a sick child and can contribute to (or hinder) the mobilization of resources necessary to access care. Husbands play a particularly critical role in mobilizing funds and facilitating transport to facilities. Conclusion Caregivers in Sierra Leone have endured in the absence of adequate health care for decades: their resourcefulness in devising multiple strategies for care must be recognized and integrated into the service delivery reforms that are making health care increasingly available.