How does power shape District Health Management Team responsiveness to public feedback in Low-and-Middle Income Countries? An interpretive synthesis.

Responsiveness is a core element of WHO's health system framework, considered important in ensuring inclusive and accountable health systems. System-wide responsiveness requires system-wide action, and District Health Management Teams (DHMTs) play critical governance roles in many health systems. However, there is little evidence on how DHMTs enhance health system responsiveness. We conducted this interpretive literature review to understand how DHMTs receive and respond to public feedback, and how power influences these processes. A better understanding of power dynamics could strengthen responsiveness and improve health system performance. Our interpretive synthesis drew on English language articles published between 2000 and 2021. Our search in Pubmed, Google Scholar, and Scopus combined terms related to responsiveness (feedback, accountability) and DHMTs (district health manager) yielding 703 articles. We retained 21 articles after screening. We applied Gaventa's power cube and Long's actor interface frameworks to synthesise insights about power. Our analysis identified complex power practices across a range of interfaces involving the public, health system, and political actors. Power dynamics were rooted in social and organisational power relationships, personal characteristics (interests, attitudes, previous experiences), and worldviews (values and beliefs). DHMTs' exercise of visible power sometimes supported responsiveness, however, they were undermined by the invisible power of public-sector bureaucracy that shaped generation of responses. Invisible power, manifesting in the sub-conscious influence of historical marginalisation, patriarchal norms, and poverty, hindered vulnerable groups from providing feedback. We also identified hidden power as influencing what feedback DHMTs received, and from whom. Our work highlights the influence of social norms, structures, and discrimination on power distribution among actors interacting with, and within, the DHMT. Recognising and building on the varied lifeworlds of actors involved in receiving and responding to public feedback, while paying attention to the broader context in which the lifeworlds are embedded has the potential to strengthen responsiveness.