Health system responsiveness for healthcare services at health facilities in Africa: a systematic review and meta-analysis

Health system responsiveness is an important aspect of public health that reflects how effectively health systems address the needs, preferences, and expectations of the population. It is considered an essential indicator for evaluating the quality of healthcare across all health settings. However, in many low- and middle-income countries, including those in Africa, the implementation of important sub-dimensions of health system responsiveness, such as dignity, autonomy, confidentiality, prompt attention, social support, basic amenities, and provider choice, is often overlooked and inadequately addressed. Generating evidence on the performance of health system responsiveness and across its sub-domains is indispensable to scale up the responsiveness of health systems. Therefore, the main purpose of this systematic review and meta-analysis is to determine the overall estimate of health system responsiveness and its sub-domains for healthcare services at health facilities in Africa. This study also performed systematic synthesis for factors associated with health system responsiveness.

This study followed the Preferred Reporting Item Review and Meta-analysis (PRISMA) guidelines. The study protocol for this review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) with reference number CRD42024584883. We carried out an extensive systematic review, searching engines and databases that included Google Scholar, PubMed, Science Direct, Scopus, and Hinari for eligible studies published between 2000 and July 28, 2025. Data from the included studies was retrieved, arranged in Microsoft Excel, and analyzed using STATA 17. A random-effect model was used to determine the total effect of all studies. The methodological quality of the included studies was examined using the Joanna Briggs Institute (JBI) critical appraisal tool. Publication bias was assessed using a funnel plot and Egger’s test. The Cochrane Q statistic and I² test were used to assess the extent of statistical heterogeneity among the included studies.

This review included 18 primary studies with 19,341 study participants. Accordingly, the pooled prevalence of health system responsiveness (HSR) in Africa was 62.86% (95% CI: 59.42, 66.29). The HSR sub-domains with the highest performance were dignity (70.86%) and confidentiality (70.27%). In contrast, the lowest overall prevalence was reported in prompt attention to the patients, at 54.06%. In a subgroup analysis by country, the highest combined prevalence of HSR was observed in Ghana (74.73%) and South Africa (69.22%), while the lowest pooled prevalence was found in Nigeria (52.47%). In this study, individuals’ sociodemographic variables (lower educational status, older age, urban residency), utilizing privately owned health facilities, having good perceived health status, presence of obstetric complications during the current pregnancy, nighttime childbirth, mode of childbirth (cesarean section or assisted instrumental delivery), visiting traditional healers, and being satisfied with healthcare services were found to be significantly associated with health system responsiveness.

This systematic review and meta-analysis found that the pooled estimate of health system responsiveness in Africa remains low compared with similar studies in other low- and middle-income countries. Furthermore, dignity and confidentiality were the highest-rated sub-domains, whereas prompt attention, provider choice, and access to supportive care were the most underperforming aspects of HSR. Therefore, clinicians, health administrators, and all other concerned stakeholders need to collaborate to scale up overall health system responsiveness and across its sub-domains in all healthcare settings. The government health facilities should continuously evaluate the performance of health system responsiveness as one of the essential indicators of standard medical care.