Abstract
People-centred health systems depend on more than inviting patients, families, and communities to provide feedback. Meaningful engagement requires opportunities for people to influence decisions and healthcare organizations that can respond to their priorities. This structured narrative review used targeted searches of PubMed-indexed literature and World Health Organization sources to identify relevant reviews, health-systems studies, and recent evidence. The synthesis focused on leadership approaches that support a shift from one-way consultation to meaningful partnership in low- and middle-income countries (LMICs), drawing on literature on community participation, patient and public involvement, co-creation, social accountability, and people-centred care. The literature indicates that partnership is more credible when leaders create inclusive representation, share decision-making, allocate time and resources, clarify accountability, and close feedback loops by showing how community input affects services. Common barriers include hierarchical decision processes, limited institutional capacity, unequal opportunities to participate, communication gaps, and poor follow-through on feedback. Drawing these findings together, this review proposes the LISTEN leadership framework: Listen, Include, Share Decisions, Train and Resource Participation, Establish Accountability Loops, and Notice Equity and Outcomes. The framework is presented as a practical synthesis rather than a validated instrument. People-centred leadership should therefore be assessed not only by whether patients and communities are invited to participate, but also by whether their involvement influences decisions, strengthens trust and responsiveness, and contributes to more equitable and higher-quality health systems.
Keywords: people-centred care, patient experience, healthcare leadership, community engagement, quality improvement, health systems
Plain Language Summary
Health systems often say that patients and communities should be involved in decisions, but involvement can remain limited to meetings, surveys, or requests for feedback. This review asks what healthcare leaders can do to turn that consultation into a real partnership. Evidence from LMICs shows that engagement works better when leaders include people early, make participation safe and accessible, give communities useful information and resources, and show clearly how feedback affected decisions. Engagement is weaker when leaders ask for opinions but keep all decision-making power inside the institution. We propose a simple leadership framework called LISTEN. It encourages leaders to listen systematically, include people who are often left out, share decisions, resource participation, close accountability loops, and measure whether partnership improves equity, trust, and services. The framework can guide hospitals, primary care services, public health programs, and health authorities that want people-centred care to become an organizational practice rather than a slogan.
Introduction
The language of people-centred care is now familiar across health policy, clinical practice, and health-system reform. The underlying idea is straightforward: health services should be organized around the needs, values, preferences, and circumstances of people and communities rather than around diseases, professional boundaries, or institutions alone. The World Health Organization (WHO) Framework on Integrated People-Centred Health Services places engagement and empowerment alongside governance, accountability, service reorientation, coordination, and an enabling environment.1 WHO guidance on community engagement similarly treats leadership, trust, dialogue, participation, and feedback as conditions for quality and resilient services.2
This agenda is especially relevant to LMICs. Primary health care reforms increasingly emphasize community participation and multisectoral action, yet health systems may face workforce shortages, limited financing, variable management capacity, large rural or displaced populations, and substantial social and geographic inequities.3 In these settings, people-centredness cannot be reduced to bedside communication. It must also address who helps define priorities, whose knowledge is valued, how services respond to local realities, and whether communities can hold institutions accountable.
Recent reviews show both momentum and unfinished work. A scoping review found that published evidence on people-centred primary health care remains concentrated in high-income settings, while organizational leadership, community engagement, and mutual accountability emerged as recurring components of people-centred care.4 A subsequent systematic scoping review found that empirical application of the WHO people-centred framework remained limited, with trust and co-production acting as facilitators and health literacy, workforce, and primary-care capacity acting as barriers.5 These findings suggest an implementation gap: health systems increasingly endorse participation, but the leadership work needed to make participation consequential is less consistently developed.
The distinction between consultation and partnership is therefore important. Consultation asks people what they think. Partnership goes further by creating shared influence over problem definition, priorities, design, implementation, monitoring, or evaluation. Neither approach is inherently appropriate in every situation. Emergency decisions, regulatory functions, and technical choices may require different degrees of participation. The leadership problem arises when organizations describe consultation as empowerment, invite participation without the capacity to respond, or rely on a small group of easily reached representatives while marginalized voices remain absent.
Related terms are used differently across this literature. In this review, patient and family engagement refers mainly to involvement in care, service design, or evaluation; community participation refers to collective involvement in identifying priorities and shaping services; co-design, co-creation, and co-production describe collaborative development or implementation across one or more stages; social accountability refers to mechanisms through which communities seek answerability and institutional response; and shared governance refers to more formalized shared influence over decisions. These concepts overlap, but they are not treated as interchangeable.
Leadership is the central analytical lens in this review because leaders shape how authority, resources, participation structures, feedback pathways, and accountability are organized. LMICs are highly heterogeneous: political systems, decentralization, cultural norms, conflict exposure, financing, and institutional capacity vary substantially across countries and settings. The review therefore seeks cross-cutting leadership lessons rather than a universal implementation model. Its specific contribution is to integrate evidence that is often dispersed across community participation, patient and public involvement, co-creation, co-production, social accountability, and organizational leadership, and to translate that synthesis into a practical framework for leaders seeking to embed partnership into routine health-system practice.
Methods
A structured narrative review approach was used because the literature spans heterogeneous concepts, study designs, intervention types, and levels of the health system. The aim was to critically synthesize leadership-relevant evidence rather than estimate a pooled intervention effect. This approach allowed a focused synthesis without implying the comprehensiveness required of a prospectively registered systematic or scoping review.
Targeted searches were undertaken in PubMed for peer-reviewed reviews and empirical health-systems literature, complemented by searches of WHO publications and citation chaining from key articles. Search concepts combined terms related to people-centred or person-centred care, patient engagement, family engagement, community participation, patient and public involvement, co-design, co-creation, co-production, social accountability, leadership, governance, primary health care, health systems, and LMICs. Priority was given to systematic, scoping, realist, and narrative reviews; multicountry studies; and publications that explicitly described enabling conditions, barriers, power relations, governance, or leadership.
Because this was a narrative synthesis, formal risk-of-bias scoring and PRISMA flow counts were not applied. Evidence was interpreted thematically around five questions: how participation is structured; how power and decision-making are shared; what leaders and organizations do to enable participation; what commonly disrupts partnership; and what outcomes are used to judge success. The synthesis was informed by the WHO people-centred care framework but was not restricted to studies using that terminology. This broader approach was necessary because LMIC literature often describes similar practices using terms such as community participation, social accountability, participatory research, community advisory mechanisms, or co-creation. The selected literature was intended to represent the major conceptual and empirical strands of the field rather than provide an exhaustive bibliometric or systematic account of every active research group or publication. During revision, the literature was updated through September 2026 to incorporate recent empirical evidence from LMIC settings.
From Participation to Partnership: What the Evidence Shows
Participation is Common, but Decision-Making Power is Often Limited
The literature has long supported community participation as a principle of health-system strengthening, but the depth of participation varies considerably. A large systematic review of health-systems research in LMICs found that communities were frequently involved in implementing interventions but were much less often involved in defining the problems those interventions were intended to solve.6 This imbalance matters because implementation without agenda-setting can mobilize community labor while leaving institutional priorities unchanged.
A subsequent analysis of community capability emphasized that meaningful participation depends on what communities have, how they are able to act, and whose interests are represented. External linkages, access to information, skills, and local leadership can strengthen collective capability; weak financing, limited inclusiveness, and poor conflict-resolution capacity can undermine it.7 The implication for healthcare leaders is that participation cannot be treated as a meeting format. It requires investment in the conditions that allow participants to understand issues, contribute confidently, challenge assumptions, and remain involved over time.
A similar pattern appears in patient and public involvement. A systematic review of 61 studies from 34 countries found that collaboration occurred across LMIC health research, but its impact was often poorly reported and was usually described from researchers’ perspectives rather than those of patients or the public.8 A 2026 scoping review of structured patient and public involvement programs identified an even sharper institutional gap: although diverse engagement activities were present, formal infrastructure for sustained partnership was scarce, with recurring barriers including hierarchical decision-making, limited awareness, literacy barriers, digital exclusion, and absent systems for reimbursement and coordination.9
Co-Creation Works Best When Leaders Design for Context, Not for Ceremony
Co-creation and co-design provide a useful lens because they require stakeholders to work together across more than one stage of a project. A systematic review of co-creation in public health interventions in LMICs found that safe spaces, local resources, early involvement of future implementers, contextual assessment, and tailoring were important facilitators. Systemic constraints, socioeconomic vulnerability, insufficient time, and funding limitations repeatedly complicated implementation.10 These findings shift the leadership task away from simply inviting participants and toward designing a process that people can realistically enter and influence.
This distinction is important in resource-constrained settings. Participation has direct and indirect costs. Community members may lose income or travel long distances to attend meetings. Patients and caregivers may have limited time, literacy, digital access, or familiarity with institutional language. Health workers may already be managing high workloads. A leadership approach that ignores these constraints may unintentionally select for participants who are wealthier, more educated, more connected, or more comfortable speaking to professionals. The result can look participatory while reproducing the same inequities the process was intended to address.
Accountability Requires a Responsive Institution, Not Only an Empowered Community
Social accountability literature makes this point especially clearly. In sub-Saharan Africa, effective initiatives have been associated with coalitions, context-sensitive design, accessible information, clearly defined roles, and meaningful citizen engagement. At the same time, weak funding, corruption, fear of reprisal, and health-system barriers can limit what participation achieves.11 This means that community voice is only one side of the accountability relationship.
A realist review of 37 social accountability initiatives found that provider responsiveness was influenced by whether providers viewed citizen groups as legitimate and whether those groups could offer forms of professional or personal support, while broader political and bureaucratic accountability channels produced more mixed results.12 There was no universal blueprint.
Evidence from Community Score Card initiatives illustrates how structured dialogue can create negotiation between communities and providers. Reported outcomes have included empowerment, provider responsiveness, accountability, trust, and service improvements, although inclusion of marginalized groups and responsiveness at higher system levels remained difficult.13 The leadership lesson is practical: collecting complaints or scores is not enough. Institutions need authority, resources, routines, and named responsibility for responding to what communities identify.
Trust is Both an Input and an Outcome
Trust repeatedly appears in the literature as a condition for participation and as a possible product of well-designed partnership. Communities are more likely to engage when they believe that leaders will listen, protect them from retaliation, and explain decisions. Providers are more likely to respond when they see community processes as legitimate rather than adversarial or symbolic. At the same time, trust can be damaged when organizations repeatedly request feedback but do not communicate what happened afterward.5,12,13
This helps explain why direct links between participation and clinical outcomes are difficult to demonstrate. Rifkin argued that community participation is better understood as a context-dependent process that can support ownership, uptake, and sustainability rather than as a discrete intervention with a predictable effect size.14 In maternal and newborn health, a systematic review likewise found that community participation was often part of multifaceted interventions and that qualitative investigation was essential for understanding why participation succeeded or failed.15 For leaders, the appropriate question is therefore not only whether engagement improves a particular health indicator, but whether it improves relationships, relevance, responsiveness, and the conditions through which better care becomes possible.
Leadership Strategies for Meaningful Partnership
Begin with Listening That Can Change the Agenda
Listening becomes meaningful when it occurs before priorities have been fixed. Leaders can use community dialogues, patient stories, advisory groups, participatory needs assessments, complaints data, service-use patterns, and frontline staff observations to identify problems that may not be visible in administrative dashboards. The key is not the method itself but whether information arrives early enough to affect what the organization decides to work on.
This requires leaders to tolerate findings that challenge professional assumptions. A people-centred process may reveal that the barrier perceived by clinicians is not the barrier experienced by patients. It may show that a technically sound service is difficult to reach, unaffordable in practice, culturally unacceptable, poorly explained, or distrusted. Listening should therefore be treated as a leadership function tied to priority-setting, not as a communication activity added after decisions are made.
Deliberately Include People Who are Usually Missing
Representation is one of the hardest problems in participatory health systems. Community leaders, patient advocates, and civil society organizations can be valuable partners, but no individual can automatically represent all people affected by a service. Women, adolescents, people with disabilities, displaced populations, rural communities, linguistic minorities, people living in poverty, and those who have had negative experiences with care may be less visible in conventional engagement structures.
Leaders therefore need an inclusion strategy. That may involve using more than one engagement channel, providing transport or remote options, meeting outside working hours, simplifying technical information, using local languages, offering disability accommodations, and compensating participation where appropriate. Inclusion also requires attention to intra-community power. A crowded meeting does not guarantee that less powerful participants are heard.
Share Decisions at the Level Where Shared Decisions are Possible
Partnership does not require every decision to be made by consensus. It does require clarity about what is open to influence. Leaders should explain which decisions can be co-designed, which are constrained by regulation or resources, who holds final accountability, and how disagreements will be handled. This transparency prevents false expectations and protects trust.
Evidence on co-production in LMICs suggests that context-specific solutions become more feasible when researchers, managers, frontline workers, communities, and policy actors work together rather than sequentially. Co-production capacity needs to be developed at individual, institutional, and contextual levels, with resources matched to the work expected from participants.16 This principle applies equally to service design: shared decisions require shared information, time, facilitation, and organizational authority.
Make Partnership an Organizational Capability
People-centred engagement is fragile when it depends on a single enthusiastic leader. Organizations need routines that can survive staff turnover and competing priorities. Practical infrastructure may include patient and family advisory groups, community committees, designated engagement leads, standard feedback pathways, service co-design procedures, dashboards that include experience and equity measures, and governance meetings where community feedback is a standing agenda item.
Evidence from patient- and family-centred care frameworks shows that leadership, engagement, service delivery, learning, and environment are interdependent organizational domains rather than isolated projects.17 Training is therefore useful, but training without structural change is unlikely to sustain partnership. Leaders must align roles, incentives, supervision, budgets, and decision pathways with the behavior they expect.
Close the Feedback Loop
One of the simplest tests of meaningful engagement is whether participants can see what happened because they participated. Organizations should communicate what they heard, what they changed, what they could not change, and why. This feedback may be provided through community meetings, facility noticeboards, SMS messages, radio, social media, patient portals, or reports to advisory groups, depending on context.
Closing the loop turns participation into an accountability relationship. It also provides a way to distinguish listening from performance. When leaders document actions taken in response to feedback, participation becomes visible inside the organization and measurable over time. WHO guidance on social participation emphasizes institutionalizing inclusive participation across policy and decision-making processes rather than treating it as an occasional consultation.18
Measure What Matters: Equity, Trust, Responsiveness, and Service Change
Participation should not be judged solely by the number of meetings held or people attending. Process indicators are useful, but they can reward activity without demonstrating influence. A stronger measurement approach asks who participated, whether under-represented groups were included, whether participants understood their role, whether their input changed decisions, how quickly institutions responded, and whether trust, access, experience, or service quality improved.
WHO guidance on community engagement and social participation places relationship-building, inclusive participation, and shared responsibility at the center of quality, people-centred services.2,18 In practice, leaders should combine quantitative indicators with qualitative evidence. Numbers can show reach and timeliness; narratives can reveal whether people felt respected, whether power was genuinely shared, and why a process worked differently across settings.
Recent empirical evidence reinforces the gap between formal commitment and sustained influence. In Ghana, qualitative research found that patient and public participation was functioning more visibly at community level than at higher health-system levels, while participants described benefits for access, responsiveness, and community-health worker relationships.19 A 2025 analysis of 102 ministries of health across LMICs similarly found uneven institutionalization of community participation across the policy cycle, with participation reported more often in planning than in implementation, monitoring, or policy review.20 Together, these studies support the need to treat participation as an institutional leadership capability rather than a one-off engagement activity.
The LISTEN Leadership Framework
Drawing the reviewed evidence together, this article proposes the LISTEN framework as a practical leadership synthesis for moving from consultation to partnership. It is not presented as a validated measurement instrument. Rather, it organizes recurring evidence into six leadership behaviors that can be tested, adapted, and evaluated in different health-system contexts. Figure 1 presents the six domains as a continuous leadership cycle and links them to expected system outcomes. Table 1 translates each domain into practical leadership actions, examples, and possible indicators.
Figure 1.
The LISTEN Leadership Framework for Patient, Family, and Community Partnership in People-Centred Health Systems. The framework synthesizes six leadership domains for moving from consultation toward meaningful partnership: Listen, Include, Share Decisions, Train and Resource Participation, Establish Accountability Loops, and Notice Equity and Outcomes. The framework is a conceptual synthesis from this narrative review and is proposed for application in low- and middle-income and resource-constrained settings; prospective evaluation and validation are required.
Table 1.
The LISTEN Leadership Framework for Moving from Consultation to Partnership. The Framework Is a Conceptual Synthesis from This Narrative Review and Requires Prospective Validation
| Domain | Leadership Action | Examples in Practice | Possible Indicators |
|---|---|---|---|
| L – Listen systematically | Create recurring channels for patient, family, community, and frontline-worker insight before priorities are fixed. | Community dialogue; patient stories; experience data; participatory needs assessment. | Proportion of major service-improvement priorities informed by user/community evidence. |
| I – Include under-represented voices | Identify who is missing and reduce practical, social, linguistic, and digital barriers to participation. | Targeted outreach; local-language facilitation; transport/access support; multiple participation channels. | Representation by geography, gender, age, disability, displacement or other locally relevant equity dimensions. |
| S – Share decisions and design | Be explicit about which decisions can be influenced and involve partners early enough to shape them. | Co-design workshops; community priority-setting; patient/family input into service protocols and pathways. | Percentage of engagement processes with documented decision influence. |
| T – Train and resource participation | Build the skills, time, information, facilitation, and institutional capacity required for partnership. | Orientation for community partners; leadership training; protected staff time; reimbursement where appropriate. | Participation retention; participant confidence; budget/time allocated to engagement. |
| E – Establish accountability loops | Assign responsibility for responses and report back what changed, what did not, and why. | Action logs; community scorecards; public response reports; feedback dashboards. | Response time; proportion of issues closed with documented action or explanation. |
| N – Notice equity, trust, and outcomes | Evaluate not only activity but also fairness, trust, responsiveness, access, quality, and unintended effects. | Mixed-method evaluation; equity stratification; trust and experience measures. | Change in trust, experience, access, service quality, and distribution of benefits across groups. |
Implications for Low-Resource and Fragile Health Systems
The case for partnership is sometimes viewed as less practical when health systems are under severe resource pressure. In reality, resource constraints make prioritization and trust more important, not less. When services cannot meet every need, leaders need credible ways to understand which barriers are most consequential to communities and which changes are feasible. Community knowledge can also identify low-cost adjustments that are invisible to centralized planning, such as changing clinic hours, simplifying referral instructions, improving communication around fees, reorganizing waiting processes, or using trusted local networks for health information.
At the same time, partnership should not become a mechanism for transferring state or institutional responsibility onto communities. Asking families to compensate for workforce shortages, asking volunteers to sustain underfunded services, or expecting community committees to solve structural financing problems can be presented as participation while effectively shifting burden downward. People-centred leadership must therefore distinguish empowerment from substitution. Communities can co-produce solutions, but formal institutions remain accountable for stewardship, safety, financing, workforce conditions, and equitable access.
Fragile and conflict-affected settings add further considerations. Leadership structures may be decentralized or contested; populations may be displaced; trust in public institutions may be low; and service delivery may involve government, private, humanitarian, and community actors simultaneously. In these settings, a practical partnership model should begin with mapping who has legitimacy, who is excluded, which actors can act on feedback, and where accountability can realistically be located. The LISTEN framework is deliberately flexible enough to be applied at facility, district, program, or system level, but each domain should be adapted to local political and social conditions rather than applied as a checklist detached from context.
Research Priorities
The literature still leaves several important questions unanswered. First, studies need to distinguish clearly between information sharing, consultation, collaboration, co-design, and shared governance. Without this clarity, very different forms of participation are grouped together and conclusions become difficult to interpret. Second, evaluations should report who participated and who did not. Equity cannot be inferred from the presence of a community representative.
Third, research should measure institutional responsiveness. Many studies assess whether communities were engaged but not whether leaders acted on what they heard. A core outcome for future work should therefore be decision influence: what decisions changed, how quickly, and at what level of the system. Fourth, more LMIC-led studies are needed that examine participation as an organizational and leadership capability rather than only as a project-level intervention. Finally, future research should test whether structured leadership approaches such as LISTEN improve trust, service responsiveness, equity, patient experience, workforce-community relationships, and implementation outcomes.
Limitations
This review has limitations. It used a structured narrative rather than a systematic or scoping-review design and therefore does not claim exhaustive retrieval of all relevant literature. The selected sources were intended to capture the major conceptual and empirical strands of the field rather than provide a complete bibliometric map of every active research group or publication. The terminology of participation is inconsistent, and relevant work may be published under concepts not captured by the search approach. The evidence base is also heterogeneous and includes studies focused on research involvement, public health interventions, primary care, social accountability, and organizational care models. These literatures are related but not interchangeable.
In addition, much of the evidence on patient and family partnership comes from high-income settings, while LMIC evidence more often uses community participation, social accountability, or co-creation terminology. Outcomes are frequently process-based, context-specific, and difficult to compare. The LISTEN framework should therefore be understood as a theory-informed practical synthesis generated from the reviewed literature, not as a validated scale or causal model.
Conclusion
People-centred healthcare cannot be achieved by inviting patients and communities into processes whose priorities, options, and decisions have already been fixed. The evidence reviewed here suggests that meaningful partnership depends on leadership that shares influence, builds capability, protects inclusion, creates responsive institutions, and closes the feedback loop. In LMICs, these requirements are shaped by resource constraints, hierarchy, social inequity, and variable institutional capacity, but they are part of how health systems become more trusted, responsive, and accountable. By integrating evidence that is often dispersed across community participation, patient and public involvement, co-production, social accountability, and leadership literatures, this review adds an actionable leadership synthesis through the LISTEN framework: Listen systematically, Include under-represented voices, Share decisions and design, Train and resource participation, Establish accountability loops, and Notice equity, trust, and outcomes. The framework can be adapted at facility, district, program, or system level, but its application should remain sensitive to local governance, resources, culture, and institutional capacity. Future research should test LISTEN prospectively and judge engagement by whether it changes decisions, strengthens relationships, and improves responsiveness and equity.
Acknowledgments
The author acknowledges SIMAD University, Mogadishu, Somalia, for academic support. The author also acknowledges the Department of Intensive Care Unit, Dr. Sumait Hospital, SIMAD University, Mogadishu, Somalia, and the health professionals, educators, and health system leaders working to strengthen critical care services in Somalia.
Funding Statement
This work was supported by the Center for Research and Development (CRD), SIMAD University, Mogadishu, Somalia. The funder had no role in the review design, manuscript writing, interpretation, or decision to submit the article for publication.
Abbreviations
IPCHS, Integrated People-Centred Health Services; LMICs, low- and middle-income countries; PHC, primary health care; WHO, World Health Organization.
Data Sharing Statement
No new datasets were generated or analyzed for this narrative review. The evidence discussed is available through the cited publications and publicly accessible organizational sources.
Ethics Approval and Informed Consent
Not applicable. This article is a narrative review of published literature and publicly available policy documents and did not involve human participants, identifiable data, or animal research.
Disclosure
The author declares that the review was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No new datasets were generated or analyzed for this narrative review. The evidence discussed is available through the cited publications and publicly accessible organizational sources.