Understanding decision-making around human and livestock health in sub-Saharan Africa: A systematic literature review.

Household decisions shape health outcomes in subsistence farming communities in sub-Saharan Africa (SSA) where human wellbeing is closely linked to livestock productivity. We conducted a systematic review, guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), of 135 primary studies from Embase, Scopus, PubMed, Web of Science and Google Scholar. Using the Household Production of Health (HPH) framework, we structured research questions, extracted and synthesised evidence and identified health interventions in human and livestock health in SSA. We coded decision loci (sole vs joint decision-making) and characterised their prevalence, context and determinants of household health outcomes. Sole decisions dominated (40 % of human studies, 42 % of livestock studies) with men making the majority of the decisions, especially in livestock health, while joint decisions were less common (27 %, 32 % respectively) and focused on maternal, neonatal and child health. Women's decision-making power tended to increase with education, income and urban residence, while male authority was greater in rural areas where fewer income-earning opportunities for women prevail. The two HPH frameworks are tightly linked as behaviours that improve livestock health and productivity benefit nutrition, income and access to care for household members. We recommend gender-responsive, One Health policies that support women's control in areas of existing responsibility and engage men as active partners in shared decision-making within households to reduce inequalities. These efforts should be supported by progress towards universal health coverage, functioning health insurance schemes and accessible veterinary services to reduce inequalities and within-household trade-offs, and to improve health and livelihood resilience in SSA.