BACKGROUND:
Despite global commitments to disability inclusion, how these commitments are governed, negotiated, and operationalised within public health systems in low- and middle-income countries (LMICs) remains poorly understood. Inequities experienced by people with disabilities are recognised as human rights concerns under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), yet persistent gaps remain between formal policy commitments and implementation in LMICs.1-4 This study examined how governmental policy-makers and programme managers in South Africa and Kenya make decisions about disability-targeted policies and programmes, and the factors shaping these decisions.

METHODS:
Using a systems-thinking approach,5 decision-making was conceptualised as a dynamic, non-linear process shaped by institutions, resources, contexts, and actors. Purposive and snowball sampling were used to recruit participants, and semi-structured interviews were conducted with 14 government officials working at national and subnational levels.

RESULTS:
Thematic analysis identified eight overarching themes, including understandings of disability; perceptions and sources of evidence; barriers and facilitators to evidence use; decision-making pathways and actors; and strategies to strengthen evidence-informed action. Decision-making was adaptive and politically situated, shaped by institutional mandates, competing policy agendas, and multiple forms of evidence. Participation of organisations of persons with disabilities (OPDs) was uneven and constrained by structural and resource limitations, influencing advocacy success and whose knowledge was legitimised in policy negotiations. Global measurement tools were sometimes misaligned with local realities, highlighting tensions between international policy norms and domestic governance contexts.6

CONCLUSIONS:
Strengthening disability-related decision-making in LMICs requires institutionalising empowered disability focal points with cross-sectoral authority, enhancing the analytical, relational, and policy-diplomatic capacities of government actors, and supporting OPDs to generate and strategically mobilise community-level data. Context-sensitive, participatory, systems-informed approaches are essential to balancing power, strengthening local capacity, and aligning global disability agendas with political and economic realities to advance equitable public health outcomes for people with disabilities.