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Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: perceptions of stakeholders
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7234-3510
DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark.
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2010 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 10, Article nr 322- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In 2006, researchers and decision-makers launched a five year project, Response to Accountable Priority Setting for Trust in Health Systems (REACT) to improve planning and priority setting through implementing the Accountability for Reasonableness framework in Mbarali District in Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees.

METHODS: Individual interviews were carried out with different categories of actors and stakeholders in the district. The interview guide consisted of a series of questions asking respondents to describe their perceptions regarding the applicability and feasibility of each condition of the Accountability for Reasonableness framework to priority setting. Interviews were analysed using thematic framework analysis. Documentary data was used to support, verify and highlight key issues that emerged.

RESULTS: Almost all stakeholders viewed Accountability for Reasonableness as an important and feasible approach for improving priority setting and health service delivery in their context. However, a few aspects of the Accountability for Reasonableness framework were seen as difficult to implement given the socio-political conditions and traditions in Tanzania. Respondents mentioned budget ceilings and guidelines, low level of public awareness, unreliable and untimely funding as well as limited capacity of the district to generate local resources as the major contextual factors that hamper the full implementation of the framework in their context.

CONCLUSION: This study was one of the first assessments of the applicability of Accountability for Reasonableness in health care priority setting in Tanzania. The analysis, overall, suggests that the Accountability for Reasonableness framework could be an important tool for improving priority-setting process in the contexts of resource poor settings. However, the full implementation of Accountability for Reasonableness framework would require a proper capacity-building plan to all relevant stakeholders, particularly members of the community since public accountability is the ultimate aim, and it is the public that will live with the consequences of priority setting decisions.

Place, publisher, year, edition, pages
BioMed Central, 2010. Vol. 10, Article nr 322- p.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-38475DOI: 10.1186/1472-6963-10-322ISI: 000285691700001PubMedID: 21122123OAI: oai:DiVA.org:umu-38475DiVA: diva2:378224
Funder
EU, European Research Council, 517709FAS, Swedish Council for Working Life and Social Research, 2006-1512
Note

This paper is part of a larger study of the European Union's funded REACT project which is testing the applicability of the Accountability for Reasonableness approach to priority setting in Mbarali District in Tanzania. Other data came from a study conducted by the first author as part of his PhD research project on Priority Setting in Health Care Institutions. SM was supported by a doctoral fellowship from the Swedish Center Party Donation for Global Research Collaboration; Swedish Research School for Global Health; the University of Dar es Salaam, Tanzania, and the African Doctoral Dissertation Research Fellowship offered by the African Population and Health Research Centre (APHRC) in partnership with the International Development Research Centre (IDRC) and Ford Foundation. AKH, JB, BN and PK were supported by the EU funded REACT project grant number: PL 517709. MSS was supported by the Centre for Global Health at the Umea University, with support from FAS, the Swedish Council for Working Life and Social Research (grant number 2006-1512).

Available from: 2010-12-15 Created: 2010-12-15 Last updated: 2017-12-11Bibliographically approved
In thesis
1. Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania: opportunities, challenges and the way forward
Open this publication in new window or tab >>Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania: opportunities, challenges and the way forward
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

During the 1990s, Tanzania, like many other developing countries, adopted health sector reforms. The most common policy change under health sector reforms has been decentralisation, which involves the transfer of power and authority from the central levels to the local governments. However, while decentralisation of health care planning and priority-setting in Tanzania gained currency in the last decade, its performance has, so far, been less than satisfactory. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority-setting in district health management were studied through action research. As part of this overall project, this doctoral thesis aims to analyse the existing health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness approach to priority setting in Tanzania.

Methods

A qualitative case study in Mbarali district formed the basis of exploring the socio-political and institutional contexts within which health care decision-making takes place. The thesis also explores how the Accountability for Reasonableness intervention was shaped, enabled and constrained by the interaction between the contexts and mechanisms. Key informant interviews were conducted with the Council Health Management Team, local government officials, and other stakeholders, using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting processes in the district were observed.

Main findings

The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The findings showed that decentralisation, in whatever form, does not automatically provide space for community engagement. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality.

In addition, the thesis found that while the Accountability for Reasonableness approach to priority setting was perceived to be helpful in strengthening transparency, accountability, stakeholder engagement and fairness, integrating the innovation into the current district health system was challenging.  

Conclusion

This thesis underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context, can lead to better prediction of the effects of the innovation, pinpoint stakeholders’ concerns, and thereby illuminate areas requiring special attention in fostering sustainability. Additionally, the thesis stresses the need to recognise and deal with power asymmetries among various actors in priority-setting contexts.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2011. 65 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1407
Keyword
decentralisation, health care, accountability for reasonableness, priority setting, health systems, Tanzania
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-40377 (URN)978-91-7459-155-2 (ISBN)
Public defence
2011-03-18, Room 135, Family Medicine, Building 9A, Umeå University Hospital, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2011-02-25 Created: 2011-02-22 Last updated: 2015-04-29Bibliographically approved

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Maluka, StephenSan Sebastian, MiguelHurtig, Anna-Karin

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