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Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation
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, Dar Es Salaam, Tanzania.
Institute of Development Studies, University of Dar Es Salaam, 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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2011 (English)In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 6, Article nr 11- p.Article in journal (Refereed) Published
Abstract [en]

Background: Despite the growing importance of the Accountability for Reasonableness (A4R) framework in priority setting worldwide, there is still an inadequate understanding of the processes and mechanisms underlying its influence on legitimacy and fairness, as conceived and reflected in service management processes and outcomes. As a result, the ability to draw scientifically sound lessons for the application of the framework to services and interventions is limited. This paper evaluates the experiences of implementing the A4R approach in Mbarali District, Tanzania, in order to find out how the innovation was shaped, enabled, and constrained by the interaction between contexts, mechanisms and outcomes.

Methods: This study draws on the principles of realist evaluation - a largely qualitative approach, chiefly concerned with testing and refining programme theories by exploring the complex interactions of contexts, mechanisms, and outcomes. Mixed methods were used in data collection, including individual interviews, non-participant observation, and document reviews. A thematic framework approach was adopted for the data analysis.

Results: The study found that while the A4R approach to priority setting was helpful in strengthening transparency, accountability, stakeholder engagement, and fairness, the efforts at integrating it into the current district health system were challenging. Participatory structures under the decentralisation framework, central government's call for partnership in district-level planning and priority setting, perceived needs of stakeholders, as well as active engagement between researchers and decision makers all facilitated the adoption and implementation of the innovation. In contrast, however, limited local autonomy, low level of public awareness, unreliable and untimely funding, inadequate accountability mechanisms, and limited local resources were the major contextual factors that hampered the full implementation.

Conclusion: This study documents an important first step in the effort to introduce the ethical framework A4R into district planning processes. This study supports the idea that a greater involvement and accountability among local actors through the A4R process may increase the legitimacy and fairness of priority-setting decisions. Support from researchers in providing a broader and more detailed analysis of health system elements, and the socio-cultural context, could lead to better prediction of the effects of the innovation and pinpoint stakeholders' concerns, thereby illuminating areas that require special attention to promote sustainability.

Place, publisher, year, edition, pages
BioMed Central, 2011. Vol. 6, Article nr 11- p.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-39690DOI: 10.1186/1748-5908-6-11ISI: 000287512600001PubMedID: 21310021OAI: oai:DiVA.org:umu-39690DiVA: diva2:394722
Funder
FAS, Swedish Council for Working Life and Social Research, 2006-1512EU, European Research Council, PL 517709
Note

This paper is part of a larger study of the EU-funded REACT project, which tests the applicability of the A4R 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; the 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. PK, JB, BN, OEO and AKH were supported by the EU-funded REACT project, grant number: PL 517709. MSS was supported by the Centre for Global Health at Umea University, with support from FAS, the Swedish Council for Working Life and Social Research (grant number 2006-1512).

Available from: 2011-02-03 Created: 2011-02-03 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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