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  • 1.
    Maluka, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania: opportunities, challenges and the way forward2011Doctoral 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.

  • 2.
    Maluka, Stephen
    et al.
    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.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark.
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O. Box 235, Iringa, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: perceptions of stakeholders2010In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 10, p. Article nr 322-Article in journal (Refereed)
    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.

  • 3.
    Maluka, Stephen
    et al.
    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.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, Dar Es Salaam, Tanzania.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL-Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark .
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O.Box 235, Iringa, Tanzania .
    Olsen, Öystein E
    Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania .
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation2011In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 6, p. Article nr 11-Article in journal (Refereed)
    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.

  • 4.
    Maluka, Stephen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania.
    San Sebastiån, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL-Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark.
    Olsen, Øystein E
    DBL-Centre for Health Research and Development and Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania.
    Shayo, Elizabeth
    National Institute for Medical Research (NIMR), P.O. Box 9653, Dar Es Salaam, Tanzania.
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O. Box 235, Iringa, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Decentralized health care priority-setting in Tanzania: evaluating against the accountability for reasonableness framework2010In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 71, no 4, p. 751-759Article in journal (Refereed)
    Abstract [en]

    Priority-setting has become one of the biggest challenges faced by health decision-makers worldwide. Fairness is a key goal of priority-setting and Accountability for Reasonableness has emerged as a guiding framework for fair priority-setting. This paper describes the processes of setting health care priorities in Mbarali district, Tanzania, and evaluates the descriptions against Accountability for Reasonableness. Key informant interviews were conducted with district health managers, local government officials and other stakeholders using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting in the district was observed. The results indicate that, while Tanzania has a decentralized public health care system, the reality of the district level priority-setting process was that it was not nearly as participatory as the official guidelines suggest it should have been. Priority-setting usually occurred in the context of budget cycles and the process was driven by historical allocation. Stakeholders' involvement in the process was minimal. Decisions (but not the reasoning behind them) were publicized through circulars and notice boards, but there were no formal mechanisms in place to ensure that this information reached the public. There were neither formal mechanisms for challenging decisions nor an adequate enforcement mechanism to ensure that decisions were made in a fair and equitable manner. Therefore, priority-setting in Mbarali district did not satisfy all four conditions of Accountability for Reasonableness; namely relevance, publicity, appeals and revision, and enforcement. This paper aims to make two important contributions to this problematic situation. First, it provides empirical analysis of priority-setting at the district level in the contexts of low-income countries. Second, it provides guidance to decision-makers on how to improve fairness, legitimacy, and sustainability of the priority-setting process.

  • 5.
    Maluka, Stephen Oswald
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sebastián, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Shayo, Elizabeth
    National Institute of Medical Research (NIMR), Dar es Salaam, United Republic of Tanzania.
    Byskov, Jens
    DBL—Centre for Health Research and Development, University of Copenhagen, Copenhagen, Denmark.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar es Salaam, United Republic of Tanzania.
    Decentralization and health care prioritization process in Tanzania: from national rhetoric to local reality2011In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 26, no 2, p. e102-e120Article in journal (Refereed)
    Abstract [en]

    During the 1990s, Tanzania like many other developing countries adopted health sector reforms. The most common policy change under the health sector reforms has been decentralization, which involves the transfer of power and authority from the central level to local authorities. Based on the case study of Mbarali district in Tanzania, this paper uses a policy analysis approach to analyse the implementation of decentralized health care priority setting. Specifically, the paper examines the process, actors and contextual factors shaping decentralized health care priority setting processes. The analysis and conclusion are based on a review of documents, key informant interviews, focus group discussion, and notes from non-participant observation. The findings of the study indicate that local institutional contexts and power asymmetries among actors have a greater influence on the prioritization process at the local level than expected and intended. The paper underlines the essentially political character of the decentralization process and reiterates the need for policy analysts to pay attention to processes, institutional contexts, and the role of policy actors in shaping the implementation of the decentralization process at the district level. Copyright (c) 2010 John Wiley & Sons, Ltd.

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