Institute of Development Studies

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The Accountability for Reasonableness Approach to Guide Priority Setting in Health Systems Within Limited Resources – Findings From Action Research at District Level in Kenya, Tanzania, and Zambia
(2014-12) Byskov, Jens; Marchal, Bruno; Maluka, Stephen; Zulu, Joseph M.; Bukachi, Salome A.; Hurtig, Anna-Karin; Blystad, Astrid; Kamuzora, Peter; Michelo, Charles; Nyandieka, Lilian N.; Ndawi, Benedict; Bloch, Paul; Olsen, Øystein E.; Consortium, React
Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT).
Challenges to Fair Decision-Making Processes in The Context of Health Care Services: A Qualitative Assessment from Tanzania
(2012-06) Shayo, Elizabeth; Norheim, Ole F.; Mboera, Leonard; Byskov, Jens; Maluka, Stephen; Kamuzora, Peter; Blystad, Astrid
Fair processes in decision making need the involvement of stakeholders who can discuss issues and reach an agreement based on reasons that are justifiable and appropriate in meeting people's needs. In Tanzania, the policy of decentralization and the health sector reform place an emphasis on community participation in making decisions in health care. However, aspects that can influence an individual's opportunity to be listened to and to contribute to discussion have been researched to a very limited extent in low-income settings. The objective of this study was to explore challenges to fair decision-making processes in health care services with a special focus on the potential influence of gender, wealth, ethnicity and education. We draw on the principle of fairness as outlined in the deliberative democratic theory. The study was carried out in the Mbarali District of Tanzania. A qualitative study design was used. In-depth interviews and focus group discussion were conducted among members of the district health team, local government officials, health care providers and community members. Informal discussion on the topics was also of substantial value. The study findings indicate a substantial influence of gender, wealth, ethnicity and education on health care decision-making processes. Men, wealthy individuals, members of strong ethnic groups and highly educated individuals had greater influence. Opinions varied among the study informants as to whether such differences should be considered fair. The differences in levels of influence emerged most clearly at the community level, and were largely perceived as legitimate. Existing challenges related to individuals' influence of decision making processes in health care need to be addressed if greater participation is desired. There is a need for increased advocacy and a strengthening of responsive practices with an emphasis on the right of all individuals to participate in decision-making processes. This simultaneously implies an emphasis on assuring the distribution of information, training and education so that individuals can participate fully in informed decision making.
Challenges to Fair Decision-Making Processes in the Context of Health Care Services: A Qualitative Assessment from Tanzania
(BioMed Central, 2012) Shayo, Elizabeth H; Norheim, Ole F; Mboera, Leonard E G; Byskov, Jens; Maluka, Stephen O.; Kamuzora, Peter; Blystad, Astrid
Fair processes in decision making need the involvement of stakeholders who can discuss issues and reach an agreement based on reasons that are justifiable and appropriate in meeting people’s needs. In Tanzania, the policy of decentralization and the health sector reform place an emphasis on community participation in making decisions in health care. However, aspects that can influence an individual’s opportunity to be listened to and to contribute to discussion have been researched to a very limited extent in low-income settings. The objective of this study was to explore challenges to fair decision-making processes in health care services with a special focus on the potential influence of gender, wealth, ethnicity and education. We draw on the principle of fairness as outlined in the deliberative democratic theory.
Decentralization and Health Care Prioritization Process in Tanzania: from National Rhetoric to local Reality
(2011) Maluka, Stephen O.; Hurtig, Anna-Karin; Sebastián, Miguel S; Shayo, Elizabeth; Byskov, Jens; Kamuzora, Peter
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 © 2010 John Wiley & Sons, Ltd.
Decentralization and Health Care Prioritization Process in Tanzania: From National Rhetoric to Local Reality
(2011-03) Maluka, Stephen; Hurtig, Anna-Karin; Sebastian, Miguel San; Shayo, Elizabeth; Byskov, Jens; Kamuzora, Peter
Implementing Accountability for Reasonableness Framework at District Level in Tanzania: a Realist Evaluation
(BioMed Central, 2011) Maluka, Stephen O.; Kamuzora, Peter; SanSebastián, Miguel; Byskov, Jens; Ndawi, Benedict; Olsen, Øystein E; Hurtig, Anna-Karin
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
Implementing Accountability for Reasonableness Framework at District Level in Tanzania: A Realist Evaluation
(2011-02) Maluka, Stephen; Kamuzora, Peter; Sansebastián, Miguel; Byskov, Jens; Ndawi, Benedict; Olsen, Øystein E.; Hurtig, Anna-Karin
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. 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. 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. 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.
Improving District Level Health Planning and Priority Setting in Tanzania through Implementing Accountability for Reasonableness Framework: Perceptions of stakeholders
(BioMed Central, 2010-12) Kamuzora, Peter; Sebastián, Miguel S; Byskov, Jens; Ndawi, Benedict; Hurtig, Anna-Karin
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, Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from the perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees.
Improving District Level Health Planning and Priority Setting in Tanzania Through Implementing Accountability for Reasonableness Framework: Perceptions of Stakeholders
(2010-12) Maluka, Stephen; Kamuzora, Peter; Sebastian, Miguel San; Byskov, Jens; Ndawi, Benedict; Hurtig, Anna-Karin
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, Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from the perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees. 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 each condition of the Accountability for Reasonableness framework in terms of priority setting. Interviews were analysed using thematic framework analysis. Documentary data were used to support, verify and highlight the key issues that emerged. 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 Accountability for Reasonableness were seen as too 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 the limited capacity of the district to generate local resources as the major contextual factors that hampered the full implementation of the framework in their context. 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 processes in the contexts of resource-poor settings. However, the full implementation of Accountability for Reasonableness would require a proper capacity-building plan, involving all relevant stakeholders, particularly members of the community since public accountability is the ultimate aim, and it is the community that will live with the consequences of priority-setting decisions.
Promoting Community Participation in Priority Setting in District Health Systems: Experiences From Mbarali District, Tanzania
(2013-11) Kamuzora, Peter; Maluka, Stephen; Ndawi, Benedict; Byskov, Jens; Hurtig, Anna-Karin
Promoting Community Participation in Priority Setting in District Health Systems: Experiences from Mbarali District, Tanzania
(Co-action Publishing, 2013) Kamuzora, Peter; Maluka, Stephen O.; Ndawi, Benedict; Byskov, Jens; Hurtig, Anna-Karin
Community participation in priority setting in health systems has gained importance all over the world, particularly in resource-poor settings where governments have often failed to provide adequate publicsector services for their citizens. Incorporation of public views into priority setting is perceived as a means to restore trust, improve accountability, and secure cost-effective priorities within healthcare. However, few studies have reported empirical experiences of involving communities in priority setting in developing countries. The aim of this article is to provide the experience of implementing community participation and the challenges of promoting it in the context of resource-poor settings, weak organizations, and fragile democratic institutions.
A systems perspective on the importance of global health strategy developments for accomplishing today’s Sustainable Development Goals
(Oxford University Press, 2019-07-30) Byskov, Jens; Maluka, Stephen; Marchal, Bruno; Shayo, Elizabeth; Blystad, Astrid; Bukachi, Salome; Zulu, Joseph; Michelo, Charles; Hurtig, Anna-Karin; Bloch, Paul
Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemporary health systems are appropriate to optimize population health within the framework of cross cutting targets of the Sustainable Development Goals (SDGs). We applied a scoping review approach to identify and review literature of scientific databases and other programmatic web and library-based documents on historical and contemporary health systems policies and strategies at the global level. Early literature supported the 1977 launching of the global target of Health for All by the year 2000. Reviewed literature was used to provide a historical overview of systems components of global health strategies through describing the conceptualizations of health determinants, user involvement and mechanisms of priority setting over time, and analysing the importance of historical developments on barriers and opportunities to accomplish the SDGs. Definitions, scope and application of health systems-associated priority setting fluctuated and main health determinants and user influence on global health systems and priority setting remained limited. In exploring reasons for the identified lack of SDG-associated health systems and priority setting processes, we discuss issues of accountability, vested interests, ethics and democratic legitimacy as conditional for future sustainability of population health. To accomplish the SDGs health systems must engage beyond their own sector boundary. New approaches to Health in All Policies and One Health may be conducive for scaling up more democratic and inclusive priority setting processes based on proper process guidelines from successful pilots. Sustainable development depends on population preferences supported by technical and managerial expertise.

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