Browsing by Author "Kamuzora, Peter"

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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).
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    Accountable Priority Setting for Trust in Health Systems - the Need for Research into a New Approach for Strengthening sustainable Health Action in Developing Countries
    (BioMed Central, 2009) ByskovEmail, Jens; Bloch, Paul; Blystad, Astrid; Hurtig, Anna-Karin; Fylkesnes, Knut; Kamuzora, Peter; Kombe, Yeri; Kvåle, Gunnar; Marchal, Bruno; Martin, Douglas K; Michelo, Charles; Ndawi, Benedict; Ngulube, Thabale J; Nyamongo, Isaac; Olsen, Øystein E; Onyango-Ouma, Washington; Sandøy, Ingvild F; Shayo, Elizabeth H; Silwamba, Gavin; Songstad, Nils G; Tuba, Mary
    Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed. Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i) relevance to the local setting, decided by agreed criteria; ii) publicizing priority-setting decisions and the reasons behind them; iii) the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv) the provision of leadership to ensure that the first three conditions are met. REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being applied in an action research framework to examine the potential of AFR to support sustainable improvements to health systems performance. This paper reports on the project design and progress and argues that there is a high need for research into legitimate and fair priority setting to improve the knowledge base for achieving sustainable improvements in health outcomes.
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    Applying Policy Analysis in Tackling Health-equity Related Implementation Gaps
    (2006-01) Gilson, Lucy; Erasmus, Ermin; Kamuzora, Peter; Mathews, Verona; Ngulube, T. J; Scott, Vera
    In international health policy debates the problems experienced in implementing new policies and interventions are generally seen as resulting from the weak use of available evidence and the failure to hold health workers accountable for their actions. Both of these causes are then sometimes linked to the lack of political will to improve implementation. This paper presents an alternative perspective that takes fuller account of the ways in which the exercise of power shapes implementation experiences.
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    Autonomy without capacity: the role of health facility governing committees in planning and budgeting in Tanzania
    (University of Dar es Salaam, 2023-03) Maluka, Stephen; Kamuzora, Peter; Hurtig, Anna-Karin; San Sebastian, Miguel; Mtasingwa, Lilian; Kapologwe, Ntuli
    Since the inception of health-sector reforms in Tanzania in the 1990s, health planning and implementation was decentralised to the Council Health Management Teams (CHMTs) headed by the District Medical Officer (DMO). This arrangement centralised the autonomy for planning, budgeting and resource allocation at the district level with very limited autonomy and authority at the health facility and community level. Since 2017/2018, the government of Tanzania has further transferred the autonomy to plan, budget and manage financial resources to health facilities. Under the current arrangements, each health facility prepares its comprehensive annual health plan and budget, and funds for the implementation of the plans are transferred directly from the Ministry of Finance and Planning (MoFP) to health facilities; the policy known as Direct Health Facility Financing (DHFF). Each health facility is supposed to have a planning team responsible for preparing annual plans. The team is required to: (i) conduct a thorough assessment of the implementation of the previous year comprehensive health facility plans to guide preparation of subsequent annual plan; (ii) gather community opinions regarding priorities and challenges in accessing health care services to inform the planning process; (iii) conduct a robust situational analysis about the morbidity and mortality trends, underlying causes and health system bottlenecks hampering the delivery and uptake of interventions; (iv) prepare plans in accordance to existing guidelines; (v) provide feedback of the approved facility plan to Health Facility Governing Committee (HFGC), Village Development Committee (VDC) and Ward Development Committee (WDC); and (vi) ensure that the plans are responsive to local needs (facility and population). The central government issues guidelines that steer the planning process at the district and health facility levels. The CHMTs and health facilities need to abide by these guidelines when preparing their annual health plans. Similarly, the central government supplies the budget making guidelines, which stipulate the ‘budget ceilings’ that every district and health facility has to adhere to. All facility plans are at later stage consolidated into a Comprehensive Council Health Plan (CCHP) for the whole district. Similarly, the preparation of the CCHP is led by a guideline from the central government. The consolidation process is done by the CCHP planning team led by the District Medical Officers (DMOs). After endorsement at the Council level, the plan is submitted to the Regional Secretariat (RS) for assessment, approval and submission to the national level. At this level, the plan is assessed by assessors comprising members from the President’s Office-Regional Administration and Local Government (PORALG) – Health and MoH and recommended for funding.
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    Can Action Research Strengthen District Health Management and Improve Health Workforce Performance? A Research Protocol
    (2013) Mshelia, C.; Huss, R.; Mirzoev, T; Elsey, H.; Baine, S. O.; Aikins, Moses; Kamuzora, Peter; Bosch-Capblanch, X.; Raven, J.; Wyss, K.; Green, A.; Martineau, T.
    The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome.
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    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.
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    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.
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    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
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    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.
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    Factors Influencing Implementation of the Community Health Fund in Tanzania
    (2006) Kamuzora, Peter; Gilson, Lucy
    Although prepayment schemes are being hailed internationally as part of a solution to health care financing problems in low-income countries, literature has raised problems with such schemes. This paper reports the findings of a study that examined the factors influencing low enrolment in Tanzania’s health prepayment schemes (Community Health Fund). The paper argues that district managers had a direct influence over the factors explaining low enrolment and identified in other studies (inability to pay membership contributions, low quality of care, lack of trust in scheme managers and failure to see the rationale to insure). District managers’ actions appeared, in turn, to be at least partly a response to the manner of this policy’s implementation. In order better to achieve the objectives of prepayment schemes, it is important to focus attention on policy implementers, who are capable of re-shaping policy during its implementation, with consequences for policy outcomes.
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    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.
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    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
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    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.
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    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.
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    Leaving no one behind: using action research to promote male involvement in maternal and child health in Iringa region, Tanzania
    (2020-10-02) Maluka, Stephen; Japhet, Paul; Fitzgerald, Sian; Begum, Khadija; May, Alexander; Kamuzora, Peter
    Introduction Male involvement has been reported to improve maternal and child health (MCH) outcomes. However, most studies in low-income and middle-income countries have reported low participation of men in MCH-related programmes. While there is a growing interest in the involvement of men in MCH, little is known on how male involvement can be effectively promoted in settings where entrenched unequal gender roles, norms and relations constrain women from effectively inviting men to participate in MCH. Methods and analysis This paper reports participatory action research (PAR) aimed to promote male participation in pregnancy and childbirth in Iringa Region, Tanzania. As part of the Innovating for Maternal and Child Health in Africa project, PAR was conducted in 20 villages in two rural districts in Tanzania. Men and women were engaged separately to identify barriers to male involvement in antenatal care and during delivery; and then they were facilitated to design strategies to promote male participation in their communities. Along with the PAR intervention, researchers undertook a series of research activities. A thematic analysis was used to analyse the data. The common strategies designed were: engaging health facility committees; using male champions and male gatekeepers; and using female champions to sensitise and provide health education to women. These strategies were validated during stakeholders’ meetings, which were convened in each community. Discussion The use of participatory approach not only empowers communities to diagnose barriers to male involvement and develop culturally acceptable strategies but also increases sustainability of the interventions beyond the life span of the project. More lessons will be identified during the implementation of these strategies.
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    Non-Decision Making in Occupational Health Policies in Developing Countries,
    (Taylor & Francis Group, 2013-06-19) Kamuzora, Peter
    Developing countries have no. significant policies for occupational health. This analysis identifies four broad mechanisms through which state- and enterprise-level decision makers in developing countries diffuse attemps to instigate improvements in occupational health: inaction or stifling of such efforts during policy implementation; exercise of power; appeal to the existing bias (norms, rules, procedures) of the system; and prevailing dominant ideology. Addressing these limiting factors requires initiating a process of raising the occupational health policy profile that recognizes the importance of empowering workers' organizations, and enabling professionals to play an active role in the generation of occupational health knowledge required to improve occupational health in the developing countries.
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    The Politics of Implementing Intersectoral Policies for Primary Health Care Development: Experience and Lessons from Tanzania
    (1995) Kamuzora, Peter
    The paper reviews the initiatives made by the Government of Tanzania to develop intersectoral collaboration for the implementation of Primary Health Care(PHC). It explains why there has been little in those directions. A number of shortcomings were identified during the different phases of PHC implementation, these include: misconception of PHC by the MoH as PHC was paradoxically initiated in the MoH (national level) as a vertical programme alongside other vertical programmes which were not coordinated, formation of the PHC coordinating committees alongside development committees existing at village, district and regional levels gave rise to unnecessary multiplication of committees at these levels: a tendency by the MoH to refrain from implementing its past decisions such as dropping the formation of a National Health Council to guide the PHC-oriented policy formulation process at national level; weakening the national level coordinating mechanism by lack of political legitimacy it deserves; and inadequate legal mechanisms proposed in the 1983 PHC guidelines to back up PHC implementation which were made in reference to only the village level PHC committee. Experience of implementing PHC in Tanzania highlights the point that intersectoral collaboration is not simply a technical issue but as influenced by socio-political factors. This article has raised a number of issues which have to be noted in order to improve intersectoral collaboration in Tanzania. First, is the need to place PHC on Tanzania's political agenda. This may taken time but it is a necessary exercise to undertake. Second, effective mechanisms to foster policy coordination at national level should be developed. Third, intersectoral coordination processes at national level should guide similar processes at subnational levels. Fourth, is always to be aware of an counteract the problems presented by the medical model in health programmes implementation processes.
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    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.
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    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