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).
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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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    advantages and risk of economic partnership agreement
    (2007-10) Maluka, Stephen O.
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    Africa’s Debt Bondage: A Case for Total Cancellation
    (2001) Rugumamu, Severine M.
    From the early 1980s to the present, Africa’s external debt burden has become increasingly onerous and unmanageable. The continent’s inability to service its debt is vividly reflected not only by a massive build-up of arrears but most importantly, by the number and frequency of rescheduling. Although most concerned parties agree on the urgent need for creative and innovative approaches to resolve Africa’s debt crisis, opinions differ considerably as to what exactly needs to be done. Recent partial and often disjointed debt relief measures that have been tried to manage the debt crisis have been found largely inadequate. It is hereby proposed that debt should be cancelled for highly indebted poor countries. This is precisely because debt repayment is economically exhausting as it continues to block future development; it is politically destabilising as it threatens social harmony; and, it is ethically unacceptable as it hurts the poorest of the poor.
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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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    Are Tanzanian Households Moving Away from Extended? Evidence from Demographic and Health Survey Data
    (2013) Dungumaro, Esther W.
    This paper uses cross-sectional data from four Demographic and Health Surveys (DHS) conducted between 1996 and 2010 to establish trends in nuclear and extended households in Tanzania. Associations between types of households and sex of head of household, age of head of household, household size and educational attainment of head of household as the explanatory variables were tested using Pearson’s Chi Square. Multivariate logistic regression model was used to examine independent correlates to living in a nuclear than extended household. Results on trends of nuclear and extended households indicate that Tanzanian households have moved away from extended to largely nuclear. The findings of the study show that nuclear households are associated with household size, place of residence, household wealth index, as well as age and sex of head of household. Furthermore, the study reveals that in urban areas, there are more extended than nuclear households. This observation cautions the existing overgeneralization that nuclear households are more prevalent in urban areas. More site specific analyses are needed to inform both policy and pragmatic interventions.
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    An Assessment of the Implementation of the Re-structured Community Health Fund in Gairo District in Tanzania
    (Tanzania Journal of Development Studies, 2020) Asantemungu, Raphael; Maluka, Stephen
    While the government of Tanzania has been implementing community health fund (CHF) for more than two decades, the uptake of the scheme has been persistently low due to management and performance problems. As a response, from 2011 a new initiative was adopted that changed the overall structure, management and benefit packages of the CHF. This paper assesses the implementation of the newly re- structured CHF in Gairo District in Morogoro Region. This study employed a descriptive qualitative case study design using three types of data collection techniques, namely individual interviews (n=14), focus group discussions (n=4) and document review. A thematic approach was used to analyse the data. Findings show that the re-structured CHF has improved the pooling and provider payment mechanism compared to the old CHF. Benefit packages have been expanded to include referral services up to regional level. However, stakeholders, including community members, had negative perceptions of the restructured CHF owing to high annual premium rates, low incentive to enrolment officers, weak registration network and poor quality of health care services. In order to improve CHF performance and achieve universal health coverage, the central Government needs to invest more in the improvement of the quality of health care services, particularly the availability of drugs and medical supplies. Additionally, the government should make CHF scheme compulsory to all members of the community who do not have alternative health insurance.
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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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    Availability of Domestic Water and Sanitation in Households: A Gender Perspective Using Survey Data in South Africa
    (2013) Dungumaro, Esther W.
    The availability of domestic water and adequate sanitation is high on the agenda of both international and local communities. Despite concerted efforts to achieve the targets set by the Millennium Development Goal (MDG) for water and sanitation, current levels of water supply and adequate sanitation coverage remain largely inadequate. Various contributing factors, including economic and demographic pressures, account for the lack of adequate domestic water and sanitation. This paper analyzes the availability of water and sanitation in South Africa by gender of head of household. Lack of water and poor sanitation is one of the many challenges faced by poor urban populations. The paper examines gender differentials and the availability of domestic water and sanitation using the 2002 South Africa General Household Survey. The analysis is primarily descriptive. However, principal component analysis is also used for the purposes of estimating the wealth of households. The study finds a relationship between the socioeconomic status of households and the availability of water and sanitation. However, it does not find any major difference in the wealth of households and the availability of adequate water and sanitation by gender of household head. Based on these findings, the study recommends that generalizations concerning the feminization of poverty need to be avoided and that interventions in the realm of water and sanitation need to take account of the socioeconomic status of households and of their areas of residence
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    Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania
    (WILLEY & Sons, 2019-01) Kuwawenaruwa, August; Remme, M; Mtei, Gemini; Makawia, Suzan; Maluka, Stephen; Kapologwe, Ntuli; Borghi, Jo
    Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in‐depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health‐governing committees.
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    Biodiversity Conservation and the Poor: Practical Issues beyond Global Conferences
    (Scientific Research, 2013-08) Dungumaro, Esther W.
    The paper focuses on biodiversity—an issue that easily gets left out of consideration because it is hard to measure. While efforts to reduce over-fishing or conservation of water resources are relatively easy to discuss in quantitative terms, biodiversity in terms of plant species is usually covered by crude and even invalid figures. The paper begins by providing a brief historical overview of attempts to define biodiversity, going back to the early efforts in Africa to deal with conservation and showing how definitions have evolved overtime and how they have shaped conservation efforts. While the main focus of the paper is biodiversity conservation and the poor, the paper makes references to the World Summit on Sustainable Development (WSSD) and other important global conferences including the World Conference on Environment and Development and Convention on Biological Diversity. The paper finds that international conferences by and large do not adequately address the issue of biodiversity and the poor. The limited commitment shown by political leaders at the conferences should be a reason for global and local authorities to create an environment that enables communities to meet their daily needs, foster development and conserve biodiversity.
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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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    Capacity Development in Fragile Environments: Insights from Parliaments in Africa
    (2011) Rugumamu, Severine M.
    Capacity development in fragile environments in Africa has often proven to be a complex undertaking. This has largely been because of existing knowledge gaps on what exactly causes fragility of states, the economy and society. The liberal peace development model that generally informs post‐conflict reconstruction and capacity development has a limited conception of fragility by narrowly focusing on the national dimensions of the problem, promoting donor‐driven solutions, emphasizing minimal participation of beneficiary actors in the identification and prioritization of capacity development needs, and by subcontracting the design and management of projects and programs. The resulting capacity development impact has generally been disappointing. In the absence of homegrown strategic plans, stakeholder participation and ownership, international development partners have all too often addressed capacity gaps by financing training, supply of equipment and professional exchanges of parliamentarians and parliamentary staffers. These efforts usually achieved their presumed number targets but tended to ignore addressing the larger issues of political economy within which capacity development take place. However, the recent re‐conceptualization of parliamentary capacity development as a development of nationally owned, coordinated, harmonized, and aligned development activities seems to be gaining growing attention in Africa. As the experience of Rwanda eloquently demonstrates, capacity development is essentially about politics, economics and power, institutions and incentives, habits and attitudes – factors that are only partly susceptible to technical fixes and quantitative specifications. These structural factors have to be negotiated carefully and tactfully.
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    Challenges and Opportunities to Climate Change Adaptation and Sustainable Development Among Tanzanian Rural Communities
    (2010) Dungumaro, Esther W.; Hyden, Goran
    In more recent years climate change impacts have been obvious around the globe. This non-contentious reality has resulted in various global initiatives to reduce climate change impacts. However, differences exist in opportunities and capacity to adaptation. This paper, descriptive in nature, draws heavily from literature and also uses 2002 Tanzanian population and housing census to identify and discuss major challenges and opportunities to climate change adaptation and sustainable development in rural areas of Tanzania. Two groups are of focus; pastoralist herders and smallholder farmers. Analysis indicates that opportunities to climate change adaptation among rural community include their knowledge and experience. Challenges are centered on the pervasive poverty, rapid population increase and high illiteracy rates. Forces beyond their control including funds and governance also present definite limits to climate change adaptation. The paper suggests among others, the effective implementation of two top policies: education and social security funding.
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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.