Department of Political Science and Public Administration

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    Manifestations and Strategies to Deal with Politics’ Science Adulteration in Community Engagement Healthcare Research
    (Medwin Publishers, 2024-02-05) Damian, Respicius Shumbusho
    Community and Public Engagement (CPE) is increasingly acknowledged as an appropriate approach in healthcare and other policy related research. However, it is also becoming clear that community engagement necessarily involves and is significantly affected by politics. This paper illuminates the manifestations of politics in community engagement research drawing examples from a community-level study that was carried out in Kasulu, a rural district in Tanzania. Specifically, the paper starts by providing some conceptual highlights on community engagement and politics, then it proceeds to show the different forms and shapes that politics can take in community-level research. Further, it argues that community engagement is by its nature a defacto victim of politics. Finally, it suggests workable strategies and tactics that could be considered by community engagement researchers to remedy scientific research from being adulterated by politics. Four strategies that were employed in our project namely creating cognitively aware communities, preparing and orienting stakeholders to engagement guidelines, the use of Community Advisory Committees, and ensuring diversity in all engagement platforms are described and exemplified. If effectively used, these measures can potentially improve the uptake and sustainability of the solutions that community-level healthcare engagement research partnerships tend to generate.
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    Universal Health Coverage: A Qualitative Study of Urban Communities in Tanzania
    (Quest Journals, 2022-09-09) Waindi, Wilfred; Damian, Respicius Shumbusho; Sansa, Godfrey E
    This is a report of a qualitative cross-sectional study conducted in twelve urban communities in Tanzania to explore how urban communities experience and define disparities in universal health coverage. Tanzania sanctions free access to an ‘essential package of health services as a means towards universal health coverage. The study was motivated by the fact that; many health sector reforms intended to achieve universal health coverage (UHC) have often adopted a technocratic top-down approach, with little attention being paid to the urban communities’ perspective in identifying context-specific gaps to inform the design of such reforms. This usually led to transformations that are unresponsive to local urban needs. The study revealed that ‘the essential package of health services under implementation in Tanzania, created a universal sense of entitlements to free healthcare at public healthcare facilities in the country for the targeted vulnerable groups. However, there is frequent unavailability of some services in the package forcing patients to seek such services in private healthcare facilities. This has led to inequities in population coverage, access and financial protection. Most respondents reported the affordability of medical costs at private facilities as the main barrier to universal financial protection. From the perspective of urban Tanzanians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as; shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers’ attitudes, and perceived poor quality of health services. The study discovered that the journey toward UHC in Tanzania requires the institution of appropriate interventions to fill the financial protection gaps and the access-related gaps. The continuing Health Sector Reforms undergoing in the country need to address context-specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks.
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    Transitioning health workers from PEPFAR contracts to the Uganda government payroll
    (Health Policy and Planing, 2021-11-09) Zakumumpa, Henry; Damian, Respicius Shumbusho; Rujumba, Joseph; Amde, Woldekidan; Maniple, Everd; Ssengooba, Freddie
    Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President’s Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates (‘high absorbers’) and two with the lowest absorption rates (‘low absorbers’). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n=14), representatives of PEPFAR-implementing organizations (n=16), district health teams (n=15) and facility managers (n=22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in ‘high absorber’ districts were identified as the presence of transition ‘champions’, prioritizing HWs in district wage bill commitments, host facilities providing ‘bridge financing’ to transition workforce during salary delays and receiving donor technical support in district wage bill analysis—attributes that were absent in ‘low absorber’ districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.
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    Youth underrepresentation as a barrier to sexual and reproductive healthcare access in Kasulu district, Tanzania: A qualitative thematic analysis
    (International Journal of Public Health, 2020-04-09) Damian, Respicius Shumbusho; Zakumumpa, Henry; Fon, Sharon
    Objectives Representation of the key groups in community-level healthcare decisions is a prerequisite for accountable and responsive primary healthcare systems. However, meaningful representation requires both the presence of individuals who represent the key community groups and their capacity to influence the key healthcare plans and decisions. Our study explored how the underrepresentation of the youth in health facility committees, the decentralized community- and facilitylevel healthcare decision-making forums affects youth access to sexual and reproductive health services. Methods A multisite case study involving focus group discussions, interviews, and meeting observation was conducted in eight primary healthcare facilities in Kasulu, a rural district in Tanzania. Inductive thematic analysis was used to identify the key emerging themes. Results Five major themes were identified in connection with youth underrepresentation and limited access to sexual reproductive health as a ‘taboo’ phenomenon in the communities. These were: numbers do not matter, passive representation, sociopolitical gerontocracy, economic vulnerability, and mistrust and suspicion. Conclusions Gradual emancipatory and transformative efforts are needed to normalize the representation of the youth and their concerns in formal community-level decision-making institutions.
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    The Quest for Free and Fair Elections: The Permanent Voters’ Register (PVR) in Tanzania
    (University of Dar es Salaam, 2006) Bernadeta, Killian; Ng'wanza, Kamata
    Historically, every time there was an election in Tanzania a fresh voter registration was conducted. This turned to be not only a tedious and expensive exercise but also it was fraudulent. After the re-introduction of multipartyism questions were raised on the fairness of this system of registering voters. Recommendations were made that a permanent voter register be introduced to address some of the problems caused by a less sophisticated and easy to manipulate temporary voter register. Prior to the 2005 General Elections, for both the Union and Zanzibar Governments, a permanent voter register was introduced. The way the exercise was conducted, both in the mainland and Zanzibar, is the subject of this article. Attention is paid to whether or not the voter register creates a foundation for free and fair elections. Our analysis shows that the exercise of registering voters itself, especially in Zanzibar, was in no way free and fair, hence creating a weak foundation on which to build subsequent electoral stages.
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    Finnish Aid and Rural Development in Southern Tanzania: Empowering the Poor?
    (University of Dar es Salaam, 2009) Bernadeta, Killian
    For almost four decades, a significant amount of Finnish aid to Tanzania has been spent supporting various projects in the two southern regions of Mtwara and Lindi. Beginning mid-1990s up to mid-2005, the Finns implemented a program known as Rural Integrated Project Support (RIPS), designed to empower rural communities in Mtwara and Lindi to own and control the development process. Based on fieldwork in villages in Mtwara and Lindi, this article sets out to examine the extent to which the Finnish intervention in participatory-development planning has resulted in the empowerment of the rural populations. The article argues that, rather than leading to empowerment of the rural communities, the RIPS program reproduced and consolidated the power of the government bureaucracy. These findings challenge the assumed relationship between participatory approaches and the reality of peoples’ empowerment.
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    The Role of the West in Promoting Democracy in East Africa
    (Brill, 2009) Bernadeta, Killian
    This article sets out to provide a general assessment of the extent to which democracy promotion programmes of the Western donor countries to the East African countries facilitate the attainment of meaningful democratic institutions and processes. Based on the trends and content of democracy promotion programmes in Kenya, Tanzania and Uganda since the adoption of the multi-party politics in the 1990s, the article attempts to show that rather than enhancing popular participation, democracy promotion programmes by Western donor countries and multilateral and organizations are largely intended to achieve political order and macroeconomic stability rather than democracy per se. Technical and procedural support to democracy promotion tends to underplay the influence of the underlying structural and political factors inherently entrenched into the political system. As a result, the bulk of democracy promotion fund is mainly directed at reforming the state without necessarily democratizing it.
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    A Proposed Structure of the Union in Tanzania: Political Parties at a Crossroad
    (Brill, 2014) Bernadeta, Killian
    This article focuses on the implications of a particular constitutional design of decentralization on the behaviour of political parties as representative institutions. As Tanzania seeks to enact a new constitution, the proposed changes in the Draft Constitution of 2013 on the structure of the United Republic of Tanzania will most likely lead to new trends on how political parties organize, compete, cooperate and mobilize electoral support. The article argues that whereas a two-tier government model has been able to compel political parties to forge broad-based fronts thereby leading to national stability, on the other side, it has not adequately addressed issues and interests of the constituent governments partly due to its centralized party system. The proposed three-government model has expanded avenues of people’s participation in decision-making processes but without addressing the mechanisms through which political parties will be compelled to promote coalition-building, national consensus and political stability.
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    Local Government Elections in Tanzania: Why NEC Should Take Over their Management
    (The African Review, 2006) Liviga, Athuman; Ahmed, Rasul
    Any free and fair election should be managed by an organ or Electoral Management Body (EMB) that is respected and which does not have any bias for or against those who are contesting. The EMB should be above partisan party politics. This article notes that the manner in which elections at mitaa, vitongoji and vijiji levels have been conducted in Tanzania fell short of the aforementioned attributes. The current practice is that the Minister responsible for local governments has substantial authority over the supervision and coordination of local government elections. The Minister is one of the Members of Parliament and a member of a political party participating in the elections. This practice traverses acceptable democratic principles, which demand that the organ that manages an election should not side with any of the contestants and be above political parties. Democratic elections must be guided by the idea that the EMB has the trust and confidence of all stakeholders, and not otherwise. This was not the case in the three civic elections held in Tanzania in 1993, 1999 and 2004. The problems observed in these civic elections warrant the immediate need for reforms in managing grassroots elections. After going through the structure of local government authorities, the electoral system, and drawing on some practices of other countries in relation to the management of both general and local government elections, the article thus argues that the management of both general and local government elections should be taken over by a reformed National Electoral Commission, whose independence will no longer be called into question.
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    In Search of security without guns: The role of grassroots institutions in addressing Conflict and Mitigating Conflict in Tanzania
    (The African Review, 2018-06) Bernadeta, Killian; Parestico, Pastory
    Over recent decades there has been an increasing recognition that a sizeable share of justice and security provision takes place outside state structures. Consequently, there has been a mounting interest in studying non-state actors in security and justice provision including grassroots community structures. Although there is a plethora of studies on the role of grassroots security institutions in Africa, such studies remain largely gender-blind. This article contributes to the existing knowledge on community organized-security mechanisms by exploring the manner in which gender roles and relations are socially constructed at the grassroots structures of justice, peace and security.
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    The State and Identity Politics in Zanzibar: Challenges to Democratic Consolidation in Tanzania
    (Taylor & Francis Group, 2008-05) Bernadeta, Killian
    A group of islands off the coast of East Africa, Zanzibar has been a semi‐autonomous part of the United Republic of Tanzania since 1964. Despite a common language (Swahili), religion (Islam), and a high rate of intermarriage among the islands' multi‐racial communities (including Africans and individuals of Arab, Persian, and Indian descent), Zanzibar politics has been marred by political conflicts that have culminated into political stand‐offs, violence and lack of social and civic peace. At the core of these conflicts is the politicization of racial identity by leaders seeking the legitimacy to rule. Thus, unlike in Tanzania mainland, struggle for the control of the state in Zanzibar has been intense, deadly and zero‐sum. Indeed, the distinctive character of the Zanzibar state itself makes it appealing for the political elites to politicize ethno‐racial identities in order to claim legitimacy to rule. Two other things are at stake regarding the Zanzibar state: namely, the identity of the state (whether it is an Arab or African state) and sovereignty of the state (Zanzibar vs. Tanzania). This political instability threatens not only Zanzibar's relatively new democratic institutions, but also the Union between Tanganyika and Zanzibar and the prospects for democratic consolidation in Tanzania.
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    Women’s marginalization in participatory forest management: Impact of Responsibilization in Tanzania
    (Elsevier, 2020-09) Bernadeta, Killian
    This paper analyses the consequences of responsibilization for women in natural resource management in Southern Tanzania. Participatory forest management (PFM) and Participatory Land Use Planning in Southern Tanzania provide a case study to interrogate how responsibilization impacts on the existing social order in a given community. As the study findings show, participatory initiatives have not fully reached rural women who are still under-represented and insufficiently equipped to participate in public decision-making, which maintains women's marginalization. In Tanzania there has been progress in community rights for forest management. Following the Forest Policy (1998) and Forest Act (2002), Tanzanian villages can establish Village Land Forest Reserves and manage and utilize natural resources for the benefit of the community. The success of decentralized forest governance depends on the interplay between power, authority and social relations. This is determined by the capacity of communities to participate and by the government's responsiveness to the people's voice. Based on our case study, women do not have equal opportunities to raise their voice like men, and women are marginalized in the decisions made about forest management and in the distribution of benefits from the natural resources with which their communities are endowed. This has policy implications in the sense that processes and structures of decentralized forest governance seem unable to address the needs of women.
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    (Sabinet, 2009-10-01) Killian, Bernadeta
    Do multiparty elections facilitate or hinder the process of democratic consolidation in Zanzibar? Since Tanzania’s return to a multiparty system in 1992 three rounds of general elections have been held in Zanzibar, all of them marred by gross irregularities, fraud, violence, and insecurity. All three elections were also followed by a political stalemate, with a major opposition party rejecting defeat, refusing to recognise the elected government, and challenging the results. Consequently, the legitimacy of the elected government has remained questionable for more than a decade. This puts in question the reliance on the ‘election-centric concept’ of the ‘consolidation’ phase, which tends to place a great deal of hope in the holding of periodic elections. This by no means suggests that elections do not matter in Zanzibar. They matter in terms of keeping the flame of democratic struggle alive. Also, as the findings in this article indicate, there is a need to pay attention not only to elections but, equally importantly, to other processes and institutions of governance that enhance the rule of law and individual rights.
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    Governance of Coastal Resources in Southern Tanzania: Comparing Beach Management Units and Marine Bay Ruvuma Estuary Marine Park
    (NEPSUS, 2019) Kweka, Opportuna L.; Katikiro, Robert E.; Minja, Rasul Ahmed; Namkesa, Faraja D.
    This paper compares two type of partnerships for management of coastal resources in Tanzania: Beach Management Units (BMUs) and the Mnazi Bay Ruvuma Estuary Marine Park (MBREMP). It examines their configuration of actors, governance systems and sustainability outcomes. Drawing from a triangulated analysis of interviews, focus groups, surveys, oral histories, participant observation and secondary data, the paper provides a mapping of the actors involved in these partnerships and their networks; and examines their legitimacy in terms of input, process, output and social and ecological outcomes as perceived by local communities living. Preliminary findings suggest that neither partnership seem to have yielded the expected socio-economic and ecological outcomes. Both face governance challenges related to structural, financial and participatory failures. Both are poorly equipped and the funds accrued from fines and fees are not enough to support alternative livelihood activities or provide alternative fishing gear. Communities see these partnerships as focusing on conservation and as having failed to address major social and economic needs. The structures of the BMUs and MBREMP need to be revised thoroughly to improve the actual role of communities and fishers in the governance of coastal resources. This would improve a sense of ownership and increase cooperation and trust. The benefits accrued from the income resulting from fees or fines must be transparent and shared broadly, no matter how small, as it would improve stewardship. Another important way to support fishers and limit pressure on resources near to shore would be to facilitate access to boats and gear to allow them to fish in the deep sea.
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    Rural Communities’ Healthcare Governance Partnerships: a Lay Participant Perspective”
    (The Second Annual Conference of the Social Sciences (August 31 to September 1 2015), 2015-09-01) Damian, Respicius Shumbusho
    This paper analyzes the capability and influence of rural community actors in community-based healthcare governance partnerships, namely the Health Facility Governance Committees (HFGCs) using the Lay Participant perspective. Practical evidences are drawn from a mixed methods study conducted in Karagwe and Morogoro districts between May 2013 and March 2015. The analysis shows that all community actors, especially individual community members, community representatives, elected community leaders, informal community groups, and Civil Society Organizations (CSOs) as well as Non-Governmental Organizations (NGOs) have pertinent weaknesses that make them unable to contribute effectively towards enforcing accountability of public officials and health services providers. The main reason is that, the design and social context of rural communities make partnerships for empowerment partnerships for disempowerment. In conclusion, community-based healthcare governance partnerships cannot work best in the current context of Tanzanian rural communities. Therefore, there is a need for rational capacity building interventions aimed at empowering all the defined community actors and transformational redesign of the community healthcare governance systems.
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    The Paradox of Voter Turnout in the 2010 Tanzania General Elections: The Case of Three Constituencies
    (University of Dar es Salaam, 2012-11-09) Damian, Respicius Shumbusho
    This study examined the causes of low voter turnout in the Tanzania 2010 general elections. The focus was on the general causes of low voter turnout and the influence of voter education and voter mobilization by political parties on voter turnout. The study adopted a case study strategy where Karatu, Ubungo, and Igalula constituencies were purposely sampled. Data was generated by conducting structured interviews with 150 respondents from voters who had registered for the 2010 general elections and in-depth interviews with 32 stakeholders, including candidates, political party leaders, election officials and leaders of CSOs. The findings revealed that low voter turnout was caused by a combination of factors. These factors include voters’ concerns about economic hardship, low political efficacy among voters, the belief that individual vote can not make significant change, loss of confidence in the democratic value of elections, and the lack of significant competition within the elections. The findings also demonstrate that voter education was not effective enough in terms of influencing higher voter turnout due to the weakness in planning and implementation. The government left financing attention in hands of Development Partners. Political parties, instead of mobilizing voters to vote, concentrated on advertizing their policies and candidates as well as attacking their opponents. The role of achieving higher turnout to support them on Election Day was in most cases skipped. The study recommends that there should be a permanent government fund for voter education, a well planned and sustainable voter education programme, a review of election laws, the establishment of a permanent fund for mobilizing finance for Voter Education. In addition, psephologists should conduct intensive studies on the effect of civic competency and the behavior of institutions such as political parties on voter turnout in Tanzania.
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    Lay Participation, People Policing Money to Improve Health Outcomes in Rural Tanzania
    (University of Dar es Salaam, 2014-11-18) Damian, Respicius Shumbusho
    Background:The past twenty years have seen remarkable shits in thinking about health governance. Increasingly, community-based financial accountability mechanisms such as Health Governance Committees, Public Report Cards (PRCs), Citizen Score Card (CSCs), Patient Rights Charters, and Public Expenditure Tracking Systems (PETs) are emphasized as alternative to the defunct arm’s length financial control mechanisms. It is argued that community actors, especially citizens, organized citizen groups, and elected representatives at grassroots’ level enjoy the use of collective action, power, and voice as best tools for holding providers and health bureaucrats accountable for spending and financial decisions in order to improve health outcomes. However, little evidences affirm that the lay community actors are capable enough to hold bureaucrats and providers accountable for financial decisions and spending outcomes. This paper examines the capability of community actors to hold health bureaucrats and providers accountable for financial decisions and spending outcomes. Methods: The study was conducted in two rural districts namely Morogoro and Karagwe. It involved detailed interviews with 50 key informants including health technocrats and bureaucrats at district level, elected leaders at village and ward levels, members of facility health governance committees, representatives of selected civil society organization and a structured questionnaire with 100 villagers randomly sampled from households in two villages in the districts. Supplementary data was collected from documentary sources from health facilities, government reports, and previously published research findings. Results: Study findings show that community-based financial accountability mechanisms are not (in practice) as effective as they are theoretically promoted by donors and international community. There are different limitations that make community-based accountability mechanisms of limited usefulness including constraining power tensions and rent seeking behavior among members who form participatory accountability forums, inadequate skills and limited information access for most of the community actors, cultural virtues that do not support challenging authorities, and little political will and support from both the central and local government. Conclusion: Community based financial accountability mechanisms and initiatives serve an important role of empowering community actors to participate profitably in making financial decisions and priority setting forums. However, these mechanisms have not been able to serve as means for exit, especially facilitating for influence and control of bureaucrats and providers by community actors. In some of the ways, when participatory forums such as Health Facility Governance Committees are encouraged to adopt formal and artificial procedures, they accidentally serve as forums for silencing community actors rather than empowering them.
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    Essential medicine stock-outs in rural primary health care – exploring the contribution of politics and resulting perceptions in Kasulu District, Tanzania
    (International Journal of Development and Sustainability, 2018-07-10) Damian, Respicius Shumbusho; Bana, Benson; Kessy, Ambrose
    Stock-outs of essential medicines and medical items remains a persistent problem in Tanzania, despite the several policy initiatives and interventions since the 1990s. We conducted a qualitative case study, which involved 24 in-depth interviews and eight focus group discussions with the Community Health Fund stakeholders who were facility in-charges, grassroots leaders, and members of Health Facility Governance Committees from eight primary health facilities in Kasulu District Council. The analysis involved transcribing and coding textual data to identify the key themes that emerged. The study identified four main themes that explained how the politics contribute to persistent stock outs, especially: 1) stock-outs as capital in electoral politics; 2) misinformation and rent-seeking; 3) dyads among street-level bureaucrats; and 4) competition and struggle for power and control over resources. We also identified four themes reflecting the dominant perceptions associated with stock-outs in the study communities namely: 1) feeling marginalized; 2) mistrust and suspicion of authority; 3) frustration of health workers; and 4) informal drug sellers as ‘the best'. These perceptions influence the way communities tend to define their role in health care financing and governance as well as the relationship between communities and health workers. While economic, administrative, and technical forces might influence stock outs, the politics within the management and governance of the Community Health Fund, which included rent-seeking, misinformation, and competition, significantly affected the legitimacy of the Community Health Fund. The resulting low enrollment and unwillingness to contribute makes medicines’ financing from community sources unsustainable. Therefore, empowering communities to mobilize locally available resources and exercise autonomous control over financial resources and medicine is imperative for addressing persistent stock outs.
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    Community empowerment and accountability in rural primary health care: The case of Kasulu district in Tanzania
    (University of Dar es Salaam, 2018-10-20) Damian, Respicius Shumbusho
    This study investigated the relationship between empowerment and community-based accountability in rural Primary Health Care. The focus was on empowerment attributes among community members, existing legal and institutional frameworks, the management of the Community Health Fund, and the role of Health Facility Governance Committees in Kasulu district. The study employed a mixed method approach that included both quantitative and qualitative data collection and analysis methods. The study found that the majority had lower levels of empowerment (87.3percent) and limited capability to demand and enforce accountability (73.1 percent). The feeling of having power to influence choices; trust in health workers, government officials, and community leaders; possession of skills related to finance and health care; and the capacity to obtain, analyse, and understand financial and health related information were significantly associated with the capability to enforce accountability. However, gender, education, employment status, and occupation were found to have significant influence on the variation in the capability. Married males in the young-adult age with average rural household income, employed and having higher education were more likely to have the capability to enforce accountability. Principal Component Analysis results revealed that building mutual trust, increasing power and confidence of community members, adequate availability and utility of relevant and simplified information, and improving skills related to financial and health service monitoring could enhance the capability to demand and enforce accountability. The findings also revealed the existence of a gap between the formal guidelines and actual operations of both the Community Health Fund and Health Facility Governance Committees. Community-level participation in the Community Health Fund is limited to mobilisation, contribution, and accessing contribution updates through notice boards. Health Facility Governance Committees have limited autonomy to make financial and purchase decisions while the district council exercises more control over allocation and purchase decisions. Delays in decisions result in persistent stock-outs of medicine and medical items, which cause mistrust from communities and thus limit the readiness to contribute and monitor resources and service delivery. Essentially, limited confidence, legitimacy, and trust that Health Facility Governance Committees can address critical concerns of the communities undermine their efficacy as institutions for enhancing community-based accountability. The study concludes that community-based accountability interventions are more likely to be effective if they integrate promotion of agency among communities and improving the opportunity structure. Specifically, both enhancing the capacities of community-level actors to hold service providers and government officials accountable and creating institutional environments that facilitate community actors’ control over the key financial and service delivery decisions and actions are imperative. Finally, a participatory approaches to designing and implementing health policy interventions is critical for developing community ownership as a key prerequisite for successful community-based accountability. Among others, the study recommends strengthening capacities of community-level implementers, improving cooperation between the district council and community-level stakeholders, and interventional studies to assess the impact of trust, information, and financial skills on community-based accountability.
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    Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda
    (Global Health Research and Policy, 2018-07-11) Zakumumpa, Henry; Damian, Respicius Shumbusho; Dube, Nkosiyazi; Rutebemberwa, Elizeus
    Background: Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda. Methods: This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semistructured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13). Results: Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage. Conclusion: The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.