Role of health facility governing committees in strengthening social accountability to improve the health system in Tanzania: protocol for a participatory action research study.

INTRODUCTION: Social accountability is important for improving the delivery of health services and empowering citizens. The government of Tanzania has transferred authority to plan, budget and manage financial resources to the lower health facilities since 2017. Health facility governing committees (HFGCs) therefore play a pivotal role in ensuring social accountability. While HFGCs serve as bridges between health facilities and their communities, efforts need to be made to reinforce their capacity. This project therefore aims to understand whether, how and under what conditions informed and competent HFGCs improve social accountability. METHODS AND ANALYSIS: This study adopts a participatory approach to realist evaluation, engaging members of the HFGCs, health managers and providers and community leaders to: (1) map the challenges and opportunities of the current reform, (2) develop an initial programme theory that proposes a plan to strengthen the role of the HFGCs, (3) test the programme theory by developing a plan of action, (4) refine the programme theory through multiple cycles of participatory learning and (5) propose a set of recommendations to guide processes to strengthen social accountability in the Tanzanian health system. This project is part of an ongoing strong collaboration between the University of Dar es Saalam (Tanzania), and Umeå University (Sweden), providing opportunities for action learning and close interactions between researchers, decision-makers and practitioners. ETHICS AND DISSEMINATION: Ethical approval to conduct the study was obtained from the National Ethical Review Committee in Tanzania- National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/3928). Permissions to conduct the study in the health facilities were given by the President's Office Regional Administration and Local Government and relevant regional and district authorities. The results will be published in open-access, peer-reviewed journals and presented at scientific conferences.

The effects of community-based interventions on the uptake of selected maternal and child health services: experiences of the IMCHA project in Iringa Tanzania, 2015-2020.

BACKGROUND: Maternal and child health (MCH) improvement has been prioritised in resource-constrained countries. This is due to the desire to meet the global sustainable development goals of achieving a maternal mortality rate of 70 per 100000 live births by 2030. The uptake of key maternal and child health services is crucial for reducing maternal and child health mortalities. Community-Based Interventions (CBIs) have been regarded as among the important strategies to improve maternal and child health service uptake. However, a paucity of studies examines the impacts of CBIs and related strategies on maternal and child health. This paper unveils the contribution of CBIs toward improving MCH in Tanzania. METHODS: Convergent mixed method design was employed in this study. Questionnaires were used to examine the trajectory and trend of the selected MCH indicators using the baseline and end-line data for the implemented CBI interventions. Data was also collected through in-depth interviews and focus group discussions, mainly with implementers of the interventions from the community and the implementation research team. The collected quantitative data was analysed using IBM SPSS, while qualitative data was analysed thematically. RESULTS: Antenatal care visits increased by 24% in Kilolo and 18% in Mufindi districts, and postnatal care increased by 14% in Kilolo and 31% in Mufindi districts. Male involvement increased by 5% in Kilolo and 13% in Mufindi districts. The uptake of modern family planning methods increased by 31% and 24% in Kilolo and Mufindi districts, respectively. Furthermore, the study demonstrated improved awareness and knowledge on matters pertaining to MCH services, attitude change amongst healthcare providers, and increased empowerment of women group members. CONCLUSION: Community-Based Interventions through participatory women groups are vital for increasing the uptake of MCH services. However, the success of CBIs depends on the wide array of contextual settings, including the commitment of implementers of the interventions. Thus, CBIs should be strategically designed to enlist the support of the communities and implementers of the interventions.

Leaving no one behind: using action research to promote male involvement in maternal and child health in Iringa region, Tanzania.

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.

Why do pregnant women in Iringa region in Tanzania start antenatal care late? A qualitative analysis.

BACKGROUND: When started early in pregnancy and continued up till childbirth, antenatal care (ANC) can be effective in reducing adverse pregnancy outcomes. While the proportion of women who attend ANC at least once in low income countries is high, most pregnant women attend their first ANC late. In Tanzania, while over 51% of pregnant women complete ≥4 visits, only 24% start within the first trimester. This study aimed to understand the factors that lead to delay in seeking ANC services among pregnant women in Tanzania. METHODS: This qualitative descriptive case study was conducted in two rural districts in Iringa Region in Tanzania. A total of 40 focus group discussions (FGDs) were conducted involving both male and female participants in 20 villages. In addition, 36 semi-structured interviews were carried out with health care workers, members of health facility committees and community health workers. Initial findings were further validated during 10 stakeholders' meetings held at ward level in which 450 people participated. Data were analysed using thematic approach. RESULTS: Key individual and social factors for late ANC attendance included lack of knowledge of the importance of early visiting ANC, previous birth with good outcome, traditional gender roles, fear of shame and stigma, and cultural beliefs about pregnancy. Main factors which inhibit early ANC attendance in Kilolo and Mufindi districts include spouse accompany policy, rude language of health personnel and shortage of health care providers. CONCLUSIONS: Traditional gender roles and cultural beliefs about pregnancy as well as health system factors continue to influence the timing of ANC attendance. Improving early ANC attendance, therefore, requires integrated interventions that address both community and health systems barriers. Health education on the timing and importance of early antenatal care should also be strengthened in the communities. Additionally, while spouse accompany policy is important, the implementation of this policy should not infringe women's rights to access ANC services.

Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning, allocation, and use of financial resources.

While decentralisation of health systems has been on the policy agenda in low-income and middle-income countries since the 1970s, many studies have focused on understanding who has more decision-making powers but less attention is paid to understand what those powers encompass. Using the decision space approach, this study aimed to understand the amount of decision-making space transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania. The findings of this study indicated that the decentralisation process in Tanzania has provided authorities with a range of decision-making space. In the areas of priority setting and planning, district health authorities had moderate decision space. However, in the financial resource allocation and expenditure of funds from the central government, the districts had narrow decision-making space. The districts, nevertheless, had wider decision-making space in mobilising and using locally generated financial resources. However, the ability of the districts to allocate and use locally generated resources was constrained by bureaucratic procedures of the central government. The study concludes that decentralisation by devolution which is being promoted in the policy documents in Tanzania is yet to be realised at the district and local levels. The study recommends that the central government should provide more space to the decentralised district health systems to incorporate locally defined priorities in the district health plans.

Strengthening post-graduate educational capacity for health policy and systems research and analysis: the strategy of the Consortium for Health Policy and Systems Analysis in Africa.

BACKGROUND: The last 5-10 years have seen significant international momentum build around the field of health policy and systems research and analysis (HPSR + A). Strengthening post-graduate teaching is seen as central to the further development of this field in low- and middle-income countries. However, thus far, there has been little reflection on and documentation of what is taught in this field, how teaching is carried out, educators' challenges and what future teaching might look like. METHODS: Contributing to such reflection and documentation, this paper reports on a situation analysis and inventory of HPSR + A post-graduate teaching conducted among the 11 African and European partners of the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA), a capacity development collaboration. A first questionnaire completed by the partners collected information on organisational teaching contexts, while a second collected information on 104 individual courses (more in-depth information was subsequently collected on 17 of the courses). The questionnaires yielded a mix of qualitative and quantitative data, which were analysed through counts, cross-tabulations, and the inductive grouping of material into themes. In addition, this paper draws information from internal reports on CHEPSAA's activities, as well as its external evaluation. RESULTS: The analysis highlighted the fluid boundaries of HPSR + A and the range and variability of the courses addressing the field, the important, though not exclusive, role of schools of public health in teaching relevant material, large variations in the time investments required to complete courses, the diversity of student target audiences, the limited availability of distance and non-classroom learning activities, and the continued importance of old-fashioned teaching styles and activities. CONCLUSIONS: This paper argues that in order to improve post-graduate teaching and continue to build the field of HPSR + A, key questions need to be addressed around educational practice issues such as the time allocated for HPSR + A courses, teaching activities, and assessments, whether HPSR + A should be taught as a cross-cutting theme in post-graduate degrees or an area of specialisation, and the organisation of teaching given the multi-disciplinary nature of the field. It ends by describing some of CHEPSAA's key post-graduate teaching development activities and how these activities have addressed the key questions.

Access and utilisation of healthcare services in rural Tanzania: A comparison of public and non-public facilities using quality, equity, and trust dimensions.

This study compared the access and utilisation of health services in public and non-public health facilities in terms of quality, equity and trust in the Mbarali district, Tanzania. Interviews, focus group discussions, and informal discussions were used to generate data. Of the 1836 respondents, 1157 and 679 respondents sought healthcare services on their last visit at public or non-public health facilities, respectively. While 45.5% rated the quality of services to be good in both types of facilities, reported medicine shortages were more pronounced among those who visited public rather than non-public health facilities (OR = 1.7, 95% CI 1.4, 2.1). Respondents who visited public facilities were 4.9 times less likely than those who visited non-public facilities to emphasise the influence of cost in accessing and utilising health care (OR = 4.9, CI 3.9-6.1). A significant difference was also found in the provider-client relationship satisfaction level between non-public (89.1%) and public facilities (74.7%) (OR = 2.8, CI: 1.5-5.0), indicating a level of lower trust in the later. Revised strategies are needed to ensure availability of medicines in public facilities, which are used by the majority of the population, while strengthening private-public partnerships to harmonise healthcare costs.

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.

BACKGROUND: 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). METHODS: This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods. RESULTS: The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. CONCLUSIONS: District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.

Involving decision-makers in the research process: Challenges of implementing the accountability for reasonableness approach to priority setting at the district level in Tanzania.

The past two decades have seen a growing call for researchers, policy-makers and health care providers to collaborate in efforts to bridge the gaps between research, policy and practice. However, there has been a little attention focused on documenting the challenges of dealing with decision-makers in the course of implementing a research project. This paper highlights a collaborative research project aiming to implement the accountability for reasonableness (AFR) approach to priority setting in accordance with the Response to Accountable Priority Setting for Trust in Health Systems (REACT) project in Tanzania. Specifically, the paper examines the challenges of dealing with decision-makers during the project-implementation process and shows how the researchers dealt with the decision-makers to facilitate the implementation of the REACT project. Key informant interviews were conducted with the Council Health Management Team (CHMT), local government officials and other stakeholders, using a semi-structured interview guide. Minutes of the Action Research Team and CHMT were analysed. Additionally, project-implementation reports were analysed and group priority-setting processes in the district were observed. The findings show that the characteristics of the REACT research project, the novelty of some aspects of the AFR approach, such as publicity and appeals, the Action Research methodology used to implement the project and the traditional cultural contexts within which the project was implemented, created challenges for both researchers and decision-makers, which consequently slowed down the implementation of the REACT project. While collaboration between researchers and decision-makers is important in bridging gaps between research and practice, it is imperative to understand the challenges of dealing with decision-makers in the course of implementing a collaborative research project. Such analyses are crucial in designing proper strategies for improved communication and for the utilisation of research projects over time.

Challenges of disseminating clinical practice guidelines in a weak health system: the case of HIV and infant feeding recommendations in Tanzania.

BACKGROUND: Clinical guidelines aim to improve patient outcomes by providing recommendations on appropriate healthcare for specific clinical conditions. Scientific evidence produced over time leads to change in clinical guidelines, and a serious challenge may emerge in the process of communicating the changes to healthcare practitioners and getting new practices adopted. There is very little information on the major barriers to implementing clinical guidelines in low-income settings. Looking at how continual updates to clinical guidelines within a particular health intervention are communicated may shed light on the processes at work. The aim of this paper is to explore how the content of a series of diverging infant feeding guidelines have been communicated to managers in the Prevention of Mother to Child Transmission of HIV Programme (PMTCT) with the aim of generating knowledge about both barriers and facilitating factors in the dissemination of new and updated knowledge in clinical guidelines in the context of weak healthcare systems. METHODS: A total of 22 in-depth interviews and two focus group discussions were conducted in 2011. All informants were linked to the PMTCT programme in Tanzania. The informants included managers at regional and district levels and health workers at health facility level. RESULTS: The informants demonstrated partial and incomplete knowledge about the recommendations. There was lack of scientific reasoning behind various infant feeding recommendations. The greatest challenges to the successful communication of the infant feeding guidelines were related to slowness of communication, inaccessible jargon-ridden English language in the manuals, lack of summaries, lack of supportive supervision to make the guidelines comprehensible, and the absence of a reading culture. CONCLUSION: The study encountered substantial gaps in knowledge about the diverse HIV and infant feeding policies. These gaps were partly related to the challenges of communicating the clinical guidelines. There is a need for caution in assuming that important changes in guidelines for clinical practice can easily be translated to and implemented in local programme settings, not least in the context of weak healthcare systems.

Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania.

BACKGROUND: 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 public-sector 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. DESIGN: Key informant interviews were conducted with the Council Health Management Team (CHMT), community representatives, namely women, youth, elderly, disabled, and people living with HIV/AIDS, and other stakeholders who participated in the preparation of the district annual budget and health plans. Additionally, minutes from the Action Research Team and planning and priority-setting meeting reports were analyzed. RESULTS: A number of benefits were reported: better identification of community needs and priorities, increased knowledge of the community representatives about priority setting, increased transparency and accountability, promoted trust among health systems and communities, and perceived improved quality and accessibility of health services. However, lack of funds to support the work of the selected community representatives, limited time for deliberations, short notice for the meetings, and lack of feedback on the approved priorities constrained the performance of the community representatives. Furthermore, the findings show the importance of external facilitation and support in enabling health professionals and community representatives to arrive at effective working arrangement. CONCLUSION: Community participation in priority setting in developing countries, characterized by weak democratic institutions and low public awareness, requires effective mobilization of both communities and health systems. In addition, this study confirms that community participation is an important element in strengthening health systems.

Challenges to fair decision-making processes in the context of health care services: a qualitative assessment from Tanzania.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Using stakeholder analysis to support moves towards universal coverage: lessons from the SHIELD project.

Stakeholder analysis is widely recommended as a tool for gathering insights on policy actor interests in, positions on, and power to influence, health policy issues. Such information is recognized to be critical in developing viable health policy proposals, and is particularly important for new health care financing proposals that aim to secure universal coverage (UC). However, there remain surprisingly few published accounts of the use of stakeholder analysis in health policy development generally, and health financing specifically, and even fewer that draw lessons from experience about how to do and how to use such analysis. This paper, therefore, aims to support those developing or researching UC reforms to think both about how to conduct stakeholder analysis, and how to use it to support evidence-informed pro-poor health policy development. It presents practical lessons and ideas drawn from experience of doing stakeholder analysis around UC reforms in South Africa and Tanzania, combined with insights from other relevant material. The paper has two parts. The first presents lessons of experience for conducting a stakeholder analysis, and the second, ideas about how to use the analysis to support policy design and the development of actor and broader political management strategies. Comparison of experience across South Africa and Tanzania shows that there are some commonalities concerning which stakeholders have general interests in UC reform. However, differences in context and in reform proposals generate differences in the particular interests of stakeholders and their likely positioning on reform proposals, as well as in their relative balance of power. It is, therefore, difficult to draw cross-national policy comparisons around these specific issues. Nonetheless, the paper shows that cross-national policy learning is possible around the approach to analysis, the factors influencing judgements and the implications for, and possible approaches to, management of policy processes. Such learning does not entail generalization about which UC reform package offers most gain in any setting, but rather about how to manage the reform process within a particular context.

Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation.

BACKGROUND: Despite the growing importance of the Accountability for Reasonableness (A4R) framework in priority setting worldwide, there is still an inadequate understanding of the processes and mechanisms underlying its influence on legitimacy and fairness, as conceived and reflected in service management processes and outcomes. As a result, the ability to draw scientifically sound lessons for the application of the framework to services and interventions is limited. This paper evaluates the experiences of implementing the A4R approach in Mbarali District, Tanzania, in order to find out how the innovation was shaped, enabled, and constrained by the interaction between contexts, mechanisms and outcomes. METHODS: This study draws on the principles of realist evaluation -- a largely qualitative approach, chiefly concerned with testing and refining programme theories by exploring the complex interactions of contexts, mechanisms, and outcomes. Mixed methods were used in data collection, including individual interviews, non-participant observation, and document reviews. A thematic framework approach was adopted for the data analysis. RESULTS: The study found that while the A4R approach to priority setting was helpful in strengthening transparency, accountability, stakeholder engagement, and fairness, the efforts at integrating it into the current district health system were challenging. Participatory structures under the decentralisation framework, central government's call for partnership in district-level planning and priority setting, perceived needs of stakeholders, as well as active engagement between researchers and decision makers all facilitated the adoption and implementation of the innovation. In contrast, however, limited local autonomy, low level of public awareness, unreliable and untimely funding, inadequate accountability mechanisms, and limited local resources were the major contextual factors that hampered the full implementation. CONCLUSION: This study documents an important first step in the effort to introduce the ethical framework A4R into district planning processes. This study supports the idea that a greater involvement and accountability among local actors through the A4R process may increase the legitimacy and fairness of priority-setting decisions. Support from researchers in providing a broader and more detailed analysis of health system elements, and the socio-cultural context, could lead to better prediction of the effects of the innovation and pinpoint stakeholders' concerns, thereby illuminating areas that require special attention to promote sustainability.

Decentralization and health care prioritization process in Tanzania: from national rhetoric to local reality.

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.

Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: Perceptions of stakeholders.

BACKGROUND: In 2006, researchers and decision-makers launched a five-year project - Response to Accountable Priority Setting for Trust in Health Systems (REACT) - to improve planning and priority-setting through implementing the Accountability for Reasonableness framework in Mbarali District, 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. METHODS: Individual interviews were carried out with different categories of actors and stakeholders in the district. The interview guide consisted of a series of questions, asking respondents to describe their perceptions regarding 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. RESULTS: Almost all stakeholders viewed Accountability for Reasonableness as an important and feasible approach for improving priority-setting and health service delivery in their context. However, a few aspects of 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. CONCLUSION: This study was one of the first assessments of the applicability of Accountability for Reasonableness in health care priority-setting in Tanzania. The analysis, overall, suggests that the Accountability for Reasonableness framework could be an important tool for improving priority-setting 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.

Decentralized health care priority-setting in Tanzania: evaluating against the accountability for reasonableness framework.

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

Accountable priority setting for trust in health systems--the need for research into a new approach for strengthening sustainable health action in developing countries.

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.

Factors influencing implementation of the Community Health Fund in Tanzania.

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 enrollment in Tanzania's health prepayment schemes (Community Health Fund). The paper argues that district managers had a direct influence over the factors explaining low enrollment 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.

FIOH-sponsored newsletter misrepresents asbestos hazards in Zimbabwe.

The Finnish Institute of Occupational Health (FIOH) has received support from the World Health Organization (WHO) and the International Labor Office (ILO) to publish the African Newsletter on Occupational Health and Safety. The African Newsletter on Occupational Health and Safety should not be a medium for industry propaganda, or the source of misinformation among the workers of Africa. Instead, FIOH should provide the same level of scientific information in Africa that it does in Finland and other developed countries.