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

Abstract

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 in Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from 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 the applicability and feasibility of each condition of the Accountability for Reasonableness framework to priority setting. Interviews were analysed using thematic framework analysis. Documentary data was used to support, verify and highlight 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 the Accountability for Reasonableness framework were seen as 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 limited capacity of the district to generate local resources as the major contextual factors that hamper 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 process in the contexts of resource poor settings. However, the full implementation of Accountability for Reasonableness framework would require a proper capacity-building plan to all relevant stakeholders, particularly members of the community since public accountability is the ultimate aim, and it is the public that will live with the consequences of priority setting decisions. ; This paper is part of a larger study of the European Union's funded REACT project which is testing the applicability of the Accountability for Reasonableness approach to priority setting in Mbarali District in Tanzania. Other data came from a study conducted by the first author as part of his PhD research project on Priority Setting in Health Care Institutions. SM was supported by a doctoral fellowship from the Swedish Center Party Donation for Global Research Collaboration; Swedish Research School for Global Health; the University of Dar es Salaam, Tanzania, and the African Doctoral Dissertation Research Fellowship offered by the African Population and Health Research Centre (APHRC) in partnership with the International Development Research Centre (IDRC) and Ford Foundation. AKH, JB, BN and PK were supported by the EU funded REACT project grant number: PL 517709. MSS was supported by the Centre for Global Health at the Umea University, with support from FAS, the Swedish Council for Working Life and Social Research (grant number 2006-1512).