The REACT project RE sponse to AC countable priority setting for T rust in health systems

1. A Develop and introduce the application of AFR District health system planning and management – study context THE AFR ACTION • EVALUATION RESEARCH • The evaluation domains • AFR process • Management Capability and Process including AFR • Human Resources Performance • HIV/AIDS • Malaria • Emergency Obstetric Care • Generalized Care Describe, monitor ACTION RESEARCH Improve Evaluate Three stage research evaluation against AFR: 1. current situation, 2. process of change and 3. consequence for quality, equity, trust. The action research team facilitates and informs the cyclic action carried out by the district. The REACT project REsponse to ACcountable priority setting for Trust in health systems Rationing Resources - priority setting - sustainability • Priority Setting (PS): Distribution of goods and services among competing programs or people • PS occurs at all levels of health systems Government, • regional & district health authorities, hospitals, clinics, • disease control programs, community outreach. A 5 year 2006-2010 EU and FP 6 funded research program. Contract No.: PL 517709 Carried out at district level in Malindi, Kenya – Mbarali, Tanzania - Kapiri Mposhi, Zambia Study concept PS decisions are value-based: Quality Equity Access Solidarity Efficiency Democratic deliberation Compassion for the Vulnerable Rule-of-Rescue Need Trust Benefit Equality AND THESE VALUES OFTEN CONFLICT Accountability for reasonableness(AFR) Relevance:decisions based on reasons upon which stakeholderscan agree in the circumstances Publicity:reasons publicly accessible Revision (Appeals):mechanism for challenging/ revising reasons Leadership (Enforcement):to ensure that the three first conditions are met Methodology • A case study and action research (participatory) design • using quantitative and qualitative methods. • Applying AFR and continuously assessing and addressing • gaps in AFR conditions. • Evaluating AFR processes and consequences for service • management and output, immedíate outcomes and health • impact. Main Indicators The AFR application process • A number of needs for application of AFR as an approach to a district • health priority setting and management were confirmed • There is increasing involvement of health and health related organizations • in an open and accountable process • After addressing initial concerns mainly at district level, AFR is seen as • a support and not a challenge to implementation of national priorities • and district plans. • Overall, the initial acceptability of AFR has been high but its application • has been slower than planned. However, current practice of AFR • related conditions shall already be a firm basis for new insight into • priority setting and governance in the heath sector. Data collection tools and output • In each of the three districts: • 60 In Depth Interviews and 9 Focus Group Discussions in relation to • the AFR and evaluation domains based on domain specific guides • conducted • A population based questionnaire survey of 2000 persons covering core • issues from the same domains • Documentary Review of all relevant National and District based • documents has started • Facility inventories and routine data being recorded • Continuous recording of AFR processes in the form of minutes and • observations from project initiated and other meetings and activities • within and also outside the district • Data from special studies carried out for more in depth insight into • HIV/AIDS in the PLACE study and on Emergency obstetric care in the • Unmet Obstetric Needs Study Main Themes Priority setting and decision making processes • - Actual processes • Determinants of health related decision making at district, facility and • community levels. • Dynamics of decision making between various levels (from national to • community level) • AFR conditions in priority setting as expressed by informants • Actual processes of publicity,relevance,appeal/revision, • leadership/enforcement at district,facility and commuity levels • Trust, quality, equity and other values in health systems • Determinants. Workplace trust including human resource management, • interpersonal trust, trust in health systems • Dimensions of trust, quality and equity in health systems as experienced • by the users/community. • - Trust relations between various levels (from national to community) Participating institutions DBL – Centre for Health Research and Development (DBL), Denmark (coordinating) Centre for International Health (CIH), Bergen, Norway Prince Leopold Institute of Triopical Medicine (ITM), Belgium Umeå International School of Public Health (UISPH), Sweden Institute of Development Studies (IDS), Tanzania National Institute for Medical Research (NIMR), Tanzania Primary Health Care Institute (PHCI), Tanzania Centre for Public Health Research (CPHR), Kenya Institute of Anthroplogy, Gender and African Studies (IAGAS), Kenya Department of Community Medicine (DCM), Zambia Institute of Economic and Social Research (INESOR), Zambia Joint Centre of Bioethics, University of Toronto, Canada REACT consortium by: Paul Bloch (1), Astrid Blystad (2), Jens Byskov(1), Anna-Karin Hurtig (4), Knut Fylkesnes (2), Peter Kamuzora (5), Yeri Kombe (8), Bruno Marchal (3), Douglas K. Martin (12), Charles Michelo (10), Leonard Mboera (6), James Muttunga (8), Benedict Ndawi (7), Thabale Jack Ngulube (11), Isaac Nyamongo (9), Øystein Evjen Olsen (1), Washington Onyango-Ouma (9), Elisabeth Shayo (6), Gavin Silwamba (10) and Mary Tuba (10) Web: www.reactforhealth.net Contact e-mail: jby@life.ku.dk Main references: Daniels N. & Sabin J.E. Setting limits fairly: Can we learn to share Medical Resoruces? Oxford UK: Oxford University Press. 2002. Mshana S. et al. What do District Health Planners in Tanzania think about improving priority setting using 'Accountability for Reasonableness'? BMC Health Services Research 2007, 7:180 Gruskin S, Daniels N. Process is the Answer. Am.J.PH 2008; 98, 9, 1573-7