The REACT project REsponse to ACcountable priority setting for Trust in health systems Accountability for reasonableness (AFR) Relevance: decisions based on reasons upon which stakeholders can 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 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 Describe, monitor ACTION RESEARCH Evaluate Improve Develop and introduce the application of AFR EVALUATION RESEARCH The evaluation domains  AFR process  Management Capability and Process including AFR  Human Resources Performance  HIV/AIDS  Malaria  Emergency Obstetric Care  Generalized Care District health system planning and management – study context THE AFR ACTION 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. PS decisions are value-based: Compassion for the Vulnerable Equity AND THESE VALUES OFTEN CONFLICT Solidarity A 5 year EU and FP 6 funded research program. Contract No.: PL Carried out at district level in Malindi, Kenya – Mbarali, Tanzania - Kapiri Mposhi, Zambia Rule-of-Rescue Efficiency Need Study concept Democratic deliberation Benefit Access Quality Trust Equality Participating institutions 1.DBL – Centre for Health Research and Development (DBL), Denmark (coordinating) 2.Centre for International Health (CIH), Bergen, Norway 3.Prince Leopold Institute of Triopical Medicine (ITM), Belgium 4.Umeå International School of Public Health (UISPH), Sweden 5.Institute of Development Studies (IDS), Tanzania 6.National Institute for Medical Research (NIMR), Tanzania 7.Primary Health Care Institute (PHCI), Tanzania 8.Centre for Public Health Research (CPHR), Kenya 9.Institute of Anthroplogy, Gender and African Studies (IAGAS), Kenya 10.Department of Community Medicine (DCM), Zambia 11.Institute of Economic and Social Research (INESOR), Zambia 12.Joint Centre of Bioethics, University of Toronto, Canada 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. Evaluation Domains/ Value areas AFR Manage ment Human resources ContextHIV/AIDS, Emergency Onstetric Care, Malaria,, General Health Care QualityFairnessLeader- ship Skills, task, motivation ThemesProcess, procedure, resources, waiting, adherence, outcome EquityInclu- sion Aims, practice Coverage, targets ThemesCoverage, availability, access, resource and service distribution TrustAccoun- tability Stake- holder roles Turnover, relations ThemesUtilisation, acceptability, relations, encounters, processes, themes AFR conditions Gaps in Con- ditions Gaps, themes Skills, use, themes ThemesAccountability, transparency, gaps in AFR conditions, themes Main Indicators 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) 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 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. 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: Contact Main references: Daniels N. & Sabin J.E. Setting limits fairly: Can we learn to share Medical Resoruces? Oxford UK: Oxford University Press 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,