Lessons from applying Accountability for Reasonableness to priority setting at district level in Kenya, Tanzania and Zambia. Based on the REACT project "REsponse to ACcountable priority setting for Trust in health systems" By – alphabetically - Paul Bloch (1), Salome Bukachi (9), Jens Byskov(1), Anna-Karin Hurtig (4), Knut Fylkesnes (2), Peter Kamuzora (5), Yeri Kombe (8), Bruno Marchal (3), S. Mwakapalala (7), Charles Mwinuna (10), Benedict Ndawi (7), Lillian Nyandieka (8), Selestine Nzala (10), Øystein Evjen Olsen (1), Elisabeth Shayo (6), and Mary Tuba (10)

2 Participating institutions 1. DBL – Centre for Health Research and Development, University of Copenhagen, Denmark 2. CIH – Centre for International Health, University of Bergen, Norway 3. ITM - Institute of Tropical Medicine – Department of Public Health, Belgium 4. UISPH - Umeå International School of Public Health, Sweden 5. IDS - Institute of Development Studies, UDSM, Tanzania 6. NIMR - National Institute for Medical Research, Tanzania 7. PHCI - Primary Health Care Institute, Iringa, and Mbarali District, Tanzania 8. CPHR – Centre for Public Health Research of Kenya Medical Research Institute (KEMRI), Kenya 9. IAGAS – Institute of Anthropology Gender and African Studies. UON, Nairobi, Kenya 10. UNZA – University of Zambia by Department of Community Medicine, Institute of Economic and Social Research and Kapiri Mposhi District, Zambia

3  PS: Distribution of goods and services among competing programs or people  PS occurs at all levels of health systems  government, regional & district HAs, disease management organizations, research agencies, hospitals, clinical programs  Rationing resource allocation priority setting sustainability Theory

4 PS decisions are... NOT just information-based decisions VALUE-BASED DECISIONS AND THESE VALUES OFTEN CONFLICT Evidence Benefit Risk Equity Quality Access Rule-of-Rescue Efficiency Individual Responsibility Need Solidarity Compassion for the Vulnerable Democratic deliberation Equality

Daniels & Sabin, 1997 ‘Accountability for reasonableness (AFR)’  Relevance: decisions based on reasons upon which stakeholders can agree in the circumstances  Publicity: reasons publicly accessible  Revision (Appeals): quality improvement mechanism for challenging/revising reasons  Leadership (Enforcement): to ensure the 3 conditions met

6 the REACT project REsponce to ACcountable Priority Setting for Trust in Health Systems - REACT. An EU funded 5 year project Introducing and evaluating AFR at District level in Malindi in Kenya Mbarali in Tanzania Kapiri Mposhi in Zambia

7 REACT methodology A case study and action research (participatory) intervention and cross disciplinary design using quantitative and qualitative methods. Applying AFR and continuously assessing and addressing gaps in AFR conditions based on Describe-Evaluate-Improve (DEI) cycles in priority setting situations and not just annual or project bound. Focus on process. Evaluating priority setting processes and consequences for service management and output, immedíate outcomes and health impact. Research team - Action Research Team - DHMT - stakeholders

8 REACT concept overview. Monitor, describe ACTION RESEARCH Evaluate Improve REACT concept Develop & introduce the framework EVALUATION RESEARCH Evaluation domains  Management Capability and Process including AFR  Human Resources Performance  HIV/AIDS  Malaria  Emergency Obstetric Care  Generalized Care APPLICATION OF AFR THE ACTION Three stage research evaluation of AFR: 1. baseline situation, 2. processes and changes, 3. consequence for quality, equity and trust. The action research team facilitates and informs the cyclic action carried out by the district.

9 Dissemination from the baseline Frequent updates in workshops and meetings The first results were presented in the Priority setting conference in Newcastle November They showed marked differences between district services and their utilisation, but a congruence on values such as those underlying AFR conditions. Overview papers included in the 2008 Bamako Research for Health conference report and published in Health Research Policy and Systems Abstracts in this conference – Papers being developed for all - one currently accepted for publication and one under review. This presentation focuses on the action research process in the three study countries

10 Some initial findings from the baseline AFR related concepts were already existing and are highly valued in the social and cultural settings of each of the study countries A structured approach to give them higher prominence in priority setting and in governance for health is welcomed A number of needs for application of AFR as an approach to a district health priority setting and management were confirmed. Overall, the initial acceptability of AFR has been high..

The action methods Main processes and data: 1. District AFR action and recordings for DEI 2. Research assessment and targeted feed back Elements: Action Research team meetings bi-monthly Focal person (research assistant on site) Sensitisation meetings with stakeholders District Health Team meetings Planning meetings Monthly observational reports External meetings and worskhops 11

Results and main status in Tanzania Motivation identified and sensitisation done AFR implementation part of all meetings The district now routinely publicizes priorities to ”all” organizations and to communities. The district is strengthening its communication expertise for AFR Uptake throughout the district. ”This is a new culture in the district health sector” But: More focus on national constraints than on local opportunities for AFR. 12

Results and main status in Zambia Better decisions and fewer AFR gaps: Tender for a Maternity redone with more stakeholders Peer groups ensure compromise NGO approaches changed Transparency in team building Support through sharing vehicles An agreed limited service range allowed new facilities to be opened District guided user fees for insurance paid services 13

Results and main status in Kenya Sensitization and conflict Many opportunities for AFR agreed Frequent senior staff changes delayed the process Election violence defocused Post election reorganisation into two ministries consumed all staff efforts – could AFR have helped ? Little real action, but motivation allows refocusing on a lasting AFR action team based on longest serving team members – an organization for all countries in movig beyond REACT 14

Assessment of results The application of AFR took very different form and intensity in the three countries in spite of agreed guides for implementation The AFR managerial action was much delayed and has only really led to priority setting action in Zambia, but has built a foundation for such in Tanzania. An ambitious baseline led to major delays and defocused from the core action process and evaluation design, but its richness is itself leading to major AFR and associated publications No funding for development was a condition – and constraint? Institutional main priorities, work overload, little researcher economic benefit, funding realities in all institutions and limited implementation management skills were all serious constraints to an effective action research project. Are action research and research into action well recognized? 15

What have we confirmed and learnt Fairness is conceptually based on accountability and legitimacy Trust is based on fairness and is supported by transparency and inclusiveness of decisions concerning compromises between stakeholders according to a balance between values agreed to be important - such as quality and equity. Trust also depends on culturally acceptable processes within a district management framework. Trust can facilitate implementation of policies and interventions Full analyses shall further unpack reasons for change 16

Next steps Establish a permanent AFR approach in the study districts under support and possible scale up at the provincial level Continue dissemination, advocacy, advisory functions and progress monitoring after the project period. Publish: Information in place for many baseline and some process papers. 7 PhD studies ongoing – mainly from baseline data. 17

18 Conclusions The REACT application of AFR in action research has established a working relationship with the current district health system and therefore already represents a research into action process. The project’s potential to facilitate internal ownership and subsequent long term sustainability of improvements to health sector performance is increasingly being realized. The content, strategies/methods and approaches that the REACT project is using appear to support good governance and democratization within health systems management. Read more:

Recommendations The potential of the approach has not yet been adequately explored, but the need and demand for it has been strongly confirmed. Based on project experiences AFR based pilot programs in a stronger programmatic and management context can be recommended. Action oriented AFR pilot programs can be planned to also include a scientific evaluation 19