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

Abstract

BackgroundDespite 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.MethodsThis 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.ResultsThe 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.ConclusionThis 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.

Priority setting for the implementation of artemisinin-based combination therapy policy in Tanzania: evaluation against the accountability for reasonableness framework

“…Where it has been used to evaluate priority-setting decisions, it facilitated the identification of key areas that needed improvement [21,22]. Daniels and Sabin, who developed the framework, suggest that 'accountability for reasonableness' is relevant to pharmaceutical priority setting:…”

Evaluating healthcare priority setting at the meso level: A thematic review of empirical literature

“…Majority of the papers attributed the failure to meet this condition to constant failure by decision makers to provide rationale for decisions made ( Bravo Vergel & Ferguson, 2006; Bukachi et al ., 2014; Gibson et al ., 2006; Maluka et al ., 2010a; Zulu et al ., 2014). For example, Bravo Vergel & Ferguson (2006), observed that though the primary care trusts in England made some effort to communicate priority setting policies through general practitioners and in some few instances through flowcharts and leaflets, the provision of rationale for the decisions were never given.…”

How do community health committees contribute to capacity building for maternal and child health? A realist evaluation protocol

“…However, few realist evaluations have been conducted in a low-income country context [23][24][25][26][27][28][29][30] and the authors are cautious of methodological issues that may arise. Notably, as experienced during IPT development, limited reports and literature document the context or contextual influences in which a programme operates, and though the researcher is to complete additional searches to highlight such concepts, contextual information may be missing or overlooked.…”

“…Finally, realist evaluations are increasingly being used to inform complex health interventions, [21][22][23] with an emerging application in lowincome and middle-income countries. [23][24][25][26][27][28][29] Advocates note that their methodological design better enables the evaluation of complex health interventions compared to quasi-experimental designs. 22 30 Realist evaluations A form of theory-based evaluation, realist evaluations aim to identify 'what works, for whom, and under what circumstances', by developing context-mechanismoutcome configurations (CMOCs).…”