The REACT project
REsponse to ACcountable priority setting for Trust in
health systems
Rationing
A 5 year 2006-2010 EU and FP 6 funded research program. Contract No.: PL 517709
Resources - priority setting - sustainability
Carried out at district level in Malindi, Kenya – Mbarali, Tanzania - Kapiri Mposhi, Zambia
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.
PS decisions are value-based:
Quality
Study concept
A
District health system planning and
management – study context
Efficiency
Develop and introduce the
application of AFR
THE AFR ACTION
Trust
AND THESE VALUES OFTEN CONFLICT
EVALUATION RESEARCH
Describe, monitor
The evaluation domains
AFR process
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
ACTION
RESEARCH
Improve
Management Capability and
Process including AFR
Human Resources Performance
HIV/AIDS
Malaria
Evaluate
Emergency Obstetric Care
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.
Generalized Care
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.
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.
Evaluation
Domains/
Value areas
Quality
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
Fairness Leadership
Equity
Inclusion
Trust
Accoun- Staketability holder
roles
Gaps in Gaps,
Conthemes
ditions
AFR
conditions
Data collection tools and output
AFR
Manage
ment
Aims,
practice
Human
Context HIV/AIDS, Emergency
resources
Onstetric Care, Malaria,,
General Health Care
Skills,
Themes Process, procedure,
task,
resources, waiting,
motivation
adherence, outcome
Coverage, Themes Coverage, availability,
targets
access, resource and service
distribution
Turnover, Themes Utilisation, acceptability,
relations
relations, encounters,
processes, themes
Skills, use, Themes Accountability,
themes
transparency, gaps in AFR
conditions, themes
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
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
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