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)
Participating institutions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
DBL – Centre for Health Research and Development, University of
Copenhagen, Denmark
CIH – Centre for International Health, University of Bergen, Norway
ITM - Institute of Tropical Medicine – Department of Public Health,
Belgium
UISPH - Umeå International School of Public Health, Sweden
IDS - Institute of Development Studies, UDSM, Tanzania
NIMR - National Institute for Medical Research, Tanzania
PHCI - Primary Health Care Institute, Iringa, and Mbarali District,
Tanzania
CPHR – Centre for Public Health Research of Kenya Medical
Research Institute (KEMRI), Kenya
IAGAS – Institute of Anthropology Gender and African Studies. UON,
Nairobi, Kenya
UNZA – University of Zambia by Department of Community Medicine,
Institute of Economic and Social Research and Kapiri Mposhi District,
Zambia
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Theory
 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
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PS decisions are . . .
NOT just information-based
decisions
VALUE-BASED
DECISIONS
Quality
Evidence
Compassion for the Vulnerable
Rule-of-Rescue
Risk
Equity
Equality
Solidarity
Access
Benefit
Individual Responsibility
Democratic deliberation
Efficiency
Need
AND THESE VALUES OFTEN CONFLICT
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‘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
Daniels & Sabin, 1997
the REACT project
REsponce to ACcountable Priority Setting for
Trust in Health Systems - REACT.
An EU funded 5 year project 2006 - 2010
Introducing and evaluating AFR at District level in
Malindi in Kenya
Mbarali in Tanzania
Kapiri Mposhi in Zambia
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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
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REACT concept overview
.
APPLICATION OF AFR
THE ACTION
REACT concept
Develop & introduce the framework
EVALUATION RESEARCH
Monitor, describe
Evaluation domains
Management Capability and
Process including AFR
Improve
ACTION
RESEARCH
Human Resources Performance
HIV/AIDS
Malaria
Evaluate
Emergency Obstetric Care
Generalized Care
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.
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Dissemination from the baseline
 Frequent updates in workshops and meetings
 The first results were presented in the Priority setting
conference in Newcastle November 2008. 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 2009
 6 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
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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.
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The action methods
Main processes and data:
1.
2.
District AFR action and recordings for DEI
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
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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.
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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
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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
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Assessment of results
 The application of AFR took very different form and intensity in

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
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?
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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
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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.
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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: http://www.health-policy-systems.com/content/7/1/23
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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
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