Decentralized health care priority-setting in Tanzania: Evaluating against the accountability for reasonableness framework

BackgroundPriority setting in every health system is complex and difficult. In less wealthy countries the dominant approach to priority setting has been Burden of Disease (BOD) and cost-effectiveness analysis (CEA), which is helpful, but insufficient because it focuses on a narrow range of values – need and efficiency – and not the full range of relevant values, including legitimacy and fairness. 'Accountability for reasonableness' is a conceptual framework for legitimate and fair priority setting and is empirically based and ethically justified. It connects priority setting to broader, more fundamental, democratic deliberative processes that have an impact on social justice and equity. Can 'accountability for reasonableness' be helpful for improving priority setting in less wealthy countries?MethodsIn 2005, Tanzanian scholars from the Primary Health Care Institute (PHCI) conducted 6 capacity building workshops with senior health staff, district planners and managers, and representatives of the Tanzanian Ministry of Health to discussion improving priority setting in Tanzania using 'accountability for reasonableness'. The purpose of this paper is to describe this initiative and the participants' views about the approach.ResultsThe approach to improving priority setting using 'accountability for reasonableness' was viewed by district decision makers with enthusiastic favour because it was the first framework that directly addressed their priority setting concerns. High level Ministry of Health participants were also very supportive of the approach.ConclusionBoth Tanzanian district and governmental health planners viewed the 'accountability for reasonableness' approach with enthusiastic favour because it was the first framework that directly addressed their concerns.

Background: In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country’s level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania.Methods: A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes.Results: There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts.Conclusion: This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.

Hospital priority setting with an appeals process: a qualitative case study and evaluation

BackgroundPriority setting in health care is a challenge because demand for services exceeds available resources. The increasing demand for less invasive surgical procedures by patients, health care institutions and industry, places added pressure on surgeons to acquire the appropriate skills to adopt innovative procedures. Such innovations are often initiated and introduced by surgeons in the hospital setting. Decision-making processes for the adoption of surgical innovations in hospitals have not been well studied and a standard process for their introduction does not exist. The purpose of this study is to describe and evaluate the decision-making process for the adoption of a new technology for repair of abdominal aortic aneurysms (endovascular aneurysm repair [EVAR]) in an academic health sciences centre to better understand how decisions are made for the introduction of surgical innovations at the hospital level.MethodsA qualitative case study of the decision to adopt EVAR was conducted using a modified thematic analysis of documents and semi-structured interviews. Accountability for Reasonableness was used as a conceptual framework for fairness in priority setting processes in health care organizations.ResultsThere were two key decisions regarding EVAR: the decision to adopt the new technology in the hospital and the decision to stop hospital funding. The decision to adopt EVAR was based on perceived improved patient outcomes, safety, and the surgeons' desire to innovate. This decision involved very few stakeholders. The decision to stop funding of EVAR involved all key players and was based on criteria apparent to all those involved, including cost, evidence and hospital priorities. Limited internal communications were made prior to adopting the technology. There was no formal means to appeal the decisions made.ConclusionThe analysis yielded recommendations for improving future decisions about the adoption of surgical innovations. ese empirical findings will be used with other case studies to help develop guidelines to help decision-makers adopt surgical innovations in Canadian hospitals.

Centralized drug review processes: Are they fair?

BackgroundMid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level.MethodsThis qualitative study took place as part of a broader project, “Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers”. Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions.ResultsParticipants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints.ConclusionSupervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level.

Ensuring relevance for Cochrane reviews: evaluating processes and methods for prioritizing topics for Cochrane reviews

Integration of leprosy control into primary health care is the most comprehensive and permanent system of delivering care to leprosy patients. But so far only a few countries have adopted this approach, largely on account of a fear of failure. Over the past decade Ghana has developed a model approach towards the transition from a vertical to an integrated programme. The highlights of our approach included the development of the leprosy service as part of the overall development of the health service, increasing capacity building for leprosy control at the district and subdistrict levels as well as the establishment of a regular and effective monitoring to identify and correct operational problems early. This paper describes the principles behind the integration, the strategies adopted and how they were implemented. It also includes the achievements made as well as the problems that were encountered and how they were solved.

This article discusses the behavior of Members of the Republic of Indonesia's Representative Council (DPR RI) in the 2014-2019 period in exercising their powers. DPR members for the 2014-201 period were 17 sentenced to imprisonment by the Corruption Court (Corruption), and involved Provincial Government Officials, Local Government Officials and Entrepreneurs. The question is how is the relationship model of DPR RI members, Local Government Officials, and Entrepreneurs doing corruption? What environment supports the ongoing corruption of DPR members. Forms of corruption DPR members receive money from Local Government Officers of Maluku Province, North Maluku Province, and Local Government Officials of Deiyai Regency, Papua Province. The Model of Relationship between Members of the DPR and Local Government Officials, and the relations between Regional Officials and Entrepreneurs are mutually beneficial. Members of the House of Representatives receive money for their services to fight for regional government development projects. Local Government officials are willing to give money to DPR members, approval of the proposed development project is approved by the DPR according to his proposal. Local Government Official money comes from Entrepreneurs who will carry out regional development projects.The environment that supports the corrupt behavior of DPR members comes from the environment of DPR members who mutually support and cooperate in obtaining money, the process of becoming a DPR member who needs a lot of money, hidden support from party elites, the interests of Provincial Government Officials to obtain development budgets according to their proposals, support indirectly from the entrepreneur.

BackgroundLike many low- and middle-income countries, South Africa established a dedicated HIV monitoring and evaluation (M&E) system to track the national response to HIV/AIDS. Its implementation in the public health sector has however not been assessed. Since responsibility for health services management lies at the district (sub-national) level, this study aimed to assess the extent to which the HIV M&E system is integrated with the overall health system M&E function at district level. This study describes implementation of the HIV M&E system, determines the extent to which it is integrated with the district health information system (DHIS), and evaluates factors influencing HIV M&E integration.MethodsThe study was conducted in one health district in South Africa. Data were collected through key informant interviews with programme and health facility managers and review of M&E records at health facilities providing HIV services. Data analysis assessed the extent to which processes for HIV data collection, collation, analysis and reporting were integrated with the DHIS.ResultsThe HIV M&E system is top-down, over-sized, and captures a significant amount of energy and resources to primarily generate antiretroviral treatment (ART) indicators. Processes for producing HIV prevention indicators are integrated with the DHIS. However processes for the production of HIV treatment indicators by-pass the DHIS and ART indicators are not disseminated to district health managers. Specific reporting requirements linked to ear-marked funding, politically-driven imperatives, and mistrust of DHIS capacity are key drivers of this silo approach.ConclusionsParallel systems that bypass the DHIS represent a missed opportunity to strengthen system-wide M&E capacity. Integrating HIV M&E (staff, systems and process) into the health system M&E function would mobilise ear-marked HIV funding towards improving DHIS capacity to produce quality and timely HIV indicators that would benefit both programme and health system M&E functions. This offers a practical way of maximising programme-system synergies and translating the health system strengthening intents of existing HIV policies into tangible action.

Introduction - international experience of rationing (or priority setting). Part 1 How to set priorities: setting priorities - what is holding us back inadequate information or inadequate institutions?. Part 2 Governments and rationing: developments in the Nordic countries goodbye to the simple solutions reactivation of the prioritization process in Finnish health care Israel's basic basket of health services - the importance of being explicitly implicit setting priorities "American style". Part 3 Priorities in developing countries: health priority dilemmas in developing countries public health priorities and the social determinants of ill health. Part 4 Ethical dilemmas: accountability for reasonableness in private and public health insurance tragic choices in health care - lessons from the Child B case fairness as a problem of love and the heart - a clinician's perspective on priority setting the ethics of decentralizing health care priority setting in Canada. Part 5 Techniques for determining priorities: priority setting and health technology assessment - beyond evidence based medicine and cost effectiveness analysis the rationing of surgery - clinical judgement versus priority access scoring. Part 6 Involving the public: public involvement in health care priority setting - are the methods appropriate and valid? rationing health care in New Zealand how the public has a say explicit rationing, deprivation disutility and denial disutility - evidence from a qualitative study. Part 7 Rationing specific treatments: priority setting in practice when sentiments run high - the Di Bella case and others increasing demand for accountability - is there a professional response? conclusion - where are we now?.

The tropical forests of Western Equatorial Africa are home to extraordinary biodiversity, including sympatric chimpanzees (Pan troglodytes troglodytes) and western lowland gorillas (Gorilla gorilla gorilla). The region is also comprised of significant stands of Intact Forest Landscapes (IFL) that are in rapid decline. As part of a regional monitoring effort, we partnered with local government officials, conservation NGOs, and the timber company working in the region to assess ape abundances in relation to habitat characteristics and anthropogenic disturbances and compare IFL and non-IFL areas in the Sangha Trinational landscape, Republic of Congo. We found that chimpanzees and gorillas occur at high densities in IFL, as well as non-IFL. To better understand how selective logging changes floristic factors, we compared herb and tree densities from botanical surveys conducted in IFL and non-IFL. IFL had higher tree stem densities and less terrestrial ground herbs than logged habitats. However, few ape resources were logged in this extraction cycle and areas with tree stems removed had higher abundances of ape preferred terrestrial herbs, which may contribute to the elevated ape abundance estimates. Floristic differences in logged forest were however identified to coincide with differences in ape resource use. The chimpanzee tree nesting niche was reduced in non-IFL as night nests were constructed significantly closer to the ground than in IFL. Whereas gorilla nest height locations did not differ significantly between IFL and non-IFL. To identify other potential anthropogenic impacts, we assessed direct and indirect impacts of road expansion and illegal hunting on wildlife in these remote areas. Increased access to IFL that facilitates illegal hunting raises concern for protecting wildlife across Western Equatorial Africa. We urge that the results of biodiversity assessments and strategic aspects of long-term protection should be taken into account when identifying conservation set-asides and maintaining diverse states of modified forests. Finally, the results of our monitoring efforts are provided as evidence of the value of long-term collaborations among local stakeholders, government officials, conservation agencies, and industrial partners to improve the implementation of certification standards and biodiversity conservation initiatives.

Background: The Non –Communicable Disease (NCD) unit in Malaysia has had much focus in recent years as its country undergoes a major epidemiologic transition with the rise in the four largest contributors of NCD deaths namely cardiovascular disease, cancer, diabetes and chronic respiratory disease. In line with reducing the burden of NCD both for the patient and healthcare, the district health office plays a vital role in managing disease prevention through adequate planning, focusing on the implementation of primary, secondary and tertiary prevention and monitoring the health of the population.
\nMaterials and Methods: A literature review was conducted through online database search such as Google Scholar and PubMed to identify articles that were related to the current management of non-communicable disease prevention. Initial keywords used were district health management, non-communicable disease, prevention and Malaysia. The reference list was also reviewed for related articles including some that were handpicked.
\nResult: Healthcare system in Malaysia is performed as a top down exercise whereby most of the national planning is conducted at federal level by the Ministry of Health. However, at the ground level, the district health office needs to conduct situational analysis to identify the needs and challenges of the local community within their jurisdiction. The management of NCD prevention is focusing on the implementation of actions through primary, secondary and tertiary prevention levels that fall within the role of health professionals and health care providers in primary care, hospitals and community services environment.
\nConclusion: Community empowerment and health education are important components in primary prevention of NCD. Early diagnosis and prompt treatment for NCD provided at the district level will stop the progression of the disease, leading to a better prognosis. Tertiary prevention in the form of rehabilitation at district level reduces and limits the disability and impairment related to NCD.

Environmental governance refers to the process of making environmental decisions, who makes them and how they are carried out. It includes formal and informal institutional arrangements for resource and environmental decision-making and management. This study examined the degree to which Barishal City Corporation (BCC) and Sylhet City Corporation (SCC), two divisional cities of Bangladesh, integrated environmental governance into sustainable urbanization. This study has collected data through questionnaire survey from 600 stakeholders (300 from each city corporation) along with key informant interviews from the government officials of the selected City Corporations. The study's findings show that environmental governance can pave the way to creating a sustainable city a reality. The ineffective enforcement of environmental laws and regulations, the lack of organizational coordination, responsibility, and responsiveness, and the deficiencies in resource mobilization are also identified as some of the few issues in this regard. This study argues that cities may be made sustainable by raising environmental awareness and changing the way of thinking of citizens and local government officials so that they believe everyone of them has a role to play in building a sustainable city. Creating sustainable cities cannot be legislated or decided: it must become a part of the life of every resident and organization in the city. The main drawback of this paper is that it only examines two of Bangladesh's twelve city corporations.

This study tried to obtain solutions on four subjects : Tbackground and meaning of resident participation, (2) the method for effectively conduct of resident participation, (3) problemsregarding resident participation. and (4) the grasping of the influence factors of local government officers' consciousness concerning resident participation. An outline of the main results are as follows.1) Many local government officers strongly recognize the needs of resident participation. Regarding the background of their support, there are such recognition of the realities as problems solution by the assembly or the top-down approach which have run into a stand-still due to the rapidly changing of the sense of values, life-style and behavior patterns of rural residents.2) Many local government officers think that resident participation not causing any serious problems. It is commonly thought that resident participation will produce such ploblems asan infringement of the role and authority of the assembly, dispersion of leadership of the local government andencouragement of the egoism of the residents. However, it became clear that almost all of them do not worry about occurrence of such problems.3) Many local government officers evaluate such a method to promote resident participation as a supply of information, make the residents realize that participation produces good results, create a child participation system for social activities, and form a daily activity base.4) It became clear that consciousness of local government officers regarding resident participation is affected by such factors as attribution of age, experience in administrative work, experience in administrative work regarding resident participation, the state of dealing with resident participation and the peculiarity of belonging to a municipality. Especially, experiences of administrative work regarding resident participation strongly influences their evaluation attitude concerning effects and problems with resident participation.