Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation
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Notice bibliographique
Résumé
BACKGROUND: Despite 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. METHODS: This 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. RESULTS: The 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. CONCLUSION: This 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.
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Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,066 | 0,006 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,000 |
| Communication savante | 0,000 | 0,002 |
| Science ouverte | 0,001 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découle