The accountability for reasonableness approach to guide priority setting in health systems within limited resources--findings from action research at district level in Kenya, Tanzania, and Zambia.

BACKGROUND: Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT). METHODS: This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods. RESULTS: The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. CONCLUSIONS: District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.

Barriers to emergency obstetric care services: accounts of survivors of life threatening obstetric complications in Malindi District, Kenya.

INTRODUCTION: Pregnancy-related mortality and morbidity in most low and middle income countries can be reduced through early recognition of complications, prompt access to care and appropriate medical interventions following obstetric emergencies. We used the three delays framework to explore barriers to emergency obstetric care (EmOC) services by women who experienced life threatening obstetric complications in Malindi District, Kenya. METHODS: A facility-based qualitative study was conducted between November and December 2010. In-depth interviews were conducted with 30 women who experienced obstetric "near miss" at the only public hospital with capacity to provide comprehensive EmOC services in the district. RESULTS: Findings indicate that pregnant women experienced delays in making decision to seek care and in reaching an appropriate care facility. The "first" delay was due to lack of birth preparedness, including failure to identify a health facility for delivery services regardless of antenatal care and to seek care promptly despite recognition of danger signs. The "second" delay was influenced by long distance and inconvenient transport to hospital. These two delays resulted in some women arriving at the hospital too late to save the life of the unborn baby. CONCLUSION: Delays in making the decision to seek care when obstetric complications occur, combined with delays in reaching the hospital, contribute to ineffective treatment upon arrival at the hospital. Interventions to reduce maternal mortality and morbidity must adequately consider the pre-hospital challenges faced by pregnant women in order to influence decision making towards addressing the three delays.