1Department of Public Health, University of Zambia, Lusaka, Zambia
2Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark
3Institute of Development Studies, University of Dar Es Salaam, Dar Es Salaam, Tanzania
4Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
5National Institute of Medical Research (NIMR), Dar Es Salaam, Tanzania
6Institute of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya
7Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia
8International Public Health Consultant, Copenhagen, Denmark
9Primary Health Care Institute (PHCI), Iringa, Tanzania
10Umeå International School of Public Health, Umeå University, Umeå, Sweden
The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. This has again influenced the development of the concept, but not led to universal application. The potential use in health technology assessments (HTAs) has recently been identified by Daniels et al as yet another excellent justification for AFR-based process guidance that refers to both qualitative and a broader participatory input for HTA, but it has raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions and the through these repeatedly documented motivation for their consolidation, we argue that it can even be unethical not to take AFR conditions beyond their still mainly formative stage and test their application within routine health systems management for their expected support to more sustainable health improvements. The ever increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. Legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and indeed differences in evidence to arrive at a by all understood, accepted, but not necessarily agreed compromise in a current context - until major premises for the decision change. AFR should be widely adopted in projects and services under close monitoring and frequent reviews.
Daniels N, Porteny T, Urrutia J [correction of Urritia J]. Expanded HTA: enhancing fairness and legitimacy [published correction appears in Int J Health Policy Manag. 2016;5(5):347]. Int J Health Policy Manag. 2016;5(1):1-3. doi:10.15171/ijhpm.2015.187
Sandman L, Gustavsson E. Beyond the black box approach to ethics! Comment on “Expanded HTA: enhancing fairness and legitimacy.” Int J Health Policy Manag. 2016;5(6):393–394. doi:10.15171/ijhpm.2016.43
Holm S. The second phase of priority setting. Goodbye to the simple solutions: the second phase of priority setting in health care. BMJ. 1998, 317 (7164): 1000-1002. doi:10.1136/bmj.317.7164.1000
Ham C, Coulter A. Global Challenges of Health Care Rationing. London, UK; Open University Press; 2000.
Daniels N, Sabin JE. Limits to health care: Fair procedures, democratic deliberation and the legitimacy problem for Insurers. Philosophy and Public Affairs. 1997;26(4):303-502. doi:10.1111/j.1088-4963.1997.tb00082.x.
Martin D, Singer P. A strategy to improve priority setting in health care institutions. Health Care Anal. 2003;11(1):59-68.
Kapiriri L, Martin DK. A strategy to improve priority setting in developing countries. Health Care Anal. 2007;15:159-167. doi:10.1007/s10728-006-0037-1
Gruskin S, Daniels N. Process is the point: justice and human rights: priority setting and fair deliberative process. Am J Public Health. 2008;98(9):1573-1537. doi:10.2105/AJPH.2007.123182
Daniels N, Sabin JE. Accountability for reasonableness: an update. BMJ. 2008;337:a1850. doi:10.1136/bmj.a1850
Yin RK. Case Study Research: Design and Methods. Thousand Oaks, CA: Sage Publications; 1994.
LeCompte MD, Schensul JJ, Weeks MR, Singer M. Researcher Roles & Research Partnerships. London: AltaMira Press; 1999.
Kapiriri L, Norhem OF, Martin DK. Fairness and accountability for reasonableness. Do the views of priority setting decision makers differ across health systems and levels of decision making? Soc Sci Med. 2009;68(4):766-733. doi:10.1016/j.socscimed.2008.11.011
Mshana S, Shemhilu H, Ndawi B, et al. What do District Health Planners in Tanzania think about improving priority setting using 'Accountability for Reasonableness'? BMC Health Serv Res. 2007;7:180. doi:10.1186/1472-6963-7-180
Byskov J, Bloch P, Blystad A, et al. Accountable priority setting for trust in health systems - the need for research into a new approach for strengthening sustainable health action in developing countries. Health Res Policy Syst. 2009;7:23 doi:10.1186/1478-4505-7-23.
Maluka S, Hurtig AK, San Sebastian M, et al. Decentralized health care priority setting in Tanzania: Evaluating against the accountability for reasonableness framework. Soc Sci Med. 2010;71:751-759. doi:10.1016/j.socscimed.2010.04.035
Maluka S, Hurtig AK, San Sebastian M, Shayo E, Byskov J, Kamuzora P. Decentralization and health care prioritization process in Tanzania: From national rhetoric to local reality. Int J Health Policy Manag. 2011;26(2):e102-e120. doi:10.1002/hpm.1048.
Tuba M, Sandoy IF, Bloch P, Byskov J. Fairness and legitimacy of decisions during delivery of malaria services and ITN interventions in Zambia. Malaria Journal 2010, 9:309 doi:10.1186/1475-2875-9-309. http://www.malariajournal.com/content/9/1/309
Maluka S, Kamuzora P, San Sebastian M, Byskov J, Ndawi B, Hurtig AK. Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: Perceptions of stakeholders. BMC Health Serv Res. 2010;10:322. doi:10.1186/1472-6963-10-322
Maluka S, Kamuzora P, San Sebastian M, Byskov J, Ndawi B, Olsen ØE, Hurtig AK. Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation. Implement Sci. 2011;6:11 doi:10.1186/1748-5908-6-11
Maluka SO. Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania. Glob Health Action. 2011;4:7829 doi:10.3402/gha.v4i0.7829
Daniels N. Invited Commentary: Legitimacy and fairness in priority setting in Tanzania. Glob Health Action 2011;4:8472. doi:10.3402/gha.v4i0.8472
Shayo EH, Norheim OF, Mboera LE, et al. Challenges to fair decision-making processes in the context of health care services: a qualitative assessment from Tanzania. Int J Equity Health. 2012;11:30 doi:10.1186/1475-9276-11-30
Byskov J, Marchal B, Maluka S, et al. 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. Health Rese Policy Syst. 2014;12:49. doi:10.1186/1478-4505-12-49
Primary Health Care Institute (PHCI). AFR Training Packages. Iringa, Tanzania: PHCI; 2010.
Ndawi B, Bloch P, Byskov J. Pilot application of AFR in 4 districts in Tanzania Unpublished Initiation report). Primary Health Care Institute, Tanzania and DBL- Centre for Health Research and Development, University of Copenhagen; 2012.
World Health Organization (WHO). Declaration of Alma-Ata International Conference on Primary Health Care. Alma-Ata: USSR; 1978.
Pateman C. Participation and Democratic Theory. Cambridge: Cambridge University Press; 1970
Webler T, Tuler S. Fairness and competence in citizen participation theoretical reflections from a case study. Adm Soc. 2000;33(5):566-595. doi: 10.1177/00953990022019588
Pearce J, Branyiczki I, Bigley G: Insufficient bureaucracy: trust and commitment in articularistic organisations. Organ Sci. 2000;11:148-162. doi:10.1287/orsc.184.108.40.20608
Gould-Williams J. The importance of HR practices and workplace trust in achieving superior performance: a study of public sector institutions. Int J Human Res Manag. 2003;1:28-54.
Biehl S, Petryna A. When People Come First, Critical Studies in Global Health. Princeton, NJ: Princeton University Press; 2013.