Email updates

Keep up to date with the latest news and content from BMC Health Services Research and BioMed Central.

Open Access Research article

Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: Perceptions of stakeholders

Stephen Maluka12*, Peter Kamuzora1, Miguel San Sebastián2, Jens Byskov3, Benedict Ndawi4 and Anna-Karin Hurtig2

Author Affiliations

1 Institute of Development Studies, University of Dar Es Salaam, P.O. Box 35169 Dar Es Salaam, Tanzania

2 Umeå International School of Public Health (UISPH), Umea University SE 90185 Umeå, Sweden

3 DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark

4 Primary Health Care Institute (PHCI), P.O. Box 235, Iringa, Tanzania

For all author emails, please log on.

BMC Health Services Research 2010, 10:322  doi:10.1186/1472-6963-10-322

Published: 1 December 2010



In 2006, researchers and decision-makers launched a five-year project - Response to Accountable Priority Setting for Trust in Health Systems (REACT) - to improve planning and priority-setting through implementing the Accountability for Reasonableness framework in Mbarali District, Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from the perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees.


Individual interviews were carried out with different categories of actors and stakeholders in the district. The interview guide consisted of a series of questions, asking respondents to describe their perceptions regarding each condition of the Accountability for Reasonableness framework in terms of priority setting. Interviews were analysed using thematic framework analysis. Documentary data were used to support, verify and highlight the key issues that emerged.


Almost all stakeholders viewed Accountability for Reasonableness as an important and feasible approach for improving priority-setting and health service delivery in their context. However, a few aspects of Accountability for Reasonableness were seen as too difficult to implement given the socio-political conditions and traditions in Tanzania. Respondents mentioned: budget ceilings and guidelines, low level of public awareness, unreliable and untimely funding, as well as the limited capacity of the district to generate local resources as the major contextual factors that hampered the full implementation of the framework in their context.


This study was one of the first assessments of the applicability of Accountability for Reasonableness in health care priority-setting in Tanzania. The analysis, overall, suggests that the Accountability for Reasonableness framework could be an important tool for improving priority-setting processes in the contexts of resource-poor settings. However, the full implementation of Accountability for Reasonableness would require a proper capacity-building plan, involving all relevant stakeholders, particularly members of the community since public accountability is the ultimate aim, and it is the community that will live with the consequences of priority-setting decisions.