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Abstract: Priority-setting has become one of the biggest challenges faced by health decision-makers worldwide. Fairness is a key goal of priority-setting and Accountability for Reasonableness has emerged as a guiding framework for fair priority-setting. This paper describes the processes of setting health care priorities in Mbarali district, Tanzania, and evaluates the descriptions against Accountability for Reasonableness. Key informant interviews were conducted with district health managers, local government officials and other stakeholders using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting in the district was observed. The results indicate that, while Tanzania has a decentralized public health care system, the reality of the district level priority-setting process was that it was not nearly as participatory as the official guidelines suggest it should have been. Priority-setting usually occurred in the context of budget cycles and the process was driven by historical allocation. Stakeholders’ involvement in the process was minimal. Decisions (but not the reasoning behind them) were publicized through circulars and notice boards, but there were no formal mechanisms in place to ensure that this information reached the public. There were neither formal mechanisms for challenging decisions nor an adequate enforcement mechanism to ensure that decisions were made in a fair and equitable manner. Therefore, priority-setting in Mbarali district did not satisfy all four conditions of Accountability for Reasonableness; namely relevance, publicity, appeals and revision, and enforcement. This paper aims to make two important contributions to this problematic situation. First, it provides empirical analysis of priority-setting at the district level in the contexts of low-income countries. Second, it provides guidance to decision-makers on how to improve fairness, legitimacy, and sustainability of the priority-setting process. [Copyright &y& Elsevier]

Abstract: Economic considerations are often cited as important determinants of health-seeking behavior. This paper describes a situation in peri-urban Tanzania where user fees do not constitute the primary reason why mothers delay seeking prompt treatment at a public health facility for their young, febrile children. Mothers commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence, they engage in extended home-based treatment. Drawing upon an ethnographic study, this paper illustrates how cultural knowledge about disease symptomatology, cultural meanings associated with febrile illness, gender relations, and patterns of communication between health care providers and mothers significantly influence outcomes for childhood febrile illnesses. It is argued that an overemphasis on the correlation between user fees and treatment delays with regard to childhood illnesses tends to divert attention from other significant cultural factors and existing structural constraints that influence the dynamics of health care seeking and health outcomes. At a time when calls to implement artemisinine-based combination therapy as one of the front-line strategies in Tanzania are increasingly frequent, there is a need to pay closer attention to the contextual factors and socio-cultural dynamics that influence patterns of treatment-seeking for childhood malaria. [Copyright &y& Elsevier]

Background: People who inject drugs (PWID) suffer from a high burden of infectious disease. At the same time, they often have poor access to health care. As in other East African countries, the population of PWID is growing in Tanzania, but little is known about their contact with health care services. In this paper we examine patterns of health care use among PWID in Dar es Salaam and identify what factors are associated with regular contact with clinicians during illness.Methods: We conducted a baseline cross-sectional study as part of a prospective cohort study involving PWID. We recruited 578 PWID, of whom 273 were newly enrolled on an integrated methadone-assisted treatment (MAT) program and 305 were community-recruited. At baseline, we interviewed the MAT program enrollees before they received services at the program clinics. We used bivariate and multiple logistic regression analyses to identify the factors associated with seeking medical care when ill.Results: Only 25.4% of 578 participants reported seeing clinicians regularly when they needed medical care. Participants were more likely to see clinicians regularly if they were employed, (OR: 2.25, 95% CI: 1.28-3.98), had higher income levels (OR: 1.10, 95% CI: 1.00-1.22), were parents (OR: 1.71, 95% CI: 1.09-2.68), or knew where to seek affordable care (OR: 3.42, 95% CI: 2.12-5.52).Conclusion: PWID in Dar es Salaam generally did not seek health care when needed. To improve their health care seeking behaviour, it is important to advise PWID about where to seek affordable health care and to increase their income-generating skills. [ABSTRACT FROM AUTHOR]

Abstract: Time preferences for health has a role in informing discounting practice in economic evaluation of health care interventions. Yet virtually no empirical evidence on time preferences for health are available for sub-Saharan Africa. The objectives of this paper are therefore to estimate time preferences for health in Tanzania, and to explore the relationship between time preferences for one''s own private health and for others health. Determinants of time preference rates are also explored. A sample of the general population participated, and each person was asked to indicate the maximum duration of more distant ill-health they would be willing to accept in return for a specified delay in the onset of the condition. People were randomised to answer either questions in the context of their own health or in the context of others health. Estimations were done using clustered least squares regression with robust standard errors. The implied mean and median discount rates were 0.07 and 0.058, respectively. Time preferences for one''s own and others’ health—conceptualised as social health—seem to be roughly the same in this sample, but people seem to discount the most severe health condition at a significantly lower rate than the least severe condition. [Copyright &y& Elsevier]

Abstract: Effective health care is a relational activity, that is, it requires social relationships of trust and mutual understanding between providers and those needing and seeking care. The breakdown of these relationships is therefore impoverishing, cutting people off from a basic human capability, that of accessing of decent health care in time of need. In Tanzania as in much of Africa, health care relationships are generally also market transactions requiring out-of-pocket payment. This paper analyses the active constitution and destruction of trust within Tanzanian health care transactions, demonstrating systematic patterns both of exclusion and abuse and also of inclusion and merited trust. We triangulate evidence on charges paid and payment methods with perceptions of the trustworthiness of providers and with the socio-economic status of patients and household interviewees, distinguishing calculative, value based and personalised forms of trust. We draw on this interpretative analysis to argue that policy can support the construction of decent inclusive health care by constraining perverse market incentives that users understand to be a source of merited distrust; by assisting reputation-building and enlarging professional, managerial and public scrutiny; and by reinforcing value-based sources of trust. [Copyright &y& Elsevier]