Examining effects of decision-making space and its practices on health systems performance in Tanzania

许多低收入和中等收入国家（LMICs），包括坦桑尼亚，自1990年代以来一直在实施权力下放，通过提高效率、服务质量和促进民主和问责制的手段来加强卫生系统及其绩效。虽然权力下放在中低收入国家广泛实行，但实证研究主要集中在理解中央政府向下级政府提供决策权的程度上。一些审查决策空间实际使用情况的研究侧重于权力下放对一个或几个保健系统功能领域的影响，而不是涉及多个功能领域。其他研究仅在少数地区进行，因此很难探索决策空间的行使在不同地区之间如何变化以及造成这些变化的因素。此外，审查权力下放对改善卫生系统绩效的有效性证据的研究很少，结果好坏参半。在早期研究的基础上，我们的目标是更好地了解权力下放的地方当局如何以及是否利用权力下放的机会来改善卫生系统绩效。具体目标是：(i)分析坦桑尼亚分散的卫生系统中从中央政府转移到外围机构的决策权；（ii）评估地方政府官员和地区卫生管理人员在分散的卫生系统内行使的实际决策空间；评估分散的地区卫生系统的绩效；（iv）调查决策空间对坦桑尼亚卫生系统绩效的影响；（五）使国家和地区两级的决策者参与，目的是为政策提供信息，并在分散的保健系统内改进决策空间的做法。拟议的研究将在坦桑尼亚20个选定的地区进行，为期三年。该项目将采用多案例研究设计，并采用定性比较分析（QCA）方法。采用有目的抽样技术，选出10个表现最好和10个表现较差的地区。表演将以坦桑尼亚卫生部进行的2018年星级评估为基础。

Many low and middle income countries (LMICs), including Tanzania, have been implementing decentralisation since 1990s as a process to strengthen health systems and its performance through improved efficiency, quality of services and a means of promoting democracy and accountability. While decentralisation is widely practiced in LMICs empirical studies have predominantly focused on understanding the extent of the decision-making authority provided by the central government to the authorities at the lower levels. A few studies which have examined the actual use of decision-making space have focused on the influence of decentralisation on one or few health systems functional areas rather than addressing multiple functional areas. Other studies have only been conducted in a few districts making it difficult to explore how the exercise of the decision space vary across the districts and the factors that account for the variations. Additionally, studies examining the evidence for the effectiveness of decentralisation on improving health system performance are scarce and results are mixed. Building on earlier studies, we aim to better understand how and if decentralized local authorities use decentralisation opportunities for improving health systems performance. Specific objectives are to: (i) analyse the decision-making authorities transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania; (ii) assess the actual decision-making space exercised by local government officials and district health managers within the decentralised health system; (iii) assess performance of the decentralised district health systems; (iv) investigate effects of the decision-making space on health systems performance in Tanzania; (v) engage decision makers at the national and district levels aiming at informing policy and improving the practice of decision space within the decentralized health systemsThe proposed study will be carried out in 20 selected districts in Tanzania over a three-year period. The project will adopt a multiple-case study design and apply a Qualitative Comparative Analysis (QCA) approach. Purposive sampling technique will be used to select 10 best performing and 10 worse performing districts. The performance will be based on the 2018 Star Rating assessment conducted by the Ministry of Health in Tanzania.