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

自20世纪90年代以来，包括坦桑尼亚在内的许多中低收入国家一直在实施权力下放，通过提高效率和服务质量以及促进民主和问责制来加强卫生系统及其绩效。虽然低收入国家广泛实行权力下放，但经验研究主要侧重于了解中央政府向下级当局提供决策权力的程度。一些研究审查了决策空间的实际使用情况，重点是权力下放对一个或几个卫生系统功能领域的影响，而不是解决多个功能领域。其他研究只在少数地区进行，因此难以探讨决策空间的行使在各区之间的差异以及造成差异的因素。此外，审查权力下放对改善卫生系统绩效的有效性的证据的研究很少，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提高卫生系统的绩效。具体目标是：（一）分析坦桑尼亚分散式卫生系统中从中央政府转移到外围机构的决策权力;（二）评估地方政府官员和地区卫生管理人员在分散式卫生系统中行使的实际决策空间;（三）评估分散式地区卫生系统的绩效; ㈣调查决策空间对坦桑尼亚卫生系统绩效的影响;（五）让国家和地区各级的决策者参与进来，目的是为政策提供信息，并改善分散的卫生系统内的决策空间做法。在坦桑尼亚选定的地区，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。将采用目的抽样技术选出10个表现最佳和10个表现较差的地区。表现将基于坦桑尼亚卫生部进行的2018年星星评级评估。

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.