Question According to Dasgupta and Gupta The increasing tu.docx

Question:
According to Dasgupta and Gupta “The increasing turbulence in
the external business environment has focused attention on the
resources and organizational capabilities as the principal source
of competitive advantage.” (2009, p.204).
Discuss with reference to appropriate literature sources, the
extent to which the creation, sharing and utilization of
knowledge is central to this resource based view of competitive
advantage.
Reference: Dasgupta, M. And Gupta, R.K. (2009) Innovation in
Organizations: A Review of the Role of Organizational
Learning
Instructions for the completion of assessment part two:
The question is deliberately broad. Students are therefore
allowed to focus their answers on the field in which their course
is based. This may aid the search for literature and examples
through offering appropriate boundaries to your work.
The assessment must be submitted electronically via ‘Turnitin’.
Please familiarize yourself with the regulations on late
submission. Last minute accidents involving the loss of data
sticks, corrupted files, faulty laptops and so on can be guarded
against by backing your work up thoroughly and regularly.
Do not put your name on the assessment – use your student
number for identification only. The maximum word count for
part two of this assessment is 2,200 words, +/- 10%. This word
count includes any appendices (which you should not need to
any extent) but excludes the words in the reference list. This

word count must be adhered to.
This is an essay not a report, so you should avoid the use of
bullet points and lists. This is an essay question which is
effectively asking you to complete a critical evaluation of the
literature on the topics and use this literature to form arguments
to address the discussion.
Please note that tutors will not be able to pre-assess draft
assessments. We will comment on short sections if students are
concerned about their writing style, and we are happy to advice
on outline structures. Please do not ask tutors to comment on
whole draft assessments.
Accurate referencing of sources is crucial in this coursework.
There are resources available in the Learning Resource Centre
and via the student advice shops to help. The referencing system
used on this module is the APA Referencing system. Please
make sure you are familiar with this. Marks will be deducted for
inaccurate referencing.
Shayo et al. International Journal for Equity in Health 2012,
11:30
http://www.equityhealthj.com/content/11/1/30
RESEARCH Open Access
Challenges to fair decision-making processes in
the context of health care services: a qualitative
assessment from Tanzania
Elizabeth H Shayo1,2,3*, Ole F Norheim1, Leonard E G
Mboera3, Jens Byskov4, Stephen Maluka5,
Peter Kamuzora5 and Astrid Blystad1,2
Abstract
Background: Fair processes in decision making need the
involvement of stakeholders who can discuss issues and
reach an agreement based on reasons that are justifiable and

appropriate in meeting people’s needs. In Tanzania,
the policy of decentralization and the health sector reform place
an emphasis on community participation in
making decisions in health care. However, aspects that can
influence an individual’s opportunity to be listened to
and to contribute to discussion have been researched to a very
limited extent in low-income settings. The
objective of this study was to explore challenges to fair
decision-making processes in health care services with a
special focus on the potential influence of gender, wealth,
ethnicity and education. We draw on the principle of
fairness as outlined in the deliberative democratic theory.
Methods: The study was carried out in the Mbarali District of
Tanzania. A qualitative study design was used. In-
depth interviews and focus group discussion were conducted
among members of the district health team, local
government officials, health care providers and community
members. Informal discussion on the topics was also of
substantial value.
Results: The study findings indicate a substantial influence of
gender, wealth, ethnicity and education on health
care decision-making processes. Men, wealthy individuals,
members of strong ethnic groups and highly educated
individuals had greater influence. Opinions varied among the
study informants as to whether such differences
should be considered fair. The differences in levels of influence
emerged most clearly at the community level, and
were largely perceived as legitimate.
Conclusions: Existing challenges related to individuals’
influence of decision making processes in health care need
to be addressed if greater participation is desired. There is a
need for increased advocacy and a strengthening of
responsive practices with an emphasis on the right of all

individuals to participate in decision-making processes.
This simultaneously implies an emphasis on assuring the
distribution of information, training and education so that
individuals can participate fully in informed decision making.
Keywords: Fairness, Decision-making processes, Health care
services, Health systems
* Correspondence: [email protected]
1Department of Public Health and Primary Health Care,
University of Bergen,
P. O. Box 78045020, Bergen, Norway
2Centre for International Health, University of Bergen, P.O.
Box 78045020,
Bergen, Norway
Full list of author information is available at the end of the
article
© 2012 Shayo et al.; licensee BioMed Central Ltd. This is an
Open Access article distributed under the terms of the Creative
Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and
reproduction in any medium, provided the original work is
properly cited.
mailto:[email protected]
http://creativecommons.org/licenses/by/2.0
11:30 Page 2 of 12
Background
This paper focuses on decision making processes in health
care with a particular emphasis on the potential influence
of gender, wealth, ethnicity and education. Decision-

making in health care is a complex process that ideally
means identifying and choosing between alternatives on
the basis of the values and preferences of the stakeholders
in question. Fair process grounded in liberal democratic
theory implies the involvement of stakeholders who dis-
cuss and reach an agreement based on reasons that are
justifiable and appropriate in meeting people’s needs [1].
Stakeholders in health care include managers, care provi-
ders, patients, and the leaders and members of communi-
ties. The active participation of stakeholders in decision-
making processes is one of the fundamental principles in
primary health care (PHC) in the Alma-Ata Declaration
[2]. It implies the delegation of power and the inclusion of
all segments of the population to ensure that everyone
gets an opportunity to participate effectively in decision
making related to issues that affect their lives.
Active participation is achieved through a joint process
of sharing ideas which enables individuals to influence
decisions in a ‘representational’ manner [3]. The basic
assumption is that shared decision making helps to im-
prove the quality of the decision-making process, and, in
the context of health, improves health outcomes [4].
This line of thinking is grounded in liberal democratic
theory and decentralisation policy which argues for the
importance of involving stakeholders in decision making
processes. Immense challenges remain as to how to en-
sure stakeholder participation and how to decide at what
points they should be actively involved.
The reasoning behind active participation in health
care-related decision making moves beyond the equity
aspect. Stakeholder involvement has been deemed vital
in the sense that it enhances the likelihood that local
needs are addressed hence increasing efficiency and re-
sponsiveness in health service delivery. A fundamental

equity principle is that everyone affected by a particular
decision is involved in the process with their ideas being
listened to and taken into consideration. This approach
is perceived to enhance the chance that individuals can
access the basic needs necessary to protect and maintain
good health [5]. It has been demonstrated that people
prefer to implement ideas that they, themselves, find im-
portant [6] rather than those imposed by others [5]. Be-
cause of different values and interests among the
stakeholders, deliberative democratic thinking puts an
emphasis on deliberation and joint reflection [1]. Joint
reflection is achieved through consensus building or
through voting. However, a majority vote does not neces-
sarily guarantee that the decisions made are the most ap-
propriate ones. For a well functioning health system,
empowerment of stakeholders [7,8] through awareness
raising is important so they can be fully involved and can
vote on the aspects they think are important to them. This
will ultimately enhance fairness in decisions being made.
Deliberative democratic theory calls for collective deci-
sions that are arrived at by stakeholders when they come
together. Through deliberations, moral disagreement can
be resolved with reasons that are justifiable by stake-
holders who can think and act fairly despite the presence
of different interests [1]. Deliberative democracy has been
defined by Cohen as an association whose affairs are gov-
erned by the public deliberation of its members [9]. Gut-
mann and Thompson have suggested three ‘fundamental
principles’ as keys in deliberative democracy theory; publi-
city, accountability and reciprocity [1]. Publicity in this
context means that reasons behind decisions should be
publicly available and accessible. Accountability implies
that decision makers are held responsible for particular
decisions in ways that discourage biases and fraud, and
Reciprocity implies that procedures are followed during

discussions to ensure that everyone maintains respect for
and listens to each other’s ideas and views. With an em-
phasis on these principles, deliberation can be achieved
despite disagreement among the group members. Gut-
mann and Thompson argue; "when citizens reason recip-
rocally, they seek fair terms of social cooperation for their
own sake; they try to find mutually acceptable ways of re-
solving moral disagreements" Pg.2[1]. To allow this to
happen, it is vital to create, an environment that allows
participation to take place.
Under the decentralisation policy and health sector
reforms initiated in the 1990s in Tanzania, decision-
making processes in health care services were devolved to
the local authorities at district level [10,11]. Substantial
emphasis was placed on community participation and on
securing health care decisions that emerge from the grass-
roots level. A key policy element has been to ensure that
the community is actively involved in identifying and
prioritising between the problem areas they experience.
This approach is to enhance the fairness and legitimacy of
the decisions being made and links with what is advocated
in deliberative democratic theory. However, studies from
Tanzania indicate that, despite the well formulated policy
intentions of the decentralisation and the health sector
reforms, community views are rarely taken into consider-
ation in district-level decision-making processes [12–14].
Top-down and authoritarian approaches prevail in that
managers make decisions based on their own assump-
tions, knowledge and priorities.
Even when stakeholders are involved, the extent to
which the ‘reciprocity’ principle works is unclear. The
aspects that can affect the ability and opportunity for indi-
viduals or segments of the population to make a contribu-
tion to and be listened to during decision-making

processes in health care have not been assessed sufficiently
11:30 Page 3 of 12
in low income settings. The objective of this study was to
explore the challenges to achieving fairness in decision-
making processes with special focus on the potential influ-
ence of gender, wealth, ethnicity and education.
The Tanzanian health care system
Tanzania is located in East Africa, and is made up of 26
regions and 129 districts. The health care system is
structured from the community to the national level,
and each level plays a defined role. Health services are
provided in a pyramidal structure starting from the dis-
pensary as the lowest level via the health centres and the
hospitals, with the larger referral hospitals at regional or
national level at the top. Although most health services
are provided by the government (64%), there is a long
history of faith-based health services as well as an in-
creasing number of private health institutions and orga-
nizations [15]. There is a private public partnership in
the delivery of health services.
There is also a hierarchical structure in health care deci-
sion making at district level. The Council Health Manage-
ment Team (CHMT) has the mandate to prepare the
council health plan and to make health care decisions that
are submitted to the district Full Council for discussion
and approval. The role of the CHMT is to relate actively
both ‘downwards’ and ‘upwards’ in the system. Diverse
committees exist within the district, as well as at lower
levels, and their role is to develop plans to be submitted to

the CHMT [16,17]. Apart from the CHMT members,
other important stakeholders in this system include the
local government authority, the managers of health facil-
ities, health facility committees, health boards, non- gov-
ernmental organizations, private health service providers,
and members of the community. According to the princi-
ples of the Tanzanian decentralisation policy, the discus-
sion about health related priority setting and decision
making is to start from the community and health facility
levels where different committees exist. Decisions made at
the local levels are later to be forwarded to the CHMT
and eventually to the Full Council. The aim is to ensure
that the decision making process is informed by the
people in the district. It has, however, been documented
that in actual practice this flow is not adhered to, as many
of the committees within the district remain inactive [18].
Our study was carried out in the Mbarali District. The
district is located in the south western part of Tanzania.
The study is part of a larger EU funded project entitled,
‘Response to accountable priority setting for trust’
(REACT) which had its base in the same district be-
tween 2006 and 2011 [19]. REACT assessed approaches
to improving fairness in priority setting within the health
sector drawing upon the framework, ‘Accountability for
Reasonableness (AFR). Our study does not actively draw
upon the AFR framework, which is directly linked to the
dynamics of priority setting processes, but uses the find-
ings obtained within the REACT project that reflect gen-
eral decision making processes in health care. As
explained above, the paper draws upon a theoretical ap-
proach based within deliberate democratic thinking to
frame the study and make sense of the findings.
Methods
Study site

In the 2002 National Population Census, the Mbarali Dis-
trict had a population of 234,101 (114,738 males and
119,363 females) with an estimated annual growth rate of
3%. The district has strong rural characteristics. The main
ethnic groups are Sangu, Hehe, Bena, Sukuma, Maasai
and Nyakyusa, with Sangu and Nyakyusa being the most
numerous. A majority of the inhabitants depend on sub-
sistence rice farming and livestock keeping as the main
economic activities. The district is served by public and
private health facilities including two hospitals, two health
centres and 43 dispensaries. Figures from 2002 indicate
that 46% and 5.2% of the adult population had primary
and secondary education respectively [20].
Study design
The study applied a qualitative design with in-depth
interviews as the main data collection technique. A
qualitative method was chosen in an attempt to gain a
detailed and nuanced description of the experiences with
health care decision making. This method allowed for
the follow up of topics arising during the course of the
interviews. In addition to the interviews, one focus
group discussion was carried out with members of the
Council Health Management Team (CHMT) in order to
discuss the findings emerging from the interviews.
Recruitment of the informants
A purposive sampling technique was employed to recruit
the informants. The investigators, in collaboration with the
Mbarali District Medical Officer (DMO), discussed and
agreed upon the criteria for the selection of the informants.
Participation in the decision making process was used as a
main criteria in the recruitment process. A total of 33
informants were included in the study: 23 in the interviews
and 10 in the focus group. In the interviews, 11 informants
were recruited at district level, seven at health-facility level

and five at community level. The focus group discussion
comprised 10 members at district level. The district-level
informants were key members of the CHMT and co-opted
members such as the malaria focal person, the district
AIDS coordinator, and the reproductive and child health
coordinator. Other targeted informants included district
officials and representatives of non-governmental organisa-
tions (NGOs). Facility-based informants included health
workers, among them the managers’ (head of the health
11:30 Page 4 of 12
facilities). In order to gain an indication of how perceptions
of the factors influencing decision making in health care at
district and facility levels compared with views at the com-
munity level, a few knowledgeable individuals were
recruited. At this level, literacy and being influential in their
respective localities were the additional criteria.
Data collection
Interview guides were developed for each subcategory of
informants. The guides were aimed to measure the gaps
in the Accountability For Reasonableness conditions
which the REACT project aimed at. They were also
designed in an open manner in an attempt to generate
data related to the potential influence of gender, wealth,
ethnicity and education on decision making in health care.
Questions related to the representation of women or
members of particular groups, to their particular roles,
examples of their participation/nonparticipation were
included in the guide. The focus group guide covered the
same topics. The guides were developed by REACT’s
qualitative team, and were later refined and translated into

Kiswahili. Five of the authors of this paper speak Swahili,
and all interviews and the focus group discussion were car-
ried out in Swahili, which is the lingua franca of Tanzania.
Although interview and topic guides were used during the
interviews, the researchers encouraged the informants to
reflect broadly on the topic and were sensitive to themes
that arose in the course of the interviews and discussions.
With consent from the study participants, digital recorders
were used to record the interviews and the discussion. For
those who did not wish to be recorded (five out of 23 in-
depth interviews), detailed handwritten notes were taken
by a research assistant. The notes were carefully reviewed
and refined in detail immediately after the interviews took
place. The interviews and the focus group discussion lasted
between one and two hours each. Informal discussions
with informants at district, health facility and community
levels took place during the data collection period. These
conversations contributed to deepening the under-
standing of the findings emerging from the interviews,
and created grounds for further probing in particular
areas. Handwritten field notes were made on a daily
basis.
Data analysis
The recorded interviews and focus group discussions
were transcribed verbatim, and were later translated
from Kiswahili to English with an emphasis on retaining
culturally embedded expressions. After translation had
been completed, the first author carefully read all the
transcripts and notes and listened to all the recordings
to get to know the full material well. Thereafter, a
process of detailed coding was carried out manually
drawing upon the pre-defined major categories of
gender, wealth, ethnicity and education as a general
guide. This enabled us to identify the specific pieces of
text that expressed the informants’ experiences and per-

ceptions related to the influence of gender, wealth, ethni-
city and education on of decision-making processes in
health care. Brief quotes or summaries of the content
were noted in the margins of the transcripts. Recurring
issues or patterns as well as nuances, ambiguities or con-
tradictions within the emerging topics were systematic-
ally searched for. Information obtained from the
interviews and the focus groups were triangulated in the
analysis process to enhance the confidence of the data.
The information gained during the informal conversa-
tions was also reviewed again at this point to increase
the understanding of the material, but no direct quotes
are drawn from the field notes in the results section. At
each step the investigators discussed the emerging find-
ings to enhance the soundness of the interpretation, with
the first and last author being most active in the process.
Ethics
The study received ethical approval from the Medical Re-
search Coordinating Committee of the National Institute
for Medical Research, Tanzania (NIMR/HQ/R.8a/Vol. 1X/
416). Permission to conduct the study was further obtained
from Mbeya regional and Mbarali district authorities. Per-
mission to use the data was also obtained from the REACT
scientific committee. The objective of the study was clearly
expressed to informants before written informed consent
was sought. The principles of voluntariness, rights of with-
drawal, confidentiality and anonymity were strictly adhered
to throughout the study.
Results
Owing to the targeting of district officials and health work-
ers, the informants were more educated than the average
population. Only five out of the 23 informants in the inter-
views and two in the focus group were women. This gender
bias was related to the fact that the levels from which our

informants were recruited were dominated by men. The
age range of the informants was 39–70 years: 40–54 at dis-
trict level, 39–55 at health-facility level and 43–70 at com-
munity level. As explained above, informants at all levels
were asked to reflect broadly on their knowledge and ex-
perience regarding the potential influence or lack of influ-
ence of the dimensions of gender, ethnicity, wealth and
education on health related decision making processes.
Gender
Informants were asked about the level of women’s repre-
sentation in and contribution to decision-making bodies,
the extent to which their views were taken into consider-
ation, how women’s participation was perceived and po-
tential barriers to their participation and influence.
11:30 Page 5 of 12
The initial response of the study informants at all
levels referred to the clear political agenda of Tanzania,
and emphasised the importance placed on gender con-
siderations in decision-making bodies. It was reported
that at governmental level it is spelt out clearly how
many men and women are to be part of various commit-
tees. Decision-making bodies followed these guidelines so
women were well represented. Women were said to be
appointed to central positions, and informants said that
women’s views were listened to and taken into consider-
ation in the same way as those of men. They explained
that what matters in decision-making processes is the
strength of the arguments made and not the gender of the
person raising the concern. The following statement was
common throughout the interviews:

“Nowadays the gender issue is considered. Women are
given leadership positions. In this district, the District
Commissioner and Education and Agriculture Officers
are women. We have a woman in the Council Health
Management Team, and she is involved in everything at
the office. If she is not present a meeting is postponed.
Women are given opportunities to contribute and are
listened to like men.” (District informant, male)
It was maintained by most of the informants that the
more women gain confidence and influence, the more
fairness will be achieved.
In the course of the interviews a far more nuanced pic-
ture of women’s actual involvement in decision making
processes emerged. For example, informants explained
that actual voice given to a woman depended on the sec-
tion or committee in which she works. Women were said
to have particular influence in the district meetings where
decisions about maternity issues are discussed. Therefore
the opinions of women were particularly listened to and
valued in these sub-meetings and sub-committees. At the
community level, women were also reported to be given
substantial influence in the Village Health Committees,
as they are the main implementers of health-related
issues at a family level. It emerged that beyond the
women- dominated spheres of maternal health, women’s
attendance in and contribution to health related discus-
sions were far from obvious. The discrepancy between
the ideals of equality in terms of representation in di-
verse committees and the actual practice was also ques-
tioned during the interviews. One informant put it this
way:
“If you think carefully about our district you will find

that women make up the majority (of the population),
but they are the minority in the decision-making
bodies. In the district council, we have three women
out of the total of 11 councillors. Now, when voting,
even if they (the female representatives) have an
important issue to bring up, when counting the votes
they lose. I will say that women aren’t sufficiently
represented, and I think this is not solely this district’s
problem but a problem found in the entire country.”
(District informant, male)
Informants held that the fewer of females in the deci-
sion making bodies, the smaller the chance for their
views to be taken on board because, they would be
outvoted.
Many male informants claimed that low levels of edu-
cation were a challenge for women’s involvement in the
decision making bodies. The necessary expertise among
women was often lacking. Informants said that, even
when vacancies were advertised, women would not apply
for the positions because they lacked formal skills, and
they could not be forced to apply. This challenge was
related to a lack of adequate skills, interest and ability.
This scenario was said to make it difficult to implement
the official guidelines of equal representation of men
and women in decision-making bodies at the district
level.
In the course of the interviews, differences emerged
between male and female informants regarding women’s
influence. Male informants emphasised women’s partici-
pation more strongly while female informants brought
up numerous complaints related to women’s actual roles
in decision-making bodies from the community to the
district level. Female informants argued that women’s

views were not sufficiently listened to.
“An opinion can be rejected just because it comes
from a female member. . . A woman can argue for the
importance of providing training related to health
service provision in the planning meetings, but the
issue may not be considered, as other suggestions like
constructing buildings (suggested by men) are given
priority.” (District informant, female)
Women were said to end up crying sometimes because
of frustrations resulting from being undermined by men
as revealed in the following quote;
“My opinions are taken into account because of my
confidence and standing. But sometimes women are
even crying in the planning meeting as their views are
not taken into consideration” (District informant,
female)
It was held that, even for the educated women, it was
difficult to get their views through simply because they
came from women. At the community level, the chal-
lenges of women’s involvement in decision making
11:30 Page 6 of 12
emerged as particularly serious with more direct refer-
ence to the female gender per se. One female community
informant explained:
“In the meetings, even when there are knowledgeable
women present, we are not listened to when we present

our views. We are always asked, "Who are you?”
Throughout the interviews at all levels it was maintained
that women had not gained sufficient confidence in formu-
lating and presenting ‘strong points’ (hoja za msingi). It was
held that little public exposure and shyness made them lag
behind. Apart from reservations regarding women’s skills
and competence, a scepticism regarding the appropriate-
ness of women’s involvement in decision-making bodies
emerged, particularly at community level. A lack of trust in
women’s abilities to carry out proper assessment and deci-
sion making emerged among some of the informants. They
were very direct in expressing their views about women’s
incompetence as one said:
“There are very few things which women can do
because of their nature. There are things which we
just force them to do, although we know that they
really can’t do them. For example women cannot
supervise the construction of the dispensary, so why
should we listen to their opinions?” (Community
informant, male)
It was concluded by the majority of the informants
that the actual influence of women varies starkly from
one decision-making body to another and from one level
of authority to another, with the community level facing
the greatest challenges in terms of ensuring the inclusion
of women’s views.
Wealth
The potential impact of economic status on decision-
making processes in health care services was also
explored. At the district and health facility levels, a very
limited influence of wealth was recorded from the infor-
mant’s statements. Informants stated that in areas where

guidelines were properly followed, the influence of well-
to-do people was minimal. One informant concluded:
“We are not influenced by an individual’s
economic status. If you are well-off, it is relevant
to you and your family but not for the hospital
management team. What matters here is how
strong a person’s arguments are.” (Health facility
informant, male)
Informants also argued that at the community level
the wealth of a person had little impact, particularly if
it was combined with low education. One informant
stated:
“. . . People are after constructive ideas and only that.
What is more, rich people are few in our village.
Others may have many cattle, but they don’t have a
substantial influence owing to their poor education.”
(Community informant, male)
A different picture of the influence of wealth emerged
as we moved closer to the community. Informants
acknowledged that as far back as people could recall the
wealth of a person has influenced decision-making pro-
cesses. A continued impact of rich people emerged
because of their ability to offer assistance in various
matters. Rich individuals used their power to influ-
ence decisions in more direct ways, as this quote
illustrates:
“There are individuals here known as "Burushi". These
people are a mixture of Arabs and Africans, and are
financially well-off. They have plenty of money. In the
meetings, if they want a certain decision to be made,
even if it is of no benefit to the community, it is

commonly accepted. Decision makers have no choice
as the "Burushi" make substantial contributions to
health-related issues.” (District informant, male)
A more common phenomenon touched upon by al-
most all the informants was the ability of rich people to
influence decision-making processes more directly
through bribery. Bribery brings wealth to the heart of
decision making, and gives affluent individuals more
power. The asset implied by the well-to-do was linked
with male gender.
It emerged in the interviews that when a wealthy per-
son speaks he is listened to more than others, not only
because he is in a better position because of his
resources, but because of perceptions that wealthier
people are more ‘intelligent’ than the poor. One inform-
ant put it in the following way:
“I must be frank; a poor person’s influence on the
decision-making process is minimal because of his
status. He might have good ideas, but because he is
poor, he has no influence. . . It is the opinions of the
rich person that to a large extent are implemented. I
know myself that when you have a good life you also
have a good ability to think, but if you are poor your
thinking capacity becomes limited as you are thinking
about very small things. While you are thinking about
stiff porridge (ugali) others are thinking of cars.
Therefore, to convince people becomes really hard
because you’re thinking: "How am I going to get my
11:30 Page 7 of 12

lunch today?" while your friend is thinking of cars and
machines.” (Community informant, male)
The manner in which a degree of legitimacy was given
to such scenarios emerged in several of the interviews
and informal talks at community level. Moreover, the in-
fluence of wealth emerged as more pronounced when it
was coupled with high education of an individual.
Ethnicity
As with the other points raised, the immediate response
from the district and health facility informants regarding
the potential influence of ethnic affiliation was that eth-
nicity had a very limited influence in Tanzania. This in-
stant reply was situated within the discourse of the late
Tanzanian President Julius Nyerere, who used his entire
career to advocate against differentiation based on ethnic
criteria. The fact that members of the district decision-
making bodies and facility committees would always be-
long to different ethnic groups was also brought up as a
factor that worked against tribalism. It was maintained
that individuals in such positions were obliged to follow
governmental rules and regulations, which makes it very
difficult to promote decisions that favour particular eth-
nic groups. Emphasis was again placed on an individual’s
knowledge and skills relating to a particular topic. One
informant stated:
“. . . Although you may find that a majority of the
health staff in a certain unit/department originates from
the same ethnic group, when it comes to decision
making in health care services, the person’s capabilities
or skills are considered to a greater extent than their
ethnic affiliation.” (District informant, male)

Regarding gender and wealth, a more complex picture
did emerge in the course of the interviews. For example,
informants expressed that a leader at any level will listen
far more attentively to the opinions from individuals who
originate from his/her own ethnic group. District and
health facility informants provided numerous examples of
how ethnic affiliation was made relevant concerning issues
such as staff transfers, payment of allowances, promotions
and training opportunities. The following quote illustrates:
“. . . Here there is a department that is dominated by a
certain ethnic group. When it comes to decision
making, you may reach an agreement in relation to a
particular health issue, but later you find that the
decision has been changed without any official reason.
If you ask yourself who changed the decision, you will
realise that it is the head of the department, who
originates from the same ethnic group as the person
who ends up being favoured. He commonly favours
his "colleagues" (from the same ethnic group) and that
is not a secret here.” (District informant, female)
Informants expressed the view that, in the community,
certain ethnic groups have a strong tendency to domin-
ate or influence others. The largest ethnic group in the
community was said to use their numerical advantage to
exploit or oppress others. This was even more apparent
as this group was also wealthy. Large and strong clans
within particular ethnic groups could also have undue
influence as reflected in the following quote:
“. . . There is a certain clan in this community with a
very strong influence in decision-making meetings. Even
the local government leaders are afraid of them. It is a
very big clan that affects the government of this village.
This is also a rich clan that doesn’t follow government

regulations.” (Community informant, female)
Education
Informants perceived educational level as a very import-
ant factor in decision-making processes. Educated indivi-
duals and professionals were strongly depended upon by
their leaders when making decisions. The importance of
education was emphasised strongly to an extent where
local knowledge was devalued. One informant said:
“. . . An educated person first of all is a professional
and the advice he gives has scope. Opinions and
decisions given by non-educated individuals are
doubtful” (Community informant, male)
Two different concerns regarding the representation of
groups with low education emerged: one related to a lack
of influence and the other related to too much influence
in the decision making processes. It was argued that if
individuals with lower level of formal education were bet-
ter represented, common people’s problems would be
more readily identified and addressed. One informant had
this to say:
“We, health facility managers are not involved in the
District Health Committee meetings. As a result we
don’t receive most of the things we are in need of. Let
them invite us to these meetings even once a year,
even if it will be at our own expense. They are afraid
to call us because they fear being asked questions
specifically related to the expenditures.” (Health
facility informant, male)
It was argued that a real challenge was linked to the
fact that when the formal educational level of an individ-
ual is low, a person tends to lack the necessary confi-

dence to take an active part in discussions, and will not
11:30 Page 8 of 12
be able to present his/her argument clearly. This view
supported the argument provided by some informants
that the attendance and representation of less educated
individuals often does not lead to the desired results in
terms of a true grass-roots engagement and does not im-
pact on the decision-making processes.
There was a strong focus among the district level
informants on the substantial influence of individuals
with very low levels of education in the decision making
processes. They referred specifically to the Full Council
where the majority of the members are made up by the
Councillors who represent communities. The informants
from district level raised serious concerns that these
councillors are given substantial power to engage in
district-level decision making but often lack the educa-
tion and expertise related to the issues they discuss and
eventually vote on. It was held that as councillors, they
are often not in a position to be well enough informed
and to judge the issue at stake from different positions.
According to the informants, the result are uninformed
decisions;
“Most of the Councillors have little knowledge to
conceptualise what is being discussed. Usually they
attend the meeting just to listen, and when it reaches
the time for voting they just agree and sign in order
to pass the resolution. From my experience I can say
that some of these members do not understand what

is being discussed. Most of the health issues are not
understood by non-medical personnel. A resolution
may be passed with the understanding that the
council has reached consensus, but in reality it might
be a decision proposed and enforced by a single
member of the council as the other voters simply
have agreed but may not have understood the issue
being discussed.” (District informant, male)
The informants reported that the impact of grass-
roots representation in actual practice was limited as the
representatives were unable to grasp many of the issues
at stake, and would vote in ways that would not favour
community opinion. However, many informants would
also argue that there are community members who, des-
pite a lack of formal education, have an excellent ability
to provide constructive ideas by drawing upon their var-
ied competence and experience. Thus, a complexity of
views were raised regarding the challenges of ensuring
informed grass-roots engagement and grass-roots im-
pact at a time when formal education and specialised
knowledge is increasingly demanded.
Discussion
This study indicates extensive limitations in terms of fair
participation in the decision- making processes in health
care in the study district in Tanzania. The influence of
gender, wealth, ethnicity and education presents sub-
stantial challenges. At a general level, the tendency was
clearly one of placing more trust and power in men, in
wealthy and formally educated individuals as well as in
individuals from powerful ethnic groups. The influence
was more pronounced at the community level than at
the district and facility levels. At the district level, the in-
fluence, particularly of wealth and ethnicity, was deemed
to be minimal. This was attributed to the fact that mem-

bers of decision making bodies would come from differ-
ent ethnic origins and would have different economic
status. For example in the Full Council meetings, these
factors were said to hardly play a role as the members
are obliged to adhere to government rules and regula-
tions that strictly stipulate the procedures to be followed
and it is not easy to deviate from them.
At the onset of the discussion, it is interesting to note
the way the interviewees started their responses by addres-
sing the importance of the principles of fairness in terms
of gender, ethnicity, wealth and education, and the lack of
discrimination on the basis of such characteristics. This
immediate response was seen to become more nuanced
and ambiguous in the course of the discussions. It is im-
portant to comment upon this seemingly ‘politically cor-
rect’ response with a brief reference to Tanzanian history.
In Tanzania, the former president Mwalimu J. K. Nyer-
ere’s political agenda from independence focused on
fighting against a class society based on poverty, disease
and ignorance, which he saw as the main enemies of de-
velopment. He worked on the basis of socialist ideals
and the village became the core of his policy through
the ‘ujamaa na kujitegemea’ (socialism and self reliance).
A prime legacy of Nyerere was to unite all ethnic groups
in the country through a joint language ‘Kiswahili’ [21].
Through this agenda, the battle against tribalism in Tanza-
nia was fought through slogans such as ‘united we stand,
divided we fall’ (‘umoja ni nguvu, utengano ni udhaifu’).
This made Tanzania a showcase for maintaining peace
and unity in a multi-ethnic setting [22]. Nyerere based his
policy on social justice principles where each individual
was to have the right to be respected and be listened to re-
gardless of social status [23]. Despite his good intention,
he did not spell out clearly the manner in which the grass-

roots’ level was to be heard in the face of a strong and au-
thoritarian state.
The immediate response of the informants regarding
gender, wealth, ethnicity and education must also be
understood in light of the later health sector reform and
the decentralisation policy in Tanzania which strongly
advocate bottom-up approaches in decision making [24].
Emphasis is placed on community or grass root involve-
ment where every individual is to participate equally in
discussing their problem areas and suggesting solutions.
11:30 Page 9 of 12
The recognition and emphasis of the village or the com-
munity as the focus of or basis for development has
remained central for close to 50 years in Tanzania. In re-
cent years, active engagement of people in debate has
been encouraged [24,25]. This has increased recognition
of the importance of poor and marginalized segments of
society having a right to air their grievances. The funda-
mental assumption is that when diverse stakeholders
from grassroots are involved, decision making improves
as it takes place closer to where the problems are
located. Communities are called upon to take an active
part in and to challenge decisions that affect their health.
These visions have been a central part of Tanzania’s in-
dependent history, and it is within this contextual back-
drop that the immediate response from the informants
must be understood. However, the implementation of
ideas of decentralization policy has largely remained the-
ory [14]. The initial responses are also in line with the
deliberative democratic thinking that in a fair process,

there should be reasoning among equal citizens and
shared commitment to the resolution. To achieve this,
in the deliberation, stakeholders should decide on the
agenda, discuss the issue, propose solutions and support
those solutions with reasons [9]. Each stakeholder is to
have equal voice in the decision making since the distri-
bution of power and resources is not supposed to shape
their chances of contributing or playing an authoritative
role in the deliberations.
Beyond the initial response, our study findings indicate
that gender, ethnicity, wealth and education do, in prac-
tice, pose substantial challenges in making fair decisions.
This study cannot, in any substantial manner, quantify
or explain the discrepancy between the levels of ideals
and values on the one hand and the level of practice on
the other. But we can indicate a few aspects of the chal-
lenges that emerged in our study findings, and ways in
which some of these seem to not only appear at the level
of discriminatory practice, but also at the level of ideas
and ideals in a way that may impose serious constraints
on principles of fairness.
Our findings indicate that, despite the strong focus on
gender balance in decision-making bodies, substantial
challenges remain. There is still a lack of women with
the necessary formal competence or skills to occupy cer-
tain positions. Beyond this, women were said to be lis-
tened to less seriously during discussions than their
male counter parts. Informants expressed the view that,
in meetings where educated and active women were
involved, it was often difficult for them to be heard be-
yond the field of maternal and child health. At the com-
munity level, the findings were even more serious as the
fundamental ability of women to make a meaningful
contribution to the discussions was questioned by sev-

eral of the male informants, revealing a true distrust
between the genders. This lack of ability was not merely
linked to a lack of experience in voicing their views or to
a lack of formal education or training, but was related to
their nature as women. These findings reflect strong
traces of patriarchal ideology as have been found also in
a number of other studies [26–28].
A similar line of reasoning emerged from the findings
related to wealth and influence. People with higher in-
come were reported to be listened to more than the poor.
This finding emerged as far more apparent at lower levels,
and not least at the community level. Informants at the
community level argued that the rich would be in a better
position not only because of their financial resources, but
because poor individuals were perceived to have lower
thinking capacity; the more affluent were perceived to be
more intelligent than the poorer. The influence of wealth
has been reported in another study where members of de-
cision making bodies were chosen because of their fun-
draising ability [29]. This implies that poor people’s views
will be heard to less extent, although they may be the ones
who may experience a problem more acutely and may be
most affected by the potential decisions. This tendency to
allow the wealthy to have more influence has been pointed
out as reason for caution also in other studies [30] if fair-
ness is to be achieved. Despite the enormous historical
focus on the dangers of tribalism, ethnicity did also emerge
as challenge in our study. The majority ethnic group in the
community was said to be more likely to be respected and
listened to than other groups, not least if its power in
terms of numbers was coupled with wealth. A bias was
noted also in the district departments when a majority of
the staff belonged to a particular ethnic group. Our find-
ings indicate that advantage or disadvantage based on eth-
nic criteria in decision-making contexts needs to be

watched carefully also in present day Tanzania.
The influence of education was, not surprisingly, pro-
nounced. People with formal education were said to have
substantial influence owing to their increased knowledge
and competence, while individuals with little education
had less influence. Other studies have found that educated
individuals were thought to have more confidence [31] and
thus feel more comfortable in engaging in complex discus-
sion. In our study, the elected councillors who approve dis-
trict decisions were considered by some informants to lack
the necessary education and understanding to vote in an
informed way in many of the questions addressed. These
councillors have authoritative power, yet at times lack the
necessary knowledge in approving decisions in health care.
This point has been raised also in other studies [29,32–34].
With this in mind, the approaches to ensuring proper
community representation need to be thought out, and the
necessary knowledge and information need to be imparted
to councillors so that they can make informed decisions
for better health outcomes.
11:30 Page 10 of 12
The study findings indicate that deliberative demo-
cratic thinking that advocates fairness and legitimacy in
decision-making processes [1,9] continues to be under-
mined, and that it is not yet adequately practiced or con-
ceptualised in our study district. The objective of
participation in decision making is to make sure that
decisions reached are informed by the people. For this
principle to function, as the reciprocity principle of de-
liberative democratic theory states, each stakeholder

needs to have an equal chance to contribute and being
heard regardless of inherent power differences. Our find-
ings bring a serious dilemma. How can one possibly take
on board ideas from all stakeholders in an effort to en-
hance the democratic process and, at the same time be
able to address the needs in an adequate and informed
way as perceived by stakeholders themselves? Our study
indicates that the basis for fair and legitimate decision
making is far from being reached, and that the chal-
lenges need serious and renewed efforts. Despite this,
enhancing fairness and legitimacy through the inclusion
of people beyond powerful individuals is deemed vital,
as shown by Kapiriri and Martin [35].
When informants question women’s or poor people’s
innate ability to take part in informed decision making
constructively, and consider it fair that other individuals
legitimately act or decide on their behalf, we are not
talking merely of discrimination, but of challenges to
human rights-based fairness principles in a more funda-
mental way.
Prevailing biases affect people’s self esteem and sense of
worth, which in turn affect their ability to be open, cre-
ative and vocal. On such grounds Gibson et al. propose
adding ‘empowerment’ to the fairness conditions as pro-
posed by the ethical framework Accountability for Rea-
sonableness [36]. This line of thinking, emphasizes
appropriate training and orientation to enable stake-
holders to contribute substantially [14,33,37–39]. Em-
powerment has been defined as the process and outcome
whereby those without power gain information, skills, and
confidence and thus control over decisions pertaining to
their own lives [40]. Empowerment processes can take
place at the individual, organizational or community
levels. Green argues; “The poor, divorced from centres of

decision making dominated by elites with different inter-
ests, must be empowered to participate in the decisions
which affect them” [7]. In a decision-making context, sta-
keholders should be obliged to respect the opinions of
each other. This is the fundamental argument of delibera-
tive theorists who advocate for mechanisms that reduce
the influence of all asymmetric power relations and au-
thoritarian approaches in decision-making processes. De-
liberative democracy advocates for a just society where
decisions are made collectively and become a public good
[9]. Rawls clarifies that power in decision making has to
be located independently of the economic and social pos-
ition of individuals [41]. More consultative and participa-
tory approaches are called for in an attempt to secure the
participation of broader segments of the population [1,6].
The struggle to find ways to include the views of women,
the poor, individuals from every ethnic segment and from
both educated and non-educated parts of the population
has to remain in focus in the years ahead.
Strengths and limitations of the study
The findings of this study are based on a limited number of
informants located at different levels within the district.
There is nonetheless reason to believe that the findings
have relevance beyond the study district as policies, bureau-
cratic structures and multi-ethnic environments are found
in all parts of Tanzania. It is indeed likely that the findings
may have relevance for many other settings in newly devel-
oping democracies where there has been less focus on com-
munity voice and involvement than in Tanzania.
Conclusion
The findings from this study have revealed that fairness
principles in health care decision making processes are
greatly undermined in the present study district in
Tanzania. Women, poor individuals, members of minority

ethnic groups and less educated individuals were found to
be discriminated against in decision-making bodies. The
findings were more pronounced at community than at
health facility and district levels. The findings revealed that
such biases were related to perceptions of women, the less
educated and poor individuals as less knowledgeable and
having a lower thinking capacity. These notions imply fun-
damental challenges to the implementation of democratic
and justice theories as spelled out by deliberative demo-
cratic thinking. We argue that such notions pose a very
real threat in health care decision making as they may sys-
tematically undermine the views and experiences of par-
ticular segments of the population. There seems to be a
prevailing lack of knowledge and also a lack of acceptance
of the principles on which the political system is built, in-
cluding the fundamental right of everyone to be heard. In-
tensive advocacy related to fairness principles and to
people’s rights to participation in decision making pro-
cesses should be strongly emphasised in the years to
come. The clear distinctions between the findings at com-
munity levels and at district levels indicate that ensuring
equal opportunities in terms of access to education and
information will, in the long run, lead to a situation where
stakeholders at every level are given a chance to partici-
pate in a fair way and make legitimate decisions in health
care since they will be knowledgeable on the issues at
stake. Only in this way can the true community voice be
secured regardless of gender, wealth, ethnic origin and
educational level.
11:30 Page 11 of 12
Competing interests

The authors declare that they have no competing interests.
Authors’ contributions
EHS participated in the development of the tools, collected and
refined the
data, carried out the analysis and drafted the manuscript. AB
was central in
the process of developing the guides, made a follow-up visit to
the field site
during data collection, took part in the analysis process and
revised the draft
manuscripts. PK participated in the development of the tools,
took part in
the data collection process and reviewed the manuscript. OFN,
LEGM and
SM reviewed the manuscript several times. JB conceived the
idea of the
project, developed the methodology and reviewed the
manuscript. All
authors read and approved the final manuscript.
Acknowledgements
Through funding and support from the European Union’s Sixth
Framework
Programme (INCO-2003-A.1.2, contract PL517709) for the
Specific Targeted
Research and Innovation Project REACT - ‘Strengthening of
fairness and
accountability in priority setting for improving equity and
access to quality
health care at district level in Tanzania, Kenya and Zambia’.
We are also
grateful to the Norwegian government through its Quota scheme
for
financial support. We are grateful to Dr. �ystein Evjen Olsen
for conceiving

the concept of the project and for jointly with Dr. Paul Bloch
and others
contributing to detailing research methods, tools and guiding
procedures.
We thank Bruno Marchal for the scientific coordination of
permits to access
and publish the project data, the Mbarali district authority and
our
informants for positive collaboration. We are also grateful to
Nils Gunnar
Songstad for providing diverse support when developing this
manuscript.
Special thanks are extended to reviewers for providing
constructive and
informative comments.
Author details
1Department of Public Health and Primary Health Care,
University of Bergen,
P. O. Box 78045020, Bergen, Norway. 2Centre for International
Health,
University of Bergen, P.O. Box 78045020, Bergen, Norway.
3National Institute
for Medical Research, P.O. Box 9653, Dar es Salaam, Tanzania.
4DBL - Centre
for Health Research and Development, Faculty of Life Sciences,
University of
Copenhagen, Thorvaldsensej 57, DK 1871, Frederiksberg,
Denmark. 5Institute
of Development Studies, University of Dar es Salaam, P. O. Box
35169, Dar es
Salaam, Tanzania.
Received: 1 November 2011 Accepted: 15 May 2012
Published: 7 June 2012

References
1. Gutmann A, Thompson D: Democracy and Disagreement.
London, England:
The Belknap Press of Harvard University Press; 1996.
2. Sanders D, Schaay N, Mohamed S: Primary Health Care. In
International
Encyclopedia of Public Health. 5th edition. Edited by Kris
Heggenhougen,
Stella Quah. San Diego: Academic; 2008:305–316.
3. Glass JJ: Citizen participation in planning: the relationship
between
objectives and techniques. J Am Plann Assoc 1979, 45(2):180–
189.
4. Gravel K, Légaré F, Graham DI: Barriers and facilitators to
implementing
shared decision-making in clinical practice: a systematic review
of health
professionals' perceptions. Implementation Science 2006, 1(16).
5. Allen GAO: Equity and Health. Rev Panam Salud Publica
2000, 7(1):1–7. ISSN
1020–4989.
6. Harris R: Introduction to decision making; Evaluating
internet research
sources. Retrieved from http://www.virtualsalt.com, 2008
(accessed in
October 2009).
7. Green M: Participatory development and the appropriation of
agency in
Southern Tanzania. Critique of anthropology 2000, 20(67):67–

89.
8. Gibson J, Martin D, Singer P: Priority setting in hospitals:
fairness,
inclusiveness, and the problem of institutional power
differences. Soc Sci
Med 2005, 61(11):2355–2362.
9. Cohen J: Deliberation and Democratic Legitimacy, in
Deliberative
democracy: essays on reasons and politics. In Edited by Bohman
J, Rehg
W. Cambridge, Massachusetts: London: The MIT press; 1997.
10. Ministry of Health: Tanzania Second Health Sector Strategic
Plan (SHSSP),
July 2003 - June 2008. Ministry of Health, 2003.
11. Ministry of Health: National Health Policy. Ministry of
Health, Dar-es-salaam
Tanzania: 2003:32.
12. Mboera LEG, Rumisha SF, Senkoro KP, Mayala BK, Shayo
EH, Kisinza WN:
Knowledge and health information communication in Tanzania.
East Afr J
Public Health 2007, 4(1):33–39.
13. Mlozi MRS, Shayo EH, Senkoro KP, Mayala BK, Rumisha
SF, Mutayoba B,
Senkondo E, Maerere A, Mboera LEG: Participatory
involvement of farming
communities and public sectors in determining malaria control
strategies
in Mvomero District, Tanzania. Tanzan Health Res Bull 2006,
8(3):134–140.

14. Maluka S, Hurtiq A-K, San Sebastian M, Shayo EH, Byskov
J, Kamuzora P:
Decentralization and health care prioritization process in
Tanzania: From
national rhetoric to local reality. Internal Journal of Health
Planning and
Management 2011, 26((e55-e73)):e102–120.
15. MoHSW: Joint External Evaluation of the Health Sector in
Tanzania, 1999-2006.
Dar-es-salaam: Ministry of Health and Social Welfare;
2007:168.
16. Maluka S, Kamuzora P, SanSebastián M, Byskov J, Ndawi
B, Olsen OE, Hurtig A-K:
Implementing accountability for reasonableness framework at
district level
in Tanzania: a realist evaluation. Implementation Science 2011,
6(11):1–15.
17. Venugopal V, Yilmaz S: Decentralization in Tanzania: An
assessment of
local government discretion and accountability Public Admin.
Dev 2010,
30:215–231.
18. Maluka S, Kamuzora P, SanSebastián M, Byskov J, Ndawi
B, Olsen OE, Hurtig
A-K: Decentralized health care priority-setting in Tanzania:
evaluating
against the accountability for reasonableness framework. Soc
Sci Med
2010, 71:751–759.
19. Byskov J, Bloch P, Blystad A, Hurtig AK, Fylkesnes K,
Kamuzora P, Kombe Y,

Kvale G, Marchal B, Martin DK, Michelo C, Ndawi B, Ngulube
TJ, Nyamongo
I, Olsen OE, Shayo EH, Silwamba G, Songstad NG, Tuba M:
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 Research Policy and Systems 2009, 7(23):1–
10.
20. The United Republic of Tanzania: Tanzania Census 2002:
analytical report, vol
X, National Bureau of Statistics, Ministry of Planning,
Economy and
Empowerment. Dar es Salaam: The National Bureau of
Statistics; 2006.
21. Mazrui AA, Mazrui AM: Swahili state and society: The
political economy of
an African language. East African Educational publishers,
1995:167.
22. Bannon S, Miguel E, Posner DN: Source of ethnic
identification in Africa:a
comperative series of national public attitude survey on
democracy, market
and civil society in Africa, Volume Working paper no 4.
afrobarometer
project; 2004:23.
23. Warrema IJ: Tanzanians to the promised land: after forty
years. In
Tanzanians to the promised land: after forty years. Edited by
Ulimwengu J, EC
H. Tanzanian: Lulu.com; 2006:14.

24. Ministry of Health: Health Sector Reform Plan of Action
1996–1999. Dar es
Salaam-Tanzania: Ministry of Health; 1996.
25. De Savigny D, Kasale H, Mbuya C, Reid G: Fixing Health
Systems. 2nd edition.:
International Development Research Centre; 2008:14.
26. Senarath U, Gunawardena N: Women's autonomy in decision
making for
health care in South Asia. Asia Pac J Public Health 2009,
21(2):137–43.
27. Okoko B, Yamuah L: Household decision-making process
and childhood
cerebral malaria in The Gambia. Arch Med Res 2006, 3:399–
402.
28. Sloan L: Women participation in decision making processes
in Arctic
Fisheries Management. Arctic Council, 2002–2004. Edited by
Kafarowski J,
Heilmann A, Karlsdttir A, 2004.
29. Rebecca A, Bruni BA, Andreas L, Martin DK: Public
engagement in setting
priorities in health care. CMAJ 2008, 179(1):15–18.
30. Baltussen R: Priority setting of public spending in
developing countries:
Do not try to do everything for everybody. Health Policy 2006,
78:149–156.
31. Flynn K, Smith M: Personality and health care decision-
making style. J

Gerontol B Psychol Sci Soc Sci 2007, 62(5):P261–P267.
32. Mshana S, Shemhilu H, Ndawi B, Momburi R, Olsen OE,
Byskov J, Martin DK:
What do district health planners in tanzania think about
improving
priority setting using 'accountability for reasonableness'? BMC
Health
Service Research 2007, 7:180.
33. Makundi E, Kapiriri L, Norheim OF: Combining evidence
and values in
priority setting: testing the balance sheet method in a low-
income
country. BMC Health Service Research 2007, 7:152.
34. Martin D, Hollenberg D, MacRae S, Madden H, Singer P:
Priority setting in a
hospital drug formulary: a qualitative case study and evaluation.
Health
Policy 2003, 66:295–303.
11:30 Page 12 of 12
35. Kapiriri L, Martin DK: A strategy to improve priority
setting in developing
countries. Health Care Anal 2007, doi:10.1007/s10728-006-
0037-1.
36. Wilkinson A: Empowerment: theory and practice. personnel
review. 1998,
27(1):40–56.

37. Saunders C, Crossing S, Girgis A, Butow P, Penman A:
Operationalising a
model framework for consumer and community participation in
health
and medical research. Australia and New Zealand Health Policy
4 2007, 4(13).
38. Martin D, Singer P: A strategy to improve priority setting
and health care
institutions. Health Care Analysis 2003, 11:59–68.
39. Park A, Jowell R, McPherson S: The future of the national
health service:
results from a deliberative poll, 1998.
40. Rifkin S, Pridmore P: Partners in Planning. London:
Macmillan; 2001.
41. Rawls J: Theory of Justice. Cambridge, Mass: Harvard
University Press; 1971.
doi:10.1186/1475-9276-11-30
Cite this article as: Shayo et al.: Challenges to fair decision-
making
processes in the context of health care services: a qualitative
assessment from Tanzania. International Journal for Equity in
Health 2012
11:30.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges

• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
http://dx.doi.org/10.1007/s10728-006-0037-
1AbstractBackgroundMethodsResultsConclusionsBackgroundTh
e Tanzanian health care systemMethodsStudy siteStudy
designRecruitment of the informantsData collectionData
analysisEthicsResultsGenderWealthEthnicityEducationDiscussi
onStrengths and limitations of the studyConclusionCompeting
interestsAcknowledgementsAuthor
detailsReferenceslink_CR1link_CR2link_CR3link_CR4link_CR
5link_CR6link_CR7link_CR8link_CR9link_CR10link_CR11link
_CR12link_CR13link_CR14link_CR15link_CR16link_CR17link
_CR36link_CR37link_CR38link_CR39link_CR40link_CR41
<<
/ASCII85EncodePages false
/AllowTransparency false
/AutoPositionEPSFiles true
/AutoRotatePages /PageByPage
/Binding /Left
/CalGrayProfile (Dot Gain 20%)
/CalRGBProfile (sRGB IEC61966-2.1)
/CalCMYKProfile (U.S. Web Coated 050SWOP051 v2)
/sRGBProfile (sRGB IEC61966-2.1)
/CannotEmbedFontPolicy /Error
/CompatibilityLevel 1.4
/CompressObjects /Tags

/CompressPages true
/ConvertImagesToIndexed true
/PassThroughJPEGImages true
/CreateJobTicket false
/DefaultRenderingIntent /Default
/DetectBlends true
/DetectCurves 0.1000
/ColorConversionStrategy /LeaveColorUnchanged
/DoThumbnails true
/EmbedAllFonts true
/EmbedOpenType false
/ParseICCProfilesInComments true
/EmbedJobOptions true
/DSCReportingLevel 0
/EmitDSCWarnings false
/EndPage -1
/ImageMemory 1048576
/LockDistillerParams true
/MaxSubsetPct 100
/Optimize true
/OPM 1
/ParseDSCComments true
/ParseDSCCommentsForDocInfo true
/PreserveCopyPage true
/PreserveDICMYKValues true
/PreserveEPSInfo true
/PreserveFlatness true
/PreserveHalftoneInfo false
/PreserveOPIComments false
/PreserveOverprintSettings true
/StartPage 1
/SubsetFonts true
/TransferFunctionInfo /Apply
/UCRandBGInfo /Preserve
/UsePrologue false
/ColorSettingsFile ()

/AlwaysEmbed [ true
]
/NeverEmbed [ true
]
/AntiAliasColorImages false
/CropColorImages true
/ColorImageMinResolution 300
/ColorImageMinResolutionPolicy /OK
/DownsampleColorImages true
/ColorImageDownsampleType /Bicubic
/ColorImageResolution 300
/ColorImageDepth -1
/ColorImageMinDownsampleDepth 1
/ColorImageDownsampleThreshold 1.50000
/EncodeColorImages true
/ColorImageFilter /DCTEncode
/AutoFilterColorImages true
/ColorImageAutoFilterStrategy /JPEG
/ColorACSImageDict <<
/QFactor 0.15
/HSamples [1 1 1 1] /VSamples [1 1 1 1]
>>
/ColorImageDict <<
/QFactor 0.15
>>
/JPEG2000ColorACSImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>
/JPEG2000ColorImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>

/AntiAliasGrayImages false
/CropGrayImages true
/GrayImageMinResolution 300
/GrayImageMinResolutionPolicy /OK
/DownsampleGrayImages true
/GrayImageDownsampleType /Bicubic
/GrayImageResolution 300
/GrayImageDepth -1
/GrayImageMinDownsampleDepth 2
/GrayImageDownsampleThreshold 1.50000
/EncodeGrayImages true
/GrayImageFilter /DCTEncode
/AutoFilterGrayImages true
/GrayImageAutoFilterStrategy /JPEG
/GrayACSImageDict <<
/QFactor 0.15
>>
/GrayImageDict <<
/QFactor 0.15
>>
/JPEG2000GrayACSImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>
/JPEG2000GrayImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 30
>>
/AntiAliasMonoImages false
/CropMonoImages true
/MonoImageMinResolution 1200
/MonoImageMinResolutionPolicy /OK

/DownsampleMonoImages true
/MonoImageDownsampleType /Bicubic
/MonoImageResolution 1200
/MonoImageDepth -1
/MonoImageDownsampleThreshold 1.50000
/EncodeMonoImages true
/MonoImageFilter /CCITTFaxEncode
/MonoImageDict <<
/K -1
>>
/AllowPSXObjects false
/CheckCompliance [
/None
]
/PDFX1aCheck false
/PDFX3Check false
/PDFXCompliantPDFOnly false
/PDFXNoTrimBoxError true
/PDFXTrimBoxToMediaBoxOffset [
0.00000
0.00000
0.00000
0.00000
]
/PDFXSetBleedBoxToMediaBox true
/PDFXBleedBoxToTrimBoxOffset [
0.00000
0.00000
0.00000
0.00000
]
/PDFXOutputIntentProfile (None)
/PDFXOutputConditionIdentifier ()
/PDFXOutputCondition ()
/PDFXRegistryName ()
/PDFXTrapped /False

/CreateJDFFile false
/Description <<
/ARA
<FEFF06270633062A062E062F06450020064706300647002006
27064406250639062F0627062F0627062A002006440625064606
340627062100200648062B062706260642002000410064006F00
620065002000500044004600200645062A064806270641064206
2900200644064406370628062706390629002006300627062A00
2006270644062C0648062F062900200627064406390627064406
4A06290020064506460020062E06440627064400200627064406
370627062806390627062A00200627064406450643062A062806
4A062900200623064800200623062C0647063206290020062506
2C06310627062100200627064406280631064806410627062A06
1B0020064A06450643064600200641062A062D00200648062B0
62706260642002000500044004600200627064406450646063406
2306290020062806270633062A062E062F062706450020004100
630072006F0062006100740020064800410064006F0062006500
20005200650061006400650072002006250635062F0627063100
200035002E0030002006480627064406250635062F0627063106
27062A0020062706440623062D062F062B002E0020064506390
020005000440046002F0041060C0020062706440631062C06270
6210020064506310627062C063906290020062F0644064A06440
02006450633062A062E062F06450020004100630072006F00620
0610074061B0020064A06450643064600200641062A062D0020
0648062B06270626064200200050004400460020062706440645
06460634062306290020062806270633062A062E062F06270645
0020004100630072006F0062006100740020064800410064006F
006200650020005200650061006400650072002006250635062F
0627063100200035002E0030002006480627064406250635062F
062706310627062A0020062706440623062D062F062B002E>
/BGR
<FEFF04180437043f043e043b043704320430043904420435002
004420435043704380020043d0430044104420440043e0439043a
0438002c00200437043000200434043000200441044a043704340
4300432043004420435002000410064006f006200650020005000

44004600200434043e043a0443043c0435043d044204380020043
704300020043a0430044704350441044204320435043d0020043f
04350447043004420020043d04300020043d043004410442043e0
43b043d04380020043f04400438043d0442043504400438002004
3800200443044104420440043e043904410442043204300020043
704300020043f04350447043004420020043d04300020043f0440
043e0431043d04380020044004300437043f04350447043004420
43a0438002e002000200421044a04370434043004340435043d04
3804420435002000500044004600200434043e043a0443043c043
5043d044204380020043c043e0433043004420020043404300020
044104350020043e0442043204300440044f04420020044100200
04100630072006f00620061007400200438002000410064006f00
620065002000520065006100640065007200200035002e0030002
0043800200441043b043504340432043004490438002004320435
0440044104380438002e>
/CHS
<FEFF4f7f75288fd94e9b8bbe5b9a521b5efa76840020005000440
04600206587686353ef901a8fc7684c976262535370673a548c002
000700072006f006f00660065007200208fdb884c9ad88d2891cf6
2535370300260a853ef4ee54f7f75280020004100630072006f006
2006100740020548c002000410064006f00620065002000520065
006100640065007200200035002e003000204ee553ca66f49ad87
248672c676562535f00521b5efa76840020005000440046002065
8768633002>
/CHT
<FEFF4f7f752890194e9b8a2d7f6e5efa7acb76840020004100640
06f006200650020005000440046002065874ef653ef5728684c976
2537088686a5f548c002000700072006f006f00660065007200204
e0a73725f979ad854c18cea7684521753706548679c300260a853e
f4ee54f7f75280020004100630072006f0062006100740020548c0
02000410064006f00620065002000520065006100640065007200
200035002e003000204ee553ca66f49ad87248672c4f86958b555f
5df25efa7acb76840020005000440046002065874ef63002>
/CZE
<FEFF005400610074006f0020006e00610073007400610076006
5006e00ed00200070006f0075017e0069006a007400650020006b

0020007600790074007600e101590065006e00ed00200064006f0
06b0075006d0065006e0074016f002000410064006f0062006500
20005000440046002000700072006f0020006b00760061006c006
90074006e00ed0020007400690073006b0020006e006100200073
0074006f006c006e00ed006300680020007400690073006b00e10
072006e00e100630068002000610020006e00e100740069007300
6b006f007600fd006300680020007a0061015900ed007a0065006e
00ed00630068002e002000200056007900740076006f015900650
06e00e900200064006f006b0075006d0065006e00740079002000
5000440046002000620075006400650020006d006f017e006e00e
90020006f007400650076015900ed007400200076002000700072
006f006700720061006d0065006300680020004100630072006f0
0620061007400200061002000410064006f006200650020005200
65006100640065007200200035002e0030002000610020006e006
f0076011b006a016100ed00630068002e>
/DAN
<FEFF004200720075006700200069006e0064007300740069006
c006c0069006e006700650072006e0065002000740069006c0020
006100740020006f0070007200650074007400650020004100640
06f006200650020005000440046002d0064006f006b0075006d00
65006e007400650072002000740069006c0020006b00760061006
c00690074006500740073007500640073006b007200690076006e
0069006e006700200065006c006c006500720020006b006f00720
0720065006b007400750072006c00e60073006e0069006e006700
2e0020004400650020006f0070007200650074007400650064006
50020005000440046002d0064006f006b0075006d0065006e0074
006500720020006b0061006e002000e50062006e0065007300200
0690020004100630072006f00620061007400200065006c006c00
6500720020004100630072006f006200610074002000520065006
100640065007200200035002e00300020006f00670020006e0079
006500720065002e>
/DEU
<FEFF00560065007200770065006e00640065006e00200053006
90065002000640069006500730065002000450069006e00730074
0065006c006c0075006e00670065006e0020007a0075006d00200
0450072007300740065006c006c0065006e00200076006f006e00

2000410064006f006200650020005000440046002d0044006f006
b0075006d0065006e00740065006e002c00200076006f006e0020
00640065006e0065006e002000530069006500200068006f00630
06800770065007200740069006700650020004400720075006300
6b006500200061007500660020004400650073006b0074006f007
0002d0044007200750063006b00650072006e00200075006e0064
002000500072006f006f0066002d00470065007200e4007400650
06e002000650072007a0065007500670065006e0020006d00f600
63006800740065006e002e002000450072007300740065006c006
c007400650020005000440046002d0044006f006b0075006d0065
006e007400650020006b00f6006e006e0065006e0020006d00690
0740020004100630072006f00620061007400200075006e006400
2000410064006f006200650020005200650061006400650072002
00035002e00300020006f0064006500720020006800f600680065
007200200067006500f600660066006e006500740020007700650
07200640065006e002e>
/ESP
<FEFF005500740069006c0069006300650020006500730074006
100200063006f006e0066006900670075007200610063006900f3
006e0020007000610072006100200063007200650061007200200
064006f00630075006d0065006e0074006f007300200064006500
2000410064006f006200650020005000440046002000700061007
2006100200063006f006e00730065006700750069007200200069
006d0070007200650073006900f3006e002000640065002000630
061006c006900640061006400200065006e00200069006d007000
7200650073006f007200610073002000640065002000650073006
3007200690074006f00720069006f002000790020006800650072
00720061006d00690065006e00740061007300200064006500200
063006f00720072006500630063006900f3006e002e0020005300
65002000700075006500640065006e00200061006200720069007
200200064006f00630075006d0065006e0074006f007300200050
00440046002000630072006500610064006f007300200063006f0
06e0020004100630072006f006200610074002c00200041006400
6f00620065002000520065006100640065007200200035002e003
000200079002000760065007200730069006f006e006500730020
0070006f00730074006500720069006f007200650073002e>

/ETI
<FEFF004b00610073007500740061006700650020006e0065006
900640020007300e4007400740065006900640020006c00610075
0061002d0020006a00610020006b006f006e00740072006f006c0
06c007400f5006d006d006900730065007000720069006e007400
6500720069007400650020006a0061006f006b00730020006b007
60061006c00690074006500650074007300650074006500200041
0064006f006200650020005000440046002d0064006f006b00750
06d0065006e00740069006400650020006c006f006f006d006900
730065006b0073002e002e00200020004c006f006f00640075006
40020005000440046002d0064006f006b0075006d0065006e0074
00650020007300610061007400650020006100760061006400610
02000700072006f006700720061006d006d006900640065006700
610020004100630072006f0062006100740020006e0069006e006
7002000410064006f006200650020005200650061006400650072
00200035002e00300020006a00610020007500750065006d00610
0740065002000760065007200730069006f006f006e0069006400
6500670061002e000d000a>
/FRA
<FEFF005500740069006c006900730065007a002000630065007
30020006f007000740069006f006e00730020006100660069006e
00200064006500200063007200e90065007200200064006500730
0200064006f00630075006d0065006e0074007300200041006400
6f00620065002000500044004600200070006f007500720020006
400650073002000e9007000720065007500760065007300200065
0074002000640065007300200069006d007000720065007300730
069006f006e007300200064006500200068006100750074006500
20007100750061006c0069007400e900200073007500720020006
40065007300200069006d007000720069006d0061006e00740065
00730020006400650020006200750072006500610075002e00200
04c0065007300200064006f00630075006d0065006e0074007300
2000500044004600200063007200e900e90073002000700065007
500760065006e0074002000ea0074007200650020006f00750076
0065007200740073002000640061006e007300200041006300720
06f006200610074002c002000610069006e007300690020007100
75002700410064006f00620065002000520065006100640065007

200200035002e0030002000650074002000760065007200730069
006f006e007300200075006c007400e9007200690065007500720
0650073002e>
/GRE
<FEFF03a703c103b703c303b903bc03bf03c003bf03b903ae03c3
03c403b5002003b103c503c403ad03c2002003c403b903c200200
3c103c503b803bc03af03c303b503b903c2002003b303b903b100
2003bd03b1002003b403b703bc03b903bf03c503c103b303ae03c
303b503c403b5002003ad03b303b303c103b103c603b100200041
0064006f006200650020005000440046002003b303b903b100200
3b503ba03c403cd03c003c903c303b7002003c003bf03b903cc03c
403b703c403b103c2002003c303b5002003b503ba03c403c503c0
03c903c403ad03c2002003b303c103b103c603b503af03bf03c500
2003ba03b103b9002003b403bf03ba03b903bc03b103c303c403a
d03c2002e0020002003a403b10020005000440046002003ad03b3
03b303c103b103c603b1002003c003bf03c5002003ad03c703b50
3c403b5002003b403b703bc03b903bf03c503c103b303ae03c303b
503b9002003bc03c003bf03c103bf03cd03bd002003bd03b100200
3b103bd03bf03b903c703c403bf03cd03bd002003bc03b5002003c
403bf0020004100630072006f006200610074002c002003c403bf0
02000410064006f00620065002000520065006100640065007200
2000200035002e0030002003ba03b103b9002003bc03b503c403b
103b303b503bd03ad03c303c403b503c103b503c2002003b503ba
03b403cc03c303b503b903c2002e>
/HEB
<FEFF05D405E905EA05DE05E905D5002005D105D405D205D
305E805D505EA002005D005DC05D4002005DB05D305D9002
005DC05D905E605D505E8002005DE05E105DE05DB05D9002
000410064006F006200650020005000440046002005E205D105D
505E8002005D405D305E405E105D4002005D005D905DB05D5
05EA05D905EA002005D105DE05D305E405E105D505EA0020
05E905D505DC05D705E005D905D505EA002005D505DB05DC
05D9002005D405D205D405D4002E002005DE05E105DE05DB
05D9002005D4002D005000440046002005E905E005D505E605
E805D905DD002005E005D905EA05E005D905DD002005DC05
E405EA05D905D705D4002005D105D005DE05E605E205D505

EA0020004100630072006F006200610074002005D5002D00410
064006F006200650020005200650061006400650072002000350
02E0030002005D505D205E805E105D005D505EA002005DE05
EA05E705D305DE05D505EA002005D905D505EA05E8002E>
/HRV
<FEFF005a00610020007300740076006100720061006e006a006
5002000410064006f00620065002000500044004600200064006f
006b0075006d0065006e0061007400610020007a00610020006b0
0760061006c00690074006500740061006e002000690073007000
6900730020006e006100200070006900730061010d0069006d006
100200069006c0069002000700072006f006f0066006500720020
00750072006501110061006a0069006d0061002e0020002000530
0740076006f00720065006e006900200050004400460020006400
6f006b0075006d0065006e007400690020006d006f00670075002
0007300650020006f00740076006f007200690074006900200041
00630072006f00620061007400200069002000410064006f00620
065002000520065006100640065007200200035002e0030002000
690020006b00610073006e0069006a0069006d002000760065007
2007a0069006a0061006d0061002e>
/HUN
<FEFF004d0069006e0151007300e9006700690020006e0079006f
006d00610074006f006b0020006b00e90073007a00ed007400e90
07300e900680065007a002000610073007a00740061006c006900
20006e0079006f006d00740061007400f3006b006f006e002000e9
007300200070007200f300620061006e0079006f006d00f3006b00
6f006e00200065007a0065006b006b0065006c002000610020006
2006500e1006c006c00ed007400e10073006f006b006b0061006c
002c00200068006f007a007a006f006e0020006c00e90074007200
65002000410064006f00620065002000500044004600200064006
f006b0075006d0065006e00740075006d006f006b00610074002e
0020002000410020006c00e90074007200650068006f007a006f0
0740074002000500044004600200064006f006b0075006d006500
6e00740075006d006f006b00200061007a0020004100630072006
f006200610074002c00200061007a002000410064006f00620065
002000520065006100640065007200200035002e0030002000e90
07300200061007a002000610074007400f3006c0020006b00e900

7301510062006200690020007600650072007a006900f3006b006
b0061006c00200020006e00790069007400680061007400f3006b
0020006d00650067002e>
/ITA
<FEFF005500740069006c0069007a007a0061007200650020007
10075006500730074006500200069006d0070006f007300740061
007a0069006f006e0069002000700065007200200063007200650
0610072006500200064006f00630075006d0065006e0074006900
2000410064006f006200650020005000440046002000700065007
200200075006e00610020007300740061006d0070006100200064
00690020007100750061006c0069007400e000200073007500200
07300740061006d00700061006e00740069002000650020007000
72006f006f0066006500720020006400650073006b0074006f007
0002e0020004900200064006f00630075006d0065006e00740069
00200050004400460020006300720065006100740069002000700
06f00730073006f006e006f0020006500730073006500720065002
000610070006500720074006900200063006f006e002000410063
0072006f00620061007400200065002000410064006f006200650
02000520065006100640065007200200035002e00300020006500
2000760065007200730069006f006e00690020007300750063006
3006500730073006900760065002e>
/JPN
<FEFF9ad854c18cea51fa529b7528002000410064006f00620065
00200050004400460020658766f8306e4f5c6210306b4f7f752830
57307e30593002537052376642306e753b8cea309267005927965
0306b4fdd306430533068304c3067304d307e3059300230c730b9
30af30c830c330d730d730ea30f330bf3067306e53705237307e30
5f306f30d730eb30fc30d57528306b9069305730663044307e3059
30023053306e8a2d5b9a30674f5c62103055308c305f0020005000
440046002030d530a130a430eb306f3001004100630072006f006
2006100740020304a30883073002000410064006f006200650020
00520065006100640065007200200035002e003000204ee5964d3
067958b304f30533068304c3067304d307e30593002>
/KOR
<FEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020b370
c2a4d06cd0d10020d504b9b0d1300020bc0f0020ad50c815ae30c5

d0c11c0020ace0d488c9c8b85c0020c778c1c4d560002000410064
006f0062006500200050004400460020bb38c11cb97c0020c791c
131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c002
00050004400460020bb38c11cb2940020004100630072006f0062
006100740020bc0f002000410064006f006200650020005200650
06100640065007200200035002e00300020c774c0c1c5d0c11c00
20c5f40020c2180020c788c2b5b2c8b2e4002e>
/LTH
<FEFF004e006100750064006f006b00690074006500200161006
90075006f007300200070006100720061006d0065007400720075
00730020006e006f0072011700640061006d00690020006b00750
07200740069002000410064006f00620065002000500044004600
200064006f006b0075006d0065006e007400750073002c0020006
b007500720069006500200073006b00690072007400690020006b
006f006b0079006200690161006b0061006900200073007000610
075007300640069006e007400690020007300740061006c006900
6e0069006100690073002000690072002000620061006e0064007
9006d006f00200073007000610075007300640069006e00740075
0076006100690073002e0020002000530075006b0075007200740
069002000500044004600200064006f006b0075006d0065006e00
7400610069002000670061006c006900200062016b00740069002
0006100740069006400610072006f006d00690020004100630072
006f006200610074002000690072002000410064006f006200650
02000520065006100640065007200200035002e00300020006100
72002000760117006c00650073006e0117006d006900730020007
60065007200730069006a006f006d00690073002e>
/LVI
<FEFF0049007a006d0061006e0074006f006a0069006500740020
0161006f00730020006900650073007400610074012b006a00750
06d00750073002c0020006c0061006900200069007a0076006500
690064006f00740075002000410064006f0062006500200050004
4004600200064006f006b0075006d0065006e0074007500730020
006b00760061006c0069007400610074012b00760061006900200
06400720075006b010101610061006e0061006900200061007200
2000670061006c006400610020007000720069006e00740065007
200690065006d00200075006e0020007000610072006100750067

006e006f00760069006c006b0075006d007500200069006500730
0700069006500640113006a00690065006d002e00200049007a00
76006500690064006f006a0069006500740020005000440046002
00064006f006b0075006d0065006e007400750073002c0020006b
006f0020007600610072002000610074007601130072007400200
06100720020004100630072006f00620061007400200075006e00
2000410064006f006200650020005200650061006400650072002
00035002e0030002c0020006b0101002000610072012b00200074
006f0020006a00610075006e0101006b0101006d0020007600650
07200730069006a0101006d002e>
/NLD (Gebruik deze instellingen om Adobe PDF-documenten
te maken voor kwaliteitsafdrukken op desktopprinters en
proofers. De gemaakte PDF-documenten kunnen worden
geopend met Acrobat en Adobe Reader 5.0 en hoger.)
/NOR
<FEFF004200720075006b0020006400690073007300650020006
9006e006e007300740069006c006c0069006e00670065006e0065
002000740069006c002000e50020006f007000700072006500740
0740065002000410064006f006200650020005000440046002d00
64006f006b0075006d0065006e00740065007200200066006f007
20020007500740073006b00720069006600740020006100760020
006800f800790020006b00760061006c006900740065007400200
07000e500200062006f007200640073006b007200690076006500
7200200065006c006c00650072002000700072006f006f0066006
50072002e0020005000440046002d0064006f006b0075006d0065
006e00740065006e00650020006b0061006e002000e50070006e0
0650073002000690020004100630072006f006200610074002000
65006c006c00650072002000410064006f0062006500200052006
5006100640065007200200035002e003000200065006c006c0065
0072002000730065006e006500720065002e>
/POL
<FEFF0055007300740061007700690065006e006900610020006
4006f002000740077006f0072007a0065006e0069006100200064
006f006b0075006d0065006e007400f3007700200050004400460
020007a002000770079017c0073007a010500200072006f007a00
64007a00690065006c0063007a006f015b0063006901050020006

f006200720061007a006b00f30077002c0020007a006100700065
0077006e00690061006a0105006301050020006c0065007000730
07a01050020006a0061006b006f015b0107002000770079006400
720075006b00f30077002e00200044006f006b0075006d0065006
e0074007900200050004400460020006d006f017c006e00610020
006f0074007700690065007200610107002000770020007000720
06f006700720061006d006900650020004100630072006f006200
61007400200069002000410064006f00620065002000520065006
100640065007200200035002e0030002000690020006e006f0077
0073007a0079006d002e>
/PTB
<FEFF005500740069006c0069007a00650020006500730073006
1007300200063006f006e00660069006700750072006100e700f5
0065007300200064006500200066006f0072006d0061002000610
0200063007200690061007200200064006f00630075006d006500
6e0074006f0073002000410064006f00620065002000500044004
60020007000610072006100200069006d00700072006500730073
00f5006500730020006400650020007100750061006c006900640
0610064006500200065006d00200069006d007000720065007300
73006f0072006100730020006400650073006b0074006f0070002
0006500200064006900730070006f00730069007400690076006f
0073002000640065002000700072006f00760061002e0020004f0
07300200064006f00630075006d0065006e0074006f0073002000
5000440046002000630072006900610064006f007300200070006
f00640065006d0020007300650072002000610062006500720074
006f007300200063006f006d0020006f0020004100630072006f00
6200610074002000650020006f002000410064006f00620065002
000520065006100640065007200200035002e0030002000650020
007600650072007300f50065007300200070006f0073007400650
0720069006f007200650073002e>
/RUM
<FEFF005500740069006c0069007a00610163006900200061006
30065007300740065002000730065007401030072006900200070
0065006e007400720075002000610020006300720065006100200
064006f00630075006d0065006e00740065002000410064006f00
6200650020005000440046002000700065006e007400720075002

00074006900700103007200690072006500200064006500200063
0061006c006900740061007400650020006c006100200069006d0
07000720069006d0061006e007400650020006400650073006b00
74006f00700020015f0069002000700065006e007400720075002
0007600650072006900660069006300610074006f00720069002e
002000200044006f00630075006d0065006e00740065006c00650
02000500044004600200063007200650061007400650020007000
6f007400200066006900200064006500730063006800690073006
50020006300750020004100630072006f006200610074002c0020
00410064006f00620065002000520065006100640065007200200
035002e00300020015f0069002000760065007200730069007500
6e0069006c006500200075006c0074006500720069006f0061007
20065002e>
/RUS
<FEFF04180441043f043e043b044c04370443043904420435002
004340430043d043d044b04350020043d0430044104420440043e
0439043a043800200434043b044f00200441043e0437043404300
43d0438044f00200434043e043a0443043c0435043d0442043e04
32002000410064006f006200650020005000440046002c0020043
f044004350434043d04300437043d043004470435043d043d044b
044500200434043b044f0020043a0430044704350441044204320
435043d043d043e04390020043f04350447043004420438002004
3d04300020043d043004410442043e043b044c043d044b0445002
0043f04400438043d044204350440043004450020043800200443
044104420440043e04390441044204320430044500200434043b0
44f0020043f043e043b044304470435043d0438044f0020043f044
0043e0431043d044b04450020043e0442044204380441043a043e
0432002e002000200421043e043704340430043d043d044b04350
020005000440046002d0434043e043a0443043c0435043d044204
4b0020043c043e0436043d043e00200020043e0442043a0440044
b043204300442044c002004410020043f043e043c043e0449044c
044e0020004100630072006f00620061007400200438002000410
064006f0062006500200052006500610064006500720020003500
2e00300020043800200431043e043b043504350020043f043e043
70434043d043804450020043204350440044104380439002e>
/SKY

<FEFF0054006900650074006f0020006e0061007300740061007
60065006e0069006100200070006f0075017e0069007400650020
006e00610020007600790074007600e100720061006e006900650
0200064006f006b0075006d0065006e0074006f00760020004100
64006f00620065002000500044004600200070007200650020006
b00760061006c00690074006e00fa00200074006c0061010d0020
006e0061002000730074006f006c006e00fd00630068002000740
06c0061010d006900610072014800610063006800200061002000
74006c0061010d006f007600fd006300680020007a00610072006
9006100640065006e0069006100630068002e0020005600790074
0076006f00720065006e00e900200064006f006b0075006d00650
06e00740079002000500044004600200062007500640065002000
6d006f017e006e00e90020006f00740076006f0072006901650020
0076002000700072006f006700720061006d006f0063006800200
04100630072006f00620061007400200061002000410064006f00
620065002000520065006100640065007200200035002e0030002
000610020006e006f0076016100ed00630068002e000d000a>
/SLV
<FEFF005400650020006e0061007300740061007600690074007
60065002000750070006f0072006100620069007400650020007a
00610020007500730074007600610072006a0061006e006a00650
0200064006f006b0075006d0065006e0074006f00760020004100
64006f0062006500200050004400460020007a00610020006b006
1006b006f0076006f00730074006e006f0020007400690073006b0
061006e006a00650020006e00610020006e0061006d0069007a00
6e006900680020007400690073006b0061006c006e0069006b006
9006800200069006e0020007000720065007600650072006a0061
006c006e0069006b00690068002e0020002000550073007400760
0610072006a0065006e006500200064006f006b0075006d006500
6e0074006500200050004400460020006a00650020006d006f006
7006f010d00650020006f0064007000720065007400690020007a
0020004100630072006f00620061007400200069006e002000410
064006f0062006500200052006500610064006500720020003500
2e003000200069006e0020006e006f00760065006a01610069006
d002e>
/SUO

<FEFF004b00e40079007400e40020006e00e40069007400e4002
000610073006500740075006b007300690061002c0020006b0075
006e0020006c0075006f0074002000410064006f0062006500200
050004400460020002d0064006f006b0075006d0065006e007400
740065006a00610020006c0061006100640075006b00610073007
4006100200074007900f6007000f60079007400e400740075006c
006f0073007400750073007400610020006a00610020007600650
064006f0073007400750073007400610020007600610072007400
65006e002e00200020004c0075006f00640075007400200050004
40046002d0064006f006b0075006d0065006e0074006900740020
0076006f0069006400610061006e0020006100760061007400610
020004100630072006f0062006100740069006c006c0061002000
6a0061002000410064006f0062006500200052006500610064006
5007200200035002e0030003a006c006c00610020006a00610020
0075007500640065006d006d0069006c006c0061002e>
/SVE
<FEFF0041006e007600e4006e00640020006400650020006800e
4007200200069006e0073007400e4006c006c006e0069006e0067
00610072006e00610020006f006d0020006400750020007600690
06c006c00200073006b006100700061002000410064006f006200
650020005000440046002d0064006f006b0075006d0065006e007
40020006600f600720020006b00760061006c0069007400650074
0073007500740073006b007200690066007400650072002000700
0e5002000760061006e006c00690067006100200073006b007200
6900760061007200650020006f006300680020006600f60072002
0006b006f007200720065006b007400750072002e002000200053
006b006100700061006400650020005000440046002d0064006f0
06b0075006d0065006e00740020006b0061006e002000f6007000
70006e00610073002000690020004100630072006f00620061007
40020006f00630068002000410064006f00620065002000520065
006100640065007200200035002e00300020006f0063006800200
0730065006e006100720065002e>
/TUR
<FEFF004d00610073006100fc0073007400fc002000790061007a
013100630131006c0061007200200076006500200062006100730
06b01310020006d0061006b0069006e0065006c00650072006900

6e006400650020006b0061006c006900740065006c00690020006
200610073006b013100200061006d0061006301310079006c0061
002000410064006f0062006500200050004400460020006200650
06c00670065006c0065007200690020006f006c0075015f007400
750072006d0061006b0020006900e70069006e002000620075002
00061007900610072006c0061007201310020006b0075006c006c
0061006e0131006e002e00200020004f006c0075015f0074007500
720075006c0061006e0020005000440046002000620065006c006
70065006c0065007200690020004100630072006f006200610074
002000760065002000410064006f0062006500200052006500610
0640065007200200035002e003000200076006500200073006f00
6e0072006100730131006e00640061006b00690020007300fc007
200fc006d006c00650072006c00650020006100e70131006c0061
00620069006c00690072002e>
/UKR
<FEFF04120438043a043e0440043804410442043e04320443043
9044204350020044604560020043f043004400430043c04350442
0440043800200434043b044f0020044104420432043e044004350
43d043d044f00200434043e043a0443043c0435043d0442045604
32002000410064006f006200650020005000440046002c0020044
f043a04560020043d04300439043a04400430044904350020043f
045604340445043e0434044f0442044c00200434043b044f00200
43204380441043e043a043e044f043a04560441043d043e043304
3e0020043404400443043a04430020043d04300020043d0430044
104420456043b044c043d043804450020043f04400438043d0442
04350440043004450020044204300020043f04400438044104420
440043e044f044500200434043b044f0020043e04420440043804
3c0430043d043d044f0020043f0440043e0431043d04380445002
00437043e04310440043004360435043d044c002e002000200421
04420432043e04400435043d045600200434043e043a0443043c0
435043d0442043800200050004400460020043c043e0436043d04
300020043204560434043a0440043804420438002004430020004
100630072006f006200610074002004420430002000410064006f
00620065002000520065006100640065007200200035002e00300
02004300431043e0020043f04560437043d04560448043e045700
20043204350440044104560457002e>

/ENU (Use these settings to create Adobe PDF documents for
quality printing on desktop printers and proofers. Created PDF
documents can be opened with Acrobat and Adobe Reader 5.0
and later.)
>>
/Namespace [
(Adobe)
(Common)
(1.0)
]
/OtherNamespaces [
<<
/AsReaderSpreads false
/CropImagesToFrames true
/ErrorControl /WarnAndContinue
/FlattenerIgnoreSpreadOverrides false
/IncludeGuidesGrids false
/IncludeNonPrinting false
/IncludeSlug false
/Namespace [
(Adobe)
(InDesign)
(4.0)
]
/OmitPlacedBitmaps false
/OmitPlacedEPS false
/OmitPlacedPDF false
/SimulateOverprint /Legacy
>>
<<
/AddBleedMarks false
/AddColorBars false
/AddCropMarks false
/AddPageInfo false
/AddRegMarks false
/ConvertColors /NoConversion

/DestinationProfileName ()
/DestinationProfileSelector /NA
/Downsample16BitImages true
/FlattenerPreset <<
/PresetSelector /MediumResolution
>>
/FormElements false
/GenerateStructure true
/IncludeBookmarks false
/IncludeHyperlinks false
/IncludeInteractive false
/IncludeLayers false
/IncludeProfiles true
/MultimediaHandling /UseObjectSettings
/Namespace [
(Adobe)
(CreativeSuite)
(2.0)
]
/PDFXOutputIntentProfileSelector /NA
/PreserveEditing true
/UntaggedCMYKHandling /LeaveUntagged
/UntaggedRGBHandling /LeaveUntagged
/UseDocumentBleed false
>>
]
>> setdistillerparams
<<
/HWResolution [2400 2400]
/PageSize [595.440 793.440]
>> setpagedevice

Question According to Dasgupta and Gupta The increasing tu.docx

Question According to Dasgupta and Gupta The increasing tu.docx

Recommended

Recommended

More Related Content

Similar to Question According to Dasgupta and Gupta The increasing tu.docx

Similar to Question According to Dasgupta and Gupta The increasing tu.docx (17)

More from makdul

More from makdul (20)

Recently uploaded

Recently uploaded (20)

Question According to Dasgupta and Gupta The increasing tu.docx