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Donabedian suggested seven pillars on which quality rests: efficacy, effectiveness, efficiency, optimality, acceptability, legitimacy and equity [9].
Donabedian [4] also described seven attributes that in his view collectively defined health-care quality: efficacy, effectiveness, efficiency, optimality, acceptability, legitimacy and equity.
Commonly underpinning this subset of the concept literature was the Donabedian quality framework of structure, processes and outcomes [ 37, 38, 47, 48], and/or pillars of quality (efficacy, effectiveness, efficiency, optimality, acceptability, legitimacy, and equity) [ 49].
Technical quality relating to Donabedian pillars of efficacy, effectiveness, efficiency, and optimality refers to the product and its cost (e.g., length of stay, infection, mortality rates), whereas functional quality refers to service delivery issues (Donabedian pillars of acceptability, legitimacy, and equity), and includes customer satisfaction.
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This study was part of a multi-centre research project conducted in one district in Kenya, Tanzania and Zambia, the "Response to Accountable priority setting for Trust in health systems" (REACT), which aimed to strengthen the legitimacy and fairness of priority setting at district level with focus on equity, quality and trust in health systems [ 16].
During the baseline study, concepts of legitimacy and fairness in PS processes were found to be grounded in local values of equity and impartiality.
Participating institutions are presented in Figure 2. The objectives of the project are to strengthen the legitimacy and fairness of priority setting at district level in Tanzania, Zambia and Kenya, and to evaluate potential changes in quality, equity and trust pertaining to health services and interventions.
Legitimacy and fairness are related in that legitimacy may be enhanced by a commitment to fair decision making [ 3- 6].
Donabedian [11] reported items of quality measurements as efficacy, effectiveness, efficiency, legitimacy, optimality, acceptability and equity.
They correctly note that the noncontractual elements, such as social and psychological connections between employers and employees, are powerful independent determinants of employees' organizational commitment and often profoundly influence their assessment of the legitimacy, equity, and humaneness associated with the employment contract (Baron 1988).
Moreover, public health workers (HWs) are an essential link between the government and the population in all areas of the country, including the most remote ones, which could help develop the legitimacy of the government and demonstrate the government's commitment to service provision and equity [ 8].
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