Addressing challenges in tuberculosis adherence via performance-based payments for integrated case management: protocol for a cluster randomized controlled trial in Georgia.

From Europe PMC via Jisc Publications RouterHistory: ppub 2019-08-01, epub 2019-08-28Publication status: PublishedFunder: Department of Interational Development; Grant(s): MR/P015018/1Funder: Medical Research Council; Grant(s): MR/P015018/1Funder: Welcome Trust; Grant(s): MR/P015018/1Funder: Economic and Social Research Council; Grant(s): MR/P015018/1BACKGROUND:Tuberculosis is one of the greatest global health concerns and disease management is challenging particularly in low- and middle-income countries. Despite improvements in addressing this epidemic in Georgia, tuberculosis remains a significant public health concern due to sub-optimal patient management. Low remuneration for specialists, limited private-sector interest in provision of infectious disease care and incomplete integration in primary care are at the core of this problem. METHODS:This protocol sets out the methods of a two-arm cluster randomized control trial which aims to generate evidence on the effectiveness of a performance-based financing and integrated care intervention on tuberculosis loss to follow-up and treatment adherence. The trial will be implemented in health facilities (clusters) under-performing in tuberculosis management. Eligible and consenting facilities will be randomly assigned to either intervention or control (standard care). Health providers within intervention sites will form a case management team and be trained in the delivery of integrated tuberculosis care; performance-related payments based on monthly records of patients adhering to treatment and quality of care assessments will be disbursed to health providers in these facilities. The primary outcomes include loss to follow-up among adult pulmonary drug-sensitive and drug-resistant tuberculosis patients. Secondary outcomes are adherence to treatment among drug-sensitive and drug-resistant tuberculosis patients and treatment success among drug-sensitive tuberculosis patients. Data on socio-demographic characteristics, tuberculosis diagnosis and treatment regimen will also be collected. The required sample size to detect a 6% reduction in loss to follow-up among drug-sensitive tuberculosis patients and a 20% reduction in loss to follow-up among drug-resistant tuberculosis patients is 948 and 136 patients, respectively. DISCUSSION:The trial contributes to a limited body of rigorous evidence and literature on the effectiveness of supply-side performance-based financing interventions on tuberculosis patient outcomes. Realist and health economic evaluations will be conducted in parallel with the trial, and associated composite findings will serve as a resource for the Georgian and wider regional Ministries of Health in relation to future tuberculosis and wider health policies. The trial and complementing evaluations are part of Results4TB, a multidisciplinary collaboration engaging researchers and Georgian policy and practice stakeholders in the design and evaluation of a context-sensitive tuberculosis management intervention. TRIAL REGISTRATION:ISRCTN, ISRCTN14667607 . Registered on 14 January 2019

How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia

From PubMed via Jisc Publications RouterThis paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these. The study was conducted in Tbilisi, Georgia. A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops. Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement. Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy. [Abstract copyright: © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.]11pubpub

Influence of household demographic and socio-economic factors on household expenditure on tobacco in six New Independent States

<p>Abstract</p> <p>Background</p> <p>To identify demographic and socio-economic factors that are associated with household expenditure on tobacco in Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation, and Tajikistan.</p> <p>Methods</p> <p>Secondary analysis of the data available through the World Bank Living Standards Monitoring Survey conducted in aforementioned countries in 1995–2000. The role of different variables (e.g. mean age of household members, household area of residence, household size, share of adult males, share of members with high education) in determining household expenditure on tobacco (defined as tobacco expenditure share out of total monthly HH consumption) was assessed by using multiple regression analysis.</p> <p>Results</p> <p>Significant differences were found between mean expenditure on tobacco between rich and poor – in absolute terms the rich spend significantly more compared with the poor. Poor households devote significantly higher shares of their monthly HH consumption for tobacco products. Shares of adult males were significantly associated with the share of household consumption devoted for tobacco. There was a significant negative association between shares of persons with tertiary education within the HH and shares of monthly household consumption devoted for tobacco products. The correlation between household expenditures on tobacco and alcohol was found to be positive, rather weak, but statistically significant.</p> <p>Conclusion</p> <p>Given the high levels of poverty and high rates of smoking in the New Independent States, these findings have important policy implications. They indicate that the impact and opportunity costs of smoking on household finances are more significant for the poor than for the rich. Any reductions in smoking prevalence within poor households could have a positive economic impact.</p

The role of supportive supervision on immunization program outcome - a randomized field trial from Georgia

<p>Abstract</p> <p>Background</p> <p>One of the most common barriers to improving immunization coverage rates is human resources and its management. In the Republic of Georgia, a country where widespread health care reforms have taken place over the last decade, an intervention was recently implemented to strengthen performance of immunization programs. A range of measures were taken to ensure that immunization managers carry out their activities effectively through direct, personal contact on a regular basis to guide, support and assist designated health care facility staff to become more competent in their immunization work. The aim of this study was to document the effects of "supportive" supervision on the performance of the immunization program at the district(s) level in Georgia.</p> <p>Methods</p> <p>A pre-post experimental research design is used for the quantitative evaluation. Data come from baseline and follow-up surveys of health care providers and immunization managers in 15 intervention and 15 control districts. These data were supplemented by focus group discussions amongst Centre of Public Health and health facility staff.</p> <p>Results</p> <p>The results of the study suggest that the intervention package resulted in a number of expected improvements. Among immunization managers, the intervention independently contributed to improved knowledge of supportive supervision, and helped remove self-perceived barriers to supportive supervision such as availability of resources to supervisors, lack of a clear format for providing supportive supervision, and lack of recognition among providers of the importance of supportive supervision. The intervention independently contributed to relative improvements in district-level service delivery outcomes such as vaccine wastage factors and the DPT-3 immunization coverage rate. The clear positive improvement in all service delivery outcomes across both the intervention and control districts can be attributed to an overall improvement in the Georgian population's access to health care.</p> <p>Conclusion</p> <p>Provider-based interventions such as supportive supervision can have independent positive effects on immunization program indicators. Thus, it is recommended to implement supportive supervision within the framework of national immunization programs in Georgia and other countries in transition with similar institutional arrangements for health services organization.</p> <p>Abstract in Russian</p> <p>See the full article online for a translation of this abstract in Russian.</p

Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes. This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries. The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.Health financing Health seeking behavior Access to health care Primary care Georgia

Household catastrophic health expenditure: evidence from Georgia and its policy implications

Abstract Background To quantify extent of catastrophic household health expenditures, determine factors influencing it and estimate Fairness in Financial Contribution (FFC) index in Georgia to establish the baseline for expected reforms and contribute to the design and fine-tuning of the major reforms in health care financing initiated by the government mid-2007. Methods The research is based on the nationally representative Health Care Utilization and Expenditure survey conducted during May-June 2007, prior to preparing for new phase of implementation for the health care financing reforms. Households' catastrophic health expenditures were estimated according to the methodology proposed by WHO – Ke Xu 1. A logistic regression (logit) model was used to predict probability of catastrophic health expenditure occurrence. Results In Georgia between 2000 and 2007 access to care for poor has improved slightly and the share of households facing catastrophic health expenditures have seemingly increased from 2.8% in 1999 to 11.7% in 2007. However, this variance may be associated with the methodological differences of the respective surveys from which the analysis were derived. The high level of the catastrophic health expenditure may be associated with the low share of prepayment in national health expenditure, adequate availability of services and a high level of poverty in the country. Major factors determining the financial catastrophe related to ill health were hospitalization, household members with chronic illness and poverty status of the household. The FFC for Georgia appears to have improved since 2004. Conclusion Reducing the prevalence of catastrophic health expenditure is a policy objective of the government, which can be achieved by focusing on increased financial protection offered to poor and expanding government financed benefits for poor and chronically ill by including and expanding inpatient coverage and adding drug benefits. This policy recommendation may also be relevant for other Low and Middle Income countries with similar levels of out of pocket payments and catastrophic health expenditures.</p

Determinants analysis of outpatient service utilisation in Georgia: can the approach help inform benefit package design?

Abstract Background The healthcare financing reforms initiated by the Government of Georgia in 2007 have positively affected inpatient service utilisation and enhanced financial protection, especially for the poor, but they have failed to facilitate outpatient service use among chronic patients. Non-communicable diseases significantly affect Georgia’s ageing population. Consequently, in this paper, we look at the evidence emerging from determinants analysis of outpatient service utilisation and if the finding can help identify possible policy choices in Georgia, especially regarding benefit package design for individuals with chronic conditions. Methods We used Andersen’s behavioural model of health service utilisation to identify the critical determinants that affect outpatient service use. A multinomial logistic regression was carried out with complex survey design using the data from two nationally representative cross-sectional population-based health utilisation and expenditure surveys conducted in Georgia in 2007 and 2010, which allowed us to assess the relationship between the determinants and outpatient service use. Results The study revealed the determinants that significantly impede outpatient service use. Low income, 45- to 64-year-old Georgian males with low educational attainment and suffering from a chronic health problem have the lowest odds for service use compared to the rest of the population. Conclusions Using Andersen’s behavioural model and assessing the determinants of outpatient service use has the potential to inform possible policy responses, especially those driving services use among chronic patients. The possible policy responses include reducing financial access barriers with the help of public subsidies for sub-groups of the population with the lowest access to care; focusing/expanding state-funded benefits for the most prevalent chronic conditions, which are responsible for the greatest disease burden; or supporting chronic disease management programs for the most prevalent chronic diseases and for special age groups aimed at the timely detection, education and management of chronic patients

Healthcare utilization and expenditures for chronic and acute conditions in Georgia: does benefit package design matter?

BACKGROUND: In 2007 the Georgian government introduced a full state-subsidized Medical Insurance Program for the Poor (MIP) to provide better financial protection and improved access for socially and financially disadvantaged citizens. Studies evaluating MIP have noted its positive impact on financial protection, but find only a marginal impact on improved access. To better assess whether the effect of MIP varies according to different conditions, and to identify areas for improvement, we explored whether MIP differently affects utilization and costs among chronic patients compared to those with acute health needs. METHODS: Data were collected from two cross-sectional nationally representative household surveys conducted in 2007 and in 2010 that examined health care utilization rates and expenditures. Approximately 3,200 households were interviewed from each wave of both studies using a standardized survey questionnaire. Differences in health care utilization and expenditures between chronic and acute patients with and without MIP insurance were evaluated, using coarsened exact matching techniques. RESULTS: Among patients with chronic illnesses, MIP did not affect either health service utilization or expenditures for outpatient drugs and reduction in provider fees. For patients with acute illnesses MIP increased the odds (OR = 1.47) that they would use health services. MIP was also associated with a 20.16 Gel reduction in provider fees for those with acute illnesses (p = 0.003) and a 15.14 Gel reduction in outpatient drug expenditure (p = 0.013). Among those reporting a chronic illness with acute episode during the 30 days prior to the interview, MIP reduced expenditures on provider fees (B = -20.02 GEL) with marginal statistical significance. CONCLUSIONS: Our findings suggest that the MIP may have improved utilization and reduce costs incurred by patients with acute health needs, while chronic patients marginally benefit only during exacerbation of their illnesses. This suggests that the MIP did not adequately address the needs of the aging Georgian population where chronic illnesses are prevalent. Increasing MIP benefits, particularly for patients with chronic illnesses, should receive priority attention if universal coverage objectives are to be achieved