TB is the world’s biggest infectious disease killer with nearly 1,5 million deaths per year. Most people affected by TB live in developing countries, but the disease is also common in countries that used to be part of the Soviet Union. Georgia has a high rate of new TB cases and treatment success rates are relatively low. Because of low adherence to treatment, more than one in ten TB patients are resistant to first line drugs.
This article was previously published in the 6th issue of the biannual P³ magazine.
“Georgia changed rapidly after the fall of the Iron Curtain,” explains Prof. Bruno Marchal, Head of the Health Systems Unit in ITM’s Department of Public Health. “The health system underwent a number of dramatic reforms, leading to a full-scale privatisation and deregulation of the health sector.” His colleague Ariadna Nebot Giralt adds, “Private-for-profit providers are responsible for most of the tuberculosis care and prevention. The long treatments that TB patients require are not necessarily a priority for them.”
In order to stimulate the private actors to better engage with TB care, Georgian policymakers have set their hopes on results-based financing (RBF). Georgian partner Curatio International Foundation decided to call in expertise to accompany this process. ITM, as well as the Queen Margaret University and the London School of Hygiene and Tropical Medicine from the UK, joined in for a 48-month research project. Results4TB will assist the government in developing a provider incentive payment scheme for TB. The project runs until 2021 and is funded by the UK Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust.
Bruno and Ariadna were asked to bring in their realist evaluation experience. “We help to gain a better insight into the policy process and the problems in TB care that need to be tackled. The strength of realist evaluation lies in developing a detailed and evolving hypothesis underlying the policy with the actors involved, comparing their views with the existing evidence,” says Bruno. “In the process, one starts to see that this is not a simple policy tackling a simple problem.”
Ariadna nods and pitches in: “We involved the policymakers in a detailed problem analysis, which made them see that RBF is only part of the solution. As a result, they broadened the policy to include other interventions, including in-service training and reorganising service delivery through task shifting, for example.”
It was a particular advantage that, unlike in many other cases, Bruno and Ariadna were involved from the very early stages to design the theory-informed intervention. They will also guide the overall design of the evaluation of the policy’s impact and cost, and of the mechanisms underlying it.
“Tracing the introduction of a new policy presents a number of challenges in itself,” Bruno concludes. “On top of that, what might seem like a straightforward policy actually intervenes in a complex health system. Results4TB will therefore also shed light on how realist evaluation fares in guiding complex interventions.”
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