Designing and evaluating provider results-based financing for tuberculosis care in Georgia: understanding costs, mechanisms of effect and impact

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Tuberculosis remains one of the world's biggest killers, and Georgia is among the countries where the TB burden is high. Georgia has low TB treatment success rates, indicating that people are not completing treatment, thus posing a risk to their health and to their families and communities. Untreated TB cases lead to the development of drug resistance, which is a huge challenge for the country, for the region and the world. The GoG recognises the importance of this public health problem. Significant achievements in TB control were made during the last decade, including improvements to TB case detection and treatment. Nevertheless, challenges related to timely initiation of treatment, patients' poor adherence to treatment and lower than targeted treatment success rates remain.A number of factors could potentially explain the poor control of TB cases in Georgia, including health system (provider) related factors, such as demotivation of health care providers and delayed TB detection, and patient related factors, such as failure to seek treatment, and poor adherence to treatment. In an attempt to address these barriers, Georgia has provided patient adherence support to all TB patients since 2007, with the support of the Global Fund (GF). This includes monetary incentives to encourage continuous treatment and to cover transportation costs.Notwithstanding the introduction of incentives for patients, treatment adherence remains low and the attention has shifted to the incentives available for service providers. In Georgia, primary care facilities are predominantly privately owned and paid by capitation, without tying incentives to their performance (e.g. for case detection and referral). These providers must provide TB treatment in their mandate, but this mandate will shortly expire. Although the GoG is paying referral specialists salaries for the provision of TB services through its vertical programme, it has limited capacity for monitoring and leverage over the performance of these providers, and salaries are low compared to other specialists.The GoG is therefore planning to introduce a provider RBF intervention in pilot areas in 2017. The pilots intend to explore the potential of a provider intervention, in addition to the already existing patient incentives, to increase the motivation of both public and private providers in improving patient adherence and treatment outcomes. From a research perspective, the introduction of this scheme provides an opportunity for embedded development and research, working closely with the national programme and policy makers, and leveraging Global Fund support and influence.The main goal of the research is to participate in problem analysis during the design phase and provide evidence on the implementation and effects of the new supply side RBF scheme on adherence and treatment success rates, on the cost of the intervention, and how it works in different contexts in Georgia (including wider health system effects, intended or not). To achieve this goal, we will engage with policymakers and programme managers during the process of designing and developing the intervention. By doing so we will ensure that the design is theory-led, engage policy makers from an early stage and develop and document the iterative and participative learning process between policy makers and researchers. As well as informing policy in Georgia, the results are expected to enrich global policy debates on RBF and TB programming, including through public-private partnerships, as well as feeding into academic debate on how to combine realist evaluation techniques with trials and cost-effectiveness analysis.