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

结核病仍然是世界上最大的杀手之一，格鲁吉亚是结核病负担高的国家之一。格鲁吉亚的结核病治疗成功率较低，这表明人们没有完成治疗，从而对他们的健康及其家庭和社区构成风险。未经治疗的结核病病例导致耐药性的发展，这对该国、本区域和全世界都是一个巨大的挑战。圭亚那政府认识到这一公共卫生问题的重要性。在过去十年中，结核病控制取得了重大成就，包括结核病病例的发现和治疗有所改善。尽管如此，在及时开始治疗、患者对治疗的依从性差以及治疗成功率低于目标等方面仍存在挑战。格鲁吉亚结核病病例控制不佳的原因可能有许多，包括卫生系统（提供者）相关因素，如卫生保健提供者的积极性降低和结核病检测延迟，以及患者相关因素，如未能寻求治疗，以及对治疗的依从性差。为了克服这些障碍，格鲁吉亚在全球基金的支持下，自2007年以来向所有结核病患者提供了患者依从性支持。这包括鼓励持续治疗和支付交通费用的货币奖励，尽管对病人采取了奖励措施，但坚持治疗的程度仍然很低，注意力已转移到对服务提供者的奖励上。在格鲁吉亚，初级保健设施主要是私人拥有的，按人头付费，没有将激励措施与其业绩挂钩（例如病例发现和转诊）。这些提供者必须在其授权范围内提供结核病治疗，但这一授权将很快到期。尽管圭亚那政府通过其纵向方案为提供结核病服务的转诊专家支付工资，但圭亚那政府对这些提供者的绩效进行监测和影响的能力有限，而且与其他专家相比，圭亚那政府的工资较低，因此圭亚那政府计划于2017年在试点地区引入提供者RBF干预措施。试点计划旨在探索提供者干预的潜力，除了现有的患者激励措施外，还将增加公共和私人提供者改善患者依从性和治疗结果的动力。从研究的角度来看，该计划的推出为嵌入式开发和研究提供了一个机会，与国家方案和政策制定者密切合作，并利用全球基金的支持和影响力，研究的主要目标是在设计阶段参与问题分析，并提供新的供给侧RBF计划的实施和对依从性和治疗成功率的影响的证据，关于干预的成本，以及它在格鲁吉亚的不同情况下如何发挥作用（包括更广泛的卫生系统影响，无论是否有意）。为实现这一目标，我们将在设计和制定干预措施的过程中与决策者和方案管理人员接触。通过这样做，我们将确保设计以理论为导向，从早期阶段就让决策者参与，并制定和记录决策者和研究人员之间的迭代和参与性学习过程。除了为格鲁吉亚的政策提供信息外，预计这些结果还将丰富关于结核病防治和结核病规划的全球政策辩论，包括通过公私伙伴关系，以及为关于如何将联合收割机现实主义评估技术与试验和成本效益分析相结合的学术辩论提供投入。

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.