The provision Tuberculosis (TB) services in Georgia, as part of the general health care services, is based on a public-private mix. The government supports universal free access to TB care. At outpatient level, TB services are provided at TB units staffed by TB doctors and TB nurses.

Semi-urban units were recently integrated into district and regional level health centers (which also offer general outpatient services), most of which are private. Only a few TB units remain as separate public institutions mainly in the capital and large cities.

The proposed intervention to be tested by the Resuts4TB research project will take a Patient-Centered Care (PCC) approach with which TB patients will receive an integrated, multidisciplinary treatment at the outpatient level.

Two intervention packages are proposed considering the current set-up of TB services at the outpatient level:

 

1. Intervention package designed for TB units integrated with primary health care centers in semi-urban areas

Under the intervention, patients with TB will receive an integrated, multidisciplinary treatment at the primary health care level. An integrated team composed of a TB doctor, a TB nurse (or rural nurse for rural patients) and a Family Doctor will be established.

The package includes:

• defining new roles and responsibilities of health care providers involved in TB case management (incl., a TB doctor, a family doctor, a DOT nurse, a rural nurse) within the scope of their professional competencies to ensure an integrated patient-centered approach
• introducing new tools such as
  • facility managers guidelines on implementing the intervention   
  • case management plan for a patient
  • instruments for monitoring of the integrated team performance
• instruments for verification of the incentive scheme for providers
• training
  • on principles of patient-centered care for all members of a TB team
  • on principles of integrated care, for all members of a TB team
  • on managing side effects of TB treatment, for family doctors and TB doctors
• paying bonuses (incentive payments) to a team based on performance indicator – TB patient retained on the TB treatment.

 

2. Intervention package tailored to specialized TB services in urban areas

Under the current model, the team is composed of a TB doctor and a TB nurse.

The intervention package involves:

• introduction of new tools such as a case management plan, instruments for monitoring, a facility managers’ guideline on implementing the intervention
• training for TB doctors to manage side effects
• paying bonuses (incentive payments) to a team based on performance indicator – TB patient retained on the TB treatment.

 

The table below demonstrates functions of personnel involved in TB care under the current and proposed interventions. Bolded are new functions.

 

Distribution of function under current service and proposed intervention

	Current service provision	Intervention for TB unit integrated into PHC	Intervention for  specialized TB unit
TB doctor	Case detection Diagnostics Case management Treatment monitoring Screening for side-effects Monitoring of side-effects Management of side-effects (all) Patient education	Case detection Diagnostics Case management Treatment monitoring Screening for side-effects Monitoring of side-effects Management of side-effects (all) Patient education Counseling on tobacco, alcohol PCC approach Multidisciplinary teamwork	Case detection Diagnostics Case management Treatment monitoring Screening for side-effects Monitoring of side-effects Management of side-effects (all) Patient education Counseling on tobacco, alcohol PCC approach Teamwork
TB Nurse	DOT administration	DOT administration PCC approach Multidisciplinary teamwork	DOT administration PCC approach Teamwork
Family doctor	Case detection	Case detection Case management Screening for side-effects Management of side-effects (mild) Patient education Counseling on tobacco, alcohol PCC approach Multidisciplinary teamwork
Rural Family doctor	Case detection	Case detection Screening for side-effects Management of side-effects (mild) Patient education Family members education Counseling on tobacco, alcohol Contacts investigation PCC approach Multidisciplinary teamwork	Case detection Screening for side-effects Management of side-effects (mild) Patient education Family members education Counseling on tobacco, alcohol Contacts investigation PCC approach Multidisciplinary teamwork
Rural nurse	DOT administration	DOT administration Patient education PCC approach Multidisciplinary teamwork	DOT administration Patient education PCC approach Multidisciplinary team work

 

In both models, the facility manager has a role in the intervention package. The manager will be responsible for enabling the work of the team (such as contracting, creating job descriptions, supervision on the bonus distribution among the team etc.) and ensuring a supportive environment for providing patient-centered care. The total bonus payment for the facility includes the manager’s and the institution’s share.

Performance-based payments will be balanced among healthcare personnel to build up motivation, ensure fairness and avoid negative consequences.

The volume of a financial incentive is determined based on the following:

• The number of DS-TB and DR-TB patients on outpatient treatment in a facility
• The monthly income of a facility generated through voucher financing (average of vouchers of DS-TB and DR-TB patients) topped up by about 40%
• All players (facility, manager, TB doctor, DOT nurse / rural nurse, family doctor / rural nurse) contribution
• Similar bonus payments in large cities and district centers
• Higher bonus payment for a rural doctor compared to a family doctor in the urban area (considering low number of patients in rural areas)
• Higher bonus payment for a facility and a facility manager in an integrated TB unit compared to a specialized TB unit (considering a higher volume of work and lower number of patients)
• The facility share intended to cover small additional costs to implement the intervention (e.g. meetings, communication, travel costs etc.).

Performance-based payments will be based on the work, measured by an indicator – pulmonary DS-TB and DR-TB patients adherence rate to treatment, fulfilled per month with payments on a quarterly basis.

The intervention will be tested in eight randomly selected TB facilitates countrywide during the 24-months period. Addition eight randomly selected TB facilities will serve as control units allowing to measure the impact of the intervention on adherence to TB treatment and TB success rates as well as its cost-effectiveness and other contextual factors influencing intervention implementation.