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Category: Health Financing

  • Primary Health Care Systems: Georgia case study

    Curatio International Foundation publishes Georgia case study of primary health care system (PRIMASYS). The PRIMASYS case study covers key aspects of primary health care system, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance.

    The PRIMASYS case study applied a framework looking at how the primary health care system works and what factors (both contextual and related to policy changes) have influenced access to and performance of primary health care in Georgia since 1994. Documents review and in-depth interviews with key stakeholders were conducted in 2017 in order to understand barriers and facilitators of the system reforms in Georgia.

    Georgia PRIMASYS case study emphasizes that Georgia’s health care system has undergone radical reforms over the last two decades, significantly influenced by external drivers such as political dynamics, macroeconomic factors, international partners’ involvement and internal processes.

    The current PHC system in Georgia offers accessible and affordable services to the population, with differentiated benefits to those in greater need. However, the system still requires significant improvements to achieve its ultimate goal of delivering comprehensive, continuous and people-centered care.

    Georgia PRIMASYS case study was part of the series of 20 PRIMASYS case studies globally developed with the support of the Alliance for Health Policy and Systems Research in collaboration with the Bill & Melinda Gates Foundation. The case studies will serve as the basis for a multi-country analysis of primary health care systems, to understand the systems-level determinants of primary health care performance, and to draw cross-cutting lessons learned in the implementation of primary health care policies and systems reforms and interventions.

    Download the full report.

  • Article: Barriers to delivering mental health services in Georgia with an economic and financial focus: informing policy and acting on evidence

    A new paper discusses the economic and financial barriers to delivering mental health services in Georgia and assessing the opportunities for reform that can support the development of strategies for change.

    The article was published in BMC Health Services Research, authored by researchers from Curatio International Foundation – Lela Sulaberidze, Ivdity Chikovani, Maia Uchaneishvili, George Gotsadze and researcher from Imperial College London – Stuart Green.

    The analysis identified a variety of local economic barriers, including: the inhibition of the diversification of the mental health workforce and services due to inflexible resources; the variable and limited provision of services across the country; and the absence of mechanisms to assess the delivery and quality of existing services. The main financial barriers identified were related to out of pocket payments for purchasing high quality medications and transportation to access mental health services.

    Whilst scarcity of financial resources exists in Georgia, there are clear opportunities to improve the effectiveness of the current mental health program. Addressing system-wide barriers could enable the delivery of services that aim to meet the needs of patients. The use of existing data to assess the implementation of the mental health program offers opportunities to benchmark and improve services and to support the appropriate commissioning and reconfiguration of services.

    The article has open access and it is downloadable here.

    Also check our ResearchGate profile to access this and other interesting papers authored by CIF researchers.

  • Conference paper about realist evaluation: Informing policy, assessing its effects and understanding how it works for improved Tuberculosis management in Georgia

    In the last week of October, 2017 Brisbane, Australia hosted International Conference for Realist Research Evaluation and Synthesis – Realist2017. Realist evaluation is complex sensitive approach and is useful for decision makers because rather responding the question “does the intervention or program work” Realist Evaluation indicates “What works for whom in what circumstances, and how?”

    Curatio International Foundation and the partner institution – Institute of Tropical Medicine, from Antwerp, Belgium presented a work undertaken in the frame of #Results4TB project. During the session professor Bruno Marchal, Ariadna Nebot and Lela Sulaberidze discussed issues around Informing policy, assessing its effects and understanding how it works – Combining realist evaluation, cost analysis and impact assessment of a policy for better TB care in Georgia.

    During the session, the conference audience was informed about the new project – provider Results-Based Financing for improved TB care management in Georgia that is currently being designed to be piloted from 2018 in the country. In this project, we use Realist Evaluation approach to evaluate mechanisms of effect and impact of the intervention. At the conference research team introduced insights of using Realist Evaluation to not only elicit the Programme Theory of the policy-makers and implementers, but also of the researchers, to help

    • Policymakers to achieve a better view on the problem and the solution, and the conditions required to make it work
    • Researchers to develop a better common understanding that would lead to a better research design, and an integrated data collection and analysis strategy
    • Review of the existing evidence is supposed to contribute to better-informed policies and evaluations

    During the presentation research team emphasized the following issues: 1. Insights into the program theory elicitation process, from concept to practice; 2. Participative methods applied during the program theory elicitation.

     Please read the slightly modified presentation.

  • Georgian Solution for a Post-Soviet TB Program: Can Integration into Primary Health Care Improve TB Care?

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    By Julia Makayova

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    Former Soviet countries in the Eastern European and Central Asian (EECA) region are fighting the prevailing perception that their outdated hospital-based tuberculosis (TB) programs are failing to provide patient-centered care. Since 2005, Georgia has emerged as the regional leader in decentralizing TB services and implementing country-wide directly-observed treatment (DOTS) coverage in line with the major components of the international Stop TB strategy.

    Through several waves of healthcare reforms, former stand-alone TB dispensaries across the country,  except the major cities, have become physically integrated into Primary Health Care (PHC) centers which are now owned by private providers who contract TB doctors (in Georgia—only phtysiatrists) and DOT nurses to deliver TB services as part of the TB state program. Universal access to diagnostic and treatment services is ensured and facilitated by demand-side incentives and robust monitoring and evaluation practices which are reflected in high 83% treatment success rate for all new and ralapse cases registered in 2014.

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    Photo credit: Sophio Gokhelashvili

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    However, the most challenging drug-resistant TB (DR-TB) remains Georgia’s Achilles heel, as no more than 43% of patients completed treatment successfully in 2013, and every third of them interrupted treatment in the past three years.

    [/vc_column_text][vc_column_text]The latest TB adherence report in Georgia found that almost half of drug-resistant patients are lost to follow-up already by the 8th month of treatment. This figure is not surprising if we put ourselves in the shoes of patients who have to travel to TB units six days a week for at least 18 months (DOTS units are not within walking distance for most patients, and flexible programs like Video-Observed Treatment (VOT) have limited coverage under pilot schemes). Poor management of side effects from anti-TB drugs also contributes to dropouts. Ironically, hospitalized patients in the Tbilisi TB center are better off as they have access to medical specialists who manage their adverse reactions. In rural areas, patients do not always use general healthcare services, required to complement their TB treatment. Despite structural integration of TB services into primary care facilities, the vertical TB program is not linked with the PHC services. As a result, TB patients are not well informed about certain free general care services under the UHC program, and they avoid additional expenses associated with seeking specialists on their own. Grossly underpaid, TB doctors are discouraged to meticulously engage in holistic patient care which are required to support drug-resistant patients. Budding medical students see no appealing career path in phthisiatry either, so the numbers of TB specialists are declining. The shortage is already felt in some regions where only one TB doctor serves several districts. Lack of coordination between the TB program and primary care services exacerbates sub-optimal organization of TB services. While a TB doctor, family doctor and other specialists often occupy the same facility, they do not share patient records and rarely cross-manage co-morbidities. As a result, formal decentralization of TB services in rural and semi-urban areas falls short of providing country-wide patient-centered care: if you want to receive quality treatment, better go to the Tbilisi TB center. Although the government is committed to addressing these shortcomings,[/vc_column_text][vc_column_text]

    it is unclear whether a vertical program can cope with these challenges, even with further investments.

    [/vc_column_text][vc_column_text]Drug-resistant patients require a flexible chronic care model which is more appropriate for the primary care level. Moreover, the declining TB epidemic will eventually  phtysiatry redundant and the costly TB center unsustainable. This raises the question: how to uphold the benefits of holistic care offered at the primary care level without losing the capacity of a strong infection control vertical program? How much responsibility for TB care can family doctors successfully assume? Georgia has decided to test the feasibility of integrating TB services into primary care. Currently, I am here studying how such model could work.

    I conducted a literature review on TB case management at the primary health care (PHC) level and found that[/vc_column_text][vc_column_text]

    integration of specialized TB services into general practice is now understood to be essential to patient-centered care.

    [/vc_column_text][vc_column_text]Conceptually, PHC centers which are operated by a family doctor or general practitioner can be ideal sites for participating in TB control as they are geographically close to patients, can deal with a broad range of health conditions, and ensure confidentiality which is crucial for stigmatized TB patients. However, it does not mean that all family doctors are expected to fully treat TB and assume all responsibilities of TB specialists. A quite successful model of TB care features multidisciplinary team case-manegement, practiced in countries like Norway, UK, and the US, which have 50% fewer patients lost to follow up, than Georgia (data on Norway, UK, USA). Particularly designed to support patients with more complex needs, multidisciplinary teams include a mix of prefossionals such as a TB lead physician (general practitioner), case manager, infectious disesase doctor or other TB specialist, as well as a social worker, peer supporter, psychiatrist, and legal services representative. However, all countries have different history of TB epidemic and TB care management, making it impossible to simply adopt more successful models. Reforming vertical TB programs is still new, so countries learn by trial and error. Several countries in the EECA region started engaging family doctors in TB control beyond case identification and diagnostic referral, enabling them to provide DOTS in Uzbekistan, Romania and Moldova, and even allowing family doctors in Serbia to prescribe anti-TB drugs. Unfortunately, there is little documented evidence from international practices in shifting TB service provision from specialized care to general practice. Country reports and project evaluations usually discuss normative dimenstions of interventions, and document specific inputs and outcomes, but rarely go in depth on the rationale behind certain programmatic choices and on-going operational challenges.[/vc_column_text][vc_column_text]

    We need more present-day evidence that fills the gaps of publication delays to inform policy decisions promptly.

    [/vc_column_text][vc_column_text]In March, Georgia launched a 48-month Results-Based Financing (RBF) scheme for tuberculosis care, hoping to incentivize family doctors and TB specialists (phtysiatrists and DOT nurses) to collaborate in patient-centered TB management. It is expected that giving family doctors more responsibility for TB case management would bring health services closer to patients. Engagement of family doctors would also stimulate the creation of linkages between TB doctors and other health specialists, ensuring that patients receive quality health services along the continuum of care. This program is currently in the design stage. Selective RBF schemes for TB have been introduced in Kazakhstan and Moldova, and pilots are underway in Armenia and Romania. Little impact evidence is documented in this area as well, and I hope the blog will encourage more timely and informal international knowledge exchange.

    What we understand so far is that countries have to deal with a number of health system and individual barriers related to health financing, medical beliefs and attitudes, as well as communication and leadership skills of healthcare managers at all levels of care. Several studies consistently note that proper coordination of TB case management activities did not happen when family doctors and TB specialists were assigned new roles without ensuring that they understand and accept them. Other studies warn us not to underestimate the importance of healthcare managers whose leadership and motivation are as crucial as the competency of medical specialists. Moreover,[/vc_column_text][vc_column_text]

    designing a flawless intervention from a system’s perspective will not ensure acceptability and uptake of the innovation by health professionals and patients.

    [/vc_column_text][vc_column_text]Studies in Brazil, Turkey and India note that health workers’ resistance to changing professional practice was one of the major impediments to smooth TB integration in general practice. Hierarchical professional relationships among medical specialists are common in vertical programs such as here in Georgia. To establish successful case management of TB in primary care, healthcare managers are faced with the challenging task of ensuring that family doctors do not feel dominated and undervalued by TB specialists and, on the other hand, they do not underestimate their capacity to take new responsibilities and make a positive change for TB patients. The bottom line question is:[/vc_column_text][vc_column_text]

    HOW to ensure harmonious task shifting when it requires not only acquisition of new skills and competencies but ultimately a paradigm shift for healthcare workers and patients?

    [/vc_column_text][vc_column_text]Lessons from other countries suggest that functional information sharing systems and strong linkages between healthcare professionals at all levels of care become crucial to successful integration. Delayed or incomplete patient records disempower healthcare providers as they experience inefficiency of the system, caused by duplication of activities and endless paperwork. But again, HOW to establish these linkages? What crucial inputs should not be overlooked, especially once financial and regulatory mechanisms are aligned with the intended model of care? How to establish clear guidelines for the members of TB care team, while accommodating individual patient needs and variations in health resources across the country? How to ensure personal accountability while rewarding team performance?

    Even though a lot of unanswered questions remain, the momentum for sustainable transformation is there, giving us an excellent opportunity to exchange the newest evidence and accelerate global progress towards TB eradication. As we will be following how Georgia deals with these challenges, we encourage you to share with us your experiences integrating TB services in the primary care, including innovative solutions and treatment models that promote patient-centered care.

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

    Curatio International Foundation conducted secondary data analyses of Health Service Utilization and Expenditure survey (2 waves), conducted by Ministry of Labor Health and Social Affairs of Georgia, supported by WHO and The World Bank.

    We studied factors that impact utilization of outpatient health services in Georgia. Several important findings have been revealed, that can be successfully used to update existing outpatient service package and make it more relevant to the needs of Georgian population.

    1. Household income is linked to service consumption – Families with high and middle income are more likely to use outpatient services than those who have low income;
    2. Out of the pocket payment is one of the important barriers for service usage, in particular increase of service costs by one Georgian Lari reduces the use of outpatient services by 2%;
    3. Patients with chronic illness are less likely to use outpatient services, compared to patients with acute health problems – frequency of outpatient service utilization is 2 times less;
    4. Utilization of outpatient services is affected by the age factor – people from 45 to 64 are less likely to use outpatient services and often seek self-treatment.

    To respond to the above listed challenges, it is important to fit outpatient service packages to the population needs.

    The recent changes in the Universal Health Care Program, initiated by Georgian government and launched in May, 2017 will be a step forward to improve population financial protection. The changes respond to the research findings and recommendations in regard of outpatient services, that are fully represented in the article.

    [vc_button url=”http://curatiofoundation.org/wp-content/uploads/2017/05/12961_2017_Article_197.pdf” text=”Download full article” size=”” align=”left” type=”primary” outlined=”0″ icon=”” target=”_blank”]

     

  • EPIC Studies – Governments Finance, On Average, More Than 50 Percent Of Immunization Expenses, 2010–11

    Journal Health Affairs publishes a new Article EPIC Studies: Governments Finance, On Average, More Than 50 Percent Of Immunization Expenses, 2010–11 coauthored by CIF team member Keti Goguadze.

    Abstract: Governments in resource-poor settings have traditionally relied on external donor support for immunization. Under the Global Vaccine Action Plan, adopted in 2014, countries have committed to mobilizing additional domestic resources for immunization. Data gaps make it difficult to map how well countries have done in spending government resources on immunization to demonstrate greater ownership of programs. This article presents findings of an innovative approach for financial mapping of routine immunization applied in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. This approach uses modified System of Health Accounts coding to evaluate data collected from national and subnational levels and from donor agencies. We found that government sources accounted for 27–95 percent of routine immunization financing in 2011, with countries that have higher gross national product per capita better able to finance requirements. Most financing is channeled through government agencies and used at the primary care level. Sustainable immunization programs will depend upon whether governments have the fiscal space to allocate additional resources. Ongoing robust analysis of routine immunization should be instituted within the context of total health expenditure tracking.

    The online version of the Article is available here.

  • Response to the “Final evaluation of GAVI support to Bosnia and Herzegovina"

    Gavi, the Vaccine Alliance published response to the “Final evaluation of Gavi support to Bosnia and Herzegovina” conducted by Curatio International Foundation.

    Gavi assess the final evaluation and the given recommendations as an important document for the transition country program development.

    “We view these evaluations as particularly important to help inform how we can better help countries transition away from Gavi support in the future and to provide lessons learned and recommendations that could inform Gavi’s Graduation Policy going forward.” – Read the full document.

    The evaluation assessed both financial and programmatic sustainability through an in-depth analysis of BiH’s experiences and immunization program performance before, during and after the conclusion of Gavi’s period of support for the country. The evaluation also identified factors contributing to the sustainability of these programs and their achievements and gives five key recommendations to Gavi.

    To read the final evaluation report, please follow the link.

  • The drivers of facility-based immunization performance and costs. An application to Moldova


    The drivers of facility-based immunization performance and costs.     An application to Moldova. This is the article an International peer reviewed Journal Vaccine published, Co-authored by experts from the Curatio International Foundation.

    The study was a part of a multi-country coting and financing study of routine immunization program, supported by the Bill and Melinda Gates Foundation.

    Few costing studies of primary health care services in developing countries evaluate the drivers of immunization program performance and cost. This exercise attempted to fill this knowledge gap and helped to identify organizational and managerial factors at a primary care, district and national level that affect the cost and performance of the routine immunization program in Moldova

    Visit ResearchGate to read and download the article.

  • Analyses of Costs and Financing of the Routine Immunization Program and New Vaccine Introduction in the Republic of Moldova

    In 2012-2014 Curatio International Foundation implemented the costing study that aimed to evaluate routine immunization program costs and financing as well as incremental costs and financing of a new vaccine introduction in the Republic of Moldova.

    The study was a part of a larger effort to evaluate costs and financing of routine immunization in six countries (Moldova, Benin, Uganda, Zambia, Ghana, Honduras) supported by the Bill & Melinda Gates Foundation.

    The study generated new information that will help a) improve the planning of resource requirements and financing needs at the country level; b) improve the understanding of the total immunization program costs and unit costs, as well as delivery costs of Routine Immunization services and delivery costs associated with the introduction of a new vaccine and c) contribute to updating GAVI Alliance policies on new vaccine introduction support.

    The findings of our study provide critical information for discussing issues related to the affordability of new vaccine introduction in Moldova, and the financial sustainability of the national immunization program after it graduates from GAVI support.

    Please follow the links to read the final presentation, project report and policy brief.

       

  • Healthcare Utilization and Expenditures for Chronic and Acute Conditions in Georgia: Does benefit package design matter?

    An International peer reviewed journal BMC Health Services Research publishes an article Healthcare utilization and expenditures for chronic and acute conditions in Georgia: Does benefit package design matter?, authored by experts from the Curatio International Foundation and London School of Hygiene and Tropical Medicine.

    The article presents study results, evaluating health care utilization and expenditures within the program: Medical Insurance for Poor in Georgia (MIP).

    The study assesses how the program effect varied for patients with different health conditions and identifies areas for improvement. The study documented that MIP had a more positive impact for patients with acute illnesses, while for beneficiaries with chronic illnesses, the positive impact was observed just during exacerbations.

    Increasing MIP benefits, particularly for patients with chronic illnesses, should receive priority attention if universal coverage objectives are to be achieved.

    Visit ResearchGate to read and download the article.