Addressing challenges in tuberculosis adherence via performance-based payments for integrated case management: protocol for a cluster randomized controlled trial in Georgia

Ivdity Chikovani,Akaki Zoidze,Nuredin Ibrahim Mohammed,Lela Sulaberidze,Karin Diaconu,Sophie Witter,Maia Uchaneishvili,Predrag Duric

doi:10.1186/s13063-019-3621-z

Abstract

BackgroundTuberculosis is one of the greatest global health concerns and disease management is challenging particularly in low- and middle-income countries. Despite improvements in addressing this epidemic in Georgia, tuberculosis remains a significant public health concern due to sub-optimal patient management. Low remuneration for specialists, limited private-sector interest in provision of infectious disease care and incomplete integration in primary care are at the core of this problem.MethodsThis protocol sets out the methods of a two-arm cluster randomized control trial which aims to generate evidence on the effectiveness of a performance-based financing and integrated care intervention on tuberculosis loss to follow-up and treatment adherence.The trial will be implemented in health facilities (clusters) under-performing in tuberculosis management. Eligible and consenting facilities will be randomly assigned to either intervention or control (standard care). Health providers within intervention sites will form a case management team and be trained in the delivery of integrated tuberculosis care; performance-related payments based on monthly records of patients adhering to treatment and quality of care assessments will be disbursed to health providers in these facilities.The primary outcomes include loss to follow-up among adult pulmonary drug-sensitive and drug-resistant tuberculosis patients. Secondary outcomes are adherence to treatment among drug-sensitive and drug-resistant tuberculosis patients and treatment success among drug-sensitive tuberculosis patients. Data on socio-demographic characteristics, tuberculosis diagnosis and treatment regimen will also be collected. The required sample size to detect a 6% reduction in loss to follow-up among drug-sensitive tuberculosis patients and a 20% reduction in loss to follow-up among drug-resistant tuberculosis patients is 948 and 136 patients, respectively.DiscussionThe trial contributes to a limited body of rigorous evidence and literature on the effectiveness of supply-side performance-based financing interventions on tuberculosis patient outcomes. Realist and health economic evaluations will be conducted in parallel with the trial, and associated composite findings will serve as a resource for the Georgian and wider regional Ministries of Health in relation to future tuberculosis and wider health policies.The trial and complementing evaluations are part of Results4TB, a multidisciplinary collaboration engaging researchers and Georgian policy and practice stakeholders in the design and evaluation of a context-sensitive tuberculosis management intervention.Trial registrationISRCTN, ISRCTN14667607. Registered on 14 January 2019.

Highlights

Tuberculosis is one of the greatest global health concerns and disease management is challenging in low- and middle-income countries
The trial contributes to a limited body of rigorous evidence and literature on the effectiveness of supply-side performance-based financing interventions on tuberculosis patient outcomes
Realist and health economic evaluations will be conducted in parallel with the trial, and associated composite findings will serve as a resource for the Georgian and wider regional Ministries of Health in relation to future tuberculosis and wider health policies

Summary

Introduction

Tuberculosis is one of the greatest global health concerns and disease management is challenging in low- and middle-income countries. Tuberculosis (TB) is one of the greatest global public health challenges: in 2017 alone, 10 million people developed the disease, with over 1.5 million of these cases resulting in death [1]. While technological and medical advances are increasingly assisting in disease detection [2] and treatment [3], TB management still presents substantial challenges, in low- and middle-income countries (LMICs) [1]. Low rates of case detection and treatment adherence, as well as system-level issues such as funding gaps and limited integration of TB services across provider types (public and private, secondary and primary care, and patient communities), all pose critical challenges for TB management [1].

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