How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia.

OBJECTIVES: This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. METHODS: Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these. SETTING: The study was conducted in Tbilisi, Georgia. PARTICIPANTS: A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops. RESULTS: Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement. CONCLUSIONS: Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy.

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

BACKGROUND: The healthcare financing reforms initiated by the Government of Georgia in 2007 have positively affected inpatient service utilisation and enhanced financial protection, especially for the poor, but they have failed to facilitate outpatient service use among chronic patients. Non-communicable diseases significantly affect Georgia's ageing population. Consequently, in this paper, we look at the evidence emerging from determinants analysis of outpatient service utilisation and if the finding can help identify possible policy choices in Georgia, especially regarding benefit package design for individuals with chronic conditions. METHODS: We used Andersen's behavioural model of health service utilisation to identify the critical determinants that affect outpatient service use. A multinomial logistic regression was carried out with complex survey design using the data from two nationally representative cross-sectional population-based health utilisation and expenditure surveys conducted in Georgia in 2007 and 2010, which allowed us to assess the relationship between the determinants and outpatient service use. RESULTS: The study revealed the determinants that significantly impede outpatient service use. Low income, 45- to 64-year-old Georgian males with low educational attainment and suffering from a chronic health problem have the lowest odds for service use compared to the rest of the population. CONCLUSIONS: Using Andersen's behavioural model and assessing the determinants of outpatient service use has the potential to inform possible policy responses, especially those driving services use among chronic patients. The possible policy responses include reducing financial access barriers with the help of public subsidies for sub-groups of the population with the lowest access to care; focusing/expanding state-funded benefits for the most prevalent chronic conditions, which are responsible for the greatest disease burden; or supporting chronic disease management programs for the most prevalent chronic diseases and for special age groups aimed at the timely detection, education and management of chronic patients.

Healthcare utilization and expenditures for chronic and acute conditions in Georgia: does benefit package design matter?

BACKGROUND: In 2007 the Georgian government introduced a full state-subsidized Medical Insurance Program for the Poor (MIP) to provide better financial protection and improved access for socially and financially disadvantaged citizens. Studies evaluating MIP have noted its positive impact on financial protection, but find only a marginal impact on improved access. To better assess whether the effect of MIP varies according to different conditions, and to identify areas for improvement, we explored whether MIP differently affects utilization and costs among chronic patients compared to those with acute health needs. METHODS: Data were collected from two cross-sectional nationally representative household surveys conducted in 2007 and in 2010 that examined health care utilization rates and expenditures. Approximately 3,200 households were interviewed from each wave of both studies using a standardized survey questionnaire. Differences in health care utilization and expenditures between chronic and acute patients with and without MIP insurance were evaluated, using coarsened exact matching techniques. RESULTS: Among patients with chronic illnesses, MIP did not affect either health service utilization or expenditures for outpatient drugs and reduction in provider fees. For patients with acute illnesses MIP increased the odds (OR = 1.47) that they would use health services. MIP was also associated with a 20.16 Gel reduction in provider fees for those with acute illnesses (p = 0.003) and a 15.14 Gel reduction in outpatient drug expenditure (p = 0.013). Among those reporting a chronic illness with acute episode during the 30 days prior to the interview, MIP reduced expenditures on provider fees (B = -20.02 GEL) with marginal statistical significance. CONCLUSIONS: Our findings suggest that the MIP may have improved utilization and reduce costs incurred by patients with acute health needs, while chronic patients marginally benefit only during exacerbation of their illnesses. This suggests that the MIP did not adequately address the needs of the aging Georgian population where chronic illnesses are prevalent. Increasing MIP benefits, particularly for patients with chronic illnesses, should receive priority attention if universal coverage objectives are to be achieved.

An impact evaluation of medical insurance for poor in Georgia: preliminary results and policy implications.

OBJECTIVE: The objective of this article is to assess the impact of the new health financing reform in Georgia-'medical insurance for the poor (MIP)'-which uses private insurance companies and delivers state-subsidized health benefits to the poorest groups of the Georgian population. METHODS: To evaluate the reform we looked at access to health care services and financial protection against health care costs, which are two key dimensions proposed for the universal coverage plans. The data from two nationally representative Health Utilization and Expenditure Surveys (2007 and 2010) were used, and a difference-in-difference method of evaluation was applied. FINDINGS: The MIP was not found to have a significant impact on service utilization growth nationwide, but in the capital city the MIP insured were 12% more likely to use formal health services and 7.6% more likely to use hospitals as compared with other areas of the country. The MIP impact on out-of-pocket health expenditures was greater in reducing costs of accessing services. The cost reductions were sizable and more pronounced among the poorest. Finally, the MIP significantly increased the odds of obtaining free benefits by insured individuals as compared with the control group. Such an increase was most noticeable for the poorest third of the population. CONCLUSIONS: Marginal changes in access to services and the geographically diverse impact of the MIP on service utilization points to other factors affecting health-seeking behaviour of the insured. These other factors include private insurer behaviour that may have used strategies for reducing claims and managing utilization. Equity impact of the MIP and improved financial protection, especially for the poor, are benefits to be retained by government policies when universal health coverage is rolled out nationwide and all citizens will be covered. The role of private insurance companies as financial intermediaries of the publicly funded programme needs further evaluation before moving forward.