In the effort to end Tuberculosis—one of the leading causes of death from infectious disease worldwide—overall health system improvements are crucial.
Despite substantial funding for TB prevention and treatment by donors and governments over the last decade, the worldwide incidence of TB remains high. In 2015 TB killed more than 1.8 million people, according to the World Health Organization—more than HIV and malaria. Though curable, TB requires a course of medication that lasts months or years and is not always readily available to those who need it. Across low- and middle-income countries, access to TB services is limited, and the quality of TB services is often substandard. Many countries face questions over how to use money wisely in preventing and treating the disease.
Outmoded provider payment systems often contribute to outdated, inefficient care for patients. Even when doctors and nurses are trained to provide TB care—and lab tests and drugs are made available by donors—patients do not always receive the best care.
Often, public financial management (PFM) systems contain barriers that impede the effective purchasing and provision of TB services from care to treatment, resulting in poorer health outcomes for the most vulnerable populations. This can result in cases of TB left unrecognized when providers are not incentivized to screen for it, or high levels of drug resistance as a result of poorly implemented treatment regimes.
USAID’s Health Finance and Governance (HFG) project works to improve the effectiveness and efficiency of TB service provision by identifying and recommending small improvements in TB purchasing/provider payment and related PFM to better target country health budgets towards priority TB services for the poor in several countries.
Restructuring TB Hospital Payment Systems in Kyrgyzstan and Ukraine
For TB patients in the former Soviet Union, siloed systems of TB hospitals and budgeting targeted at keeping hospitals open, means over-hospitalization and risk of further infection.
In Kyrgyzstan, where over-hospitalization was the norm for TB care, HFG has helped the government transition to a more efficient output-based payment system for TB hospitals, based on diagnosis-related groups (DRGs). DRGs are systems that classify hospital patients by diagnoses, for the purposes of payment. By paying TB hospitals more to treat contagious or difficult-to-treat, drug resistant cases, and less for simpler cases, the new payment system helps shift patients to WHO-recommended full outpatient treatment, wherever possible.
The new payment system has been a catalyst for change in Kyrgyzstan’s TB strategy—leading to the closure of extraneous hospitals, and shifting funding and specialized staff to primary health facilities for outpatient TB treatment. In early 2017, the Government of Kyrgyzstan approved a Road Map for TB System Restructuring, setting in place both immediate steps and a ten-year plan for streamlining hospital care and redirecting resources to improved outpatient treatment.
Building on the Kyrgyzstan experience, HFG is conducting cost accounting and developing DRGs for inpatient TB care in four regions of Ukraine. HFG has supported the necessary changes in the legal system, PFM, and implementation of budgeting, operating systems, funds flows, and facility autonomy, to prepare the regions to implement new provider payment methods. HFG has linked its work with broader health financing reforms in the country, with the goal of more efficient and effective TB care.
Assessing Public Finance Management and Provider Payment for TB
HFG has conducted rapid in-country assessments on PFM and provider payment for TB in Malawi, Cambodia, and the Philippines to identify barriers and bottlenecks. The assessments revealed concrete linkages between provider payment and PFM systems, and gaps in continuum of care in the countries studied. HFG provided the countries with concrete recommendations for improvement to:
- help streamline systems toward improved care across public and private sector providers;
- help better identify people exhibiting symptoms of TB; and
- ensure that patients identified with TB start and complete their full course of treatment.
HFG’s groundbreaking work on strategic purchasing for TB contributes to the nascent literature on the importance of strategic purchasing for tuberculosis. Working together, national TB programs and ministries of finance can address the effectiveness and efficiency of TB service provision, improving outcomes for TB patients.