CONSEQUENCES OF PAYMENT MECHANISMS ON TUBERCULOSIS CONTROL

Purpose: Both regular and drug-resistant TB rates are high in Armenia. The financing of healthcare providers in TB services is provided by the state budget and salaries are calculated based on the length of stay of TB patient in the hospital. The purpose of this study was to assess the impact of the provider-payment mechanism on the effective TB control and prevention.

Method: Qualitative semi-structured in-depth interviews and focus group discussions were conducted Sixty three participants from  all levels of TB control participated in the study- including experts, administrators, healthcare providers, and regular and drug-resistant TB patients.

Result: Because of per-case payment mechanisms, providers are not incentivized to achieve successful treatment outcomes. The more patients they have for a longer time, the higher their salaries. This study identified different means of intentionally increasing the number of TB cases in hospital care. Patient who are kept in the hospital for state-determined length of stay are sometimes readmitted as new cases to increase the patient count. This study also found that in many cases providers are giving TB medications in the hospital to the patient without confirming that the patient actually takes the medication. There are also cases where doctors prescribe antibiotics not required by accepted protocols. Infection control is also poorly performed. Smear positive and negative MDR and regular TB patients are located in the hospital without any proper measures of separation and infection control. Moreover, relatives and friends are allowed to stay in the TB ward, putting them at risk. There are also cases where homeless people and hospital guards without TB are admitted to the hospital, increasing the number of “TB patients” to increase income.

Conclusion: The payment mechanisms of healthcare providers of TB services may affect how medical decisions are made. Some payment mechanisms may yield inadequate TB control and prevention, leading to poorer health outcomes of TB patients. Before making policy and program decisions, the impact of payment mechanisms on healthcare services should be comprehensively studied.