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

The 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 learned.

The article was published in BMJ Journals, authored by researchers from Curatio International Foundation and –Bruno MarchalIbukun-Oluwa Omolade AbejirindeLela SulaberidzeIvdity ChikovaniMaia UchaneishviliNatia ShengeliaKarin Diaconu, Anna Vassall, Akaki Zoidze, Ariadna Nebot GiraltSophie Witter.

Guided by realist evaluation methods, a multistakeholder dialogue was organized 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 visualized how actors understood TB service provision challenges and the potential means by which results-based financing (RBF) policy could address these.

The study was conducted in Tbilisi, Georgia. 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 program, TB service providers and members of the research team were involved in the workshops.

Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organizational 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.

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 to leverage stakeholders’ knowledge and expertise on TB service delivery and RBF to codesign a new policy.

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Curatio International Foundation in partnership with Queen Margaret University (UK), London School of Hygiene and Tropical Medicine (UK) and Antwerp Institute of Tropical Medicine (Belgium) is implementing a study “Designing and evaluating provider results-based financing for tuberculosis care in Georgia: understanding costs, mechanisms of effect and impact”. 

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