Performance-Based Incentives for Health: A Way to Improve Tuberculosis Detection and Treatment Completion?
Tuberculosis is a public health emergency in Africa, Eastern Europe, and Central Asia. Of the estimated 1.7 million deaths from TB, 98 percent are in the developing world, the majority being among the poor. In order to reach the MDG and the Stop TB partnership targets for 2015, TB detection rates need to double, treatment success rates must increase to more than 7075 percent, and strategies to address HIV-associated TB and multi-drug resistant TB must be aggressively expanded. DOTS, the internationally-recommended TB control strategy is the foundation of TB control efforts worldwide. A standard recording and monitoring system built on routine service-based data allows nearly all countries in the world to track progress in case detection and treatment completion through routine monitoring. This provides a good base for measuring the impact of different strategies for improving TB control outcomes. Performance-based incentives in TB control programs include financial and material incentives directed to patients, individual health workers (in the public and private sectors), and entire health care facilities. Those directed toward patients encourage individuals to seek care (a diagnosis) and are conditional on completing steps in the treatment process to ensure adherence to the lengthy treatment schedule. Incentives directed at providers seek to improve the quality of diagnosis, expand access to treatment, improve teamwork, and encourage system changes to improve outcomes. Since multiple program strengthening interventions are implemented simultaneously, it is difficult to fully attribute performance changes to the incentives. However, evidence indicates that performance-based incentives for patients and providers directly contribute to increases in case detection and treatment completion rates. Experience in a number of countries points to the importance of careful design and implementation, particularly where it concerns the distribution of money and/or food. While more evidence is needed on the direct correlation between the incentives and performance, existing evidence suggests that incentives should be an integral element of a TB control strategy.