Analysis

Introduction

Tuberculosis (TB) is a prevalent public health challenge in India, with over a quarter of the number of global TB cases being found in the country. Approximately 2.8 million new TB cases and 150,000 new cases of multi-drug resistant TB (MDR-TB) occur in India each year, making it the country with the world’s highest incidence of both TB and MDR-TB. People living with TB in India often face significant discrimination and stigma, and many do not have access to sufficient or reliable medical care to help address their condition. Across India, major efforts are underway in both the public and private sectors to address this pervasive problem of TB.

One of the key questions that programs aiming to combat TB must address is how to effectively measure the progress and efficacy of their interventions. Strong measurement allows for effective performance management and a continual focus on achieving results for people living with TB, while ineffective measurement systems and metrics have the potential to compromise the impact of a program or initiative. This article explores two different approaches to TB measurement that are currently being employed in India. The first is the empowerment evaluation approach and the second is value-based care for TB.

Empowerment Evaluation

Empowerment evaluation is an approach that is designed to foster greater self-determination in the evaluation process. While traditional evaluation approaches often consist of an external assessor evaluating a program, an empowerment evaluation approach places the onus of assessment on those executing and participating in the program themselves. The approach is built on the theory that when stakeholders and communities conduct their own evaluations, they are more likely to believe the results are credible and to act on the recommendations in turn. 

LON ALLIES, a flagship project of USAID that is being implemented by REACH, is in the process of employing an empowerment evaluation approach to support the project. ALLIES aims to increase accountability, accessibility and effectiveness of the health system response to TB in India through the engagement of TB survivors and affected communities.  The empowerment evaluation approach provides an opportunity to elevate and enhance the voices of TB survivors, partners and the program team in assessing the success of the program and determining the way forward to achieve maximum impact.

The empowerment evaluation of the ALLIES project allows those directly responsible for creating change to identify the metrics and the targets that should be reached in order to achieve success. This process allows for greater nuance in the evaluation process by incorporating insights from a diverse range of project stakeholders. For example, TB survivors working to raise awareness of TB in their communities may face a range of roadblocks that only they are aware of. By involving TB survivors in the evaluation process, these roadblocks can be easily identified, and addressing them can be included as project targets moving forward.

Value-based Care

Value-based care is another innovation in TB measurement that is being employed in India. Value-based care is a healthcare delivery model that links payments to providers and facilities with results and outcomes as opposed to the traditional fee-for-service financial model. World Health Partners, USAID and Leapfrog to Value are partnering to employ a value-based care approach to address TB in India.

The value-based care approach tracks measures that matter to patients as opposed to those that are purely process-oriented. Measures that matter to patients may include quality of life measures, measures reflecting the care experience and measures of social determinants of health that impact people living with TB. Measures must be developed keeping in mind the local context and feasibility for providers, while avoiding the creation of perverse incentives.

The approach aligns incentives with the achievement of results for patients so that serving the needs of the patient is the first priority. Value-based care also serves to optimize costs by ensuring the right care is conducted at the right time in the right place, promoting cost-effective innovations, and improving operational efficiency. TB patients may inform the process by providing feedback to assess care experience and quality of life metrics.

Conclusion

While empowerment evaluation and value-based care have different approaches to determining measures for monitoring, both approaches share core principles and objectives. They are both devised to gather actionable insights that can inform the way forward for an intervention, and they are both designed first and foremost to serve the needs of people living with TB. While these approaches offer significant potential, they are not without their challenges. Employing an empowerment evaluation approach may be difficult in a hierarchical environment due to resistance among stakeholders to an inclusive approach. In a similar vein, value-based care requires providers to agree to payment terms that they may be reluctant to accept, which may pose a challenge. In order to ensure that these approaches can be implemented effectively in India moving forward, it is important that learnings and insights from initiatives currently employing them are captured and disseminated to the public health sector. Efforts to implement these approaches in India are in the early stages, but offer significant promise toward furthering the goal of eliminating TB across the country.