Embedding system change for people with long-term conditions: Learning from Primary Health Care reform in Georgia (ChangePHC Georgia)

Primary health care (PHC) is fundamental to sustainable and equitable health systems, but remains weak in many low- and middle-income countries (LMIC), with challenges exacerbated by an increasing burden of non-communicable diseases (NCDs). While there is increasing evidence on “what works” for enhancing PHC, few LMIC have successfully implemented these strategies. Effective implementation of such complex reform requires in-depth understanding of the consequences for stakeholders at multiple system levels, and the wider social, economic and cultural context within which PHC systems operate. ChangePHC takes advantage of ongoing PHC reform in Georgia to examine these issues in depth and in real time. Our aim is to (i) understand the performance and consequences of Georgia’s planned PHC reform across different regions and health system levels, and the likelihood of any changes being sustained; and, (ii) significantly strengthen Health Policy and Systems Research (HPSR) capacity in Georgia and the wider eastern European region. We will focus on three key NCDs targeted by the reforms (hypertension, diabetes and COPD). We will conduct six interlinked work packages (WPs) examining: 1. how service users experience and respond to the changing PHC service offering in relation to utilisation, continuity of care, and treatment burden; 2. how providers (PHC and specialists) experience the changing PHC service model, how they adopt new practices and how they respond to the changed incentives embedded in new provider payment modes; 3. how decision-makers at the different system tiers understand the PHC reform, their readiness for and commitment to implementing change; 4. how the wider political and economic context affects reform implementation at system level; 5. how major indicators of equity and access to PHC change for people with NCDs at population level, and how this varies across different regional contexts. A 6th synthesis work package will bring insights from WPs 1-5 together. Our activities will take place across three diverse regions. Using a multistage mixed methods framework, and an explicit systems lens, we will use patient and provider surveys; in-depth interviews with patients, providers, decision-makers and other stakeholders; document review; and secondary data on hospital admissions and household expenditure. We will use causal loop diagrams to build an explanatory model of PHC reform as complex system change. ChangePHC will take place over 48 months, bringing together a multidisciplinary team of researchers at Curatio International Foundation, Ilia State University, the London School of Hygiene and Tropical Medicine, and the WHO European Centre for Primary Health Care. We will embed community engagement and involvement (CEI) in all our activities through the establishment of community advisory groups. The project findings will help policymakers in Georgia and other LMICs make informed decisions on PHC reform, improving NCD outcomes and achieving Universal Health Coverage. This will be achieved through targeted policy engagement, building on the team’s strong relationships with national and multi-lateral stakeholders. The project will also strengthen HPSR capacity through a multi-pronged programme including three PhD positions; material development for undergraduate and postgraduate training; support to national CEI capacity; and the strengthening of collaborations among HPSR researchers across the eastern European region.