Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? – A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India

Document Type : Original Article

Authors

1 Department of Respiratory Medicine, Government Medical College Bhavnagar, Maharaja Krishnakumarsinhji Bhavnagar University, Bhavnagar, India

2 Department of Community Medicine, Government Medical College Bhavnagar, Maharaja Krishnakumarsinhji Bhavnagar University, Bhavnagar, India

3 Division of Clinical Epidemiology, ICMR-National Institute of Occupational Health (NIOH), Ahmedabad, India

Abstract

Background 
A direct benefit transfer (DBT) program was launched to address the dual epidemic of under-nutrition and tuberculosis (TB) in India. We conducted this study to determine whether non-receipt of DBT was associated with unfavorable treatment outcomes among patients with TB and to explore the perspectives of patients and program functionaries regarding the program.

Methods 
We conducted a retrospective cohort study among 426 patients with drug-sensitive pulmonary TB on treatment during January-September 2019 to determine the association between non-receipt of DBT and unfavorable treatment outcomes, which was followed by in-depth interviews of 9 patients and 8 program functionaries to explore their perspectives on challenges and suggestions regarding the DBT program. Multivariate logistic regression was applied to determine whether non-receipt of DBT was independently associated with unfavorable treatment outcomes, while the in-depth interviews were transcribed to describe them as codes and categories.

Results 
Among the 426 patients, 9% of the patients did not receive DBT and 91% completed their treatment. Non-receipt of DBT was associated with a 5 (95% CI: 2-12) times higher odds of unfavorable treatment outcomes on multivariable analysis. Patients not owning a bank account was the primary challenge perceived by the program staff. The patients perceived the assistance under DBT to be insufficient to buy nutritious food throughout the course of treatment. The program functionaries as well as the patients suggested increasing the existing assistance under DBT along with the provision of a monthly nutritious food-kit.

Conclusion 
DBT improved the treatment completion rates among patients with TB in our setting. Provision of a monthly nutritious food-kit with an increase in the existing assistance under DBT might further improve the treatment outcomes. Future research should determine the long-term financial sustainability for ‘DBT plus food-kit’ vs. universal cash transfers in India.

Highlights

 

Commentary Published on this Paper

  •  Closing the Evidence Gap of Cash Transfer for Tuberculosis-Affected Households; Comment on “Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? – A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India”

        Abstract | PDF

 

Keywords


  • epublished Author Accepted Version: January 9, 2022
  • epublished Final Version: January 30, 2022

 

  1. World Health Organization (WHO). Global Tuberculosis Report 2021. Geneva: WHO; 2021. https://apps.who.int/iris/rest/bitstreams/1379788/retrieve.
  2. Central TB Division; Government of India. India TB Report 2020: National Tuberculosis Elimination Programme Annual Report. New Delhi: Ministry of Health and Family Welfare; 2020.
  3. Scrimshaw NS, SanGiovanni JP. Synergism of nutrition, infection, and immunity: an overview. Am J Clin Nutr. 1997;66(2):464S-477S. doi:1093/ajcn/66.2.464S
  4. Bhargava A. Undernutrition, nutritionally acquired immunodeficiency, and tuberculosis control. BMJ. 2016;355:i5407. doi:1136/bmj.i5407
  5. Padmapriyadarsini C, Shobana M, Lakshmi M, Beena T, Swaminathan S. Undernutrition & tuberculosis in India: situation analysis & the way forward. Indian J Med Res. 2016;144(1):11-20. doi:4103/0971-5916.193278
  6. Zachariah R, Spielmann MP, Harries AD, Salaniponi FM. Moderate to severe malnutrition in patients with tuberculosis is a risk factor associated with early death. Trans R Soc Trop Med Hyg. 2002;96(3):291-294. doi:1016/s0035-9203(02)90103-3
  7. Waitt CJ, Squire SB. A systematic review of risk factors for death in adults during and after tuberculosis treatment. Int J Tuberc Lung Dis. 2011;15(7):871-885. doi:5588/ijtld.10.0352
  8. Bhargava A, Chatterjee M, Jain Y, et al. Nutritional status of adult patients with pulmonary tuberculosis in rural central India and its association with mortality. PLoS One. 2013;8(10):e77979. doi:1371/journal.pone.0077979
  9. World Health Organization (WHO). Guideline: Nutritional Care and Support for Patients with Tuberculosis. Geneva: WHO; 2013.
  10. Central TB Division; Government of India. Guidance Document: Nutritional Care and Support for Patients with Tuberculosis in India. Ministry of Health and Family Welfare; 2017. http://tbcindia.nic.in/WriteReadData/GuidanceDocument-NutritionalCare%26SupportforTBpatientsinIndia.pdf.
  11. Bhargava A, Bhargava M, Pande T, Rao R, Parmar M. N-TB: a mobile-based application to simplify nutritional assessment, counseling and care of patients with tuberculosis in India. Indian J Tuberc. 2019;66(1):193-196. doi:1016/j.ijtb.2018.10.005
  12. Central TB Division. Government of India. Nutritional Support to TB Patients (Nikshay Poshan Yojana). New Delhi: Ministry of Health and Family Welfare, Government of India; 2018. https://tbcindia.gov.in/WriteReadData/l892s/6851513623NutritionsupportDBTSchemedetails.pdf. Accessed July 29, 2019.
  13. Nirgude AS, Kumar AMV, Collins T, et al. 'I am on treatment since 5 months but I have not received any money': coverage, delays and implementation challenges of 'Direct Benefit Transfer' for tuberculosis patients - a mixed-methods study from South India. Glob Health Action. 2019;12(1):1633725. doi:1080/16549716.2019.1633725
  14. Patel BH, Jeyashree K, Chinnakali P, et al. Cash transfer scheme for people with tuberculosis treated by the National TB Programme in Western India: a mixed methods study. BMJ Open. 2019;9(12):e033158. doi:1136/bmjopen-2019-033158
  15. Klein K, Bernachea MP, Irribarren S, Gibbons L, Chirico C, Rubinstein F. Evaluation of a social protection policy on tuberculosis treatment outcomes: a prospective cohort study. PLoS Med. 2019;16(4):e1002788. doi:1371/journal.pmed.1002788
  16. Gorityala SB, Mateti UV, Konuru V, Martha S. Assessment of treatment interruption among pulmonary tuberculosis patients: a cross-sectional study. J Pharm Bioallied Sci. 2015;7(3):226-229. doi:4103/0975-7406.160034
  17. Sripad A, Castedo J, Danford N, Zaha R, Freile C. Effects of Ecuador's national monetary incentive program on adherence to treatment for drug-resistant tuberculosis. Int J Tuberc Lung Dis. 2014;18(1):44-48. doi:5588/ijtld.13.0253
  18. Torrens AW, Rasella D, Boccia D, et al. Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective cohort study in Brazil. Trans R Soc Trop Med Hyg. 2016;110(3):199-206. doi:1093/trstmh/trw011
  19. Jakubowiak WM, Bogorodskaya EM, Borisov SE, Danilova ID, Lomakina OB, Kourbatova EV. Social support and incentives programme for patients with tuberculosis: experience from the Russian Federation. Int J Tuberc Lung Dis. 2007;11(11):1210-1215.
  20. Richterman A, Steer-Massaro J, Jarolimova J, Luong Nguyen LB, Werdenberg J, Ivers LC. Cash interventions to improve clinical outcomes for pulmonary tuberculosis: systematic review and meta-analysis. Bull World Health Organ. 2018;96(7):471-483. doi:2471/blt.18.208959
  21. Durovni B, Saraceni V, Puppin MS, et al. The impact of the Brazilian Family Health Strategy and the conditional cash transfer on tuberculosis treatment outcomes in Rio de Janeiro: an individual-level analysis of secondary data. J Public Health (Oxf). 2018;40(3):e359-e366. doi:1093/pubmed/fdx132
  22. Ciobanu A, Domente L, Soltan V, et al. Do incentives improve tuberculosis treatment outcomes in the Republic of Moldova? Public Health Action. 2014;4(Suppl 2):S59-63. doi:5588/pha.14.0047
  23. Rohit A, Kumar AMV, Thekkur P, et al. Does provision of cash incentive to HIV-infected tuberculosis patients improve the treatment success in programme settings? a cohort study from South India. J Family Med Prim Care. 2020;9(8):3955-3964. doi:4103/jfmpc.jfmpc_474_20
  24. Registrar General of India. Ministry of Home Affairs. Government of India. Census of India 2011 - District Census Handbook Bhavnagar: Primary Census Abstract. New Delhi: Government of India; 2011. https://censusindia.gov.in/2011census/dchb/2414_PART_B_DCHB_BHAVNAGAR.pdf.
  25. Liamputtong P, Ezzy D. Qualitative Research Methods. 2nd ed. Melbourne: Oxford University Press; 2005.
  26. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:1093/intqhc/mzm042
  27. Central TB Division (Ministry of Health and Family Welfare). Training Modules for Programme Managers and Medical Officers (Modules 1-4). India: Government of India; 2020. https://tbcindia.gov.in/WriteReadData/NTEPTrainingModules1to4.pdf. Accessed September 4, 2021.
  28. University of California San Francisco (UCSF) - Clinical and Translational Science Institute. “Sample Size - Proportions - Sample Size Calculators.” UCSF-CTSI. http://www.sample-size.net/sample-size-proportions/. Accessed November 11, 2018. Published 2014.
  29. Hulley S, Cummings S, Browner W, Grady D, Newman T. Designing Clinical Research: An Epidemiologic Approach. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
  30. Dean AG, Arner T, Sunki G, et al. Epi Info™, A Database and Statistics Program for Public Health Professionals. Atlanta: CDC; 2011.
  31. IBM Corp. Released 2014. IBM SPSS Statistics for Windows, Version 23. 2014.
  32. Kumar R, Khayyam KU, Singla N, et al. Nikshay Poshan Yojana (NPY) for tuberculosis patients: early implementation challenges in Delhi, India. Indian J Tuberc. 2020;67(2):231-237. doi:1016/j.ijtb.2020.02.006
  33. Rupani MP, Cattamanchi A, Shete PB, Vollmer WM, Basu S, Dave JD. Costs incurred by patients with drug-susceptible pulmonary tuberculosis in semi-urban and rural settings of Western India. Infect Dis Poverty. 2020;9(1):144. doi:1186/s40249-020-00760-w
  34. Prasanna T, Jeyashree K, Chinnakali P, Bahurupi Y, Vasudevan K, Das M. Catastrophic costs of tuberculosis care: a mixed methods study from Puducherry, India. Glob Health Action. 2018;11(1):1477493. doi:1080/16549716.2018.1477493
  35. Fekadu G, Turi E, Kasu T, et al. Impact of HIV status and predictors of successful treatment outcomes among tuberculosis patients: a six-year retrospective cohort study. Ann Med Surg (Lond). 2020;60:531-541. doi:1016/j.amsu.2020.11.032
  36. Thummar PD, Rupani MP. Prevalence and predictors of hazardous alcohol use among tuberculosis patients: the need for a policy on joint tuberculosis-alcohol collaborative activities in India. Alcohol. 2020;86:113-119. doi:1016/j.alcohol.2020.03.006
  37. Ayiraveetil R, Sarkar S, Chinnakali P, et al. Household food insecurity among patients with pulmonary tuberculosis and its associated factors in South India: a cross-sectional analysis. BMJ Open. 2020;10(2):e033798. doi:1136/bmjopen-2019-033798
  38. Vandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Int J Surg. 2014;12(12):1500-1524. doi:1016/j.ijsu.2014.07.014
Volume 11, Issue 11
November 2022
Pages 2552-2562
  • Receive Date: 11 December 2020
  • Revise Date: 05 January 2022
  • Accept Date: 08 January 2022
  • First Publish Date: 09 January 2022