Comparison of two cash transfer strategies to prevent catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries: An economic modelling study

Abstract

BackgroundIllness-related costs for patients with tuberculosis (TB) ≥20% of pre-illness annual household income predict adverse treatment outcomes and have been termed “catastrophic.” Social protection initiatives, including cash transfers, are endorsed to help prevent catastrophic costs. With this aim, cash transfers may either be provided to defray TB-related costs of households with a confirmed TB diagnosis (termed a “TB-specific” approach); or to increase income of households with high TB risk to strengthen their economic resilience (termed a “TB-sensitive” approach). The impact of cash transfers provided with each of these approaches might vary. We undertook an economic modelling study from the patient perspective to compare the potential of these 2 cash transfer approaches to prevent catastrophic costs.Methods and findingsModel inputs for 7 low- and middle-income countries (Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen) were retrieved by literature review and included countries' mean patient TB-related costs, mean household income, mean cash transfers, and estimated TB-specific and TB-sensitive target populations. Analyses were completed for drug-susceptible (DS) TB-related costs in all 7 out of 7 countries, and additionally for drug-resistant (DR) TB-related costs in 1 of the 7 countries with available data. All cost data were reported in 2013 international dollars ($). The target population for TB-specific cash transfers was poor households with a confirmed TB diagnosis, and for TB-sensitive cash transfers was poor households already targeted by countries’ established poverty-reduction cash transfer programme. Cash transfers offered in countries, unrelated to TB, ranged from $217 to $1,091/year/household. Before cash transfers, DS TB-related costs were catastrophic in 6 out of 7 countries. If cash transfers were provided with a TB-specific approach, alone they would be insufficient to prevent DS TB catastrophic costs in 4 out of 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $3.8 million (95% CI: $3.8 million–$3.8 million) and $75 million (95% CI: $50 million–$100 million) per country. If instead cash transfers were provided with a TB-sensitive approach, alone they would be insufficient to prevent DS TB-related catastrophic costs in any of the 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $298 million (95% CI: $219 million–$378 million) and $165,367 million (95% CI: $134,085 million–$196,425 million) per country. DR TB-related costs were catastrophic before and after TB-specific or TB-sensitive cash transfers in 1 out of 1 countries. Sensitivity analyses showed our findings to be robust to imputation of missing TB-related cost components, and use of 10% or 30% instead of 20% as the threshold for measuring catastrophic costs. Key limitations were using national average data and not considering other health and social benefits of cash transfers.ConclusionsA TB-sensitive cash...

Active case finding among marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis diagnosis

“…Under social protection, Rudgard et al [42] suggested that a TB-specific approach (cash transfers for households with a confirmed case of TB) is more effective and affordable than a TB-sensitive (cash transfers for households with a high TB risk to strengthen their economic resilience) approach to reduce TB-specific catastrophic costs. The Government of India has announced the implementation of direct benefit transfer of ≈US$8 per month up to treatment completion for all patients notified with TB (TB-specific approach) [3,38,42,43].…”

“…The Government of India has announced the implementation of direct benefit transfer of ≈US$8 per month up to treatment completion for all patients notified with TB (TB-specific approach) [3,38,42,43]. Further research is recommended to assess the benefits of TB-specific cash transfers on catastrophic costs due to TB, including inequity in India.…”

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“…Various social protection initiatives such as cash transfers, food baskets and social insurance are endorsed to help prevent catastrophic costs. Cash transfer initiatives can follow one of the three approaches: TB sensitive (broadly to include patients with risk factors or susceptibility to TB), TB specific (exclusively for patients with TB) or TB inclusive approach (including TB as one of the conditions among others) 10…”

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