‘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

Abstract

Background : In March 2018, the Government of India launched a direct benefit transfer (DBT) scheme to provide nutritional support for all tuberculosis (TB) patients in line with END TB strategy. Here, the money (@INR 500 [~8 USD] per month) is deposited electronically into the bank accounts of beneficiaries. To avail the benefit, patients are to be notified in NIKSHAY (web-based notification portal of India’s national TB programme) and provide bank account details. Once these details are entered into NIKSHAY, checked and approved by the TB programme officials, it is sent to the public financial management system (PFMS) portal for further processing and payment. Objectives : To assess the coverage and implementation barriers of DBT among TB patients notified during April–June 2018 and residing in Dakshina Kannada, a district in South India. Methods : This was a convergent mixed-methods study involving cohort analysis of patient data from NIKSHAY and thematic analysis of in-depth interviews of providers and patients. Results : Of 417 patients, 208 (49.9%) received approvals for payment by PFMS and 119 (28.7%) got paid by 1 December 2018 (censor date). Reasons for not receiving DBT included (i) not having a bank account especially among migrant labourers in urban areas, (ii) refusal to avail DBT by rich patients and those with confidentiality concerns, (iii) lack of knowledge and (iv) perception that money was too little to meet the needs. The median (IQR) delay from diagnosis to payment was 101 (67–173) days. Delays were related to the complexity of processes requiring multiple layers of approval and paper-based documentation which overburdened the staff, bulk processing once-a-month and technological challenges (poor connectivity and issues related to NIKSHAY and PFMS portals). Conclusion : DBT coverage was low and there were substantial delays. Implementation barriers need to be addressed urgently to improve uptake and efficiency. The TB programme has begun to take action.

Rising Catastrophic Expenditure on Households Due to Tuberculosis: Is India Moving Away From the END-TB Goal?

“…However, targeting the needy and the poor is essential under these schemes. Previous assessments in India have highlighted several challenges to the implementation of the DBT scheme which needs to be addressed to improve uptake and efficiency ( 21 , 22 ). Also, considering the burden of expenditure due to TB, the amount transferred under DBT would not be enough to provide sufficient compensation for most patients as echoed in other studies ( 18 ).…”

Does provision of cash incentive to HIV-infected tuberculosis patients improve the treatment success in programme settings? A cohort study from South India

“…The NPY coverage was relatively high at 80%, compared to a previous study from Dakshina Kannada district of Karnataka State, where only 29% of the patients received the money. [ 20 ] This may be due to the differences in study population. While our study included only HIV-infected TB patients, the previous study included all TB patients.…”

“…Previous studies have also alluded to technology related challenges like poor phone and internet connectivity, which are essential for smooth functioning of web-based applications such as Nikshay and PFMS. [ 20 ]…”

Envisioning a learning surveillance system for tuberculosis

“…In the case of DBT, the coverage has been low with substantial delays. The limitation of existing tools for DBT poses challenge including the complexity of processes requiring multiple layers of approval and paper-based documentation which overburdened the staff, bulk processing once-a-month, and technological challenges (poor connectivity and issues related to NIKSHAY and PFMS portals) [ 26 ]. Several studies on cash transfers in India in other fields such as food subsidy, pension, etc found that cash transfers suffer from leakages and inaccuracies in beneficiary lists [ 26 ], lags in financial inclusion and biometric identification resulting in absence of bank accounts or Aadhar cards for beneficiaries [ 27 ] or complex and lengthy procedures in linking beneficiary data [ 28 ].…”