One dollar incentive improves tuberculosis treatment outcomes in programmatic settings in rural Uganda

Abstract

The study aim was to determine the association of a one United States dollar (USD) dollar incentive and tuberculosis (TB) treatment outcomes among people with TB receiving treatment at a rural hospital in Uganda under programmatic settings. We conducted a quasi-experiment in which people with TB were randomised (1:1 ratio) to receive either a one USD incentive at months 0, 2, 5 and 6 (Dollar arm) or routine care (Routine arm). A second control group (Retrospective controls) consisted of participants who had a treatment outcome in the preceding 6 months. Treatment outcomes were compared between the intervention and control groups using Pearson’s chi-square and Fisher’s exact tests. The association between the incentive and treatment outcomes was determined using Poisson regression analysis with robust variances. Between November 2018 and October 2019, we enrolled 180 participants (60 in the Dollar arm and 120 in the Control group). TB cure (33.3% vs. 20.8%, p = 0.068) and treatment success (70.0% vs. 59.2% p = 0.156) were higher in the Dollar arm than the Control group, while loss-to-follow-up was lower in the Dollar arm (10.0% vs. 20.8% p = 0.070). Participants in the Dollar arm were more likely to be cured (adjusted incidence rate ratio (aIRR): 1.59, 95% CI 1.04–2.44, p = 0.032) and less likely to be lost to follow-up (aIRR: 0.44, 95% CI 0.20–0.96, p = 0.040). A one-dollar incentive was associated with higher TB cure and lower loss-to-follow-up among people with TB in rural Uganda.

Factors Contributing to Pulmonary Tb Treatment Lost to Follow-Up in Developing Countries: An Overview

“…Additionally, since TB treatment requires a lengthy treatment period, conditional cash transfers were suggested to be more appropriate as a TB treatment adherence intervention (Richterman et al, 2018). This is substantiated by the Ugandan one-dollar incentive, which was solely conditional on patients turning up for their clinic appointments, which as previously stated, resulted in improved treatment outcomes (Baluku et al, 2021). Although past studies have also demonstrated that incentives increase TB successful treatment outcomes, these incentives were often too high to be viable standardised practice in resource-limited, developing countries (Ukwaja et al, 2017, Wingfield et al, 2017, Richterman et al, 2018.…”

“…As discussed earlier, socio-economic status has a significant impact on TB treatment adherence; hence, social protection is viewed as an essential component of TB control and eradication in the WHO's End-TB Strategy (Baluku et al, 2021, WHO, 2021. Previous studies conducted in developing countries have shown that social protection policies including cash or resource transfers improve TB treatment outcomes (Richterman et al, 2018, Oliosi et al, 2019.…”

“…One such initiative, launched in Uganda, was a one-dollar incentive during TB treatment (Baluku et al, 2021). The aim of this initiative was to determine whether a small 'affordable' cash incentive (equivalent to one USD) would improve TB treatment outcomes in the most vulnerable populations.…”

“…The aim of this initiative was to determine whether a small 'affordable' cash incentive (equivalent to one USD) would improve TB treatment outcomes in the most vulnerable populations. Baluku et al (2021) reported that in rural Uganda, a clinic visit at a government institution for an individual with TB symptoms costs roughly one USD, which equates to about a quarter or more of these patients' monthly household income. Accordingly, this study reported a 59% increase in the TB cure rate and a 56% reduction in treatment LTFU after providing the incentive (Baluku et al, 2021).…”

“…Although past studies have also demonstrated that incentives increase TB successful treatment outcomes, these incentives were often too high to be viable standardised practice in resource-limited, developing countries (Ukwaja et al, 2017, Wingfield et al, 2017, Richterman et al, 2018. Another reported risk of this intervention is that, if the monetary incentive is too high, it may encourage patients who are desperately in need of money to remain ill. As a result, the one-dollar incentive proposed in Uganda (Baluku et al, 2021), in which the money reward principally covers the expenditures incurred during clinic visits, is suggested to be more feasible.…”