Social protection interventions could improve tuberculosis treatment outcomes
Authors: Kingsley N Ukwaja
Journal: The Lancet Global Health (2018)

Eradication of poverty in all forms remains a global challenge identified by the UN Sustainable Development Goals.1UNSustainable Development Goals.http://www.un.org/sustainabledevelopmentDate accessed: November 2, 2018Google Scholar Tuberculosis is a disease of poverty and its transmission is perpetuated by malnutrition, overcrowding, HIV and AIDs, and other conditions associated with socioeconomic and social determinants of health.1UNSustainable Development Goals.http://www.un.org/sustainabledevelopmentDate accessed: November 2, 2018Google Scholar, 2Ukwaja KN Modebe O Igwenyi C Alobu I The economic burden of tuberculosis care for patients and households in Africa: a systematic review.Int J Tuberc Lung Dis. 2012; 16: 733-739Crossref PubMed Scopus (66) Google Scholar Ending the tuberculosis epidemic is a target of the Sustainable Development Goals that requires the implementation of various biomedical, public health, and socioeconomic interventions in addition to research and innovation.3Lönnroth K Raviglione M The WHO's new End TB Strategy in the post-2015 era of the Sustainable Development Goals.Trans R Soc Trop Med Hyg. 2016; 110: 148-150Crossref PubMed Scopus (91) Google Scholar One of the pillars of the WHO End Tuberculosis Strategy includes social protection, poverty alleviation, and actions on other determinants of tuberculosis. Social protection therefore involves prevention or alleviation of poverty or susceptibility to poverty by enhancing the capacity of individuals to protect themselves against hazards, treatment interruption, and loss of income.4Boccia D Pedrazzoli D Wingfield T et al.Towards cash transfer interventions for tuberculosis prevention, care and control: key operational challenges and research priorities.BMC Infect Dis. 2016; 16: 307Crossref PubMed Scopus (38) Google Scholar A modelling analysis5Carter DJ Glaziou P Lönnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar has shown that global tuberculosis incidence would be reduced by 84·3% if poverty was eliminated and all individuals were enrolled in social protection programmes, and implementation of the social protection component alone would reduce tuberculosis incidence by 76·1%. Social protection in the form of cash transfer interventions can be tuberculosis specific, tuberculosis inclusive, or tuberculosis sensitive depending on the target population:4Boccia D Pedrazzoli D Wingfield T et al.Towards cash transfer interventions for tuberculosis prevention, care and control: key operational challenges and research priorities.BMC Infect Dis. 2016; 16: 307Crossref PubMed Scopus (38) Google Scholar tuberculosis-specific schemes are interventions targeted at households or individuals affected by tuberculosis with the aim of improving a number of tuberculosis indicators; tuberculosis-sensitive schemes are interventions that can potentially affect tuberculosis epidemiology and control by targeting people at high risk of tuberculosis; and tuberculosis-inclusive schemes are interventions in which having tuberculosis or being a member of a household affected by tuberculosis is one of the inclusion criteria for the programme albeit not the only one.4Boccia D Pedrazzoli D Wingfield T et al.Towards cash transfer interventions for tuberculosis prevention, care and control: key operational challenges and research priorities.BMC Infect Dis. 2016; 16: 307Crossref PubMed Scopus (38) Google Scholar Small-scale studies6Ukwaja KN Alobu I Gidado M Olajumoke O Oshi DC Economic support intervention improves tuberculosis treatment outcomes in rural Nigeria.Int J Tuberc Lung Dis. 2017; 21: 564-570Crossref PubMed Scopus (16) Google Scholar, 7Wingfield T Tovar MA Huff D et al.A randomized controlled study of socioeconomic support to enhance tuberculosis prevention and treatment, Peru.Bull World Health Organ. 2017; 95: 270-280Crossref PubMed Scopus (50) Google Scholar have shown that providing social protection in the form of cash transfers to patients with tuberculosis might improve treatment outcomes. Little is known about the forms of social protection that are most effective in improving treatment outcomes and how such initiatives might be best integrated within tuberculosis control programmes, especially in high burden settings.6Ukwaja KN Alobu I Gidado M Olajumoke O Oshi DC Economic support intervention improves tuberculosis treatment outcomes in rural Nigeria.Int J Tuberc Lung Dis. 2017; 21: 564-570Crossref PubMed Scopus (16) Google Scholar Much of the early experiences in this area have been small-scale studies of tuberculosis-specific interventions done in real-life situations or randomised control trials.6Ukwaja KN Alobu I Gidado M Olajumoke O Oshi DC Economic support intervention improves tuberculosis treatment outcomes in rural Nigeria.Int J Tuberc Lung Dis. 2017; 21: 564-570Crossref PubMed Scopus (16) Google Scholar, 7Wingfield T Tovar MA Huff D et al.A randomized controlled study of socioeconomic support to enhance tuberculosis prevention and treatment, Peru.Bull World Health Organ. 2017; 95: 270-280Crossref PubMed Scopus (50) Google Scholar In The Lancet Global Health, Janaina Oliosi and colleagues,8Oliosi JGN Reis-Santos B Locatelli RL et al.Effect of the Bolsa Familia Programme on the outcome of tuberculosis treatment: a prospective cohort study.Lancet Glob Health. 2019; (published online Dec 21.)http://dx.doi.org/10.1016/S2214-109X(18)30478-9Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar report a prospective cohort study of the effects of the Bolsa Familia Program (BFP) on the outcomes of tuberculosis treatment in Brazil. The BFP is a tuberculosis-sensitive conditional cash transfer programme, which targets poor families (per capita monthly income US$25·60–51·20) with pregnant or lactating women or children and adolescents aged 17 years or younger and all extremely poor families (per capita monthly income ≤$25·60). The amount of money received per family is determined by various types of benefits planned within the scope of the programme (ie, US$25·60 basic benefit that might increase according to family composition). Areas with high BFP coverage have been shown to correlate with lower incidence of tuberculosis, but the association between the BFP programme and tuberculosis treatment outcomes is less clear.8Oliosi JGN Reis-Santos B Locatelli RL et al.Effect of the Bolsa Familia Programme on the outcome of tuberculosis treatment: a prospective cohort study.Lancet Glob Health. 2019; (published online Dec 21.)http://dx.doi.org/10.1016/S2214-109X(18)30478-9Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar The authors analysed the treatment outcomes of 1239 individuals treated for tuberculosis, of whom 196 (16%) patients qualified for and received BFP and 1043 (84%) patients did not. The findings suggest that although the proportion of patients who were cured of tuberculosis in the BFP group was not significantly different from that of patients in the non-BFP group (173 [88%] of 196 patients vs 912 [87%] of 1043 patients, p=0·774), propensity score matching showed that rate of cure was 7·6% higher and the proportion of patients who dropped out was 7% lower in the BFP group than the non-BFP group and these differences were statistically significant. The study has some limitations. Since the selection of the beneficiaries of the BFP was not random, comparison of treatment outcome between the BFP and non-BFP groups is inappropriate because the findings might be due differences in the baseline characteristics between the two groups. Propensity score matching analysis was used to overcome this limitation by estimating the conditional probability of an individual being beneficiary on the basis of their observed characteristics.8Oliosi JGN Reis-Santos B Locatelli RL et al.Effect of the Bolsa Familia Programme on the outcome of tuberculosis treatment: a prospective cohort study.Lancet Glob Health. 2019; (published online Dec 21.)http://dx.doi.org/10.1016/S2214-109X(18)30478-9Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar However, as a result of the relatively small sample size of the BFP beneficiaries used for propensity score matching, the possibility of residual confounding from covariates that are mostly missing or remain unbalanced cannot be ruled out. The BFP provides an example of how a tuberculosis-sensitive social protection intervention could be integrated in national tuberculosis programmes to ensure that patients with tuberculosis and their families are protected from the substantial costs of accessing or continuing tuberculosis care.9Ukwaja KN Alobu I Abimbola S Hopewell PC Household catastrophic payments for tuberculosis care in Nigeria: incidence, determinants, and policy implications for universal health coverage.Infect Dis Poverty. 2013; 2: 21Crossref PubMed Scopus (63) Google Scholar These findings from a middle-income country provide a potential model for scale-up of social protection interventions in other settings. However, the reach and coverage of the BFP among patients with tuberculosis at the national level requires evaluation to ensure that the cash transfer interventions are sensitive enough to identify patients with tuberculosis who are most in need. A higher level of sensitivity could be achieved using a more inclusive, non-stigmatising, targeting strategy to identify and enrol patients with tuberculosis and other beneficiaries.10Carter DJ Daniel R Torrens AW et al.The impact of a governmental cash transfer programme on tuberculosis cure rate in Brazil: a quasi-experimental approach.bioRxiv. 2018; (published online April 30.) (preprint).DOI:10.1101/311589Google Scholar This study adds to the growing evidence for the expansion of social protection interventions for individuals with tuberculosis as a valid mechanism for improving tuberculosis outcomes beyond the traditional biomedical approach.10Carter DJ Daniel R Torrens AW et al.The impact of a governmental cash transfer programme on tuberculosis cure rate in Brazil: a quasi-experimental approach.bioRxiv. 2018; (published online April 30.) (preprint).DOI:10.1101/311589Google Scholar I declare no competing interests. Effect of the Bolsa Familia Programme on the outcome of tuberculosis treatment: a prospective cohort studyBFP alone had a direct effect on tuberculosis treatment outcome and could greatly contribute to the goals of the WHO End TB Strategy. Full-Text PDF Open Access