A conditional cash transfer programme in Brazil improves leprosy treatment outcomes
Authors: Alberto Novaes Ramos, Jorg Heukelbach, Maria Leide Wand-Del-Rey Oliveira
Journal: The Lancet Infectious Diseases (2020)

Despite advances in the past three decades in implementing multidrug therapy against leprosy, by the end of 2018 approximately 210 000 new leprosy cases globally have been reported to WHO.1WHOGlobal leprosy update, 2018: moving towards a leprosy-free world.Wkly Epidemiol Rec. 2019; 94: 389-412Google Scholar Brazil, in particular, has a high burden of neglected tropical diseases,2Martins-Melo FR Carneiro M Ramos Jr, AN et al.The burden of neglected tropical diseases in Brazil, 1990–2016: a subnational analysis from the Global Burden of Disease Study 2016.PLoS Negl Trop Dis. 2018; 12e0006559Crossref PubMed Scopus (71) Google Scholar including leprosy. The country has an important role in generating scientific evidence to achieve leprosy control, as it accounts for the second highest number of new leprosy cases worldwide notified by a single country. There have been about 30 000 new cases notified in Brazil in 2018, representing 93% of all cases in the WHO region of the Americas.1WHOGlobal leprosy update, 2018: moving towards a leprosy-free world.Wkly Epidemiol Rec. 2019; 94: 389-412Google Scholar As one of the countries with highest inequality worldwide, social determinants affect decisively not only the transmission and progression of disease, but also treatment adherence and cure.3de Andrade KVF Silva Nery J Moreira Pescarini J et al.Geographic and socioeconomic factors associated with leprosy treatment default: an analysis from the 100 Million Brazilian Cohort.PLoS Negl Trop Dis. 2019; 13e0007714Crossref PubMed Scopus (12) Google Scholar, 4Pescarini JM Williamson E Nery JS et al.Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.Lancet Infect Dis. 2020; (published online Feb 14.)https://doi.org/10.1016/S1473-3099(19)30624-3Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar Thus, there is a clear need to improve evidence-based policies, considering the impact of social determinants of health and the effects of social programmes on health outcomes in the Brazilian Sistema Único de Saúde (SUS; unified health system). In The Lancet Infectious Diseases, Julia Pescarini and colleagues4Pescarini JM Williamson E Nery JS et al.Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.Lancet Infect Dis. 2020; (published online Feb 14.)https://doi.org/10.1016/S1473-3099(19)30624-3Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar report the first study to evaluate the effect of a conditional cash-transfer programme on leprosy treatment outcomes. The investigators estimated the effect of the Brazilian conditional cash-transfer programme (Programa Bolsa Família [PBF]) on leprosy treatment adherence and cure in affected Brazilian residents. The complex study design was based on available national data on epidemiological surveillance of leprosy from 2007 to 2014 (a total of 282 733 new leprosy cases notified), with the analysis of more than 11 000 patients with leprosy identified in an impressive cohort of 114 million Brazilians. The effect of receiving PBF financial resources before diagnosis of the disease was assessed in terms of the likelihood of completing multidrug therapy and achieving cure when compared with people who did not receive the PBF aid. There was strong and consistent evidence that PBF participation was associated with enhanced leprosy treatment adherence (22% increased odds) and cure of leprosy (26% increased odds).4Pescarini JM Williamson E Nery JS et al.Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.Lancet Infect Dis. 2020; (published online Feb 14.)https://doi.org/10.1016/S1473-3099(19)30624-3Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar The 100 Million Cohort database initiative permits the study of social determinants and the effects of social policies and programmes on different aspects of health, linking individual information.4Pescarini JM Williamson E Nery JS et al.Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.Lancet Infect Dis. 2020; (published online Feb 14.)https://doi.org/10.1016/S1473-3099(19)30624-3Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar For leprosy, in addition to the multidrug therapy adherence and cure dimensions addressed in the Article, the research group (with the leadership of the Brazilian Centre for Data and Knowledge Integration for Health [CIDACS]) has advanced knowledge on issues such as detection of new cases, appropriate default treatment, and development of physical disabilities.3de Andrade KVF Silva Nery J Moreira Pescarini J et al.Geographic and socioeconomic factors associated with leprosy treatment default: an analysis from the 100 Million Brazilian Cohort.PLoS Negl Trop Dis. 2019; 13e0007714Crossref PubMed Scopus (12) Google Scholar, 4Pescarini JM Williamson E Nery JS et al.Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.Lancet Infect Dis. 2020; (published online Feb 14.)https://doi.org/10.1016/S1473-3099(19)30624-3Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Nery JS Ramond A Pescarini JM et al.Socioeconomic determinants of leprosy new case detection in the 100 Million Brazilian Cohort: a population-based linkage study.Lancet Glob Health. 2019; 7: e1226-e1236Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 6Nery JS Pereira SM Rasella D et al.Effect of the Brazilian conditional cash transfer and primary health care programs on the new case detection rate of leprosy.PLoS Negl Trop Dis. 2014; 8e3357Crossref PubMed Scopus (66) Google Scholar The findings of Pescarini and colleagues reinforce the potential of PBF to increase leprosy treatment completion by reducing the financial effect of the diagnosis and by strengthening the interaction of affected people with health services. The observed adherence and cure improvements to multidrug therapy in patients with multibacillary disease strongly indicate the potential of reducing the burden of disease.4Pescarini JM Williamson E Nery JS et al.Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.Lancet Infect Dis. 2020; (published online Feb 14.)https://doi.org/10.1016/S1473-3099(19)30624-3Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar Interventions to address socioeconomic deprivation, along with continued efforts to improve access to health care, have the potential to improve leprosy treatment outcomes and disease control.3de Andrade KVF Silva Nery J Moreira Pescarini J et al.Geographic and socioeconomic factors associated with leprosy treatment default: an analysis from the 100 Million Brazilian Cohort.PLoS Negl Trop Dis. 2019; 13e0007714Crossref PubMed Scopus (12) Google Scholar, 5Nery JS Ramond A Pescarini JM et al.Socioeconomic determinants of leprosy new case detection in the 100 Million Brazilian Cohort: a population-based linkage study.Lancet Glob Health. 2019; 7: e1226-e1236Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar The adoption of PBF is useful and has positive effects on many different populations, but its success requires strong intersectoral policies that seek to reduce poverty and extreme poverty. However, as mentioned by the authors, since 2016 the Brazilian Government has implemented fiscal policies that focus on austerity measures affecting environmental, educational, and health policies, which in turn sustained and even increased poverty levels and social vulnerability of affected populations.7Lima HSC Felipe JS Silva JAA Temporão JG Padilha ARS Reis AAC SUS, health, and democracy: challenges for Brazil: manifesto of six former Health Ministers on the 16th National Health Conference.Cien Saude Colet. 2019; 24: 3713-3716Crossref PubMed Scopus (1) Google Scholar, 8Castro MC Massuda A Almeida G et al.Brazil's unified health system: the first 30 years and prospects for the future.Lancet. 2019; 394: 345-356Summary Full Text Full Text PDF PubMed Scopus (262) Google Scholar, 9Malta DC Reis AACD Jaime PC Morais Neto OL Silva MMAD Akerman M Brazil's Unified Health System and the National Health Promotion Policy: prospects, results, progress and challenges in times of crisis.Cien Saude Colet. 2018; 23: 1799-1809Crossref PubMed Scopus (29) Google Scholar In addition to the negative effect of these policies on the PBF, the current political, institutional, and economic contexts have threatened the substantial achievements made since the implementation of the Brazilian Constitution more than 30 years ago, including the sustainability of SUS.7Lima HSC Felipe JS Silva JAA Temporão JG Padilha ARS Reis AAC SUS, health, and democracy: challenges for Brazil: manifesto of six former Health Ministers on the 16th National Health Conference.Cien Saude Colet. 2019; 24: 3713-3716Crossref PubMed Scopus (1) Google Scholar, 8Castro MC Massuda A Almeida G et al.Brazil's unified health system: the first 30 years and prospects for the future.Lancet. 2019; 394: 345-356Summary Full Text Full Text PDF PubMed Scopus (262) Google Scholar, 9Malta DC Reis AACD Jaime PC Morais Neto OL Silva MMAD Akerman M Brazil's Unified Health System and the National Health Promotion Policy: prospects, results, progress and challenges in times of crisis.Cien Saude Colet. 2018; 23: 1799-1809Crossref PubMed Scopus (29) Google Scholar, 10Rasella D Basu S Hone T Paes-Sousa R Ocké-Reis CO Millett C Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study.PLoS Med. 2018; 15e1002570Crossref PubMed Scopus (105) Google Scholar In the past 3 years, changes in the National Policy of Primary Health Care, the structuring axis of the SUS, endanger the development of comprehensive care and surveillance actions aimed at leprosy control in Brazil.7Lima HSC Felipe JS Silva JAA Temporão JG Padilha ARS Reis AAC SUS, health, and democracy: challenges for Brazil: manifesto of six former Health Ministers on the 16th National Health Conference.Cien Saude Colet. 2019; 24: 3713-3716Crossref PubMed Scopus (1) Google Scholar, 8Castro MC Massuda A Almeida G et al.Brazil's unified health system: the first 30 years and prospects for the future.Lancet. 2019; 394: 345-356Summary Full Text Full Text PDF PubMed Scopus (262) Google Scholar, 9Malta DC Reis AACD Jaime PC Morais Neto OL Silva MMAD Akerman M Brazil's Unified Health System and the National Health Promotion Policy: prospects, results, progress and challenges in times of crisis.Cien Saude Colet. 2018; 23: 1799-1809Crossref PubMed Scopus (29) Google Scholar In the year of the XVI National Health Conference (Conferência Nacional de Saúde), six former Brazilian health ministers signed a manifesto summarising the impending risks that threaten the SUS, defending the universal health system as an effective instrument to provide access to health care and to foster citizenship.7Lima HSC Felipe JS Silva JAA Temporão JG Padilha ARS Reis AAC SUS, health, and democracy: challenges for Brazil: manifesto of six former Health Ministers on the 16th National Health Conference.Cien Saude Colet. 2019; 24: 3713-3716Crossref PubMed Scopus (1) Google Scholar We emphasise the great potential of this study in subsidising equitable public policies aimed at addressing favourable leprosy treatment outcomes in vulnerable populations. The study enhances the evidence of the effects of social policies on leprosy control, indicating the need to focus on poverty reduction and social inequalities in Brazil, which indeed are related to all neglected tropical diseases. The PBF should be included as an essential component of WHO's Global Leprosy Strategy 2016–20, contributing to the achievement of specific Sustainable Development Goals for neglected tropical diseases.1WHOGlobal leprosy update, 2018: moving towards a leprosy-free world.Wkly Epidemiol Rec. 2019; 94: 389-412Google Scholar, 2Martins-Melo FR Carneiro M Ramos Jr, AN et al.The burden of neglected tropical diseases in Brazil, 1990–2016: a subnational analysis from the Global Burden of Disease Study 2016.PLoS Negl Trop Dis. 2018; 12e0006559Crossref PubMed Scopus (71) Google Scholar, 4Pescarini JM Williamson E Nery JS et al.Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.Lancet Infect Dis. 2020; (published online Feb 14.)https://doi.org/10.1016/S1473-3099(19)30624-3Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar We declare no competing interests. Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental studyOur results suggest that being a beneficiary of the PBF, which facilitates cash transfers and improved access to health care, is associated with greater leprosy multidrug therapy adherence and cure in multibacillary cases. These results are especially relevant for patients with multibacillary disease, who are treated for a longer period and have lower cure rates than those with paucibacillary disease. Full-Text PDF Open Access