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. 2019 Jan 24;4(1):e001029.
doi: 10.1136/bmjgh-2018-001029. eCollection 2019.

The impact of a cash transfer programme on tuberculosis treatment success rate: a quasi-experimental study in Brazil

Daniel J Carter  1   2 , Rhian Daniel  2 , Ana W Torrens  3 , Mauro N Sanchez  4 , Ethel Leonor N Maciel  5 , Patricia Bartholomay  6 , Draurio C Barreira  7 , Davide Rasella  8 , Mauricio L Barreto  9   10 , Laura C Rodrigues  1   10 , Delia Boccia  1
Affiliations

The impact of a cash transfer programme on tuberculosis treatment success rate: a quasi-experimental study in Brazil

Daniel J Carter et al. BMJ Glob Health. .

Abstract

Background: Evidence suggests that social protection policies such as Brazil's Bolsa Família Programme (BFP), a governmental conditional cash transfer, may play a role in tuberculosis (TB) elimination. However, study limitations hamper conclusions. This paper uses a quasi-experimental approach to more rigorously evaluate the effect of BFP on TB treatment success rate.

Methods: Propensity scores were estimated from a complete-case logistic regression using covariates from a linked data set, including the Brazil's TB notification system (SINAN), linked to the national registry of those in poverty (CadUnico) and the BFP payroll.

Results: The average effect of treatment on the treated was estimated as the difference in TB treatment success rate between matched groups (ie, the control and exposed patients, n=2167). Patients with TB receiving BFP showed a treatment success rate of 10.58 percentage points higher (95% CI 4.39 to 16.77) than patients with TB not receiving BFP. This association was robust to sensitivity analyses.

Conclusions: This study further confirms a positive relationship between the provision of conditional cash transfers and TB treatment success rate. Further research is needed to understand how to enhance access to social protection so to optimise public health impact.

Keywords: Bolsa Família; causal inference; conditional cash transfer; propensity score matching; quasi-experimental design; social protection; tuberculosis.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Directed acyclic graph (DAG) outlining the pathways linking Bolsa Familia with tuberculosis (TB) outcomes. A DAG was built to conceptualise the potentially causal relationships between constructs relevant for measuring the impact of Bolsa Familia on TB treatment success rate. Red nodes are ancestors of both the outcome and the exposure (ie, confounders) while grey nodes are unassociated with the outcome and exposure. Blue nodes are ancestors of the outcome. The DAG links nodes that represent constructs that are measured by covariates table 2).
Figure 2
Figure 2
Standardised mean difference (SMD). The change in SMD in the matched and unmatched groups for each variable. A smaller difference indicates improved balance between groups; being below the threshold of 0.1 is conservatively considered to be effectively balanced. Balance has been largely improved by matching though some imbalance remains between groups. bacilo.i, initial sputum smear; disorder, any other chronic illness; est, streptomycin; eta, ethambutol; eti, ethionamide; exp, expenditure; iso, isoniazid; mental, mental disorder; pir, pyrazinamide; rif, rifampicin; thorax, chest X-ray; throat, throat culture; tst, tuberculin skin test.
Figure 3
Figure 3
Overlap in estimated propensity scores between those receiving and those not receiving Bolsa Família Programme (BFP) before matching (top left) and after matching (top right). Overlap has been substantially improved by matching to treated (exposed) patients, suggestive of the groups being balanced on the propensity score. The region of overlap extends between 0 and 1. Also presented are similar plots of variable distribution before and after matching for income, age and schooling (from top to bottom). Dotted lines on the income distributions mark the thresholds for BFP eligibility.
See this image and copyright information in PMC

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