Abstract
A direct benefit transfer (DBT) program was launched to address the dual epidemic of under-nutrition and tuberculosis (TB) in India. We conducted this study to determine whether non-receipt of DBT was associated with unfavorable treatment outcomes among patients with TB and to explore the perspectives of patients and program functionaries regarding the program. We conducted a retrospective cohort study among 426 patients with drug-sensitive pulmonary TB on treatment during January-September 2019 to determine the association between non-receipt of DBT and unfavorable treatment outcomes, which was followed by in-depth interviews of 9 patients and 8 program functionaries to explore their perspectives on challenges and suggestions regarding the DBT program. Multivariate logistic regression was applied to determine whether non-receipt of DBT was independently associated with unfavorable treatment outcomes, while the in-depth interviews were transcribed to describe them as codes and categories. Among the 426 patients, 9% of the patients did not receive DBT and 91% completed their treatment. Non-receipt of DBT was associated with a 5 (95% CI: 2-12) times higher odds of unfavorable treatment outcomes on multivariable analysis. Patients not owning a bank account was the primary challenge perceived by the program staff. The patients perceived the assistance under DBT to be insufficient to buy nutritious food throughout the course of treatment. The program functionaries as well as the patients suggested increasing the existing assistance under DBT along with the provision of a monthly nutritious food-kit. DBT improved the treatment completion rates among patients with TB in our setting. Provision of a monthly nutritious food-kit with an increase in the existing assistance under DBT might further improve the treatment outcomes. Future research should determine the long-term financial sustainability for 'DBT plus food-kit' vs. universal cash transfers in India.
Highlights
India accounted for 26% of the global incident cases of tuberculosis (TB) worldwide in 2020.1 Out of the estimated global annual incidence of 5.8 million TB cases, nearly 1.5 million were reported from India in 2020, making it the country with the highest TB burden worldwide.[1]
There is increased mortality among patients with TB due to under-nutrition.[6,7,8]. To address this dual epidemic, in the year 2013, World Health Organization (WHO) released guidelines on nutritional care and support among patients with TB.[9]. India adapted these guidelines in the year 2017 with the release of country-specific ‘Guidance document: Nutritional care and support for patients with TB in India.’[10]. Assessment of nutritional status at diagnosis, nutritional counseling through a mobile application, provision of enhanced ration, and monitoring the weight gain were a few benefits enlisted in the guidance document.[10,11]
The median (IQR) monthly family income of the patients was Indian rupees (INR) 8000 (5000-12 000) [~US$ 114 (71-171)] and 35% of the patients were living below the Characteristics of Patients Sociodemographic Characteristics Age (y) Male Educational status
Summary
India accounted for 26% of the global incident cases of tuberculosis (TB) worldwide in 2020.1 Out of the estimated global annual incidence of 5.8 million TB cases, nearly 1.5 million were reported from India in 2020, making it the country with the highest TB burden worldwide.[1]. DBT is the only scheme functional under the nutritional support program in India, the monetary benefit helps in preventing catastrophic costs and improves treatment adherence
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