Why condition cash transfers? A multimethod pilot study evaluating the conditioning of cash transfers for tuberculosis treatment

Background: Tuberculosis (TB) is the archetypal disease of poverty, driven by social determinants and causing catastrophic costs. A 2023 United Nations General Assembly resolution called for all TB-affected people to receive a social benefits package by 2027. Cash transfers have been shown to improve health outcomes; however, operational evidence on their implementation and effectiveness in reducing catastrophic costs due to TB is limited. This pilot study sought to assess the feasibility of delivering cash transfers to people affected by drug-susceptible TB to inform the design of a future trial. 

Methods: A longitudinal, non-randomized cohort study was conducted in Ho Chi Minh City, Vietnam. Half of the participants received unconditional cash transfers (UCTs) while the other half received conditional cash transfers (CCTs) after monthly appointment attendance and completion of 85% of scheduled doses. We analyzed pilot data to assess rates of participant enrollment, adherence and retention in the intervention, TB treatment success, and catastrophic cost incurrence. A 22-day time and motion study quantified the distribution of time pilot staff spent administering the cash transfer intervention by cohort. 

Results: Delivering cash transfers was feasible, with 60/70 (85.7%) and 60/66 (90.9%) of eligible individuals in the CCT and UCT cohorts agreeing to participate, respectively. Only 12.3% of CCT participants had one or more transfers withheld and 5.8% of the total expected CCTs were withheld. Delivering CCTs in the observation period took twice as much time as UCTs (32.4 hours for 43 CCT participants vs. 16.0 hours for 47 UCT participants). There were no significant differences in TB treatment success rates between the cohorts (91.7% CCT vs. 93.3% UCT). Cash transfers caused catastrophic cost incurrence to decline by 12.9% in the CCT cohort (44.2% to 38.5%) and 26.9% in the UCT cohort (26.8% to 19.6%). 

Conclusions: Cash transfers are a feasible way to mitigate the economic burden of TB in Vietnam. The conditionality assessed was not associated with any quantifiable benefits to TB-affected people, and required more effort to implement. A larger trial utilizing similar methods and outcomes is warranted. Our findings inform the design of a slightly modified approach of cash transfer delivery for the larger trial.