Table 3 An example of TB-specific cash transfer intervention: the CRESIPT study in Peru [46]

An example of a TB-specific cash transfer program was the ISIAT (Innovative Socioeconomic Interventions Against TB) project in Peru, which offered an integrated multidisciplinary community and household socio-economic intervention to TB-affected households, including food and cash transfers, microcredit, microenterprise and vocational training [28]. The results of this pilot study have informed the design of the subsequent 6-year CRESIPT (Community Randomized Evaluation of a Socio-economic Intervention to Prevent Tuberculosis) project, a community randomised study. CRESIPT aims to provide rigorous evidence of the impact of integrated social support and conditional cash transfers on: sustained cure in TB patients; prevention of TB in household contacts; and TB rates in the wider community. CRESIPT is being preceded by an on-going pilot phase to implement and refine the complex socioeconomic intervention in 32 communities, assess its impact on TB chemoprophylaxis completion, and assess its acceptance through a process evaluation.

Through engagement with participants, the national TB program and a civil society of ex-TB patients, the CRESIPT pilot developed its conditional cash transfer scheme with amounts that were perceived to be too small to affect participants’ autonomy in decision-making and large enough to reduce poverty-related TB risk factors [65]. Conditional cash transfers were provided to patient households for: i. screening for TB in household contacts and MDR-TB in patients; ii. adhering to TB treatment and chemoprophylaxis; and iii. engaging with CRESIPT social activities (household visits and participatory community meetings consisting of educational workshops and TB Clubs). A patient with non-MDR TB receiving six months of anti-TB treatment and completing all conditions optimally could receive cash transfers up to a value of US$ 230.

TB-affected households participating in the intervention received an average of US$ 183 over the course of treatment for the compliance to the conditional requirements. This amount aimed to be similar to, and thus potentially mitigate, the average TB-affected households’ direct costs of “free” TB care (i.e. TB-related costs of additional food, transport, medicines, and clinical consultations equalling approximately 10 % of an average household’s annual income). The cost of the CRESIPT pilot’s socioeconomic intervention were <10 % of overall costs of treating a TB patient with non-MDR TB in the local Peruvian setting (WHO 2014 http://www.who.int/tb/dots/planning_budgeting_tool/overview.pdf). Expert opinion suggested that an intervention that increased a National TB Programme’s budget by 50 % and led to a 33 % reduction in TB incidence would likely be adopted by governments [71, 72]. The CRESIPT pilot cash transfer intervention cost considerably less than 50 % of the per patient national TB budget, even including project staff.

An impact assessment to evaluate the effect of the CRESIPT pilot intervention on equitable access to TB treatment and prevention demonstrated improvement in treatment outcomes for patients and uptake of TB preventive therapy for the TB patients’ household members [73]. A process evaluation of the pilot suggested that: the project is likely to be sustainable due to involvement of patients and ex-patients as facilitators; there has been effective and synergistic cross-sectoral collaboration with the National TB Programme; and there is a perception from participants that the conditional cash transfers were patient-centred and empowering, especially for women. On the other hand the preliminary results of the process evaluation have shown challenges including: hidden bank charges and delays in cash transfers eroding participants’ confidence; conditional cash transfers requiring all household members to participate being poorly achieved; and high risk patients (e.g. the formerly incarcerated, the homeless, and those with drug or alcohol addiction) being difficult to engage and thus benefiting least from the intervention.