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To quantify the impact of cash transfer and microfinance interventions on a selected list of tuberculosis (TB) risk factors and assess their potential role in supporting TB control.
Published and unpublished references identified from clinical and social electronic databases, grey literature and web sites.
Eligible interventions had to be conducted in middle- or low-income countries and document an impact evaluation on any of the following outcomes: 1) TB or other respiratory infections; 2) household socio-economic position; and 3) factors mediating the association between low household socio-economic position and TB, including inadequate health-seeking behaviours, food insecurity and biological TB risk factors such as human immunodeficiency virus (HIV) and adult malnutrition. Interventions targeting special populations were excluded.
Fifteen cash transfer schemes (four unconditional and 11 conditional) and seven microfinance programmes met the eligibility criteria. No intervention addressed TB or any other respiratory infection. Of 11 cash transfer and four microfinance interventions, respectively seven and four reported a positive impact on indicators of economic well-being. A positive impact on household food security was documented in respectively eight of nine and three of five cash transfer and microfinance interventions. Improved health care access was documented respectively in 10 of 12 cash transfer and four of five microfinance interventions. The only intervention evaluating impact on HIV incidence was a microfinance project that found no effect. No cash transfer or microfinance interventions had an impact on adult malnutrition.
Cash transfer and microfinance interventions can positively impact TB risk factors. Evaluation studies are urgently needed to assess the impact of these social protection interventions on actual TB indicators.
THERE IS EVIDENCE that the reduction in tuberculosis (TB) mortality observed in Europe and North America before World War II resulted from the successful combination of economic growth and specific public health policies such as patient isolation and the elimination of bovine TB.1,2 The importance of a combined approach has recently been reinforced by a number of studies suggesting that while DOTS programmes have significantly contributed to the reduction of TB prevalence and TB mortality, socio-economic development still remains the main determinant of TB incidence decline in many regions of the world.3-5 Despite this, literature on interventions addressing structural and social determinants6 of TB is currently virtually non-existent. Through the improvement of material living conditions, psychosocial circumstances and health-seeking behaviours, these interventions have the double potential to improve access to quality TB care and also reduce people’s vulnerability to TB.
A broad range of poverty alleviation strategies may achieve the above objectives; among them, cash transfer and microfinance programmes have gathered considerable visibility in the last decade, due to both the large number of individuals enrolled and the increasing number of studies formally documenting their impact.
Cash transfers are innovative forms of social protection based on the provision of money to poor or vulnerable households and individuals (such as the elderly and children) with the aim of enabling them to move out of poverty by protecting and building their financial, physical and human capital assets.7 Cash transfers can be unconditional (given without obligation) or conditional on some behavioural requirements, such as school enrolment, health services utilisation and/or the attendance of health education workshops. Microfinance programmes are considered poverty alleviation measures aimed at directly averting deprivation.8 These programmes are based on the provision to the poor of small loans to enable them to engage in productive activities that can ultimately contribute to their long-term economic growth and productivity.8
Despite the impressive scale-up of these interventions and their acknowledged potential public health relevance,9,10 their relevance for TB control largely depends on evidence of their effect on outcomes epidemiologically linked to TB and the critical assessment of the challenges limiting their implementation in the context of TB.
This review aimed to address these issues by: 1) systematically quantifying the impact of these interventions and 2) evaluating their main design and implementation features from the perspective of TB control.
Hargreaves et al. discuss the mechanisms by which cash transfer and microfinance interventions might contribute to strengthening the international TB response, which outcome and risk factors may be potentially impacted by such interventions, and which effect should be expected depending on the stage of TB targeted (i.e., TB exposure, infection, disease and outcomes).11 Building on this conceptual framework, we designed this review to formally assess the impact of cash transfer and microfinance interventions on the hypothesised TB outcomes and risk factors. In particular, we focused on household socio-economic position and those risk factors that mediate the association between household socio-economic position and TB disease, including inappropriate health-seeking behaviours, food insecurity12 and biological risk factors impairing host immune system defences (such as human immunodeficiency virus [HIV] and adult malnutrition; Figure).
A wide range of electronic databases and websites were searched (Table 1). Eligible interventions had to: 1) address the following outcomes of interest: TB (or other respiratory infections), household socio-economic position or any of the postulated mediating risk factors (Figure); 2) explicitly document an impact evaluation (i.e., the assessment of any change in a given outcome among the intervention beneficiaries compared to the non-beneficiaries); and 3) take place in low- and middle-income countries.
Experimental and observational studies with a controlled or uncontrolled design providing a retrospective or a prospective evaluation of the intervention of interest were included. No time or language restriction was applied. Studies conducted in specific special settings (e.g., hospitals, prisons, workplaces, schools) or in specific population groups (e.g., homeless, professional categories, students) were excluded. Given the heterogeneity of the study design and study results, the evidence collected was summarised through a ’narrative synthesis’ approach.14,15
Approximately 150 documents of potential interest were appraised. Through them, we identified 15 cash transfer and 7 microfinance intervention evaluations meeting the inclusion criteria, from respectively 13 and 5 different countries (Table 2). Evidence on microfinance was integrated with data from a recent review on the impact of microfinance on poverty and household socio-economic position.16
With the exception of one microfinance intervention in Cambodia,17 none of the interventions we reviewed targeted individuals with any kind of health conditions. For both microfinance and cash transfer interventions, the selection of the target population was based mainly on socio-economic criteria, the specificity of which varied depending on the intervention objectives and resources available.
Four of the 15 cash transfer programmes were unconditional, and these were all reported from African countries, including Ethiopia,18,19 Zambia20 and Malawi21,22 (Table 2). The only African study of a conditional programme was from Malawi, in which conditionality was based on HIV testing and the collection of HIV results.23
Virtually all conditional cash programmes from Latin America required child school enrolment, the attendance of nutritional education sessions and health care uptake for children (<5 years of age) and pregnant/lactating women; adult health conditionalities were less common, and included generic health care,24,25 in-facility medically attended delivery,26,27 HIV testing and result recollection.28
Apart from the Dowa Emergency Cash Transfers (DECT) intervention in Malawi,21 cash transfer schemes all employed complex impact evaluation designs, including community randomised trials and quasi-experimental studies (Table 2). Cross-sectional surveys were more commonly employed in microfinance interventions. The impact data refer to a follow up period of between 1 and 3 years of observation in most interventions (Table 2). Only in the microfinance intervention in Cambodia was the impact of the intervention measured against TB indicators.17
Evidence was gathered from 11 cash transfer and four microfinance interventions (Table 2).
In Nicaragua, Red de Protección Social beneficiary households found a significant net increase in both the total and per capita annual consumption (Table 3).29 A net increase in the overall monthly household expenditure was observed among the beneficiary households of PROGRESA in Mexico24 and the Programa Familias en Acción in Colombia,32 whereas Rural Maintenance Programme (RMP) beneficiaries in Bangladesh experienced a 31% increase in their monthly per capita expenditure (Table 3).34 In Malawi, Mchinji households showed a significantly higher annual expenditure, a higher income from all sources,22 as well as a higher number of assets owned compared to the control households.22 These results were also observed in Zambia (Table 3).20,37 The proportion of households living below the poverty line significantly decreased in Nicaragua,29 Colombia32 and Bangladesh34 (Table 3). No effect was detected among cash transfer participants in Honduras,38 Ecuador,38 Brazil33 or Ethiopia18 (Table 2).
Microfinance appeared to significantly reduce extreme poverty, as demonstrated by the Challenge the Frontiers of Poverty Reduction/Targeting the Ultra Poor (CFRP/TUP) and the Rural Development Programme (RDP) interventions in Bangladesh39,40 (Tables (Tables33 and and4).4). The percentage of Income Generation for Vulnerable Group Development (IGVGD) households earning more than 300 Taka rose from 7% (1994) to 64% (1996); however, it dropped to 31% 3 years after the intervention.47 Additional evidence from Goldberg’s review showed the consistently positive effect of microcredit on household poverty and socio-economic position.16 The Intervention with Microfinance for AIDS (acquired immunedeficiency syndrome) and Gender Equity (IMAGE) study in South Africa appeared to somewhat improve the economic well-being of beneficiary households (Table 4).42
Evidence was gathered from nine cash transfer and five microfinance interventions (Table 1), of which respectively eight and three reported a positive impact. An increase in food expenditure was documented in the conditional transfer programmes of Mexico,30 Nicaragua,49 Colombia,32 Brazil33 and Bangladesh34 and both the social cash transfer schemes in Zambia36,37 and the Mchinji in Malawi22 (Table 3). Beneficiaries of PROGRESA in Mexico and RMP in Bangladesh experienced a significant increase in the average daily energy intake.30,34 Except for Ethiopia,18 all the cash transfer schemes in Africa documented a significant increase in the daily number of meals consumed and a reduction in the number of households still hungry after a meal.20-22 Higher food quality and diversity are also an indicator of food security,50 and were both found to be improved in the cash transfer programmes of Mexico,30 Nicaragua,49 Zambia,36 and both the DECT and Mchinji cash transfer schemes in Malawi (Table 3).21,22
Among microfinance interventions, food expenditure increased significantly among CFRP-TUP44 and Grameen Bank clients (Tables (Tables22--44),16 whereas no effect was observed among the IMAGE42 and WISDOM beneficiaries (Table 4).51 CFRP-TUP in Bangladesh39 and the Kafo Jijinew in Mali16 resulted in a significant reduction of the food insecurity experienced by clients in terms of acute food shortage,16,39 chronic food deficit39 and duration of food insecurity (Table 4).16 No effect on food security was observed among the IMAGE42 and WISDOM clients51 (Table 3). CFRP-TUP beneficiaries consumed significantly higher food quantity and quality intake compared to the control group (Table 4).44
Evidence was derived from 12 cash transfer and six microfinance interventions (Table 1). In Mexico, PROGRESA resulted in an 18% increase in child and adult health care visits in the intervention areas compared to control areas.24 A significant increase in the number of child-care visits was documented from Honduras,31 Nicaragua,29 Colombia52 and Jamaica25 (Table 3). Maternal health care also appeared to be improved, in terms of the frequency of antenatal visits,24,27,31 in-facility delivery,26,27 skilled birth attendance26,27 and the quality of services requested and received by women (Table 2).53 Mchinji beneficiaries in Malawi were significantly more likely to access heath care when sick compared to control households (Table 3).22 Unlike Zambia, where no effect was detected,36 Mchinji beneficiaries showed a significant increase in the household expenditure on each adult illness (Table 2).22 In the other Malawi study, monetary incentive resulted in a significant 27% increase in HIV testing and a 43% increase in voluntary counselling and testing attendance (Table 3).
CFRP-TUP microfinance clients experienced a significant increase in the use of formal medical care and health expenditure per ill person (Table 4),54 whereas, unexpectedly, the RDP/International Centre for Diarrhoeal Research Bangladesh intervention resulted in a significant increase in the proportion of households using self-care as an elective health care strategy (Table 2).55 Self-help group clients in India were significantly less likely than the comparison group to have experienced health exclusion.48 The Cambodia Health Committee intervention was associated with significant increases in both extra-pulmonary TB detection and earlier diagnosis compared to its hospital-based counterpart (Table 4).17 Finally, at follow-up, the IMAGE study showed a significant increase in the voluntary counselling and testing uptake in the intervention group compared to controls (Table 4).41
Impact on adult nutritional status, assessed as body mass index (BMI), was documented in three cash transfer schemes in Mexico,56 Bangladesh,34 Malawi,22 and two microfinance interventions in Ethiopia51 and Bangladesh.57 However, none of them appeared to have a significant positive impact on this indicator (Table 2). In Mexico, doubling cash transfer was associated with higher BMI among both male and female PROGRESA participants, but it was also associated with a higher prevalence of excess weight and obesity (Table 2).56 No significant reduction in HIV incidence was detected in the villages covered by the IMAGE intervention (Table 2).42
This review shows a lack of studies on microfinance and cash transfer interventions that specifically address TB or other respiratory infections. While the documented effect on risk factors epidemiologically relevant for TB may be an informative way of inferring the potential impact on TB of such interventions,58 this evidence cannot replace actual studies specifically addressing TB. The evidence gathered comes from a relatively small, heterogeneous pool of studies, making the data synthesis methodologically challenging and difficult to interpret. Also, given the relatively short follow-up period in many of the studies, little can be concluded concerning the sustainability of these impact findings. As a result, conclusions on the two main questions posed by this review should be drawn with caution.
Both conditional and unconditional cash transfer programmes have reported influences on risk factors for TB in countries with a major TB burden. In principle, if rolled out in communities with a high TB burden, these interventions have the potential to improve people’s access to TB service access and reduce people’s vulnerability to TB, by improving households’ socio-economic position and food security (in terms of both food availability and food diversity). The importance of the latter effect is supported by at least three historical studies that, despite their ecological design, present fairly convincing evidence that a low-protein diet has a direct effect on TB incidence.59 Although less consistently, this review also suggests that microfinance could benefit TB-affected communities by turning the loans received into income-generating activities. This may result in the improvement of household material well-being and also reduce household vulnerability.60 As discussed below, there may be significant barriers to successfully designing microfinance programmes for TB-affected families.
Both cash transfer and microfinance interventions had a modest positive impact on adult malnutrition, probably because nutritional status is a function not only of food availability, but also of health status and health care services utilisation.61 It is also known that lending programmes are unlikely to significantly improve nutritional status unless they are linked to education to promote nutritionally important behavioural changes.61 This last notion makes the adverse effect observed in the PROGRESA intervention even more surprising, given that participants did receive workshops on nutrition.56,62
The only study attempting to affect HIV incidence did not show the desired impact. Such results have been attributed to the fact that the microfinance and the gender and HIV training components of the I MAGE study did not directly aim to reach young people,63 but only indirectly, through changes in the household economy and information sharing between IMAGE clients and young people.63 Although both components were important elements of the interventions, such indirect targeting, together with the short follow-up period, may have been insufficient to instigate sexual behavioural changes, and therefore HIV decline, among the highest risk group.63
Targeting and conditionality are critical aspects in the design and implementation of cash transfer schemes and microfinance interventions. In the light of TB control they could be read as follows.
All the interventions appraised applied some population targeting criteria. Targeting is a complex and expensive procedure, often leading to accuracy, equity, sustainability and even stigma problems; all these factors are likely to become even more relevant when adopting either microfinance or cash transfer for TB control. It is unclear, for example, whether these interventions are best targeted at TB-affected families or very poor households. While this choice largely depends on the objective we want to achieve (e.g., TB prevention among the very poor or TB care support in TB-affected families), both options can be challenging.
In the case of microfinance, some experiences with people affected by HIV/AIDS suggest that targeting vulnerable populations (such as TB-affected families) with microfinance may result in poor loan management, inadequate use of the loan for the intended purposes, and weak repayment systems.64,65 This view is somewhat contradicted by the community-based programme conducted in Cambodia, where loan repayment rates approached 100% among TB-affected families benefiting from participation in village banks.17 Targeting TB-affected families with cash transfers may be similarly challenging from an ethical perspective, as unaffected families may be equally in need of assistance.66
Targeting very poor households at high risk of TB is also controversial. Microfinance institutions are generally reluctant to enrol very poor households due to their uncertain repayment capacity.67 It should be noted that there is a strong norm within the non-governmental microfinance sector to work towards a model of financial sustainability. High levels of loan repayment are essential, and this is of course quite different from cash transfer programmes. The IGVGD and CFRP-TUP microfinance interventions demonstrated that it is possible to bring even the most destitute households to a position where they can successfully access microfinance services.40,47 Nonetheless, when programmes were appraised in more detail, the reason for programme success did not appear to be principally due to microfinance. Rather, the main incentive to participate in IGVGD appeared to be receipt of supplementary food, whereas microfinance was probably the least successful component of the intervention, with an 8% repayment default rate among the clients.46 It is also noteworthy that the most successful microfinance programmes included in this review involved the creative and flexible collaboration between microfinance and safety net programmes (e.g., all the BRAC programmes)47 or training/education components (e.g., the IMAGE intervention).42 In conclusion, the adoption of microfinance for TB control purposes is possible; however, to be effective, additional health, nutritional and educational support may be necessary.
The experiences from Honduras, Ecuador and Columbia demonstrated that successful conditional cash transfer programmes can be implemented in very poor settings; however, the scaling up of conditional cash transfer programmes in high TB burden countries, often characterised by weak health systems and administrative capacities, may be challenging.68,69 Conditioning the cash transfer, for example, on TB care access and treatment adherence of TB-affected families may not only be impractical, but also unethical if TB services and management capacities are inadequate. In these contexts, while waiting for health systems strengthening, it may be more appropriate to test conditionality on a small scale and only under very specific TB control-related behaviour. Alternatively, conditionality could be completely removed and cash transfer used to reduce TB vulnerability by addressing household food insecurity and material living conditions.
Whereas the evidence provided from the social cash transfer schemes implemented in Zambia and Malawi20-22 seems to demonstrate that conditionality may not be essential to achieve an impact on risk factors increasing TB vulnerability, it is unclear whether changes in TB care-seeking behaviours can be achieved without conditionality, and under which conditions conditionality should be applied to maximise impact.
The global TB control community is in need of innovative strategies to move towards TB elimination. The experiences reviewed here support the hypothesis that synergies between social protection interventions and TB control programmes could be effective. Nonetheless, several questions remain unanswered, most importantly: how can these partnerships be most cost-effectively implemented, and what would be their actual impact on TB outcomes? While funding to address these important research questions materialises, a preliminary and relatively inexpensive way to move forward would be to undertake proper studies specifically exploring what obstacles limit their integration with TB control programmes and, through the retrospective analysis of existing data, assess any unintentional impact these interventions may already have had on local TB trends.
Although policy recommendations are not possible at this stage, we hope that the evidence and critical considerations here reported will encourage a new generation of socio-economic interventions addressing key TB risk factors and supporting the existing biomedical strategy. Such studies can significantly advance our understanding of the social determinants of TB and inform broader and more effective TB control policies for the future.
The authors acknowledge the role of M Petticrew for his useful intellectual contribution to the review protocol during the early stage of the project. DB worked under an ad-hoc WHO contract. Other members of the research team were funded by the Medical Research Council/Economic and Social Research Council, Innovation for Health and Development, the Wellcome Trust, the Foundation for Innovative New Diagnostics and the UK Department for International Development.
Disclaimer: Knut Lönnroth, Ernesto Jaramillo and Mukund Uplekar are staff members of the World Health Organization (WHO). The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the WHO.