Background

Illness-related costs for patients with tuberculosis (TB) ≥20% of pre-illness annual household income predict adverse treatment outcomes and have been termed “catastrophic.” Social protection initiatives, including cash transfers, are endorsed to help prevent catastrophic costs. With this aim, cash transfers may either be provided to defray TB-related costs of households with a confirmed TB diagnosis (termed a “TB-specific” approach); or to increase income of households with high TB risk to strengthen their economic resilience (termed a “TB-sensitive” approach). The impact of cash transfers provided with each of these approaches might vary. We undertook an economic modelling study from the patient perspective to compare the potential of these 2 cash transfer approaches to prevent catastrophic costs.

Methods and findings

Model inputs for 7 low- and middle-income countries (Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen) were retrieved by literature review and included countries' mean patient TB-related costs, mean household income, mean cash transfers, and estimated TB-specific and TB-sensitive target populations. Analyses were completed for drug-susceptible (DS) TB-related costs in all 7 out of 7 countries, and additionally for drug-resistant (DR) TB-related costs in 1 of the 7 countries with available data. All cost data were reported in 2013 international dollars ($). The target population for TB-specific cash transfers was poor households with a confirmed TB diagnosis, and for TB-sensitive cash transfers was poor households already targeted by countries’ established poverty-reduction cash transfer programme. Cash transfers offered in countries, unrelated to TB, ranged from $217 to $1,091/year/household. Before cash transfers, DS TB-related costs were catastrophic in 6 out of 7 countries. If cash transfers were provided with a TB-specific approach, alone they would be insufficient to prevent DS TB catastrophic costs in 4 out of 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $3.8 million (95% CI: $3.8 million–$3.8 million) and $75 million (95% CI: $50 million–$100 million) per country. If instead cash transfers were provided with a TB-sensitive approach, alone they would be insufficient to prevent DS TB-related catastrophic costs in any of the 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $298 million (95% CI: $219 million–$378 million) and $165,367 million (95% CI: $134,085 million–$196,425 million) per country. DR TB-related costs were catastrophic before and after TB-specific or TB-sensitive cash transfers in 1 out of 1 countries. Sensitivity analyses showed our findings to be robust to imputation of missing TB-related cost components, and use of 10% or 30% instead of 20% as the threshold for measuring catastrophic costs. Key limitations were using national average data and not considering other health and social benefits of cash transfers.

Conclusions

A TB-sensitive cash transfer approach to increase all poor households’ income may have broad benefits by reducing poverty, but is unlikely to be as effective or affordable for preventing TB catastrophic costs as a TB-specific cash transfer approach to defray TB-related costs only in poor households with a confirmed TB diagnosis. Preventing DR TB-related catastrophic costs will require considerable additional investment whether a TB-sensitive or a TB-specific cash transfer approach is used.

中文翻译：

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比较两种现金转移策略以防止低收入和中等收入国家受结核病影响的贫困家庭的灾难性成本：经济模型研究

背景

结核病 (TB) 患者的疾病相关费用≥病前家庭年收入的 20% 可预测不良治疗结果，并被称为“灾难性”。支持包括现金转移在内的社会保护举措有助于防止灾难性成本。为实现这一目标，可提供现金转移支付以支付确诊结核病家庭的结核病相关费用（称为“结核病特异性”方法）；或增加结核病高风险家庭的收入以增强其经济复原力（称为“结核病敏感”方法）。每种方法提供的现金转移的影响可能会有所不同。我们从患者的角度进行了一项经济模型研究，以比较这两种现金转移方式在预防灾难性成本方面的潜力。

方法和发现

通过文献回顾检索了 7 个低收入和中等收入国家（巴西、哥伦比亚、厄瓜多尔、加纳、墨西哥、坦桑尼亚和也门）的模型输入，包括各国的平均患者结核病相关费用、平均家庭收入、平均现金转移支付，以及估计的结核病特异性和结核病敏感目标人群。在 7 个国家中的所有 7 个国家中完成了对药物敏感 (DS) 结核病相关费用的分析，另外还对有可用数据的 7 个国家中的 1 个国家的耐药 (DR) 结核病相关费用进行了分析。所有成本数据均以 2013 年国际美元 ($) 报告。结核病专项现金转移支付的目标人群是确诊为结核病的贫困家庭，而结核病敏感型现金转移支付的目标人群是各国既定的减贫现金转移支付计划的目标人群。与结核病无关的国家提供的现金转移支付范围从 217 美元到 1,091 美元/年/家庭不等。在现金转移之前，7 个国家中有 6 个国家与 DS TB 相关的成本是灾难性的。如果以针对结核病的方法提供现金转移支付，仅在 6 个国家中的 4 个国家就不足以预防 DS TB 灾难性成本，当增加到足以防止 DS TB 灾难性成本时，预算将需要 380 万美元（95% CI：380 万美元至 380 万美元）和 7500 万美元（95% CI：5000 万美元至 1 亿美元）。如果改为采用对结核病敏感的方法提供现金转移支付，仅在这 6 个国家/地区中，它们都不足以防止与 DS TB 相关的灾难性成本，并且当增加到足以防止 DS TB 灾难性成本时，将需要 2.98 亿美元的预算（95% 置信区间：每个国家 2.19 亿美元至 3.78 亿美元）和 1653.67 亿美元（95% CI：1340.85 亿美元至 1964.25 亿美元）。在 1 个国家中，有 1 个国家在结核病特异性或对结核病敏感的现金转移之前和之后，与耐药结核病相关的成本是灾难性的。敏感性分析表明，我们的研究结果对于缺失的结核病相关成本成分的估算是稳健的，并且使用 10% 或 30% 而不是 20% 作为衡量灾难性成本的阈值。主要限制是使用全国平均数据，而不考虑现金转移的其他健康和社会效益。并使用 10% 或 30% 而不是 20% 作为衡量灾难性成本的阈值。主要限制是使用全国平均数据，而不考虑现金转移的其他健康和社会效益。并使用 10% 或 30% 而不是 20% 作为衡量灾难性成本的阈值。主要限制是使用全国平均数据，而不考虑现金转移的其他健康和社会效益。

结论

增加所有贫困家庭收入的对结核病敏感的现金转移方法可能会通过减少贫困而产生广泛的好处，但在预防结核病灾难性成本方面不太可能像支付结核病相关成本的结核病特异性现金转移方法那样有效或负担得起仅在确诊为结核病的贫困家庭中。预防耐药结核病相关的灾难性成本将需要大量额外投资，无论是使用对结核病敏感还是针对结核病的现金转移方法。