Presentation (CTI)

OBJECTIVES: Tuberculosis (TB) patients in India face high out-of-pocket (OOP) costs, particularly when seeking care from private providers. This study evaluates the health and financial protection benefits of increasing conditional cash transfers (CCTs) for private care-seeking compared to public-care seeking TB patients by modeling four alternative CCT scenarios.
METHODS: We selected four diverse Indian states—Uttar Pradesh, Bihar, Tamil Nadu, and Maharashtra—representing different TB burdens and socioeconomic contexts. Using R, we modeled CCT scenarios stratified by care-seeking behavior (public vs. private). Outcomes included TB treatment adherence, deaths averted, OOP costs (categorized by direct medical, direct non-medical and indirect) before and after the most generous scenario (Scenario 4), and the number of households experiencing catastrophic (CHE; >20% of annual income) or impoverishing health expenditures (IHE; below the national poverty line of $0.53/day). We also assessed equity using concentration curves and indices.
RESULTS: Greater CCT amounts led to higher TB medication adherence and more TB deaths averted in both public and private sectors, though gains plateaued after Scenario 3. For example, in Bihar and Maharashtra, deaths averted increased from 22% and 51% under Scenario 1 to 32% and 62% under Scenario 3, with no further improvement in Scenario 4. Among public care-seekers, indirect costs dominate OOP expenses; for private care-seekers, direct costs are primary. Scenario 4 produced the greatest reductions in CHE, especially among public care-seekers in Uttar Pradesh and Bihar. IHE cases fell to zero under Scenario 4 in all but Bihar’s public sector. In contrast, gains for private care-seekers were more modest in Tamil Nadu and Maharashtra, likely due to higher baseline costs and more balanced income distributions.
CONCLUSIONS: Improving TB-related CCT programs in India requires tailoring interventions by state and care sector. Prioritizing high-burden states, increasing support for private care, and addressing cost disparities can enhance equity, reduce financial hardship, and improve TB outcomes.