Brazil's cash transfer program cuts tuberculosis cases and deaths among vulnerable populations

Brazil's Bolsa Família Program (BFP), one of the world's largest conditional cash transfer programmes, was responsible for the reduction of more than half the number of tuberculosis cases and deaths among those living in extreme poverty and Indigenous groups, shows a large study coordinated by the Barcelona Institute for Global Health (ISGlobal), a center supported by "la Caixa" Foundation, the Institute of Collective Health, and the CIDACS-FIOCRUZ in Bahia, Brazil. The findings, published in Nature Medicine, have strong implications for public policies on social protection and TB control worldwide.

Brazil's Bolsa Família Program (BFP) is one of the largest conditional cash transfer programmes implemented worldwide. Since 2004, the BFP has provided financial support to the poorest families in Brazil, on the condition that they fulfil certain conditions such as taking their children to the doctor and ensuring school attendance. While these programs are well-known for reducing economic and social inequalities, they have also been shown to improve health outcomes such as child mortality, maternal deaths, and HIV cases and deaths.

Tuberculosis (TB), one of the leading infectious killers in Brazil and other low- and middle-income countries, is closely linked to poverty. "We know that TB is driven by poverty, but until now, the effects of cash transfers on disease outcomes among the most vulnerable populations had not been fully analysed," says the coordinator of the study, Davide Rasella, head of the Health Impact Assessment and Evaluation group at ISGlobal and collaborating professor of the Institute of Collective Health.

Rasella and his colleagues in Brazil analysed data, including ethnic and socioeconomic conditions, from 54.5 million low-income Brazilians between 2004 and 2015. They compared TB incidence (number of new cases), mortality (number of deaths in the population) and case fatality rate (how many people who have the disease die) among people who received BFP support (23.9 million) or not (30.6 million). In total, there were 159,777 new TB diagnoses and 7,993 TB deaths in the cohort under study. 

Stronger effects among Indigenous and extremely poor people

The results show a large decrease in TB cases and deaths among those benefiting from cash transfers. The decrease was of over 50% in extremely poor people and more than 60% among the indigenous populations. Although the program reduced TB cases across all groups, its effect was smaller in those who were less poor, and there was no significant reduction in TB deaths in that group. The TB case fatality rate (i.e. how deadly the disease is in those affected) was also lower among Bolsa Família beneficiaries compared to non-beneficiaries, although the difference between the two groups was not statistically significant.

The reason behind the BFP's effect on TB outcomes is not a mystery. "We know that the program improves access to food, both in quantity and quality, which reduces food insecurity and malnutrition- a major risk factor for TB- and strengthens people's immune defenses as a result. It also reduces barriers to accessing healthcare," says Gabriela Jesus, co-first author of the study along with Priscila Pinto, both from FIOCRUZ.

Global implications

Expanding the BFP can help Brazil address the worrying increase in TB cases among vulnerable populations following the COVID-19 pandemic. But the implications of these findings extend beyond Brazil.

Our study has far-reaching implications for policy-making in all countries with a high burden of TB."

Davide Rasella, head of the Health Impact Assessment and Evaluation group at ISGlobal

The message is clear: social protection programs not only help reduce poverty and malnutrition, but can also play a crucial role in achieving the targets of the END-TB strategy and those of the Sustainable Development Goals.