‘I am on treatment since 5 months but I have not received any money’: coverage, delays and implementation challenges of ‘Direct Benefit Transfer’ for tuberculosis patients – a mixed-methods study from South India

Figures & data

Figure 1. Steps in direct benefit transfer among tuberculosis patients notified in Dakshina Kannada District, Karnataka State, India, 2018.

PHI = Peripheral Health Institute; PFMS = Public Financial Management System; DTO = District Tuberculosis Officer; DHO = District Health Officer; STS = Senior Treatment Supervisor; DEO = Data Entry Operator; IFSC = Indian Financial Security Code; DAM = District Accounts Manager; NIKSHAY = Online TB notification portal; Aadhaar number = unique identification number for residents of India

Figure 2. Coverage of direct benefit transfer among tuberculosis patients in Dakshina Kannada district, Karnataka state, India from April to June 2018.

RNTCP = Revised National Tuberculosis Control Programme; PFMS = Public Financial Management System

Table 1. Characteristics of TB patients treated in the public sector and notified in Dakshina Kannada district, Karnataka state, India, April 2018 to June 2018 (N = 417).

Variable	Number	Percentage
Age group in years
0–17	17	04.1
18–44	208	49.9
45–59	121	29.0
60 and above	71	17.0
Gender
Female	128	30.7
Male	289	69.3
TB unit
Bantwal	40	09.6
Belthangady	18	04.3
Mangaluru North	220	52.8
Mangaluru South	32	07.7
Moodabidre	25	06.0
Puttur	63	15.1
Sullia	19	04.6
Type of TB case
New	276	66.2
Retreatment	27	06.5
Not recorded	114	27.3
Disease site
Pulmonary	227	54.4
Extra-Pulmonary	76	18.2
Not recorded	114	27.3
HIV status
Reactive	5	01.2
Non-Reactive	88	21.1
Not Recorded	324	77.7
Diagnostic test
Microscopy	206	49.4
Xpert MTB/RIF	98	23.5
Other	113	27.1
Residence
Rural	156	37.4
Urban	261	62.6
Bank account
Yes	305	73.1
No	112	26.9
Aadhaar number*
Yes	292	70.0
No	125	30.0

* 12-digit unique identification number provided to the residents of India.

Table 2. Factors associated with non-approval of payment among tuberculosis patients in Dakshina Kannada district, Karnataka state, India, April–June 2018.

		Non-approval of payment
Variable	Total	N	%	RR	95% CI	aRR	95% CI
Age group (years)
0–17	17	06	35.3	1		1
18–44	208	100	48.1	1.36	0.70–2.63	1.22	0.49–2.99
45–59	121	65	53.7	1.52	0.78–2.95	1.23	0.48–3.13
60 and above	71	38	53.5	1.51	0.76–2.99	1.14	0.44–2.98
Gender
Female	128	61	47.7	1		1
Male	289	148	51.3	0.47	0.39–0.57	0.97	0.70–1.34
TB unit
Bantwal	40	11	27.5	1		1
Belthangady	18	3	16.7	0.60	0.92–1.91	0.58	0.16–2.11
Mangaluru North	220	117	53.2	1.93	1.36–3.80	1.26	0.65–2.44
Mangaluru South	32	14	43.8	1.59	0.84–3.24	1.36	0.60–3.10
Moodabidre	25	17	68.0	2.47	1.39–4.37	1.63	0.74–3.60
Puttur	63	38	60.0	2.19	1.27–3.76	1.59	0.77–3.26
Sullia	19	09	47.4	1.72	0.86–3.43	1.40	0.55–3.57
Type of TB
New	276	114	41.3	1		1
Retreatment	27	8	29.6	0.71	0.39–1.30	0.82	0.39–1.74
Not recorded	114	87	76.3	1.84	1.55–2.19	1*
Disease site
Pulmonary	227	87	38.3	1		1
Extra-Pulmonary	76	35	46.1	1.20	0.89–1.61	1.47	0.83–2.63
Not recorded	114	87	76.3	1.99	1.63–2.41	1.01	0.70–1.46
HIV status
Reactive	5	5	100	2.24	1.99–2.52	0.96	0.37–2.48
Non-Reactive	88	53	60.2	1.29	1.05–1.58	0.88	0.62–1.25
NotRecorded	324	151	46.6	1		1
Diagnostic test
Microscopy	206	100	48.5	1		1
Xpert MTB/RIF	98	62	63.3	1.30	1.06–1.60	0.98	0.68–1.43
Other	113	47	41.6	0.85	0.66–1.11	0.81	0.47–1.39
Residence
Rural	156	60	45.6	1		1
Urban	261	149	64.7	1.48	1.18–1.85	1.30	0.94–1.80
Aadhaar number
Yes	305	107	36.6	1		1
No	112	102	81.6	2.22	1.87–2.64	0.99	0.67–1.47
Bank account
Yes	305	97	31.8	1		1
No	112	112	100	3.29	2.79–3.87	3.07	2.01–4.67

*Omitted due to collinearity with the variable disease site.

TB = tuberculosis; HIV = human immunodeficiency virus; Aadhaar number = 12-digit unique identification number provided to citizens of India; RR = unadjusted relative risk; aRR = adjusted relative risk; CI = confidence intervals;

RR and 95% CI in bold indicate variables found to be statistically significant (p value <0.05)

Figure 3. Non-hierarchical thematic map showing patient-related barriers in the implementation of DBT for TB patients notified in Dakshina Kannada district, Karnataka state, India, April-2018 to June-2018.

* 12-digit unique identification number provided to residents of India; DBT = Direct Benefit Transfer; TB = Tuberculosis

Figure 4. Non-hierarchical thematic map showing health system-related barriers in the implementation of DBT for TB patients notified in Dakshina Kannada district, Karnataka state, India, April-2018 to June-2018.

DBT = Direct Benefit Transfer; TB = Tuberculosis; NIKSHAY = online TB notification portal; PFMS = Public Financial Management System