Safety nets and tailored support : developing complex social protection interventions for tuberculosis-affected families in Vietnam

Abstract

Background: Tuberculosis (TB) is an infectious disease that although treatable and curable, continues to kill an estimated 1.3 million people per year. The disease disproportionally affects the most vulnerable people in a society and then imposes an additional social and economic burden on affected households. There is broad consensus that to end TB, the social determinants of TB must be addressed hand-in-hand with an effective biomedical response. One way to do this is through social protection, which is an efficient and redistributive way to provide income or consumption transfers, protect against livelihood risks, and enhance the social status and rights of the marginalized. Several global calls have called for social protection interventions to be made available to all people with TB. However, there is a notable absence of operational evidence on the development of interventions to alleviate the economic impacts of TB.

Aim: The primary aim of this PhD project was to understand and optimize the development of complex social protection interventions that address the costs associated with drugsusceptible TB care in Vietnam. Particular focus was placed on cash transfers and social health insurance (SHI) enrollment, which were considered interventions with the highest potential for scale-up within the context.

Results: The research employed qualitative and quantitative methodologies across four studies involving diverse stakeholder groups. Study I revealed that cash and SHI were considered priority interventions for people with TB, healthcare providers and policymakers, but future interventions needed to extend beyond economic support and better consider the social and mental wellbeing of people with TB.

A combination of cash transfers and SHI was perceived as broadly acceptable in Study II; however, concerns about cash misuse and the sufficiency of financial support were prevalent. Targeting financially vulnerable populations showed greater acceptability than providing universal access to social protection for people with TB. Conditioning the provision of a cash transfer on health-related behaviors increased stakeholder acceptability. Despite this, healthcare providers expressed concerns regarding the added burden of monitoring conditionality on an already strained health system.

Study III assessed the feasibility of procuring SHI for uninsured people with TB and identified challenges with the process. It was found to be feasible in 76.5% of instances; however, a significant minority was left uninsured and they were potentially permanently uninsurable under existing regulations.

Lastly, the PhD project assessed the delivery of both conditional and unconditional cash transfers, and found that it was feasible to deliver both. Each cohort had 354 cash transfers scheduled and 334 (94.4%) were successfully delivered in the cohort that required conditions to receive a payment, while 100% of cash transfers were delivered when conditions were not imposed. Over 22 days of self-observation, it was found it took study staff twice as much time to distribute cash transfers with conditions, which raised questions about the added burden of conditionality.

Conclusions: This PhD project provided formative evidence on developing a complex intervention in Vietnam to mitigate the economic burden of TB. While the findings indicate potential benefits associated with cash transfers and SHI, they also underscore the necessity for flexible, culturally sensitive, and multi-sectoral approaches in intervention design. Future research should aim to integrate financial support during TB with more holistic, multidimensional approaches that foster systemic changes and enhance healthcare equity for TB-affected individuals. This work not only contributes to filling important knowledge gaps but also informs actionable policy reforms and frameworks for sustainable support in the context of TB care.