One of the world's largest social programs greatly reduced tuberculosis among the most vulnerable

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 defences 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," says Rasella. The message is clear: social protection programmes 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.