Table 3 Successes, challenges and refinements of the cash transfer incentive dimension of the socioeconomic intervention

New evidence

New experience and evidence was generated that TB-specific cash transfers for TB-patients were feasible in this study setting

There was a lack of available evidence and thus clarity when prioritising the output of the cash transfers in these TB-affected households. Thus, deciding on the cash transfer amounts and timing was difficult

Following previous and updated analysis of hidden costs and income of TB-affected households [7], cash transfer amounts were increased with the aim of reducing their poverty-related TB risk factors

Collaboration

There was strong multi-sectorial collaboration with Peruvian National TB Program and bank staff, allowing multiple, virtual cash transfers to be made and recorded, reducing fraud and security risks

Account maintenance charges were introduced by the bank during implementation of the intervention and delays in cash transfers eroded participants’ trust in the project

We changed our bank service provider: the new bank had better accessibility and no charges. We self-imposed penalties on our project for late cash transfers (participants gained additional transfers)

Cash transfers

Cash transfers lasted throughout treatment, increasing equity for people with TB and HIV co-infection or MDR TB, whose treatment duration extended beyond 6 months

As a research team, we had limited experience of cash transfer interventions or working with new urban study communities

Achieving a balance between operational simplicity and complex TB-affected household needs was challenging

Opening a bank account was a first-time experience for many of the participants and qualitative participant feedback suggested that this was perceived as an empowering action, especially for female members of the household who have previously been shown to be a vulnerable subpopulation in the study setting [5]

Feedback suggested that patients would prefer immediate gratification for completion of conditions rather than delayed cash transfer bank payments

Immediate incentives were provided for attending participatory community meetings (including food baskets and high-quality vouchers documenting the date and amount owed to the participant)

Project conditions requiring all members of the TB-affected household to participate were poorly achieved and not equitable due to different household sizes

We combined conditional and unconditional cash transfers. Conditions requiring household participation were altered to be responsive to household size: incentives given were refined to be given per household member involved

Inclusiveness and high risk groups

The intervention was holistic and household-centred because, in addition to cash transfers, it provided community meetings consisting of educational workshops (covering themes such as TB treatment, transmission, prevention and also financial themes such as responsible household budgeting in an interactive manner) and TB Clubs (mutual support aiming to reduce stigma and increase empowerment, reported separately)

“High risk” patients in more urban communities were difficult to engage with (especially the formerly-incarcerated, drug- or alcohol-dependent and gang members)

Participatory community meetings for patients with MDR TB were established and increasing social support was provided to other high risk patients (including the homeless, drug or alcohol dependent, those with poor adherence and/or lack of engagement with our project)