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Review 2: "The Effect of Conditional Cash Transfers on Tuberculosis Incidence and Mortality is Determined by Ethnoracial and Socioeconomic Factors: A Cohort Study of 54 Million Individuals in Brazil"

Reviewers highlight the study's valuable insights into the health benefits of conditional cash transfer programs. However, one reviewer notes that more methodological details and robustness checks are needed.

Published onMay 17, 2024
Review 2: "The Effect of Conditional Cash Transfers on Tuberculosis Incidence and Mortality is Determined by Ethnoracial and Socioeconomic Factors: A Cohort Study of 54 Million Individuals in Brazil"

RR:C19 Evidence Scale rating by reviewer:

  • Strong. The main study claims are very well-justified by the data and analytic methods used. There is little room for doubt that the study produced has very similar results and conclusions as compared with the hypothetical ideal study. The study’s main claims should be considered conclusive and actionable without reservation.

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Review: Brazil was the first country to implement a conditional cash transfer (CCT) program when it launched the Bolsa Familia  program (BFP)  in Brazil in 2004. Since then, these types of programs have spread around the world and are available now in more than 60 counties.  CCT programs have already been shown to be effective in increasing education levels and improving a variety of health conditions for adults and children. This study finds other significant health benefits in terms of reduction in TB incidence and mortality.

The article uses inverse probability reweighting methods to evaluate the effects of BFP on tuberculosis incidence and mortality among poorer populations,, using a very large nonexperimental dataset on 54.5 million individuals followed over 12 years.  Multiple administrative datasets containing information on TB reports, mortality, and on BFP program receipt were merged to create the dataset needed for this analysis of how program receipt affects disease incidence.   Controlling for observable differences between participants and nonparticipants, the authors show that BFP participants experienced both lower incidence and lower mortality from TB.  They do not find effects on the case-fatality rate, though.  The paper also performs sensitivity analysis to check robustness to the use of different sets of conditioning variables.   Subgroup analysis show that the estimated program effects with regard to TB are largest for Indigenous, black/pardo and extremely poor populations.  

The authors suggest several ways that the BFP anti-poverty program might have contributed to such benefits, for example, by enabling health care visits,reducing food insecurity and improving nutrition,  improving housing conditions, promoting the use of better cooking fuels that reduce air pollution  and reducing overcrowding. The authors conclude that expansion of BFP could be an effective way to combat TB and perhaps also other diseases.

One aspect that was not considered in the article and perhaps might be considered in future work is the fact that reducing TB in one person could generate positive spillovers on other people by reducing contagion. It could even have potential benefits for people not participating in BFP.  Oftentimes, matching on obserables methods make a SUTVA (Single Unit Treatment Value Assumption), which might not hold with contagious diseases.  If many people concentrated in a geographic region are participating in BFP, then there could be overall a greater benefit. This aspect of geographic saturation leading to greater benefits, possibly including on nonpartipants, is something that might be studied. 

Another question is whether all cases of TB are discovered and reported.  If the group that participates in BFP goes to the doctor more often, then perhaps reporting of TB is more accurate in this group.  If TB cases among nonparticipants are less likely to be reported or take longer to be discovered, then the beneficial effects of BFP on TB incidence could be understated in this analysis.   More information on when TB cases are discovered and whether they are all reported and how this reporting might relate to their BFP status would be useful.

Overall, this paper presents compelling evidence that CCT programs are a promising approach to combatting TB and that the benefits appear to be greatest for the poorest. 

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