The Bolsa Família program (PBF, in the Portuguese acronym), one of the largest conditional income transfer programs worldwide, has been responsible for reducing tuberculosis (TB) cases and deaths by more than half among people living in extreme poverty and indigenous groups. This is what is evidenced by a study coordinated by the Institute of Collective Health (ISC/UFBA), the Center for Data and Knowledge Integration for Health (Cidacs/Fiocruz Bahia) and the Barcelona Institute for Global Health (ISGlobal). The findings, published in Nature Medicine this Friday (1/3), have strong implications for public policies on social protection and control of TB worldwide.
To participate in the Bolsa Família program, the poorest families must meet certain conditions, such as ensuring their children attend school (photo: Agência Brasil)
Since 2004, the PBF has provided financial support to the poorest families in Brazil, on the condition that they fulfill certain conditions, such as taking their children to the doctor and ensuring that they attend school. While these programs are well known for reducing economic and social inequalities, they have also been shown to improve health outcomes such as infant mortality, maternal deaths and HIV cases and deaths.
Tuberculosis, one of the main causes of infectious death 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 income transfers on disease outcomes among the most vulnerable populations had not been fully analyzed," says the study's coordinator, Davide Rasella, a collaborating professor at ISC and leader of ISGlobal's Health Impact Assessment and Evaluation group.
Rasella and other collaborating researchers analyzed 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 (number of people diagnosed with the disease who die) between people who received support from the PBF (23.9 million) and those who did not (30.6 million). In total, there were 159,777 new TB diagnoses and 7,993 TB deaths in the study cohort.
This database was created from the 100 Million Brazilian Cohort, an initiative that links information from social programs and other databases from health information systems, such as mortality and births, allowing for the study of the relationship between transmissible and non-transmissible infectious diseases and social determinants.
Stronger effects among indigenous peoples and extremely poor people
The results show a large reduction in TB cases and deaths among PBF beneficiaries. The reduction was greater than 50% among extremely poor people and greater than 60% among indigenous populations. Although the PBF reduced TB cases in all groups, its effect was less in those who were less poor, and there was no significant reduction in TB deaths in this group. The case-fatality rate of TB (i.e. how deadly the disease is among 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 PBF'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 defenses. As a result, it also reduces the barriers to accessing medical care," says Gabriela Jesus, co-author of the study with Priscila Scaff, both researchers associated with Cidacs.
Global implications
The expansion of PBF can help the country deal with the increase in TB cases among vulnerable populations after the COVID-19 pandemic. However, the implications of these discoveries go beyond Brazil.
"Our study has far-reaching implications for policymaking in countries with a high TB burden," says Rasella. The message is clear: social protection programs not only help to reduce poverty and malnutrition, but can also play a crucial role in achieving the goals of the TB Elimination Strategy and the Sustainable Development Goals.