Updated 24 February 2014

TB-voucher study 'jeopardised by nurses'

A recent poverty intervention study in KwaZulu-Natal which offered food vouchers to TB patients in order to assist their recovery, was jeopardised by the "street level bureaucracy" of health workers, a researcher has found.

Maintaining patient compliance when taking tuberculosis (TB) medication remains a problem faced by our national health authorities, particularly in the poorest parts of the country.  Given the strong link between poverty and TB in South Africa and the barriers poverty poses to access and adherence to treatment, studies that investigate and propose interventions in overcoming the relationship between poverty and ill health should be high on the public health research agenda.

Recently, a poverty intervention study was undertaken in KwaZulu-Natal - one of SA’s poorest provinces and also one of the hardest hit by TB and HIV – experimenting with a voucher system allowing TB patients to afford the nutritional energy intake required to assist their recovery. The vouchers were intended to supplement the household spend on food, getting patients to be better fed and motivated by taking their medication on a full stomach.

For the study, in which 4091 patients participated, just over half (2107) were earmarked to receive monthly vouchers each valued at R120, for a six to eight month period - measuring the feasibility and effectiveness of providing economic support to encourage adherence to prescribed treatment regimes.

Read: The symptoms of tuberculosis

Staple food items

The monthly vouchers, redeemable for all purchases made at specified general stores were considered sufficient for people to buy a number of staple food items common in SA households. As 56% of the sample population were unemployed, overall food expenditure was understandably low – and on average 54% below the food poverty line.

However, the research uncovered serious implementation concerns, most notably that less than two thirds of patients regularly received their vouchers, and highlighting critical issues that threaten such interventions from being considered for national implementation.  

The "street level bureaucracy" employed by clinic nursing staff was primarily responsible for 36.2% of eligible patients not receiving vouchers at all, and some (32.3%) receiving  vouchers for less than three months of the eight month study. 

Subjective preferences

Nurses felt that it was unfair to give vouchers to patients who, for example, were employed or already in receipt of a social grant. They also chose to ‘ration’ the vouchers so that patients who were relatively more deprived received them in preference to those who were marginally ‘less poor’. Other clinics preferred to give eligible patients their vouchers in a single batch at month end.

This ground-level adjustment of implementation policy, based on subjective preferences of healthcare workers is not uncommon, and adds another layer of complexity in determining the intended effects of such research.

Additionally, the hand-delivery of voucher books to clinics meant that vouchers could not always be provided to patients when their previous vouchers ran out, requiring them to return to their clinic again after their initial appointment date – visits which may not have been possible for many of them to attend.

Read: SA's TB rate among the highest in the world

Promising outcomes for those with vouchers

Yet from those patients who did receive voucher-support, if only for one month, some very promising outcomes were reported:

  • 97.7% of patients felt significant benefit in being able to pay for food they needed, but could previously seldom afford
  • 20.4% had less need to ask for food elsewhere, or borrow money
  • 85% of voucher-value went towards buying food
  • Less than 0.2% of voucher-value was spent on alcohol or cigarettes.
  • In patients who received at least one voucher, the treatment compliance was 10% higher (81%) than in those who did not have the benefit of the vouchers.

There is a need for economic interventions that break the cycle of poverty and tuberculosis and prevent ongoing infections, illness and death. Unfortunately, evidence for the use of such interventions is very thin, and unsupported by policy-makers who view them as ‘hand-outs’ that generate dependency and abuse. As is the case with new drug treatments, economic intervention tools should similarly be rigorously tested and evaluated.

Read: Motsoaledi wants to defeat the scourge of TB

Resource-intensive system

The ideal economic intervention for TB control is one that is broad-based and reaches all whom poverty makes vulnerable to infection and death from the disease.

Ultimately, as the KZN voucher study showed, the system of administration although protecting against theft or fraud, is time- and resource-intensive and may not be feasible in most settings.  

Further research is needed to explore how best to deliver such economic support to those eligible to receive it, particularly in low and middle-income countries where the burden of tuberculosis is highest.

Written by Dr Elizabeth Lutge. Dr Lutge is Manager of the Epidemiology, Health Research and Knowledge Management Unit in the KwaZulu-Natal Department of Health. This article is based on her recent doctorate in Epidemiology at Stellenbosch University.

(Photo of basket with groceries from Shutterstock)


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