This example is based on a study conducted shortly after the launch of the direct benefit transfer (DBT) scheme in India to identify early implementation challenges in South India.
To assess the coverage and implementation barriers of DBT among TB patients notified during April–June 2018 and residing in Dakshina Kannada, a district in South India.
In the first year of implementation, direct benefit transfers were received by 63% of eligible TB patients. Significant variation in the proportion of eligible patients receiving benefits was seen across states. Programme staff have reported challenges in registering and disbursing direct benefits to TB patients who are often migrants or children.
Areas for further investigation: What are the demographic characteristics of patients who do/do not receive benefits?
The effectiveness of the intervention is unknown.
Areas for further investigation: What is the impact of direct benefit transfers on: treatment completion; nutritional status; and/or catastrophic costs incurred during TB treatment?
Coverage of the direct benefit transfer scheme was 58% within the first eight months of implementation. 117 low-performing districts were identified as priority districts for implementation of the scheme, with 80% of districts adopting the intervention within the first two months of implementation.
By looking at the differences between sites that did/did not adopt the intervention, it was identified that less than 20% of uptake occurred in private facilities.
Areas for further investigation: What are the key barriers to achieving greater uptake of the direct benefits transfer scheme among private facilities? What additional strategies are required to promote greater adoption of the intervention in these settings?
Areas for further investigation: What are the factors that promote and hinder successful implementation of the intervention, such as delays in collecting and verifying bank account information, or processes for identifying incorrect or inactive bank accounts?
Areas for further investigation: What is the proportion of facilities registering patients for direct benefit transfers and the proportion of TB patients receiving transfers at one, two and five years post-implementation? What are the factors that will enable long-term maintenance of the intervention?
Specific research questions included:
- What was the proportion of TB patients approved for payment by the public financial management system (PFMS)?
- What proportion of TB patients received the payment?
- What delays were involved in cash transfer?
- What factors were associated with non-approval of payment?
- What were the early implementation barriers from the perspective of TB patients and health care providers?
The outcome for the quantitative component was coverage of the DBT, defined as the proportion of non-approval of payments by the public financial management system (the level responsible for initiating the payments to beneficiaries).
The qualitative component explored experiences and perceptions of barriers related to the implementation of the DBT scheme.
For the qualitative component, the population included all TB patients notified in the district between April and June 2018 and managed under the NTP. Exclusion criteria included patients residing outside of the district, and patients treated by the private sector.
For the qualitative component, the population included TB patients and providers involved in the implementation of the DBT.
The study took place in the South Indian district of Dakshina Kannada, which has a population of 2.1 million people based on 2011 census data. Dakshina Kannada has a multi-tiered health system comprising primary, secondary and tertiary health care facilities including government and private hospitals. TB services are provided by the general health system under the coordination of a district TB officer and district health officer. The district is divided into seven TB units to facilitate supervision and monitoring of TB services, each of which is staffed by a designated medication officer, supervisory staff, and laboratory supervisor. There is also a district accounts office which hosts the Public Financial Management System (PFMS) web portal and is involved in DBT.
The study evaluated the implementation of the DBT scheme, which was provided via the national web-based TB monitoring and management system called Nikshay. Following diagnosis, patient bank account and biometric identification details are collected by public health staff and entered into Nikshay. Payments of 500 Indian rupees per month (equivalent to about US$7) are processed by district-level staff. The first payment is received immediately, while subsequent payments are conditional on adherence throughout the treatment course. For paediatric patients, DBT are provided to a parent or guardian bank account.
Payment requests are reviewed and processed at three levels: the 'maker', the 'checker' and the 'approver'. First, the maker collects the patient bank information and social security number and enters it into NIKSHAY then prepares a list of beneficiaries and sends it to the checker. The checker (typically the medical officer) validates the information provided by the maker and forwards to the district TB officer for approval (the approver), who then verifies the details, removes any duplicates and approves the payment. The approved beneficiary list is then submitted to the public financial management system portal via NIKSHAY for final processing and payment.
Data collection, management and analysis
Sampling and recruitment
Purposive sampling was used to recruit TB patients and health care providers for the qualitative component. Participants were selected to represent the various cadres of health care providers involved in the DBT implementation process and TB patients who did/not receive DBT. The sample size was guided by saturation of findings.
The qualitative component was a secondary analysis of patient data routinely collected by the NTP. Data from all patients meeting the eligibility criteria were included in the study.
Data collection methods
- Quantitative: Patient data was extracted for all patients meeting the eligibility criteria from the NIKSHAY database on 1 December 2018, providing at least five months of data for each patient (starting from April–June 2018). The variables extracted included demographic and clinical characteristics, bank account number, national social ID number, payment approval by PFMS, payment credit along with dates of diagnosis, payment approval and payment.
- Qualitative: In-depth interviews were conducted by medical doctors recruited from a private medical college who were trained and experienced in qualitative research methods. The interviewers were not involved in the implementation of the DBT scheme. Interviews were conducted in the vernacular language or English based on participant preference. Following consent, interviews were audio recorded and participants were debriefed at the end of the interview and given the opportunity to clarify any points discussed during the interview. In some cases, repeat interviews were conducted if required to further explore and explain the findings of the quantitative analysis.
Data management and analysis
- Quantitative: EpiData and Stata software were used to analyse data. Continuous data were summarized using mean and standard deviation or median and interquartile range, as applicable. Categorical data were summarized as proportions. Poisson regression was used to identify factors associated with research outcome (non-approval of payment) with calculated adjusted relative risks and 95% confidence intervals. Given the exploratory nature of the study, all available variables were included in the regression model.
- Qualitative: Recorded interviewers were transcribed and used to conduct a thematic analysis on barriers to implementation by manual coding undertaken by four researchers. Researchers independently coded the transcripts using a grounded theory approach under the broad themes of patient-related and health system-related barriers. Analysis was conducted after each interview and the results were discussed among the four researchers to facilitate the identification of emerging themes and areas that required further probing in subsequent interviews. Discussion and consensus were used to resolve any differences between the researchers during the analysis process.
Based on: Nirgude AS, et al (2019). 'I am on treatment since 5 months but I have not received any money': Coverage, delays and implementation challenges of 'Direct benefit transfer' for tuberculosis patients - a mixed-methods study from south India (https://pubmed.ncbi.nlm.nih.gov/31328678/).