Why financial incentives did not reach the poor tuberculosis patients? A qualitative study of a Fidelis funded project in Shanxi, China

Background A project implemented in 50 counties of Shanxi province provided incentives to poor TB patients for their first trip to tuberculosis (TB) dispensaries. Incentives were also given to doctors for referring and supervising TB patients. A previous quantitative evaluation identified no improvement on TB case detection and management. This qualitative study was then conducted to explore reasons for project failure.Objective To understand how the incentives were distributed to and viewed by their recipients and the implications for TB and health systems.Methods Qualitative in-depth interviews were conducted with 32 TB patients, 13 village doctors, 12 village leaders, 8 TB doctors and 8 TB programme managers.Results The study revealed a lack of operational tools on how to evaluate patients' economic status and how to publicise the incentives. As a result, patients did not know the level of incentives in advance and regarded the amount as inadequate. Patients faced a huge financial burden and a long delay in treating TB, dwarfing the benefits of travel incentives. The referral and case supervision incentives were not implemented. Doctors did not receive any referral and supervision incentives in addition to those already existing.Conclusions Strategies to address health system and TB programme issues should be implemented before or alongside financial incentives. Operational details and tools for any intervention should be developed, field-tested and revised prior to wide-scale use.