Leveraging Patients' Social Networks to Overcome Tuberculosis Under-Detection in India

October 3, 2016

Globally, tuberculosis affects some 8.7 million people. Women and children in the developing world are particularly vulnerable. The disease has high mortality rates, but even for survivors, the consequences can be debilitating, with long-term health consequences. Highly effective treatments are free and available to patients in developing countries, but many of those infected with TB are neither diagnosed nor in treatment. The under-detection of TB represents a key challenge for health officials in developing countries because identifying those who have the disease is crucial to the success of any treatment program. Researchers are now exploring the possibility of offering TB patients cash bonuses for referring people to the testing centers in an effort to widen their reach to the most vulnerable. If successful, the patient-to-patient referral system could help public health officials around the globe better stop the spread of communicable diseases.

Research area: Health

Country: India

Evaluation Sample: 200 tuberculosis clinics

Timeline: 2014 - 2017

Intervention: cash transfers, information

Researchers: Jessica Goldberg, University of Maryland; Mario Macis, Johns Hopkins University; Jason Farley, Johns Hopkins University

Partners: J-PAL South Asia; Operation ASHA



In India alone, about 3.5 million people are estimated to have tuberculosis, but one third of them either haven’t been diagnosed or aren’t receiving treatment. In addition to the health effects, the impact on the Indian economy is significant: annual lost wages as a result of the disease are estimated to be some US $330 million dollars.   Infected people are disproportionately from vulnerable and marginalized populations and outreach is costly in terms of time and resources. Also, those who suffer from the disease often don’t know about the availability and effectiveness of treatment.

The India-based non-governmental organization Operation ASHA, which operates 200 tuberculosis treatment centers, is part of India’s National TB Control Programme and is interested in more effective outreach approaches to identify and treat new patients.  The pilot program will help the group understand whether this is an effective strategy for fighting the spread of TB and improving treatment in India and elsewhere. 

Photo: © World Bank / Curt Carnemark

Intervention and evaluation


Operation ASHA is piloting a program that offers cash payments to current patients if they refer people who might have tuberculosis to government testing centers.


This is a randomized controlled trial to compare the effectiveness of various financial incentives. In the first stage of the evaluation, researchers will compare conditional versus unconditional incentives. In the unconditional group, patients will be given 150 rupees (about US $2.30) for every person they persuade to visit the center for testing. In the conditional group, patients will be offered 100 rupees (US $1.50) for every person they persuade to visit the center for testing, plus an additional 150 rupees (about US $2.30) if the person tests positive for TB.  This stage of the evaluation will allow researchers to determine the effects of these incentives, as well as whether the patients have concrete information about the TB status of the people they are referring.

Researchers will also test the effectiveness of patient outreach, as compared to health worker outreach. In this stage of the evaluation, in the “patient outreach treatment” group, current patients will be given a set of referral cards and told that they will receive a reward if new people come to the center with the card and get tested. In the other treatment arm, (“patient provides names group), current patients will be invited to provide names and contact information of people whom they believe should get tested,. The patients will receive a reward if the new person, who will be approached by an Operation ASHA health worker, comes to the center and gets tested. 

Finally, there will be two versions of the “patient provides names” treatment. In the “known referrer” version, health workers will tell the new peoples who referred them. In the anonymous referrer” version, the name of the referrer will be withheld. This allows researchers to determine the extent to which social stigma is a barrier to referrals.

Policy impact

The results will help India’s state-run National TB Control Programme develop strategies for how best to combat the disease. Evidence will also be useful to health experts in other developing countries who are also seeking ways to stem the spread of the disease by boosting detection and treatment among those already infected. The incentivized patient-to-patient referral system piloted in this program has the potential to extend treatment to some of the most marginalized people and if successful, could become part of the standard public health toolkit in the detection and treatment of TB and other communicable diseases such as HIV/AIDS.