Community empowerment and Technology Building a cost effective, scalable & replicable model

April 2012

100,000 estimated cases of drug resistant TB (less than 3,000 identified); 12 cases of XXDR TB recently detected.

India- 100% DOTS coverage by RNTCP since 2006

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India’s TB burden is more than double that of second-ranked China

“If you do not diagnose, you cannot treat”

1. Inaccessible Centers- Existing public infrastructure lacks the last mile connectivity - What to choose- wages or medicine? - who will pay the bus fare? 2. Social Stigma - patients go into denial or hide symptoms - Loss of jobs - Loss of families - Patients thrown out of homes by landlords if they have TB 3. Limited/ Ineffective Education or counseling 4. The Quacks - incomplete, irregular, inadequate treatment 5. Negligible follow-up of defaulting patients 6. High cost of implementation for most other NGOs 7. Program level – lack of electronic data, inaccuracy and human errors, most important - data fudging to show targets have been met

Challenges in TB Treatment: DOTS treatment requires 60 visits to a center over 6 months

MDR-TB

•Is not susceptible to first-line TB drugs

•5-10% of the total TB cases

•mortality rate of 80 percent

XDR-TB

•Develops when patients default on MDR-TB treatment

• 20-25% of the total MDR-TB cases

•Nearly 100% mortality,

XXDR-TB

•Is unresponsive to all known TB medicines

• was recently discovered in Mumbai, India.

•Twelve cases of this strain were identified, three have died

•There is currently no way to cure this disease

•l it can be directly transferred to anyone

1. Inaccessible centers • Open the usual business hours • What to choose? • Medicine or food • Who pays the bus fare?

2. The quacks • First point of contact for the disadvantaged • Late or no diagnosis • Insufficient duration, • Unscientific combinations ( Dharavi study)

5. Poor planning, lack of commitment of government, lack of funds

3. Social Stigma • disruption of family life • Loss of Job • I will lose the patch of land where I have made my

hut ! • Why take medicine when symptoms go away?

4. At DOTS centers- lack of surveillance • No counseling • No default tracking • No incentives for employees to give their best

Factors responsible for Drug Resistance

“DOTS alone is not sufficient to curb the TB epidemic in countries with high rates of MDR-TB.” –Stop TB Working Group

The New Idea….

“Electronic datasets are needed to facilitate accuracy and analysis of data.” - WHO (2011)

“…The data was being fudged.”

– Ghulam Nabi Azad, Union Health Minister (Times of India, Oct 31, 2011)

Independent evaluation by a WHO consultant

found default rate of 36% (6 times higher than

reported). Alarming: Is India an MDR factory?

World bank research- 44% absenteeism in govt school teachers A study on health care delivery found a 43% level of absenteeism.(a)

(a) Chaudhury, Hammer, Kremer, Muralidharan and Rogers, 2003

Sensational News Item in Times of India

* “Directly Observed Therapy - Short Course”

Treatment Centers: Inadequate in

slums

• Local “last mile” centers, distributing

medication and ensuring compliance

• 5 TCs required for every DC;

currently, only 1-4, with limited hours

of operation

• Scarcity of TCs results in high default

rates, causing relapse & drug-

resistance

The DOTS* model: network of three types of facilities

Hospital/ Warehouse

DC

DC

DC

DC

DC

DC

DC

DC

Diagnostic Centers: Adequate

• Sputum tests for initial/rapid diagnosis • 5 DCs required for every hospital ;

typically present

DC

TB Hospitals: Adequate

• Government facilities providing

comprehensive diagnostics and

treatment recommendation

• Warehouse for medicine supplies,

provided free by government &

donors

Hospital/

Warehouse

India’s TB Control program: The DOTS model- lacks Access and Availability

Specialized Training • For active case finding • Conduct health awareness programs • Provide counseling to ensure adherence and prevent MDR • To destigmatize TB

Local Community Members Hired as Counselors & Providers • Work- to treat TB, detect new patients, education camps, default tracking • Advantage - familiarity with local customs, geography, and

informal address systems • MUCH LESS cost than MD doctors! • PERFORMANCE BASED SALARIES to incentivize field workers

Strategically located TB Centers • In convenient, high-traffic areas • Centers open at convenient hours • No patient needs to miss work/wages to access treatment

OpASHA’s Solution: Fill the Gaps: Community

Empowerment & eCompliance

OpASHA’s Innovative approach 1. Internationally accepted standard DOTS therapy prescribed by World Health Organization and followed by India all over the country. 2. Close coordination with Revised National TB Control Program.

– Hospitals & Diagnostic centers – TB medicines – Over-the-counter drugs like pain-killers and antacids to take care of the

side effects – NTP also provides the following

• Consumables and stationery like file covers and stock registers • Disposable plastic cups • Protein supplements • Tea and snacks for participants at awareness campaigns

– A grant two years after the patient is enrolled for treatment.

OpASHA’s Model for the “last mile”

3. Dense network of treatment centers

consisting of strategically selected, high-

traffic community centers (e.g., places of

worship and popular locally owned stores),

so that patients are no farther than a 10

minute walk from the nearest center;

extended operating hours based on

specific community needs.

4. Leverage trusted community leaders (e.g.

priests, traditional healers) to work as

DOTS providers and spread key

messages to their community

5. Rapid response testing and education of

immediate circle (e.g., family members and

neighbors) of identified patients

OpASHA’s Model for the “last mile”

Annual Detection Rate of New Sputum + Cases South Delhi

82 82

104

151 160

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60

80

100

120

140

160

180

2005 2006 2007 2008 2009

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OpASHA’s Results: Higher detection rates Model for the “last mile”

6. Corps of highly-trained, well-compensated, full-time counselors (equipped with motorcycles, as required)

7. Provision of Over-the-Counter drugs to treat side effects of TB drugs and provide camouflage.

8. Highly effective Performance-based remuneration. 9. Robust feedback loop involving government officers

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Results: OpASHA

(2010)

Other

Organizations

Default Rate 2.75% Up to 60%

OpASHA’s Model for the “last mile”

Replicable Unit

Counselor Counselor Counselor Counselor

Provider

Program Manager

Provider

10. Stringent quality control with internal and external audit.

11. Low-cost, highly leveraged operating model

Cost of full treatment = $30 per patient

Results: Significantly lower cost per patient and higher “SROI”

OpASHA Other NGOs

Cost per patient

Leverage

USD

30

USD 300

4 0.08

SROI: On NGO’s

investment

3,500% 1,000%

SROI: on total investment

by all partners

850% 719%

Assumptions: TB treatment leads to increase in productivity, which in turn raises annual

income by USD $150*; it also saves USD $11,500 in indirect expenses to the economy*;

Discount rate = 8%

* Annual TB Report, Government of India, 2007 & 2011

OpASHA’s Model for the “last mile”

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PROBLEM

• Unsupervised doses being given

• Missed doses and default

• Data fudged

• Missed doses are not tracked

• Inaccurate record keeping

• Inadequate follow-up

• Time lag between missed dose and follow-up

• Absenteeism among staff

SOLUTION

• Biometrics confirms a TB patient’s presence

• Patients/ staff scan their fingerprint at the treatment center

• This creates indisputable evidence of patient interaction, initial house visit and follow up of each missed dose

• One cannot ‘fudge’ a fingerprint!

PRIMARY OBJECTIVE - To ensure accuracy and adherence

A critical component: eCompliance- “What gets measured, gets done”

Biometric devices for automated compliance tracking deployed at all the South Delhi centers

Result: 1.5% default rate

USB Modem

for SMS

E-compliance- In collaboration with Microsoft Research & IIH

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Patient Interaction with the Biometric Terminal

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Electronic Reporting System

Online SMS Server

Health Worker & Program Manager

eDOTS Terminal

Fro

nt

End

B

ack

End

The Front End • Uses only off-the-shelf

components A fingerprint reader A netbook computer USB modem for SMS SMS Plan for 3yrs ($10)

The Back End • SMS Gateway • Central Reporting System • messages are downloaded

from the SMS server and imported into a centralized online database

SMS

How eCompliance Works

eCompliance terminals have been used in South Delhi since 2009

more terminals were installed in Jaipur in 2011

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Implementation

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Lessons Learned Our experience indicates that patients are not hesitant to give their fingerprints, and usually do so without difficulty

Patients have perceived the use of technology as a sign of the quality of treatment they are receiving

Results

• Default measured at 1.5% • Over 1,400 patient cured • Over 60,000 visits logged

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PATIENT AND COMMUNITY LEVEL • Positive impact on the psyche • Improves motivation • Seen as dedication towards quality treatment • Interest generated by technology intervention in disadvantaged areas • Re-enforces belief in the government and DOTS • Indirect benefit- discussion of health issues

AT LEVEL OF FIELD STAFF • Ensures integrity of DOTS: eliminates unsupervised doses, which are

otherwise the norm across the world • Eliminates human errors in management of DOTS. For example, if a patient

comes on the wrong day, eCompliance automatically reminds the counselors and prevents such occurrences

• Improves skills • Makes counseling easy, ie. easier to convince patients • Accurate reporting and up-to-date intelligence

– Eliminates human error • Saves time spent in going thru paper records • Real-time records allows counselors to target counseling, which reduces

workload

The Key Benefits of Biometrics

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MANAGEMENT LEVEL • Accuracy of records- retrieval for analysis and research

• Digitization of record increases productivity of staff

• Multi-level accountability and transparency

• An accurate platform for monitoring and evaluation of the core program

– Eliminates absenteeism, late coming of counselors

– Prevents tampering with patient data

– Synchronization of data at all levels of management

• Transparent treatment supervision

• Ensures accurate performance based incentives

THE PUBLIC HEALTH PERSPECTIVE • ENSURES DOTS is being delivered

• Halts the development of drug resistance due to default.

• Provides unlimited quality data for future research

The Key Benefits of eCompliance

STAFF Fear of micro-monitoring

Fear of losing jobs to computers

Initial increase in work load (hybrid system)

Fear of theft, breakages

PATIENTS Fear of electric shock!

TECH TEAM Recognition accuracy

Computational ability

- Maintenance

- Software hardware failure, viruses etc

- Need based ongoing system analysis

- Security measures needed to prevent tampering

- Reconciliation of data

Challenges and the solutions

Develop Software Further For

Daily dose regimen

Adherence for MDR-TB,

ART

Integration with MCH, midday meals etc

NCD, especially integration with DM

Zero literacy areas (use icons and audio tracks)

Migrate to inexpensive smart phones

LINKING eCompliance WITH ERP Developing Q&A/ FAQs for contact tracing

Showing educational videos on net-book/ Smart phone

Sending SMS reminders and medical information

AT NATIONAL LEVEL

Developing help lines for patients

Technology & Upgrades - Next steps

• Operation ASHA- started work in September2006

• Treated 18,000 patients so far, ( 5500 this year)

• Almost 2,070 patients were children( how many missed?)

• Challenges - Plenty!

• Diagnostic difficulties • Traditionally ignored because not infective • No gold standard • Late diagnosis-high morbidity and

mortality • Stigma, lack of schooling • Neglected by public health experts and

Policy makers alike!

TB in children =under-detected and under-reported

MDR- / XDR-TB rates in children reflect community transmission rates

Our experience with pediatric TB

Medicines- nobody thought of children? Crushing and breaking tablets- irregular treatment, bitter taste

Operation ASHA’s Exponential Growth (number of DOTs centers)

Replication of our model in 14 cities, 7 states of India, diverse regions, ethnicity, geography, demographics, social structure

REPLICATION IN CAMBODIA

Serving 6% of the population and 8% of the patients

Working in 4 ODs, in 2 provinces

34 staff, all local people except for one Technical advisor from India

Detection rate increased by 71% in Q4- 2011 in Phnom Penh

VIETNAM

Replication of the PPM & DOTS expansion

We have the seed funding, political commitment

Charismatic leadership- prospective country manager (KPMG background) 15 months in India in full time position

UGANDA

First step towards third party replication

eCompliance initiative to be replicated by a leading nonprofit, which works in 8many countries in Africa

OpASHA will be the resource centre, provide training and tech support, free software,

OTHER COUNTRIES

Ground work in progress in Ghana, Kenya and Morocco

Beyond India’s Borders: South-South Cooperation

Next Steps: To Develop Clarity and build partnerships

Establish best practices across the world by policy making – To become a resource centre – Training Nonprofits in high burden countries – Support educational activities, (text free videos, translation of training manual

etc)

Collaborate with World Bank, Government and other stake holders – Lobby with developing country govts for increased funding for PPM programs

(Stop TB grants $425 per DETECTION ALONE) – Persuade govts across the world to link grants to outcome metrics, not just

processes – Ensure that govt procedures are simplified and streamlined – Ensure that agreements with govt for TB control should include establishing

best practices

• Decentralize and de-stigmatize TB • eCompliance will remain open source • It will continue to use commercially available

hardware. • Can be quickly and freely adopted by other TB

institutions • OpASHA plans to develop capacity to help govts and

NGOs replicate its model • Grave concerns- MDR prevention and Pediatric TB • Advocacy – to express urgency, establish best

practices, and use eCompliance for best results in TB

Community empowerment &Technology together gives best results.

Conclusion