Curing Tuberculosis with a Community Based Model

June 2012

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Overview

Operation ASHA is a non-profit bringing tuberculosis treatment to more than 5 million of India and Cambodia’s poorest.

eCompliance is a biometric terminal that contributes to preventing drug-resistant strains of tuberculosis from developing during patient treatment.

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

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Tuberculosis in India

Drug Resistance in India

There are over 100,000 estimated cases of drug resistant TB in India although less than 3,000 were identified in the same year.

12 cases of extremely drug resistant TB were recently found in India. These cases had developed to the extent that no known drug could cure it.

In a recent study, only 3 out of 106 practitioners issued an appropriate prescription for drug resistant TB

1. Inaccessible Centers- Existing public infrastructure lacks the last mile connectivity

2. Social Stigma - patients go into denial or hide symptoms

- Loss of jobs

- Loss of families

- TB Patients thrown out of homes

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

“…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).

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• Familiarity with local customs, geography, and informal address

systems• Much more cost efficient 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

Annual Detection Rate

2005 2006 2007 2008 2009

020406080

100120140160180

82 82

104

151160

Prior to Operation ASHA With Operation ASHA

Dete

ction

Rat

e/ 1

00,0

00

popu

latio

nNumber of Smear (+) cases based

on ARTI data

OpASHA’s Results: Higher detection , much less default

Results: OpASHA (2010)

Other Organizations

Default Rate 2.75% Up to 60%

Social Return on Investment of 3,211%

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

–Stop TB Working Group

eCompliance: A New Idea….

“Electronic datasets are needed to facilitate accuracy and analysis of data.”

- World Health Organization (2011)

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eCompliance: Open-Source and Off-the-Shelf

Operation ASHA has developed eCompliance with Microsoft Research and Innovators in Health to reliably track and report each dose that a patient takes. It is an open-source software that runs on commercially available, ‘off-the-shelf’ components.

Netbook Computer

Fingerprint Reader

SMS Modem

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PROBLEM

• Unsupervised doses being given• Missed doses and default • Data fudged• Patients not tracked• Inaccurate record keeping• Inadequate follow-up• Time lag for follow-up• Absenteeism

SOLUTION

• Biometrics confirms a TB patient’s presence

• This creates indisputable evidence

• One cannot ‘fudge’ a fingerprint!

PRIMARY OBJECTIVE - To ensure accuracy and adherence

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

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Features of eCompliance

• Color coding shows that a patient has been successfully logged in

• The simple interface uses a minimal amount of text

• Easily translatable into other languages

Counselors can quickly identify which patients have• Visited the center• Not come into the center• Missed their dose within

48 hours

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Electronic Reporting System

Online SMS Server

Health Worker & Program Manager

Dose

missed!

eCompliance TerminalFr

ont E

ndBa

ck E

nd

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

Daily SMS

How eCompliance Works

Implementation

Lessons LearnedPatients are not hesitant to give their fingerprints

Patients perceive technology as a sign of the quality of treatment

Results• Default measured at 2.5%• Over 2,200 patient cured• 900 undergoing treatment• Over 150,000 visits logged

September 2009: 26 Terminals were installed in South DelhiSeptember 2011: 14 Terminals were installed in Jaipur June 2012: 6 Terminals were installed in West DelhiSeptember 2012: 9 Terminals were installed in Bhivandi

Cost Effectiveness

Total cost of each eCompliance terminal = $434 (Rs. 21,700)

Cost per patient = $2.90 (Rs. 145), which is expected to be offset by increased productivity (each unit will treat 150 patients over three years)

Component Cost

Netbook Computer $ 328 (Rs. 16,400)

Fingerprint Reader $ 68 (Rs. 3,400)

SMS Modem $ 28 (Rs. 1,400)

SMS Plan (per year) $ 10 (Rs. 500)

PATIENT AND COMMUNITY LEVEL• Positive impact on the psyche• Improves motivation• Seen as dedication towards quality treatment

AT LEVEL OF FIELD STAFF• Ensures integrity of DOTS: eliminates unsupervised doses• Eliminates human error• Improves skills• Makes counseling easy, ie. easier to convince patients• Accurate reporting and up-to-date intelligence • Saves time spent in going thru paper records• target counseling

The Key Benefits of Biometrics

MANAGEMENT LEVEL• Accuracy of records• Multi-level accountability and transparency• An accurate platform for monitoring

– Eliminates absenteeism, late coming– Prevents tampering– Synchronization of data

• Transparent treatment supervision• Ensures accuracy of incentives

THE PUBLIC HEALTH PERSPECTIVE• Ensures DOTS is being delivered• Prevents MDR-TB

CAN BE UPGRADED FOR• Daily dose regimen• Adherence for MDR-TB,• HIV treatment• Diabetes • Mid-day Meal schemes

The Key Benefits of eCompliance

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

CAMBODIA - since 2010 Serving 6% of the population and 8% of the patients Working in 4 Operating Districts, in 2 provinces Detection rate increased by 71%

In the pipeline…….

VIETNAM Replication of the PPM & DOTS expansion

Replication in Other Countries

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Adopting OpASHA’s Best Practices

Please visit www.opasha.org for more information about our model, our current work, and other projects.

1. Our Model Works – It is cost effective, sustainable and replicable.

2. We are the community – OpASHA directly

impacts the areas we serve.

3. Our last mile of treatment increases the effectiveness of the National TB Program and will do so in every country – strategically filling in the gaps where the government models break down.

4. Providing counseling is the best way to change behavior of the population we are targeting.

Why Now?

Rapid Scale up is necessary to achieve Millennium Development Goal #6. There is no more time to waste.