AUGUST 2020TB CARE II is funded by United States Agency for International Development (USAID) under Cooperative Agreement Number AID-OAA-A-10-0021. The project team includes prime recipient, University Research Co., LLC (URC), and sub-recipient organizations Jhpiego, Partners In Health, Project HOPE along with BEA Enterprises; Brigham and Women’s Hospital; the Canadian Lung Association; Clinical and Laboratory Standards Institute; Dartmouth Medical School: The Section of Infectious Disease and International Health; Euro Health Group; McGill University; and The New Jersey Medical School Global Tuberculosis Institute.

ContextThe rapid expansion of digital technology has created new opportunities for improving health and wellbeing. Tools such as smart phones, digital cameras, drones, and geolocation tools, as well as the use of machine learning and artificial intelligence, have transformed the flow of information within health systems. This potential has been recognized by USAID in the Digital Strategy 2020-2024, which highlights the importance of open, inclusive, and secure digital ecosystems for communities to achieve self-reliance in the digital age.

Digital technologies also have vast potential to contribute to global EndTB Goals, targets set at the United Nations General Assembly High-Level Meeting on TB in 2018, and national tuberculosis (TB) goals and strategies. TB continues to infect 10 million people each year, and is the deadliest infectious disease globally. Digital technologies have the potential to support care of patients with TB and multi-drug resistant TB (MDR-TB), TB surveillance and monitoring, capacity building, and TB program management

To leverage the potential of digital technology for TB control, USAID TB CARE II Project provided global leadership and focused technical support to:

• develop, pilot, and scale up digital systems in countries with field programs to support learning, service delivery, and patient education;

• document existing digital tools for TB control and support their dissemination; and

• foster global dialogue on effectively leveraging

Digital Health Solutions for a World Free of Tuberculosis

digital technologies for improve TB outcomes while strengthening the openness, inclusiveness, and security of digital TB ecosystems.

In line with USAID’s “Global Accelerator to End TB”, TB CARE II engaged governments, the private sector, and civil society in identifying, developing, and scaling up effective and appropriate digital solutions to support TB control in their digital ecosystem. In particular, the project advocated for community-driven and patient-centered care and prevention to improve patient satisfaction, which leads to treatment adherence, timely and full cure, and a more efficient use of resources.

The USAID TB CARE II Project (2010-2020)▶ Provided global leadership and technical support

to National TB Programs and other stakeholders to accelerate the implementation of TB, TB-HIV co-infection, and multi-drug resistant TB services.

▶ Particular emphasis on innovative technological approaches to improve TB case detection and treatment, and interventions related to infection control and programmatic management of drug-resistant TB.

▶ Strengthened TB program capacity and fostered commitment to ending TB by empowering government partners, civil society, communities, and the private sector to develop local solutions to address bottlenecks and strengthen health systems for TB control.

2 Digital Health Solutions for a World Free of Tuberculosis

Key activities and resultsDeveloping and scaling up use of digital tools to support TB programming TB CARE II worked with National TB Programs (NTPs) and other TB stakeholders to develop and scale-up digital solutions to support control of TB and MDR-TB. Some tools and resources developed by the project, many supporting multiple functions in TB prevention, service delivery, and program management, are featured below. (For more information on individual countries, see the country-specific briefs).

PATIENT CAREXpert reporting: In Bangladesh, introduction of the GeneXpert MTB/RIF molecular test in 2012 made it possible to diagnose drug sensitivity status within couple of hours; however, treatment initiation was delayed by the need to deliver results to patients across the country. TB CARE II introduced Xpert reporting, a web-based reporting tool, which enables lab technologists to enter GeneXpert results to a web application, send diagnosis results to the originating laboratory, and notify the suspected MDR-TB patient that their results are ready. The information is stored in a database server, from where it can be used for data analysis, reporting, and decision-making. Currently Xpert reporting is used in 26 GeneXpert labs throughout the country.

ConnecTB: The smartphone-based application is a patient management and retention tool which aims to improve patient experiences and outcomes while they are in treatment. On logging into the system, community-based health care workers who provide directly observed therapy (DOT) for people with TB receive their patient list for the day. As they visit their patients, they are guided through a short survey which asks them to: help the patient to take their specific treatment regimen (which is displayed onscreen); check for household contacts and screen if necessary; and ask if the patient has experienced any adverse drug events or negative side effects. Each visit is stamped with the time and location. ConnecTB also has a stand-alone module called eFlipchart for patient education, which can be integrated with the

ConnecTB app. Program managers receive a daily digest to monitor performance and take follow-up action on missed appointments, side effects, and adverse reactions if needed. A geo-mapping module supports identification of high-burden TB areas or hotspots for efficient and rapid management.

TB CARE II introduced ConnecTB into community-based MDR-TB programs in Bangladesh and South Africa, tailored to local policies and standard operating procedures. As a result, the application increased retention rates to 90 %-100%. In South Africa, the application was adopted by NGOs who work directly with multiple facilities to receive MDR-TB patient referrals for subsequent follow up and management. An assessment conducted in South Africa found ConnecTB to be a cost-effective patient management solution at $76 per patient, assuming two years of treatment and including annual maintenance, tablets, and airtime, less than 10% of the total per-patient cost of implementing a community-based TB treatment program.1

SURVEILLANCE AND MONITORINGTB CARE II worked with NTPs to strengthen electronic recording and reporting tools to increase the timeliness and quality of data. For example, TB CARE II designed an application to support weekly TB reporting by nurses providing health services to workers on remote farms

A TB CARE II staff member in Bangladesh provides an mHealth orientation to a DOT provider while visiting an MDR-TB patient’s house in a remote area

1. Moran A et al. (2020) Examining the cost of community-based tuberculosis treatment in South Africa. Int J Tuberc Lung Dis, 24(6):612–618.

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mCash/Mobile banking: As part of the community-based MDR-TB program in Bangladesh, TB CARE II provided each TB patient a small monthly allowance to supplement their diet, and each DOT provider an allowance to lower their transportation and communication costs. To efficiently, securely, and quickly carry out this transaction, the project opened mobile money accounts for all MDR-TB patients and DOT providers with mobile phones, working with Dutch Bangla Bank which provides mobile financial services. This reduced transaction times and ensured that patients and providers had a regular allowance. During 2011-2015, 592 MDR-TB patients and 445 DOT providers in 20 districts received funds through mobile banking.

BUILDING CAPACITY THROUGH E-LEARNINGDR-TB Learning Network/TB Academy: Recognizing the gap in provider skills in the management of TB, particularly MDR-TB, TB CARE II established an online training portal, the DR-TB Learning Network, which has since been incorporated into the TB Academy, with webinars also available on YouTube. The website included archived webinars and links to upcoming events, clinical case studies, and self-study materials, as well as links to key, global TB publications.

Documenting and disseminating informationTo make existing digital solutions more readily accessible to TB programs in search of effective digital solutions, TB CARE II catalogued existing tools, checklists and standard operating procedures related to digital technology for TB and developed a guidance document, Digital Technology for a World Free of Tuberculosis (2018). The document describes digital tools to support TB programming and describes a set of steps for implementing digital health for TB control. The guide also includes country-level profiles detailing the digital health situation in each of the focus countries of the USG’s National Action Plan for Combating MDR-TB (NAP). Based on the guidance document, TB CARE II developed a set of webinars focusing on technology for TB and MDR-TB. These webinars describe the digital health toolkit and how to create digital health roadmaps, and effective tools such as ConnecTB, video observed treatment (VOT), and IPConnect.

in South Africa. The tool has been further revised and updated by the USAID TB South Africa Project.

The project also increased the use of geomapping modules for program monitoring, whether incorporated with ConnectTB or other open data kit (ODK) applications. For example, TB CARE II worked with the mining industry in southern Africa to develop an application that uses geomapping to link miners to the nearest health facility offering needed services. Health facilities are also able to identify mining communities nearby to conduct outreach for TB awareness and services.

PROGRAM MANAGEMENTThe IPConnect suite of infection prevention and control applications designed to engage providers in infection prevention and control, to monitor stock outs and stock management for IPC supplies, and to manage facility-based risk assessments. Real time geo-tagged data support rapid response to outbreaks and other highly infectious incidents, and analyze gaps by geographic location. The application has been adopted by the Ministry of Health in South Africa for nationwide use and is downloadable from Google Play. The full suite of applications includes:

4 Digital Health Solutions for a World Free of Tuberculosis

Supporting global dialogueIn July 2018, TB CARE II organized a global consultation on digital technologies for TB in Delhi, India. The workshop brought together 151 participants from thirteen countries, including eight countries prioritized under the NAP. With representation from government sectors, technology companies and industry groups, and non-governmental organizations and implementing partners, country teams: 1) identified needs and opportunities for development of new digital health tools to combat MDR-TB, 2) selected innovative digital solutions to focus on in 2018-2019, and 3) developed a national digital health agenda for TB in line with local needs and capacity to scale up and sustain. Workshop materials and resources are available

on the workshop website. Following the workshop, TB CARE II continued to work with the NTP teams from the ten NAP priority countries and other countries to finalize their national agendas and roadmaps for digital health technologies.

Conclusions Digital technologies strengthen health systems at multiple levels by improving data services and information flow for system managers, facilitating communication between health providers and patients, and providing patients with tools to prevent and manage illness. To assist countries in developing open and inclusive ecosystems, TB CARE II advocated for a stronger focus on the qualitative customer experience, including protections for confidentiality and ownership of data. Digital solutions also hold strong promise for preparing health systems to support management and rapid response to other infectious diseases, such as COVID-19.

TB CARE II encouraged increased investment in digital solutions for TB control from the public and private sectors, building commitment and capacity among NTPs and other TB stakeholders to keep pace with the rapidly developing technologies, and to identify which digital solutions are effective in the local context and worth adopting to scale up nationally. Multisectoral engagement helped ensure that digital solutions were not only effective, but also contributed to the sustainability and equitability of TB control activities, supporting countries along their Journey to Self-Reliance in the digital age.

Participants at the 2018 workshop on digital technologies for TB learn about existing technologies

USAID Bureau for Global Health | TB Team

500 D Street SW | Washington, DC | 1.571.309.0217

Hala Jassim AlMossawi: Acting Director, TB CARE II • hjassim@urc-chs.com

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