Using Community Empowerment and eCompliance Suite technology for TB treatment & prevention
Description
Tuberculosis (TB) is predominantly a disease of the poor. Although preventable and fully curable, it kills one person every 17 seconds globally. Operation ASHA (OA) has developed a new paradigm to prevent and treat TB in marginalized populations. Its model combines technology with human effort to ensure adherence to the 6-8 month long treatment protocol, thereby restoring health and economic productivity to people living at the Bottom of the Pyramid. The project was implemented over a time frame of 18 months with an achievement of 91% of its planned enrolment targets.
Most conventional solutions for TB face two nearly insurmountable problems: First is inaccurate data, as agreed publicly by the Indian Health Minister (Times of India, Oct 31, 2011). A WHO consultant found a default rate of 36%, 6 times higher than the officially reported rate in India. So, in spite of exaggerated claims by most high burden countries, a large proportion of patients still default from treatment giving rise to difficult to treat form of TB such as MDR TB/XDRTB/XDRTB. Secondly use of solutions that have high cost. An example is the TB REACH funding of the Stop TB Partnership, in which average cost of detection alone was $852 (Stop TB Coordinating Meeting, Kuala Lumpur, November 2012). This means a whooping sum of $2.55billion would be required to detect 3 million missing TB cases, plus much more to treat them. <br />
OpASHA has developed a technology driven model that solves both these problems. Its data collation is dependent on fingerprint verification. The eCompliance biometric system developed in collaboration with Microsoft Research, consists of a 7 inch tablet (android based), a commercial fingerprint reader and a SMS modem. It is simple to use, has very low cost, improves staff productivity, maintains and archives data electronically, thereby improving transparency and eliminating human error. Most other biometric systems are costlier, remain highly specialized, making it difficult to use by semi-literate community health workers. Also, as a specialized device, they are a sunk cost that cannot be used for other general purpose computing tasks within an organization. <br />
In addition to the novel technology stated above, OpASHA empowers the community to take care of their health needs. OpASHA recruits and trains local, semi-literate youth who make door-to door visits to find new cases and offer medication. It also partners with local micro-entrepreneurs, whose premises are used as treatment centers. This serves to provide an ‘easy camouflage’ for patients who often lack seeking treatment due to fear of stigma in approaching a traditionally marketed TB clinic. All of the best practices discussed here improve results and also dramatically reduce costs. In all states of India & in Cambodia, OpASHA has improved detection by 30-100% over historical data. It has lowered default rate to 3%, 5-20 times lower than others. This is achieved at a cost of $40 for 6 month long treatment and $20 for detection. Thus, OpASHA’s cost per detection is nearly 42 times lower than projects funded by TB REACH. Other comparisons only reinforce such cost-efficiency. At this rate, detection of 3 million undetected patients will not cost $2.55billion, but only $60 million, an eminently achievable fundraising target.<br />
To top it all, OpASHA’s model has proven replicability and scalability. Excellent results at an affordable price is the reason why many countries and NGOs are showing keen interest in its model.
4. Funding Support from DFID, India
All outcomes were monitored and validated on a monthly basis by the stakeholders
The project used eCompliance -fingerprint-based tracking software to ensure adherence to TB treatment. With every dose administered, the patient and the community health worker (CHW) give their fingerprints. This gives an irrevocable proof that their interaction took place. The app also generates SMS alerts for missed doses through a built-in reminder system, enabling the CHW to track patients. Further counseling is provided to bring them back into the 6-month long treatment regimen. Thus, it helps in reducing drop-outs. Real-time data from eCompliance is sent to a web-based Electronic Medical Record (EMR) system that collates and analyzes it. It then produced different reports as per the user level. Thus, monitoring is also in-built in the software. The electronically generated data cannot be fudged to meet targets making it a fool proof system. Use of eCompliance makes tracking each and every patient through the entire treatment cycle, a highly dynamic process. The project staff based at the headquarters is able to see the GPS locations, time stamp and date stamp of each and every dose that was administered by the CHW, at the farthest location on the field. This also facilitates corrective action, in case of deviations from the standard procedures deployed on the field. Thus eCompliance offers real-time monitoring of field activities, from any location, that too at the click of the button. OpASHA’s field process too, is innovative. It employs local youth from within the target communities to work on the frontline as CHWs. They are trained and empowered to use the eCompliance software to track medication for TB patients. They are paid incentive-based remuneration based on the number of patients enrolled and served by them. This helps in reducing the costs of the model.Both the aspects mentioned above (technology +manpower) were together embedded in the National Tuberculosis Control Program of the respective countries i.e.: India and Afghanistan. NTP provides free medicines, diagnostic facilities and physician services for prescriptions etc. further reducing the cost of service delivery. The details explained above are implemented using a unique 14 point model for project implementation. It is given below1. Use of algorithms approved by the Government.Close coordination with the public health department and optimization of their services3. Well-trained corps of community health workers 4.Active case finding and contact tracing with support of a software application 5.Rapid response testing and de-stigmatization/ education of patients’ immediate circle 6.Door delivery of medicine, diagnostics and education 7.Amelioration of side-effects and camouflage 8.Performance-based remuneration 9.Biometric devices to track compliance and other technology applications to track staff movement, communication of lab results and payment to village level workers 10.Stringent quality control 11.Robust feedback loop 12.Franchise-like operation for easy replication 13.Very low cost operating model 14.Advocacy with stakeholders and governments to improve policy and financial sustainability
Technology acts as a major enabling factor as it overcomes all the shortcomings of the current government programmes like- inaccurate data, data manipulation, human error etc. It also facilities real time monitoring of field activities.
Partnering with the government helps in curtailing the cost of the model, as medicines, diagnostics and physicians services are provided for free
The community driven model and the eCompliance technology has already been used as part of NTP in India, Cambodia and Afghanistan. It is thereby fully compliant with the regulatory requirements of different high burden countries.
All these factors enable in replication of our technology
Substantial support from the Govt provides great leverage and is strongly liked by donors. They bring in the balance (44% for first 2 years and 22% thereafter. Institutional donors (foundations, companies, bilateral and multilateral) belong to India, US, Europe and Australia. Individual donors are distributed all over the world, as far as Korea. Most of this funding pays for one-time expenses, technology development and expansion to new areas.
The last, but perhaps the most important element of our sustainability strategy is aggressive cost reduction. Many innovations were tried, improved and adopted for this purpose. As an example, physicians, who work as counselors in most NGOs were replaced with semi-literate local youth. The latter are part of the community and easily accepted compared to highly educated physicians, who are considered “outsiders” among TB patients, most of whom are poor. Our strategy improved results and reduced counselor cost by 20 times. No wonder, “OpASHA’s cost for treating each patient in India is approximately 32 times lower than the nearest other provider.” (https://www.csis.org/blogs/smart-global-health/achieving-tb-milestones-… ). The above 3 principles have served us well. Based on these principles we have been able to replicate our model in 7 other countries viz: Cambodia, Uganda, Kenya, Peru, Dominican Republic, Tanzania, Afghanistan.
Having achieved all these criteria, we are regularly working with donors (like the World Bank), advocacy groups (like Partnership for TB Care & Control in India), activist groups (like ACTION and Results TB) and peers (like TB Alert) to convince the government that investment in TB provides massive returns to the society and deserves higher priority than currently accorded. We are in regular discussion with the Federal & Provincial Ministries of Health, Planning Commission and many other bodies to convince the Govt to defray full cost of TB treatment. The Government in India has already circulated a draft plan that envisages upto six times increase in grant.
Operation ASHA intends to take its model and technology to other parts of the world with high burden of TB. Infact it can be replicated and customized for any other disease or problem that requires long term care and regular tracking
1. Learnings are mentioned below a. Social processes to be developed in collaboration with target communities Use only local CHWs. Give small incentives. These increase detection by 33% (JPAL) . eDetection further improves detection by 20% . This is how OpASHA can reach 100% (217 patients/ Lakh/ year) detection against 55% in India.. eCompliance reduces default by 20% (JPAL) . OpASHA now achieves default rate of 2%. In initial years, it was 6%. Respective treatment success rates (TSR) are 88% and 85% . Comparable figures are: 18% default and 75% TSR in India f. Close tracking of activities with technology has reduced ‘interval from diagnosis to treatment to 1-4 days’, against upto 30 days in RNTCP. 2.The HLC recommended, to the Central Health Ministry, to extend eCompliance to “slum areas across the country especially for” patients who have defaulted in the past and MDR patients . It also observed that OpASHA’s training is comprehensive and technology is highly appreciated by patients and local RNTCP staff. IMPACT of OpASHA 1. OpASHA’s model has expanded to eight countries: Cambodia, Uganda, Kenya, Peru, Dominican Republic, Tanzania, Afghanistan. It serves 15,000 TB patients annually in over 5000 slums/ villages. 2. Since 2006, 75719 patients of normal/ DST TB, 366 patients of MDR TB have been enrolled, one patient of XDR has been treated and three patients of XDR are under treatment. 3. 195 disadvantaged persons provided dignified work. 4. 24 Female TB patients provided vocational training to prevent abandonment by families. 5.260 Haemophilia patients detected and put on treatment 6. 10,000 TB patients tested for diabetes. Those who tested positive have been linked with physicians & trained to manage diabetes in a market sustainable way 7. 93 patients’ jobs saved by our counsellors who convinced their supervisors, not to terminate them 8. Income of 124 micro-entrepreneurs in disadvantaged localities, who work as partners of OpASHA, has enhanced substantially. 9. On treatment, patients earn an additional $13,935 (Rs. 8.36 Lakh) through reinstated productivity in their lifetime, on an average (Annual TB Report 2013, Government of India). Thus, treated patients have benefited by a whopping $ 843million (Rs 5,485.3 crores) 10. With treatment of each patient, the economy saves $12,235 (Rs 7.34 Lakh) in indirect loss (Annual TB Report 2013, Government of India). The Indian and Cambodian economies have saved $740.9 million (Rs 4,816.1 crores) for patients who successfully completed treatment. 11. Detection and support with management of diabetes, heart disease and hemophilia across 80 Lakh population. 12. Distributed millions of iron, calcium tablets, analgesic, antacid, anti-emetics. No wonder, Country Director of the World Bank said, “OpASHA is the Microsoft of the NGO world. It can stop MDR and save many lives.
12. The Hindu, World Bank picks 20 projects for $1,00,000 grant, May 2, 2013 13. Modern Ghana, World TB Day: 24 March….Tuberculosis Control Needs A Complete And Patient-Centric Solution, March 24, 2014 14.Bill & Melinda Gates foundation, Informal Health Providers Treating TB Are Here to Stay, So How Do We Work with Them?, March 28, 2013 And many more
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Manisha Gupta, Ms