June 2012 Overview Operation ASHA is a nonprofit bringing tuberculosis treatment to more than 5 million of India and Cambodias poorest eCompliance is a biometric terminal that contributes to preventing drugresistant strains of tuberculosis from developing during patient treatment ID: 291210
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Slide1
Curing Tuberculosis with a Community Based Model
June 2012Slide2
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.Slide3
Tuberculosis
(TB) is an airborne infection - 9 million people new patients are found every year. 1.4 million people die of TB every year. TB has caused 10 million orphans so far- Drug resistant forms are causing untold misery
Horrifying Predictions:
- By 2015: 1.3 million drug resistant cases, needing $16 billion
- The world is at the brink of a man-made epidemic of MDR-TB
Positive aspects: TB
is curable…- Strong political & international commitment- Free medicines, diagnostics and public infrastructure
TB:
A
Global Emergency (
WHO
, 1993
)Slide4
4
India’s TB burden is more than double that of second-ranked ChinaSlide5
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 TBSlide6
1. Inaccessible Centers
- Existing public infrastructure lacks the last mile connectivity2. 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 patients6.
High cost of implementation for most other NGOs7. 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 monthsSlide7
“…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 Slide8
*
“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 AvailabilitySlide9
Specialized Training
For active case findingConduct health awareness programsProvide counseling to ensure adherence and prevent MDRTo destigmatize TB
Local Community Members Hired as Counselors &
P
roviders
Work to treat TB, detect new patients, education camps,
default trackingFamiliarity with local customs, geography, and informal address systems
Much more cost efficient than MD doctorsPerformance-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 Slide10
Annual Detection Rate
Detection
Rate/ 100,000 population
Number 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%Slide11
“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)Slide12
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 ReaderSMS ModemSlide13
13
PROBLEM Unsupervised doses being givenMissed doses and default Data fudgedPatients not trackedInaccurate record keepingInadequate follow-upTime lag for follow-upAbsenteeism
SOLUTION
Biometrics
confirms
a TB patient’s presence
This creates indisputable evidenceOne cannot ‘fudge’ a fingerprint!
PRIMARY OBJECTIVE
- To
ensure accuracy and adherence
A critical component: eCompliance-
“What gets measured, gets done”Slide14
Features of eComplianceColor coding shows that a patient has been successfully logged in
The simple interface uses a minimal amount of textEasily translatable into other languages
Counselors can quickly identify which patients have
Visited the center
N
ot come into the center
M
issed their dose within 48 hoursSlide15
15
Electronic Report
ing System
Online SMS Server
Health Worker & Program Manager
Dose missed!
eCompliance Terminal
Front End
Back 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
Daily SMS
How eCompliance WorksSlide16
Implementation
Lessons Learned
Patients
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 Delhi
September 2011:
14 Terminals were installed in Jaipur
June 2012:
6 Terminals were installed in West Delhi
September 2012:
9 Terminals were installed in BhivandiSlide17
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)Slide18
PATIENT AND COMMUNITY LEVELPositive impact on the psycheImproves motivation
Seen as dedication towards quality treatmentAT LEVEL OF FIELD STAFFEnsures integrity of DOTS: eliminates unsupervised dosesEliminates human errorImproves skillsMakes counseling easy, ie. easier to convince patientsAccurate reporting and up-to-date intelligence Saves time spent in going thru paper recordstarget counseling
The Key Benefits of BiometricsSlide19
MANAGEMENT LEVEL
Accuracy of records
Multi-level accountability and transparency
An accurate platform for monitoringEliminates absenteeism, late comingPrevents tamperingSynchronization of data
Transparent treatment supervisionEnsures accuracy of incentivesTHE PUBLIC HEALTH PERSPECTIVEEnsures DOTS is being deliveredPrevents MDR-TB CAN BE UPGRADED FOR
Daily dose regimenAdherence for MDR-TB,HIV treatmentDiabetes Mid-day Meal schemes
The Key Benefits of
eComplianceSlide20
Operation ASHA’s Exponential
Growth (number of DOTs centers)Slide21
CAMBODIA - since 2010Serving 6% of the population and 8% of the patients
Working in 4 Operating Districts, in 2 provincesDetection rate increased by 71%In the pipeline…….VIETNAMReplication of the PPM & DOTS expansion
Replication in Other CountriesSlide22
Adopting OpASHA’s Best Practices
Please visit www.opasha.org for more information about our model, our current work, and other projects.
Our Model Works – It is cost effective, sustainable and replicable.
We are the community – OpASHA directly impacts the areas we serve.
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. 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.