Using Technology and Community Empowerment to Treat Tuberculosis.

Author(s) Shelly Batra1.
Affiliation(s) 1Senior Management, Operation ASHA, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Infectious Diseases
Summary TB is has been declared a health emergency by WHO. Over 9 million people are newly infected with TB and 1.4 million die annually. Incomplete TB treatment has led to an alarming rise in DR-TB (Drug Resistant TB), a man-made epidemic. MDR-TB (Multi Drug-Resistant TB), if not fully treated, leads to the dreaded XDR-TB (Extremely Drug-Resistant TB), causing greater suffering and economic loss. Operation ASHA’s innovative idea is a combination of our comprehensive model and high leverage of low-cost biometric technology, eCompliance. We monitor every dose taken by MDR-TB patients to prevent XDR, because MDR-TB treatment is often left incomplete due to long duration and debilitating side effects.
What challenges does your project address and why is it of importance? TB is an airborne infectious disease, which transcends all socio-economic, cultural and physical barriers. India carries 26% of the worldwide TB burden. Patients are extremely poor, malnourished, living in cramped, ill-ventilated homes. Poor quality coal for cooking creates smoke, choking the lungs, thus making them susceptible to TB. They live on less than $1.25 a day (World Bank) and cannot afford to lose work and wages to access TB care. Although Government provides free diagnostics & medicines, treatment centres are few and far between. Patients find it impossible to adhere to the regimen, which requires 60 centres-visits over 6 months. Even if they start treatment, once they feel better they tend to stop for fear of losing jobs or of discrimination. This leads to various DR-TB strains, which are near to impossible to treat. Each patient infects 10-15 others, increasing the number of DR-TB cases exponentially. Social stigma, fear and misconceptions all explain poor adherence. Out of 600,000 MDR-TB patients globally, 100,000 are in India. XDR-TB is rampant. Mumbai recently reported 12 cases of TDR-TB (Totally Drug-Resistant TB), which has no treatment. DR-TB is serious socio-economic issue causing tremendous economic loss. Thus, treating MDR-TB fully will prevent XDR & TDR-TB.
How have you addressed these challenges? Do you see a solution? Operation ASHA’ (OpASHA) model and eCompliance effectively tackle lingering problems in TB treatment: patient identity fraud, missed doses, data fudging and high treatment cost. OpASHA fosters community empowerment and employs TB treatment providers who are locals from the communities we serve. With their knowledge of the local language and geography it is far easier for the treatment to reach disadvantaged people. Providers gain the community’s trust and help destigmatise TB through comprehensive education. They assure no patient loses their job or is ostracised by their family. We effectively utilise religious and social leaders to ensure patients adhere to their regimen. OpASHA establishes DOT (Directly Observed Treatment) centres within disadvantaged communities that are accessible and open at convenient times so no patient has to miss work and wages. One DOTS centre serves a population within 1.5km radius. To ensure each dose is taken we use eCompliance, which has a fingerprint reader attached to a netbook computer (or android phone). To register in our centre, new patients must provide fingerprints. Afterwards, every time they come for their free TB treatment they provide fingerprints to verify their identity. To decrease missed doses we rely on our providers and eCompliance for follow up. If a patient misses a dose, eCompliance sends an SMS immediately to the Programme Manager & Treatment Provider. Providers must follow up within 48hrs, find the patient, repeat TB education, administer TB medicine and obtain a fingerprint as proof of visit. If patients experience side-effects, providers either treat them or, if severe, refer them to the hospital.eCompliance eliminates data fudging because we use fingerprints for registering patients, rather than rely on manual data entry. The back end EMR (Electronic Medical Record) generates a set of 100% accurate reports, which previously was a time consuming task as our staff did it manually and with errors. eCompliance saves 30% of provider’s time which is now spent on valuable Active Case Finding and Patient Counselling.We recently upgraded eCompliance to follow MDR-TB treatment, thus preventing XDR-TB. We are also installing eCompliance on android phones. This substantially reduced our terminal costs by 40% and the cost of treatment per patient to less than $3. LGT Venture Philanthropy found that “OpASHA’s cost for treating each patient in India is approximately 19 times lower than the nearest other provider."
How do you know whether you have made a difference? OpASHA believes in a measurable impact, thus generating far more detailed reports than the Government. The following shows our achievement thus far:• We serve 6.1 million disadvantaged people in India and Cambodia
• 31,150+ TB patients treated in more than 3,000 rural areas and urban slums
• We have successfully reduced default rates from as high as 36% to as low as 1.5 %, thus minimising the risk of MDR-
• Treating over 70 MDR patients; supporting 2 XDR patients and one TDR patient with medicines and protein supplements.
• Distributed 570,000 painkillers, 780,000 antacid tablets, 315,000 antiemetic tablets, 240,000 iron tablets, 45,000 calcium tablets, 30,000 condoms, 12,000 sachets of Oral Rehydration Salt, 3,500 packets of protein supplements, 5 tons of food and 4000 blankets.
• 24 Female TB patients were provided vocational training to prevent them from being abandoned by families.
• $150/year increased income through reinstated productivity from TB, equivalent to an annuity of $1,877; treated patients have benefited by $56 million, $13,150 saved by economy for each person treated (Annual TB Report 2011: Govt. of India).
• 190 disadvantaged persons provided dignified sustainable full-time work.
• Income of 178 micro-entrepreneurs in disadvantaged localities (Community Partners) enhanced substantially.
• Social return on investment (SROI) of 3217% i.e. for every dollar invested, the society and the economy benefit by $49.3.Apart from the above, we also regularly measure, collate and analyse the following parameters
• User satisfaction metrics
• Access/ utilisation metrics: Detection as a percentage of prevalence; target is 100%
• Cost and sustainability metrics: Monthly expenses, Cost per patient & Cost per
Treatment / DOTS centre
• Achievement of positive health outcomes: Increase in body weight during the treatment.OpASHA has partnered with J-PAL, MIT in USA, which has conducted an RCT (randomised control trial) to assess the impact of OpASHA’s incentive-based salaries. We have received funding from USAID for the second RCT to assess the benefit of eCompliance. This is helping impact policy in India and abroad.
Have you or the project mobilized others and if so, who, why and how? The overarching principle of OpASHA is providing free, quality TB treatment to the doorsteps of the disadvantaged, while at the same time mobilising them to take self-initiative to improve their health as well as their socio-economic lifestyle. We believe OpASHA’s localised model is an efficient way of generating that mobilisation. For instance, in Cambodia all of our employees are locals, except for the Country Director. 80% of our budget is used to generate jobs for the disadvantaged in India and Cambodia. Within 6 years OpASHA became the 3rd largest TB treatment provider worldwide & the biggest in India by using a high-impact/low-cost, scalable & replicable model. In 2012 The Millennium Villages Project & Columbia University replicated our model and eCompliance in Uganda with “staggering improvement” in results. It took only 8 hours of Skype calls to train the master trainer in Uganda, who then trained their local providers. All technology, training and troubleshooting was done remotely from our office in India. Columbia University is now replicating eCompliance in the Dominican Republic.TB is not only a serious medical issue but it also has serious gender-related consequences. In India 100,000 female TB patients are thrown out of their homes each year by their families, left to die of disease and starvation. 300,000 children have to leave school because of TB either as a result of the infection, or because the parents have TB, in which case the child has to work to support the family (Government of India). OpASHA regularly employs women as TB treatment providers, thus reducing gender disparity. In return, not only do they generate income to support their families but they also gain great respect from the communities who treat them as doctors. In addition, at the end of each quarterly report we reward the provider with the most successful rate of active TB case finding.OpASHA’s delivery of effective TB treatment to women and girls, and in general to the “poorest of the poor”, remote and marginalised tribal communities in India, alleviate the adverse medical, social, economic and gender-based effects of TB, both on the individuals and their communities. This will, in turn, improve productivity, raise income, prevent economic loss, provide skills, training and employment for semi-literate providers in those communities, and enable access to services for the deeply marginalised tribes.
When your donor funding runs out how will your idea continue to live? OpASHA’s collaboration with the Indian Government increased our leverage by more than 4 times. They provide us with free TB and MDR-TB diagnostics, physician consultations and medicines for the communities we serve. The government also gives a grant per patient, which we receive 2 years after starting patient’s treatment. At the moment the government grant covers our entire field costs, i.e. cost of operations, thus our fieldwork is sustainable. Nevertheless, the grant still comes 2 years late. This means that in the meantime we need donor funds to help establish and operate those same centres for 2 years, as well as cover administrative expenses. This makes the government grant currently inadequate. As the eradication of TB is one of the Millennium Development Goals and due to rapid proliferation of DR-TB cases, the Indian government is focused more than ever on TB eradication, which has become a priority for politicians and policy makers. Hence, the Government has declared a plan to increase funds for TB treatment by at least 4 times and also to keep pace with the inflation by steadily increasing the funds. It has been decided that the money will also be given upfront to NGOs rather than being delayed for 2 years. Because of that we can use this grant to establish and operate our centres and continue treating patients year after year. Once the new plans come into place our entire programme will truly become self-sustaining and we will no longer be dependent on donor funds at all.The eCompliance initiative comes at a cost of $3 per patient, which is more than offset by increased productivity of our providers and office staff so it does not add to the per patient cost. eCompliance is therefore, self-sustaining from the very beginning.

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