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mTB by Front Line Workers in a Tribal District in India: A Pilot Study

Author(s) Archana Trivedi1, Sarabjit Chadha2, Nevin Wilson3, Sunita Prasad4, Sanjay Kumar5
Affiliation(s) 1Public Health, USEA, The Union, New Delhi, India, 2Health, Communicable Diseases, USEA, The Union, New Delhi, India, 3Health Communicable and Non Communicable Diseases, USEA The Union, New Delhi, India, 4CSR, Lilly Foundation Grant in association with Lilly MDR TB partnership, New Delhi, India, 5IT, USEA, The Union, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Innovation and Technologies
Summary The Union through a community engagement process has mapped and trained Rural Health Care providers who are “first point of contact” for marginalized and vulnerable population. The trainings have contributed to imparting knowledge about TB and referrals of TB symptomatics to the National TB Control Programme. A paper based referral mechanism is established to capture data on quality of referrals made. However, providers often lack information about referred TB symptomatics – results and follow-up. Through the mobile phone application, this project is demonstrating the use of mobile technology in establishing a mechanism to impart knowledge and continued engagement with TB symptomatics.
What challenges does your project address and why is it of importance? Background and Challenges to implementation: Front Line Workers/Rural Health Care Providers (RHCPs) are most often the first point of contact for curative services in many villages, especially in tribal and remote geographic areas. A paper based mechanism is used to capture the data on referrals made including the results of their sputum examination and the management of those diagnosed with TB.However, Front Line Workers including RHCP’s and Lab Technicians (LTs) often lack information about referred cases with chest symptoms. Validating the referrals at designated microscopic centers is resource intensive, time consuming and difficult. It is also difficult to attribute the contributions made by FLWs towards strengthening National TB Control Programme.
How have you addressed these challenges? Do you see a solution? The intervention being implemented to address the challenges is ‘CommCare’ (mobile platform), an easily customizable mobile platform that tracks the referred cases, supports FLWs and creates a central database on a real-time basis.The CommCare application is being piloted in three blocks namely Torpa, Murhu and Khunti of Khunti, a tribal district in Jharkhand, India covering a population of 2,55,372 (80% district population). Two ComCare applications have been developed. One application is being used by RHCP and NGO supervisor, and one by LTs.FLWs are provided with 30 Lava Android phones. ComCare aids FLWs with guidance on key counselling points. Each counselling point is reinforced by images and audio clips that FLW uses to engage their clients. Messages are displayed regardless of the result of sputum examination and are focused on “Shared Air, Safe Air.”
How do you know whether you have made a difference? Results and Lessons Learnt: ComCare is a management system that assists in the follow up of referred chest symptoms by FLWs for the purpose of efficient diagnosis and treatment of tuberculosis. It reduces the delay in communication of the test results and saves resources by reducing the number of visits of the FLWs to the diagnostic centres. It helps to assess the contribution of FLWs in total chest symptoms examined and TB cases diagnosed. This application provides data lost follow up cases and creates a real-time central database which in turn helps with the retrieval of cases.In three months ninety symptomatics have been referred by using this application.  From these, 17 were diagnosed as  sputum positive TB and 6 sputum negative TB. All of these 23 diagnosed Tuberculosis patients are put on DOTS and are regularly being counselled through the mobile application. The outcome of patients who are being regularly counselled will be assessed upon completion of treatment.
Have you or the project mobilized others and if so, who, why and how? Mobilisation of other stake holders: The Project has explored possibilities for sustainability and scaling up of the use of mobile technology to promote TB care and control through collaboration under the World Bank Project by the matching of 25 additional mobiles in Jharkhand (tribal state, Khunti).These mobiles have been initiated to be used in one of the Global fund Round 9 project districts in Jharkhand. The project has moved beyond pilot to scale it up and illustrates the impact of implementing innovative technologies to address the challenge of tracking referred symptomatics by front line workers.Due to the positive impact of intervention, procurement of 50 additional mobiles has occurred and expansion is being initiated in one more district of Ghazipur in Uttar Pradesh, with additional mobiles at Khunti in Jharkhand. In this implementation mobiles are given to LTs of 3 respective districts who work in close collaboration with front line workers. This implementation is being appreciated by RNTCP officials.
When your donor funding runs out how will your idea continue to live? Potential framework for sustainability when donor funding runs out: Implementation of pilot project on use of CommCare application to track TB symptomatics is initiated in a tribal district and POC grant from Dimagi (USAID fund) for 1 year and expansion has been initiated in Ghazipur (UP), Khunti (Jharkhand) and one other tribal district in Jharkhand.
Scaling up the use of the mobile application is being anticipated well in advance so that project is not restricted to a pilot study only.Proposed Partners will be Identified partners under the implementation of the Axshya Project (Global Fund Round 9) in 300 districts and Dimagi representatives.
Roles & ResponsibilitiesSelection of front line workers for the use of mobile technology application and selection of geographical areas for implementation of mobile application can be done through the Implementing NGO partners. Training of front line workers and NGO Supervisors on the use of CommCare application can be done through projects that train these front line workers by USEA, The Union. Follow up implementation of these applications is carried out by NGO supervisors of identified NGOs in implementing districts.Who Pays? Recurring costs of implementation will be carried out by linking NGOs with districts upon the take up of the NGO PP RNTCP schemes.

We intend to develop trust of the government health system and the community as to the benefits of the application and slowly encourage government investment in the project.