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Dr. Dominick Mboya

PS03_Mboya_squareDr. Dominick Mboya

Dominick Mboya has over 25 years experience as medical practice and teaching, currently employed as a research scientist at Ifakara Health Institute in Tanzania, responsible for coordinating Health System Quality Improvement initiatives implemented by Ifakara Health Institute through Initiative to Strengthen Affordability and Quality of Health Care (ISAQH). The initiative is funded by Novartis Foundation for Sustainable Development. Apart from that he is the Intervention coordinator for the Connect project designed to test the model of trained and paid Community Health Workers to accelerate achievement of MDG 4 & 5, the project is funded by Doris Duke Foundation and Comic Relief.

He has extensive clinical and teaching experience, prior to joining Ifakara Health Institute, Dominick was employed by Tanzania Ministry of Health and Social Welfare, as medical doctor and tutor in clinical officers training institutions from 1987 to 2008 where he served as Dean of studies. In collaboration with the National Tuberculosis and Leprosy Control Programme, he coordinated and facilitated capacity building trainings to health care providers on Tuberculosis and Leprosy and TB/HIV. He is a national trainer for Regional and District Health Management Teams, Integrated Management of Childhood Illness (IMCI) both conventional and Computerized Adaptation Training Tool (ICATT), Community based health insurance scheme at district levels. He is a founding member and board chair of LUPA a non- governmental no-profit organization promoting quality education in remote districts, member of the district education board and member of medical and public association of Tanzania. His interest are in area of health system strengthening and quality of health care

GHF2014 – PS15 – From Technology to Impact: Focus on Diagnostic Imaging and Neonatal Incubators

16:00
17:30
PS15 TUESDAY, 15 APRIL 2014 ROOM: 13
WORKSHOP
From Technology to Impact:
Focus on Diagnostic Imaging and Neonatal Incubators

SPEAKERS:
Dr. Klaus Schönenberger
CEO EssentialMed Foundation. Program Leader, EssentialTech, Cooperation & Development Center at the Swiss Federal Institute of Technology in Lausanne, Switzerland
Mr. Bertrand Klaiber
Chief Operating Officer, EssentialMed Foundation. Project Manager, EssentialTech, Cooperation & Development Center at the Swiss Federal Institute of Technology in Lausanne, Switzerland
Mr. Matthieu Gani
Scientific collaborator, EPFL’s Cooperation and Development Center (CODEV), Switzerland
OUTLINE:
The goal of this session is to mobilize the Global Health Community at the Forum to address the challenges in the process of developing, deploying and scaling-up innovative technologies. After short presentations of two existing projects, discussion will be opened regarding technical and socio-economic aspects such as maintenance, business models, logistics and training.The first project concerns access to radiography; In spite of its importance in primary healthcare, radiography is still not accessible to an estimated two thirds of humanity. This is a major issue in the fight against important diseases such as tuberculosis or pneumonia, but also for the proper diagnostic of trauma, with an ever growing burden of road traffic accidents. The project (www.globaldiagnostix.org ) aims to entirely develop a digital x-ray system adapted to the needs of district hospitals in resource-poor settings.The second project (www.globalneonat.org ) aims to develop an affordable and appropriate neonatal incubator. Despite the fact that child mortality is decreasing sharply globally, new solutions are required because the neonatal share of that mortality appears more and more as resistant to that trend.
PROFILES:

Dr. Klaus Benedikt Schönenberger, Program Leader & CEO EssentialMed FoundationDr. Klaus Schönenberger, Program Leader at the Cooperation and Development Center, EPFL and CEO of the EssentialMed Foundation.

Klaus Schönenberger obtained a PhD from the Swiss Federal Institute of Technology in Lausanne (EPFL), Switzerland, in 1996. After a post-doctoral research assignment at Lawrence Livermore National Laboratory (USA), he joined the medical devices industry. During 10 years, Dr. Schönenberger held various leading positions in medical devices companies, such as director of R&D and global vice-president of R&D. In his last position he was the global vice-president of Research and Technology at DJO Inc. (Vista, California) a Medical device company with annual revenue of $1bn. In 2009 he left the industry to create the EssentialMed foundation, with the goal to develop appropriate medical devices for developing countries. In 2011, he took the position of program leader at EPFL’s Cooperation and Development Center. He created and currently leads the Center’s EssentialTech programme, which aims to fight poverty through the development of appropriate technologies and implementation models.

 

BK-1Mr. Bertrand Klaiber, Chief Operating Officer, EssentialMed Foundation. Project Manager, EssentialTech, Cooperation & Development Center at the Swiss Federal Institute of Technology in Lausanne Switzerland.

Mr. Klaiber is an experienced business development manager with several achievements in launching innovative industrial and consumer electronic products.
After graduating in Electrical engineering at EPFL in 1994, Mr. Klaiber worked for 10 years as an engineer and project manager for Motorola Semiconductors and Logitech. In 2004, he completed an MBA with honors at the University of Lausanne and then worked as Stategy and Marketing manager at LEM, an international leader in electrical measurement products. In 2010 he was promoted Worldwide Business Development Manager for Energy Solutions at LEM.
In 2012 he joined the Swiss Federal Institute of Technology (EPFL) to launch the EssentialTech program that aims at developing appropriate technologies for impoverished countries. He is the COO of the EssentialMed foundation which he co-created in 2010.

 

PS15_Matthieu_GaniMr. Matthieu Gani

Mr. Gani is a scientific collaborator at EPFL’s cooperation and Development Center (CODEV). After completing an M.Sc. in Electrical Engineering, he worked on cochlear implants at the Geneva University Hospital, developing research interfaces and conducting tests with patients. He was then employed as a social worker and assistant manager at the Soup Kitchen in Lausanne, Switzerland, providing free meals and guidance to people in need. He joined CODEV’s EssentialTech team in 2013 to manage the GlobalNeonat project.

 

 

Logo_EssentialMedEcole Polytechnique Fédérale de Lausanne

 

 

 

GHF2014 – PS20 – Harnessing ICTs to Improve Tuberculosis Control

10:45
12:15
PS20 WEDNESDAY, 16 APRIL 2014 ROOM: 16 ICON_Fishbowl
Harnessing ICTs to Improve Tuberculosis Control
MODERATOR:
Dr. Lucicia Ditiu
Executive Secretary, Stop TB Partnership, World Health Organization, Switzerland
SPEAKERS:
Communications Platform for Tuberculosos to Supplement Mainstream Media: India
Ms. Barathi Ghanashyam
Founder Editor, Journalists against TB, India
mTB by Front Line Workers in a Tribal District in India: A Pilot Study
Dr. Archana Trivedi
Union South-East Asia, The Union, India
Using Technology and Community Empowerment to Treat Tuberculosis
Dr. Shelly Batra
President and Co-Founder, Operation ASHA, India
Dr. Alberto Colorado
Patient Advocate, International Public Health Consultant, Advocates for Health International, United States
Mr. Andrew Codlin
Stop TB Partnership, World Health Organization, Switzerland
OUTLINE:
PROFILES:

Ghanashyam Profile PhotoMs. Barathi Ghanashyam

Unconventional choices have shaped my personal and professional life.  Having chosen to eschew formal academics, I pursued the path of learning – learning what I wanted to, in the way I chose to – by reading, absorbing and applying what I learnt to real life situations.  I have also been deeply influenced by the intensive field trips I have undertaken into rural India in the course of my career as a development writer.  Living and interacting with rural communities have taught me to respect their traditional wisdom, the way they cope with lack of choices, the simplicity with which they find solutions to their complex problems and I have often been humbled into emulating their way of life – which is devoid of artifice of any sort.  My writing, because it resonates with field realities, is credible and important for development processes.

PS20_Archana_TrivediDr. Archana Trivedi

Medical Doctor married with two sons, served in Indian Army (Medical Branch) with 21 years of rich and dynamic work experience in the medical field with 7 years of hands on technical experience working in National Health Program on Tuberculosis. Have background of working for 7 years in Global Fund Projects with International Union Against Tuberculosis and Lung Disease, Catholic Bishop Conference of India, Catholic Relief Services and Indian Medical Association.

Have ability to work and liaise effectively with government agencies, civil society organizations, private sector, people affected with diseases and synergize with other stake holders.  Also have persuasive and innovative skills supported by thorough research, to achieve best accruals for health projects. Have ability to conceptualize and lead health projects from front in strict disciplined environment. Adept in program management to include planning, coordination, execution and monitoring & evaluation of project.

At present position in Union South-East Asia The union, implementing project to involve qualified and non-qualified private practioners to promote TB care and control. Developed mobile application to track and trace TB patients. Currently scaling up mobile application under World Bank IDM project and Grand Challenges-TB Care along with Dimagi (USAID funded project).

Batra PhotoDr. Shelly Batra

I started my professional journey as a young surgeon, of which I was dazzled by the glamour, fame and money that was part of being a doctor. Very soon I came to a cross road and decided to take the road not taken. So, on one side there were the dazzling lights, the success and the glamour but the other route was an uphill path; rocky and thorny and all around was the stench of disease and death and all I could hear were the sighs of the sick and dying; that is the road I have chosen.

Mr. Andrew Codlin

I worked along the Texas-Mexico border studying the interaction of diabetes and pulmonary infections (influenza and tuberculosis) for two years.  I then moved to Karachi, Pakistan, where I spent 3 years implementing TB case finding initiatives focused on the private healthcare sector. All of  my programs had a significant mHealth component and I worked with other TB REACH grantees to adapt our successful strategies for other country contexts.

Mira Shiva

MiraShiva200x150Dr Mira Shiva

Chairperson, Health Action International Asia -Pacific Founder, People's Health Movement

Born to a Gandhian mother and a forest conservator father, a qualified doctor herself, Dr Mira Shiva chose to live the life of an activist. Single by choice in a man's world, Shiva has not just left her mark but has successfully made a difference to society…

Her journey started from Ludhiana in 1968, when she was doing her MD from Christian Medical College. When Dr Mira Shiva was a student, she observed women were dying during child birth and the college was making efforts to prepare doctors for situations like these. It was in this college that Shiva met Dr Betty Cowan, a Professor of Medicine and Community Health who later became her inspiration. "In her I found a person motivated by community health concerns," says Shiva.

Turning point

Shiva happened to be in Bihar in 1979-80 when there was an outburst of tuberculosis in the area. "There was a spread of tuberculosis and there were no anti TB drugs available in that area. All irrational hazardous combinations were flooding the market. That was the time that I felt the pain in my heart and thought that I must take this up with the chemical ministry," recalls Shiva. This marked the major turning point in her life.

Thereafter, Shiva has never looked back. She knew what she wanted to do next. Confident in her thoughts, she followed her mind. "I always wanted to become a doctor and practice medicine but I also wanted to serve human kind," she says.

Making a difference

Shiva has made many remarkable efforts in order to make this world a better place to live in. She has been associated with civil society bodies and has been part of many government committees representing the voice of masses.

Shiva was a member of the Drug Pricing Review Committee in 2001, as well as the Chemicals Ministry and the R& D Committee in the same year. Besides, she has played an important role as a member of various bodies like the Central Council for Health, National Population Commission, National Advisory Committee on Assisted Reproductive Technologies and National Human Rights Commission. She was also on the Task Force on Safety of Food and Medicine and was Chairperson of the Task Force on Consumer Education. Shiva is also associated with civil society bodies like Health Equity and Society, All India Drug Action Network and Health Action International Asia Pacific. She is a founder member of Peoples Health Movement and a steering committee member of Diverse Women for Diversity.

But is it easy for a woman activist to fight for rights of women and poor people amidst powerful men? "There are always men to de-legitimise my presence but I am always too firm to make my way and tell them my purpose to be there. The fact that I happened to be a woman is not so important to me," declares Shiva. She has rather learned from her experience to handle people and she feels it is important for every woman to do so too. "It is important to understand that you are saying what you are saying and being a woman does not mean that you are asking for a favour," she adds.

For namesake

The lady, who named herself after Mira Bai, says that she knew that she was born to become a rebel. "I named myself after Mira Bai because people tried to kill her in three different ways but failed. I draw my inspiration from there," she says. However, born to a family with liberal thoughts, Shiva gets her strength from her Gandhian mother, who was a writer and faced odds in her life as well, as well as her grandfather, who had set up a school for girls in rural areas. Her parents were very supportive of her decisions and gave her the freedom to choose. "I got it as a sanskar that I am no less than others and that there is no difference between a boy and a girl. If you underestimate me as a girl you are asking for trouble," she declares.

But women often face attacks on their identity from a patriarchal society. So did Shiva. "I have been repeatedly addressed as ‘Mrs Mira Shiva’ and by people who know my status but each time I used to make it a point to raise my voice and correct them …I will tell them I am not Mrs Mira Shiva but Dr Mira Shiva…It has something to do with my identity and it is important to me. People try to weaken you through such means. They would tell me that I am acting non-professional and speaking for a certain section which is not true," she says. Shiva points out that men occupying positions of power expect women to follow instructions and agree with them on whatever they say, so she was naturally not like by them. But she wonders, had she been born a man , then would the reaction from men be similar? The question remains unanswered …

Dr Rifat Atun

RifatAtunDr Rifat Atun is Professor of Global Health Systems at Harvard University, where he is the Director of Global Health Systems Cluster at Harvard University's School of Public Health.

In 2006-13, Dr Atun was Professor of International Health Management and Head of the Health Management Group at Imperial College London. He is an Honorary Professor at the London School of Hygiene and Tropical Medicine. In 2008-12 he served as a member of the Executive Management Team of The Global Fund to Fight AIDS, Tuberculosis and Malaria as the Director of Strategy, Performance and Evaluation Cluster.

Rifat's research focuses on the design and implementation of health systems transformations and their impact on outcomes. His research also explores adoption and diffusion of innovations in health systems (e.g. health technologies, disease control programmes, and primary healthcare reforms), and innovative financing in global health. Organization. Rifat is a co-Investigator and the joint lead for the innovation work stream at the National Centre for Infection Prevention and Management at Imperial College. He is also a co-Investigator and the Theme Lead for 'Organisational Change, Sustainability and Evaluation' at Imperial College and Cambridge University Health Protection Research Unit for Antimicrobial Resistance and Healthcare Associated Infection. He has published widely in the Lancet, PLoS Medicine, Lancet Infectious Diseases, BMJ, AIDS, and Bulletin of the World Health Organization.

Rifat has worked with several governments globally and with the World Bank, World Health Organization, and the UK Department for International Development to design, implement and evaluate health system reform initiatives in more than 20 countries. He has led research and consultancy projects for GSK, Pfizer Inc., the Vodafone Group, Hofmann La Roche,  PA Consulting, and Tata Consulting Services.

Rifat was the Founding Director of the MSc in International Health Management, BSc in Management and Medical Science, and Founding Co-Director of the Masters in Public Health Programme at Imperial College. He has been a director of Imperial College spin out companies operating in areas of health technology.

Rifat is a member of the MRC Global Health Group as the MRC Infections and Immunity Board representative. He serves as  a member of the PEPFAR Scientific Advisory Board, the Norwegian Research Council's Global Health and Vaccination Research (GLOBVAC) Board, the Research Advisory Committee for the Public Health Foundation of India, and the US Institute of Medicine USAID Standing Committee on Strengthening Health Systems. In 2006-08 he served as a Member of the Advisory Committee for WHO Research Centre for Health Development in Japan. He was member of the Strategic Technical Advisory Group of the WHO for Tuberculosis and chaired the WHO Task Force on Health Systems and Tuberculosis Control. In 2009-12 he was the Chair of the STOP TB Partnership Coordinating Board.

Rifat is a Fellow of the Royal College of General Practitioners (UK), Fellow of the Faculty of Public Health of the Royal College of Physicians (UK), and a Fellow of the Royal College of Physicians (UK).

Learning from evidence: Advice-seeking behaviour among Primary Health Care physicians in Pakistan.

Author(s) Asmat Malik1, Cameron Willis2, Saima Hamid3, Anar Ulikpan 4, Peter Hill 5.
Affiliation(s) 1Department of Research and Development, Integrated Health Services, Islamabad, Pakistan, 2School of Population and Public Health, University of British Columbia, Vancouver, Canada, 3Department of Maternal and Reproductive Health, Health Services Academy, Islamabad, Pakistan, 4School of Population Health, The University of Queensland, Brisbane, Australia, 5School of Population Health, The University of Queensland, Brisbane, Australia.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Systems
Summary Access to information is critical for creating and maintaining high performing Primary Health Care (PHC) systems. Among multiple sources of information, advice-seeking from humans possesses significant importance for the physicians in their clinical settings because they are looking for readily available answers to their questions. We used Tuberculosis and measles as a lens for analyzing the advice-seeking behavior of PHC physicians in Pakistan. The study concludes that the heath care providers are falling prey to stagnant system behaviour. There is a need to better understand system behaviors and to identify system principles such as information flows and feedback loops.
Background The available studies provide some insights into how physicians seek information while working in PHC settings. However, as this literature is largely confined to developed countries, there is relatively little known about how physicians in low-middle income countries access or use information when faced with difficult to diagnose conditions. In these settings, where access to electronic information sources is often scarce, understanding advice seeking behaviors from human sources becomes particularly important. Using methods grounded in systems science, this study examines the advice seeking behaviour of PHC physicians in a rural district of Pakistan, analyzes the degree to which the existing PHC system supports their access to advice, and explores ways this system might be strengthened to better meet provider needs.
Objectives Tuberculosis (TB) and measles are currently providing major challenges to PHC physicians in Pakistan. We used these two conditions as a lens for analyzing the advice-seeking behavior of PHC physicans in Pakistan. The specific research questions of this study were:
• To what degree does the existing structure of the PHC system in Pakistan support physicians in accessing advice on difficult to diagnose cases of tuberculosis and measles?
• To what degree are physicians satisfied with their current access to advice on difficult to diagnose cases of tuberculosis and measles?
• What changes, if any, do physicians recommend to improve their access to advice on difficult to diagnose cases of tuberculosis and measles?
In order to answer these research questions, this study has the following specific research objectives:
• To document the flow of information on diagnosing TB and measles cases in the PHC system of Pakistan;
• To describe the advice seeking behaviour of physicians in situations of difficult to diagnose cases of TB and measles;
• To explore physicians’ satisfaction with their access to advice in difficult to diagnose cases of TB and measles;
• To identify and describe possible changes, if any, that physicians recommend to improve their access to advice in difficult to diagnose cases of TB and measles.
Methodology This study was conducted at the district level in Pakistan from January 2013 to August 2013. The organization of health services at a district level is similar across Pakistan. With a cross-sectional study design we employed three research methods comprising:
1. Mapping of formal system of flow of information for diagnosing TB and measles.
Through documentary review and targeted key informant interviews with five district health administrators and line-managers of vertical health programs, we mapped the existing system of the flow of information for assisting physicians in diagnosing TB and measles cases. Illustrations of formal information dissemination systems were developed in the form of flow charts showing the direction of flow of information and roles and responsibilities for providing information/feedback at various hierarchical levels.
2. Survey for social network analysis of physician advice seeking behaviour.
A semi-structured questionnaire was used to conduct a survey for mapping professional networks. The key questions were structured to identify whom each physician had contacted for advice whenever faced a difficult to diagnose cases of TB and measles. Out of the 61 BHUs in district Attock, only those with an appointed physician (n=49) were invited to participate. The compiled data was imported in UCINET software for generating sociograms.
3. Key stakeholder interviews.
Based on the analysis of the findings from Sociograms, the BHU physicians were divided into three groups:
• Physicians who sought advice from a designated person (formally notified by the health department)
• Physicians who sought advice from someone other than a designated person
• Physicians who did not seek advice from any other person
This grouping provided the basis for selecting 11 study respondents for in-depth interviews. All study participants agreed to one-on-one interviews and consented to audio recording. Three separate interview guides were used during these semi-structured in-depth interviews among the three groups of study respondents. The average interview time was 20 minutes. The researchers using an inductive process identified categories, sub-themes and themes. The research team then compared their findings to optimize the data conformity. The final themes were presented after the research team’s consensus on the analysis process.
Results The present configuration of the primary health care system in Pakistan is largely a result of the push for universal health coverage and Health for All under the declaration of Alma Ata Conference on PHC in 1978. Under the influence of this global movement, an extensive network of PHC clinics (5449 Basic Health Units and 579 Rural Health Centers) has been established as the first point of contact for those seeking healthcare across all districts in Pakistan.
Early detection of both TB and measles is critical to decrease morbidity and mortality rates. There are multiple sources of information available to assist physicians in diagnosing cases of TB and measles including clinical guidelines, case definitions and case detection protocols. While these information sources are largely provided through government agencies, the precise channels used for their distribution and the ways in which physicians make use of these channels have not been made explicit. Mostly they use their personal social networks in order to seek guidance in clinical care from their friends, peers, and other disease-specific experts.
With a systems approach, the thematic analysis has been categorized under four key areas. Firstly, the health leadership designs health programs and interventions without placing competent experts and a pathway to seek information on difficult cases (system organizing). Referral systems are not functional and there is no feedback on the patients’ from whom advice is being taken. As a consequence, patients are lost to the private sector. Secondly, PHC clinics do not have functional linkages with tertiary care hospitals (system network). In addition, no needs assessment for refresher trainings is conducted by the health department. Thirdly, the PHC physicians are not provided any feedback on patients sent to higher level centers (system dynamics). There exists no formal system of communication and dissemination through which the latest research or related materials are shared. In addition, there exist no opportunities where PHC physicians can be placed at secondary or tertiary care hospital on a rotation basis. Lastly, the focus of the health managers and administrators is more on administrative running of programs and meeting targets (system knowledge). Consequently, capacity building in clinical management has become a neglected priority.
Conclusion The analysis of the PHC system in Pakistan clearly demonstrates that the problems in the health sector are deeply rooted and complex in nature. The evidence from this study demonstrates that in situations where PHC physicians require further advice in diagnosing potential cases of TB or measles, it is unclear from whom this advice is being sought, or the degree to which the current PHC system enables physicians to seek this advice.
PHC level acts as a driver for healthcare delivery system whereas human resources are the main driving force behind a functional health system because they provide a human link that connects the system building blocks. However, in Pakistan, the heath care providers are falling prey to  stagnant system behaviour. The solutions require a systems’ thinking that views public health problems as a part of a wider and dynamic system, with a focus on in-depth understanding of the linkages, relationships, interactions and behaviors among the sub-system components that characterize the entire system. It is imperative to better understand system behaviors and to identify system principles such as information flows and feedback loops.

Administrative Integration of HIV Monitoring And Evaluation: A Case Study From South Africa.

Author(s) Mary Kawonga1, Sharon Fonn2, Duane Blaauw3.
Affiliation(s) 1Department of Community Health, Wits School of Public Health, Johannesburg, South Africa, 2School of Public Health, Wits School of Public Health, Johannesburg, South Africa, 3Centre for Health Policy, Wits School of Public Health, Johannesburg, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Health Systems
Summary With increasing global focus on the integration of vertical programmes within health systems, methods are needed to analyse whether general health service (horizontal) managers at district level exercise administrative authority over disease programmes (administrative integration). This study adapts "decision space" analysis to measure administrative integration of HIV programme monitoring and evaluation (M&E). The study shows that horizontal managers exercise high degrees of authority in producing HIV information but not in using it for decisions, while vertical managers use HIV information but in silos. The lack of M&E integration may undermine district health system strengthening aims.
Background In South Africa, integration is a health sector reform priority, while several vertical programmes exist, notably for HIV, tuberculosis (TB), and maternal and child health (MCH). Historically a national HIV/AIDS directorate and specialist HIV managers have vertically managed the HIV programme and HIV programme managers account for ear-marked HIV programme funding through dedicated parallel reporting mechanisms. This is at odds with current health sector decentralisation reforms that envisage integrated management of health services under the control of generalist (horizontal) managers at a decentralised district level. National health policy envisions health districts as the foundation of the national health system.
Objectives If health districts are to be the foundation of the health system as envisaged, then horizontal district managers would need to be allocated and to exercise authority over district health services, including disease-specific interventions (i.e. administrative integration). This study examines whether this is happening in the South African health system. We use the HIV programme as a case study given its traditionally vertical approach, and focus on the M&E (information) function as a tracer for analysing administrative integration. The research aims are to:
1. Describe the extent to which horizontal managers exercise authority over HIV M&E coordination.
2. Explore factors associated with exercised authority.
Methodology The research explores two hypotheses: a) vertical managers exercise higher degrees of authority than horizontal managers in administering HIV M&E; and higher management capacity and HIV M&E knowledge are associated with higher degrees of exercised authority. This cross-sectional study was conducted in two of South Africa’s nine provinces. Fifty one participants were interviewed including: a) managers primarily responsible for general health services or general health information (horizontal manager) and b) those responsible for vertical services or information (vertical manager). HIV M&E was defined as the production of HIV information (HIV data collection, collation, analysis) and use of HIV information for decisions.In the absence of existing methods for measuring 'exercised authority' over vertical programmes, Bossert's decision-space’ approach provided a useful frame. Since decision-space analysis has not been applied to either the M&E function or in the context of programme integration, it was adapted to measure ‘exercised (administrative) authority’ in this study. We defined exercised authority as a manager undertakes tasks to oversee HIV data collection, collation and analysis, and uses HIV data to review the programme and take action. To measure this, we first identified the M&E tasks that managers were expected to perform within each M&E domain (collection, collation, analysis, use) and then administered a semi-structured questionnaire to collect data on participants’ performance of these tasks. We developed four sub-scales to measure the degree of exercised authority for each M&E domain. Sub-scales comprised several items (M&E tasks), which we coded ‘no’ if a respondent did not perform the task (score zero) or ‘yes’ if s/he did. We computed an ordinal dependent variable for each HIV M&E domain and coded observed scores as ‘low’, ‘medium’, and ‘high’. We performed ordinal logistic regression to explore whether explanatory variables (actor type [horizontal or vertical], health system level, highest, qualification, duration of management experience, management capacity score, and M&E knowledge score) were predictive of higher degrees of exercised authority.
Results More than 75% of participants were female, with an undergraduate degree or higher, and had some management
training. Participant characteristics were similar between vertical and horizontal managers. Horizontal managers attained higher mean scores for HIV data collection.
Conclusion In light of the increasing focus on health system strengthening and integration, our research makes a contribution
by providing a method and scales for measuring and monitoring administrative integration. We anticipate that
these scales will be strengthened further by empirical testing on larger samples and varied settings. In applying this
method to South Africa’s public sector HIV programme, we find that HIV M&E coordination is generally not administratively integrated, characterised by horizontal managers exercising little authority in using HIV data, and vertical managers using HIV data in sub-programme silos. We argue that this programme model potentially undermines South Africa's policy aims of integrated management of district health services under the authority of horizontal general health service managers. The research also indicates that plans for integrating the HIV programme within the health system at decentralised district level should include investments in strategies to equip horizontal managers with the knowledge and skills to use programme data for decision-making.

Knowledge and Access to Health by Tuberculosis Patients in India.

Author(s) Hemmavathy M.T.Valluvan1, Karuna Sagili2, Srinath S3, Sarabjit S Chadha 4, Nevin C Wilson 5.
Affiliation(s) 1 Medical School, Monash University, Melbourne, Australia, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary India is one among the 22 highest TB burden countries contributing a large proportion of the global TB cases. To increase awareness on the issue of TB, India’s RNTCP uses several forms of media to communicate TB related information to the general population. As part of Project Akshya, a baseline Knowledge, Attitude and Practices (KAP) study was conducted in 30 districts of India to gather baseline information from specific target groups on TB. The following study analyses the KAP and describes the media behaviour of TB affected individuals in India, with a focus on their key sources of general health related and TB related information, and identifies the most trusted source of information.
Background Infectious diseases are one of the key contributors to the mortality of people around the world. Globally, of the 57 million deaths that occurred in 2011, 21 million deaths were caused by infectious diseases (WHO, 2012b). Of the infectious diseases Tuberculosis (TB) persists to be one of the leading causes of mortality since the 1800s (Houston, 1999). An estimated 8.7 million new cases of TB occurred in 2011 globally and a total of 1.4 million people died from TB (WHO, 2012a). India is the highest TB burden country accounting for 26% of global cases (WHO, 2012a).
India’s National Tuberculosis Programme-RNTCP (Revised National Tuberculosis Control Programme) uses several forms of media to communicate TB related information to the general population and TB affected individuals. These range from street plays to radio commercials (Mehrotra, 1998). A similar study was done in Chandigarh (Hemlata, 2011). The other studies that were conducted in Delhi targeted specific populations such as homemakers (R.Malhotra, 2002), and the rural population (Sharma and Sharma, 2007). However these studies  are localised and focused upon limited target groups within the general population.
Objectives In 2010, Project Axshya ACSM (Advocacy, Communication and Social Mobilisation) project was initiated in India as part of the Global Funded Round 9 India TB programme. It is being implemented in 374 districts across 23 states covering a population of approximately 75 million people. The main objective of Project Axshya is to empower the community and each individual through education/awareness on TB with various resources and knowledge that would enable India to reach the ultimate goal of reducing the mortality and morbidity caused by TB. The baseline KAP (Knowledge, Attitude and Practices) study was conducted in 30 districts of India as part of Project Axshya, which aimed to gather baseline information from specific target groups (the general population, TB patients, health service providers, NGO’s and opinion leaders) on their knowledge, attitude and practices on TB. The survey tool designed for TB patients had specific questions on their sources of information about general health and TB. By comparing the different characteristics of the TB patients and the media source through which they gained the information, we would locate the media forms currently being accessed by TB affected individuals. This will also inform future planning of the health information dissemination programs.
In this study we aim to describe the types of mass media used by TB patients to gain information on general health related, TB and DOTS and to describe the most preferred and trusted sources of mass media from the patient’s perspective and then relate it to various patient characteristics.
Methodology Study Design.
A cross sectional community based survey was conducted in 30 districts out of the 374 districts under Project Axshya. These districts were selected using stratified cluster sampling method. These districts were further divided into primary sampling (PSUs). Depending on the number of households, in each PSU a minimum of 250 households were line listed with an estimated population of 1000. 10 PSUs were randomly selected from each district. Trained field investigators from the social research organisation GfK MODE visited these selected PSU’s and conducted the survey during the months of January - March 2011 using pretested semi-structured questionnaires.
To address the study objectives, the data collected from ‘Media and Information Sources’ section of the questionnaire for TB patients in KAP has been used for analysis.Data Entry and Analysis.
The data collected was recorded in a pre-structured data-entry form in Fox Pro (version 2.6). The data was analysed and tables generated using Epidata Analysis software.

Ethical Considerations.
Baseline KAP study was approved by the Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease. Permission to conduct this study was given by the Central TB Division, Ministry of Health and Family Welfare, Government of India. Informed consent was obtained from each respondent and, where possible, written consent was obtained. Confidentiality of the data was assured.

Results The general profile of TB affected individuals interviewed in this survey in relation to their access to services informs that 67% of them have access to electricity, 14% have a radio set at their houses, 36% have television sets at their homes and 52% have mobile phones. 56% of the total TB affected individuals interviewed had BPL (Below Poverty Line) identity cards. The source of information for 65% of TB patients on any health related information was via interpersonal communication (Table 1). Likewise, interpersonal communication was the leading source of information for TB (74%)(Table 1). With regards to information on DOTS, 61% of the TB patients did not receive any information on DOTS (Table 1). 56% of those who are exposed to interpersonal communication as their source of information received information on TB from that source (Table 2). Among these 56% there was a significant difference among the low and high income households (p=0.0000), rural and urban setting (p=0.0000), among the zones such as North (p=0.0000,OR:2.87,CI:1.89-4.35), South (p=0.0000,OR:0.25,CI: 0.16-0.39), East (p=0.0000,OR:3.07,CI:2.17-4.33) and West (p=0.0000,OR:0.16,CI:0.10-0.26). Of the 220 who had a television (TV) 67% indicated TV as their source of information for general health, 60% for TB related information and 41% for information on DOTS. Of the 85 people who had a radio set at their homes, 33% indicated radio as their source of information for general health, 35% for TB related information and 14% for DOTS related information. There was also a significant difference for those who used TV as their source of information for TB between the low and high income households (p=0.000), between the rural and urban settings (p=0.000), among the zones such as North (p=0.0006), South (p=0.0000) and East (p=0.0001) and education levels (p=0.0000). 43% of TB patients chose government health staff as their choice of trusted information source, followed by 15% of the TB patients trusting the private health workers. Among the 43% of TB patients who trust government health staff, there was a significant difference among the age of 25-34 years old (p=0.0288, OR:0.61, CI:0.39-0.95) and 35-44years old (p=0.0069,OR:1.70,CI:1.15-2.50), and students (p= 0.0049,OR:0.40,CI:0.21-0.77) and lastly, among the zones such as North (p=0.00573,OR:1.44,CI: 0.99-2.09), East (p=0.0000,OR:0.48,CI:0.34-0.67) and West (p=0.0000,OR:2.62,CI:1.69-4.06) had significant differences.
Conclusion From the KAP survey of TB patients, it was observed that 74% of TB patients received their TB related information from interpersonal communication which could partly be attributed to the people they had come into contact with in order to be diagnosed with TB. However, a separate analysis on where TB patients had received health related information found that 65% responded as the source being interpersonal communication followed by 34% receiving it from television. As such, interpersonal communication is an important medium through which a large portion of the TB patients received information. On further analysis, it was found that 56% of those exposed to interpersonal communications as their source of information received information on TB from that source. Household income played a significant role as possessing a television as the source of media for TB information. 20% of those with less than Rs.4000 received their TB information from TV while 46% of those with more than Rs.4000 did so. This could be due to the higher income group having the ability to afford a television, the added increase in electricity bill and a house that accommodates it. The geographical zones of the TB patients also played a role on their source of TB information. The key source of TB information for the North was word of mouth (74%), while that of South and West was Television (53% and 29% respectively). This is an important finding as it shows that different zones have different media behaviour which could be due its varied cultural behaviours or social structure. Hence when planning IEC activities, these factors should be considered in order to utilise the most accessed resources of the target population.There are three key findings from this analysis; different income groups/settings have different sources of media exposure, the choice of media exposure differs among the different zones and the population's trusted source of information. It is important to understand that the fundamental expectation of any media aspect of a health policy is to increase awareness on a health issue and due to increased knowledge, eventually see a decrease in the overall incidence in the condition. However, before waiting at the finishing line for this result, it is crucial to make sure that the information reaches the population effectively and efficiently. Further developments to this study would include a qualitative study to assess the knowledge level of TB patients and its relation to media exposure.

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.

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-
TB.
• 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.