Transcript OPERATION ASHA-at the inflection point A local, deep, cost

Curing Tuberculosis with a Community
Based Model
June 2012
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 drugresistant strains of tuberculosis from
developing during patient treatment.
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India’s TB burden is more than double that of second-ranked
China
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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 TB
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Challenges in TB Treatment: DOTS treatment requires 60
visits to a center over 6 months
1. Inaccessible Centers- Existing public infrastructure lacks the last mile
connectivity
2. 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 patients
6. High cost of implementation for most other NGOs
7. Program level – lack of electronic data, inaccuracy and human errors,
most important - data fudging to show targets have been met
Sensational News Item in Times of India
“…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).
India’s TB Control program: The DOTS model- lacks Access
and Availability
The DOTS* model: network of three types of facilities
Hospital/
Warehouse
DC
DC
DC
Hospital/
Warehouse
DC
DC
DC
DC
DC
DC
* “Directly Observed Therapy - Short Course”
TB Hospitals: Adequate
• Government facilities providing
comprehensive diagnostics and
treatment recommendation
• Warehouse for medicine supplies,
provided free by government &
donors
Diagnostic Centers: Adequate
• Sputum tests for initial/rapid diagnosis
• 5 DCs required for every hospital ;
typically present
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 & drugresistance
OpASHA’s Solution: Fill the Gaps:
Community Empowerment
Strategically located TB Centers
• In convenient, high-traffic areas
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Centers open at convenient hours
No patient needs to miss work/wages to access treatment
Local Community Members Hired as Counselors & Providers
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Work to treat TB, detect new patients, education camps,
default tracking
Familiarity with local customs, geography, and informal address
systems
Much more cost efficient than MD doctors
Performance-based salaries to incentivize field workers
Specialized Training
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For active case finding
Conduct health awareness programs
Provide counseling to ensure adherence and prevent MDR
To destigmatize TB
OpASHA’s Results: Higher detection , much less default
Annual Detection Rate
Detection Rate/ 100,000
population
2005
2006
180
160
140
120
100
82
82
80
60
40
20
0
Prior to Operation ASHA
2007
Number of Smear
(+) cases based
on ARTI data
2008
151
2009
160
Social Return
on Investment
of 3,211%
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With Operation ASHA
Results:
OpASHA
(2010)
Other
Organizations
Default Rate
2.75%
Up to 60%
eCompliance: A New Idea….
“DOTS alone is not sufficient to curb the TB
epidemic in countries with high rates of MDRTB.”
–Stop TB Working Group
“Electronic datasets are needed to facilitate
accuracy and analysis of data.”
- World Health Organization (2011)
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
Reader
SMS Modem
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A critical component: eCompliance- “What gets measured,
gets done”
PRIMARY OBJECTIVE - To ensure accuracy and adherence
PROBLEM
• Unsupervised doses being
given
• Missed doses and default
• Data fudged
• Patients not tracked
• Inaccurate record keeping
• Inadequate follow-up
• Time lag for follow-up
• Absenteeism
SOLUTION
• Biometrics confirms a TB
patient’s presence
• This creates indisputable
evidence
• One cannot ‘fudge’ a
fingerprint!
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Features of eCompliance
• Color coding shows that a patient has
been successfully logged in
• The simple interface uses a minimal
amount of text
• Easily translatable into other
languages
Counselors can quickly
identify which patients have
• Visited the center
• Not come into the
center
• Missed their dose within
48 hours
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Front End
How eCompliance Works
The Front End
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SMS
eCompliance
Terminal
Health Worker &
Program Manager
Uses only off-the-shelf
components
A fingerprint reader
A netbook computer
USB modem for SMS
SMS Plan for 3yrs ($10)
Back End
The Back End
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Electronic Reporting
System
SMS Gateway
Central Reporting System
messages are downloaded
from the SMS server and
imported into a
centralized online
database
Online SMS
Server
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Implementation
Results
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Default measured at 2.5%
Over 2,200 patient cured
900 undergoing treatment
Over 150,000 visits logged
Lessons Learned
Patients are not hesitant to give their fingerprints
Patients perceive technology as a sign of the quality of
treatment
September 2009:
September 2011:
June 2012:
September 2012:
26 Terminals were installed in South Delhi
14 Terminals were installed in Jaipur
6 Terminals were installed in West Delhi
9 Terminals were installed in Bhivandi
Cost Effectiveness
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)
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)
The Key Benefits of Biometrics
PATIENT AND COMMUNITY LEVEL
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Positive impact on the psyche
Improves motivation
Seen as dedication towards quality treatment
AT LEVEL OF FIELD STAFF
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Ensures integrity of DOTS: eliminates unsupervised doses
Eliminates human error
Improves skills
Makes counseling easy, ie. easier to convince patients
Accurate reporting and up-to-date intelligence
Saves time spent in going thru paper records
target counseling
The Key Benefits of eCompliance
MANAGEMENT LEVEL
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Accuracy of records
Multi-level accountability and transparency
An accurate platform for monitoring
– Eliminates absenteeism, late coming
– Prevents tampering
– Synchronization of data
Transparent treatment supervision
Ensures accuracy of incentives
THE PUBLIC HEALTH PERSPECTIVE
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Ensures DOTS is being delivered
Prevents MDR-TB
CAN BE UPGRADED FOR
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Daily dose regimen
Adherence for MDR-TB,
HIV treatment
Diabetes
Mid-day Meal schemes
Operation ASHA’s Exponential Growth (number of DOTs
centers)
Replication in Other Countries
CAMBODIA - since 2010
 Serving 6% of the population and 8% of the patients
 Working in 4 Operating Districts, in 2 provinces
 Detection rate increased by 71%
In the pipeline…….
VIETNAM
 Replication of the PPM & DOTS expansion
Adopting OpASHA’s Best Practices
1. Our Model Works – It is cost effective,
sustainable and replicable.
2. We are the community – OpASHA directly
impacts the areas we serve.
3. 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.
4. 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.
Please visit www.opasha.org for more information about our model, our current work, and other projects.
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