Curing Tuberculosis with a Community Based Model June 2012

1. Curing Tuberculosis with a Community Based Model June 2012

2. Overview Operation ASHA is a non-profit bringing tuberculosis treatment to more than 5 million of India and Cambodia’s poorest. eComplianceis a biometric terminal that contributes to preventing drug-resistant strains of tuberculosis from developing during patient treatment.

3. India’s TB burden is more than double that of second-ranked China

4. 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

5. 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

6. Sensational News Item in Times of India “…The data was being fudged.” • GhulamNabi 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).

7. India’s TB Control program: The DOTS model- lacks Access and Availability • TB Hospitals: Adequate • Government facilities providing comprehensive diagnostics and treatment recommendation • Warehouse for medicine supplies, provided free by government & donors The DOTS* model: network of three types of facilities Hospital/ Warehouse DC DC DC • Diagnostic Centers: Adequate • Sputum tests for initial/rapid diagnosis • 5 DCs required for every hospital ; typically present DC Hospital/ Warehouse DC DC • 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 DC DC DC * “Directly Observed Therapy - Short Course”

8. OpASHA’s Solution: Fill the Gaps: Community Empowerment Strategically located TB Centers • In convenient, high-traffic areas • Centers open at convenient hours • No patient needs to miss work/wages to access treatment Specialized Training • For active case finding • Conduct health awareness programs • Provide counseling to ensure adherence and prevent MDR • To destigmatize TB Local Community Members Hired as Counselors & Providers • 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

9. OpASHA’s Results: Higher detection , much less default Annual Detection Rate Number of Smear (+) cases based on ARTI data Social Return on Investment of 3,211% Detection Rate/ 100,000 population

10. eCompliance: A New Idea…. “DOTS alone is not sufficient to curb the TB epidemic in countries with high rates of MDR-TB.” –Stop TB Working Group “Electronic datasets are needed to facilitate accuracy and analysis of data.” - World Health Organization (2011)

11. 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. SMS Modem Netbook Computer Fingerprint Reader

12. A critical component: eCompliance- “What gets measured, gets done” 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 • PRIMARY OBJECTIVE - To ensure accuracy and adherence SOLUTION • Biometrics confirms a TB patient’s presence • This creates indisputable evidence • One cannot ‘fudge’ a fingerprint!

13. 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

14. How eCompliance Works • 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 Dose missed! Front End SMS Health Worker & Program Manager eCompliance Terminal Daily SMS Back End Electronic Reporting System Online SMS Server 15

15. Implementation • Results • 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: 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 Bhivandi

16. 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)

17. The Key Benefits of Biometrics PATIENT AND COMMUNITY LEVEL • Positive impact on the psyche • Improves motivation • Seen as dedication towards quality treatment AT LEVEL OF FIELD STAFF • 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

18. The Key Benefits of eCompliance MANAGEMENT LEVEL • 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 • Ensures DOTS is being delivered • Prevents MDR-TB CAN BE UPGRADED FOR • Daily dose regimen • Adherence for MDR-TB, • HIV treatment • Diabetes • Mid-day Meal schemes

19. Operation ASHA’s Exponential Growth (number of DOTs centers)

20. 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

21. Adopting OpASHA’s Best Practices • 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. Please visit www.opasha.orgfor more information about our model, our current work, and other projects.