© Operation ASHA 2014 A Game-changer that can scale TB care internationally & prevent MDR TB 1

Serving more than 6.1 million people in India & Cambodia Local, deep, cost effective and high impact model Believes in measuring impact and outcome Ranked by The Global Journal as 48 th among top 100 NGOs in the world Serving more than 6.1 million people in India & Cambodia Local, deep, cost effective and high impact model Believes in measuring impact and outcome Ranked by The Global Journal as 48 th among top 100 NGOs in the world Cambodia Operations  Presence – 5 Health Operational Districts (2 in Phnom Penh, 3 in Takeo Province)  Health Centers covered – 57  Coverage – 1.1 million people  Total Staff – 57  Patients enrolled – 7,378 Cambodia Operations  Presence – 5 Health Operational Districts (2 in Phnom Penh, 3 in Takeo Province)  Health Centers covered – 57  Coverage – 1.1 million people  Total Staff – 57  Patients enrolled – 7,378 2 Operation ASHA: delivers healthcare services

3 Overview: TB is a disease that eclipses all other pandemics Source: World Health Organization In the past 200 years: 1,000 million men, women and children have died of TB. Only half as many (490 million) died because of all other major pandemics (AIDS, Small Pox, Black Death, Spanish Flu & Cholera) put together.

TB: The only disease declared a Global Emergency (WHO 1993) 4 Tuberculosis (TB) is a global pandemic fully curable infectious disease 9 million new TB patients worldwide every year 1 million patients die of TB every year TB has caused 10 million orphans Horrifying Predictions: “We are on the brink of another epidemic and it has no treatment. If Totally Drug Resistant spreads, we will go back to the dark ages” – TIME Magazine, March 4, 2013 By 2015: 1.3 million drug resistant cases, needing $16 billion to treat "The total economic burden of TB between 2006 and 2015 for 22 high burden countries is estimated to be about $3.4 trillion” – GBC Health

5 TB is highly infectious: leads to geometric progression of patients

Global 940,000 Cases Cambodia 9,300 Cases TB is a pertinent issue in Cambodia Among 22 high TB burden countries, Cambodia has the highest mortality rate 110,000 Cases Mortality Cambodia has the second highest TB prevalence Cambodia Global 12,000,000 Cases Prevalence 6

Why is TB so common in Cambodia? 7 Historical context Infrastructure Difficult terrain Poverty Poor health Low awareness Poor health seeking behavior Preference for traditional healers

Across water On land Field Supervisor 1 Field Supervisor 2 Field Auditor VHSG Field Supervisors Sputum delivery Service audits + + Diagnostics With support from MOH, CENAT, PPMHD, PHD and NGO partners Health centres Medication supply Consultation Mobile DOTS model: avoids duplication, optimizes use of existing Government infrastructure Result: An effective, closely knitted and dedicated network of mobile field supervisors bringing TB cure to the doorsteps of people who otherwise don’t have “practical” access to medical care. Random service audits of field supervisors Field Supervisors VHSG refers to Village Health Support Group. They are community volunteers in the villages appointed by the Government. DOTS refer to Directly Observed Therapy Short course. WHO recommended guideline for standard TB care where a dose is observed by healthcare workers when taken. 8 Counseling Contact tracing Active case finding Treatment Raise awareness

Operation ASHA’s solution: local, deep, high-impact & cost-effective model that empowers local communities Doorstep access to full suite of TB care Good knowledge of local terrain, culture, custom Performance based incentives for field team Accessibility Regular audits to ensure consistency of care Comprehensive and innovative use of technology Quality Work with TB patients and formal/informal grassroots network for detection and awareness building Community Training of field and public health care staff: Active case finding, awareness, adherence to treatment Improve treatment outcomes and collaboration Knowledge 9

10 Personal connection with technology Referral Screening + Field Supervisor Community Contact Tracing & Case Finding App Start Diagnosis Lab Alert + SMS Treatment Biometrics

11 Screening: contact tracing & case finding + Field Supervisor Community Methodology: To look for symptomatics of TB through community screening and tracing of contacts of positive TB patient. Objectives: Identifying patients early, enrolling them in treatment and reducing chances of infection to others in the community. Advantages: Aid screening at community level Ensures follow-up of patients according to protocol Locate hotspots in the community Results: Implemented in 6 HC (83 villages) Screened 6931 people; 474 selected for diagnostics test, 142 positive Without the App, these patients will remain missing

12 Diagnosis: lab alert + SMS Methodology: Manual Lab register is replaced with an electronic version on a computer Objectives: Automatic SMS Alert facility: When Lab Technician enters all details of patient’s Lab result, automatically, a SMS is sent to cell phone of the patient and concerned OpASHA worker. Message can be sent simultaneously to any number of persons. Advantages: Reduces time lag between availability of lab results and enrolment by over 30%. Eliminates loss to follow up: All patients are enrolled; none are lost. Results: Implemented in 5 HCs (69 villages) Registered 465 patients; 55 were diagnosed with TB

Netbook Fingerprint Reader Treatment adherence: biometrics Aim: to track each dose taken and eliminate default and generation of MDR Runs on commercially available, ‘off-the-shelf’ components: o Netbook o Fingerprint Reader Software developed by Operation ASHA, with initial support from Microsoft Research Minimum initial and running costs 13

Objectives of biometrics Attendance logs quickly inform health workers of patients who still need to take the dose Tracks missed doses, improves treatment adherence More efficient than from manual monitoring system Accurate & real-time reporting 14

Benefits of eCompliance The simple interface uses a minimal amount of text Can be easily translated into other languages Color coding makes them easy to use even for semi-literate workers High accuracy Elimination of human error Increased transparency Prevents tampering 15

Workflow of eCompliance 16

Biometrics: spread across the world Results in Cambodia Implemented in 4 HC (64 villages) in Dec 2013 Default: 0% (with technology) Enrollment: 217 patients; Completed: 120; Active: Terminals were installed in Uganda in 2012 Terminals installed in Cambodia Terminals installed in India Terminals were installed in the Dominican Republic in 2012

ie 18 Achievements (Dec May 2014) 7,378 patients enrolled HC refers to Health Centers (i.e. facilities providing primary care) operated by the Government 93.6% Treatment Success Rate Pilot phase

Website: Like us on Facebook: For more information

OpASHA: awards, partners and media coverage and many more… 20