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. eCompliance is a biometric terminal that contributes to preventing drug- resistant strains of tuberculosis from developing during patient treatment.

Tuberculosis (TB) is an airborne infection - 9 million people new patients are found every year million people die of TB every year. - TB has caused 10 million orphans so far - Drug resistant forms are causing untold misery Tuberculosis (TB) is an airborne infection - 9 million people new patients are found every year million people die of TB every year. - TB has caused 10 million orphans so far - Drug resistant forms are causing untold misery Horrifying Predictions: - By 2015: 1.3 million drug resistant cases, needing $16 billion - The world is at the brink of a man-made epidemic of MDR-TB Horrifying Predictions: - By 2015: 1.3 million drug resistant cases, needing $16 billion - The world is at the brink of a man-made epidemic of MDR-TB Positive aspects: TB is curable… - Strong political & international commitment - Free medicines, diagnostics and public infrastructure Positive aspects: TB is curable… - Strong political & international commitment - Free medicines, diagnostics and public infrastructure TB: A Global Emergency ( WHO, 1993)

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

5 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

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 Challenges in TB Treatment: DOTS treatment requires 60 visits to a center over 6 months

“…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). Sensational News Item in Times of India

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

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

Annual Detection Rate Detection Rate/ 100,000 population Number of Smear (+) cases based on ARTI data OpASHA’s Results: Higher detection, much less default Results:OpASHA (2010) Other Organizations Default Rate2.75%Up to 60% Social Return on Investment of 3,211%

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

12 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

13 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! PRIMARY OBJECTIVE - To ensure accuracy and adherence A critical component: eCompliance- “What gets measured, gets done”

14 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

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

Implementation Results Default measured at 2.5% Over 2,200 patient cured 900 undergoing treatment Over 150,000 visits logged 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

Cost Effectiveness Total cost of each eCompliance terminal = $434 (Rs. 21,700) Cost per patient = $2.90 (Rs. 145), which is expected to be offset by increased productivity (each unit will treat 150 patients over three years) ComponentCost Netbook Computer$ 328 (Rs. 16,400) Fingerprint Reader$ 68 (Rs. 3,400) SMS Modem$ 28 (Rs. 1,400) SMS Plan (per year)$ 10 (Rs. 500)

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 The Key Benefits of Biometrics

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 The Key Benefits of eCompliance

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

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 Replication in Other Countries

22 Adopting OpASHA’s Best Practices Please visit for more information about our model, our current work, and other projects. 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.