Curing Tuberculosis with a Community

minorbigarmΑσφάλεια

30 Νοε 2013 (πριν από 3 χρόνια και 8 μήνες)

68 εμφανίσεις

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.

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

DC

DC

DC

DC

DC

DC

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


P
rovide
counseling to ensure adherence

and prevent MDR


To destigmatize TB

Local Community Members Hired as Counselors &
P
roviders


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

OpASHA’s Solution:
Fill
the
Gaps
:

Community Empowerment

Annual Detection Rate

82

82

104

151

160

0
20
40
60
80
100
120
140
160
180
2005
2006
2007
2008
2009
Prior to Operation ASHA

With Operation ASHA

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 Rate

2.75%

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


N
ot come into the
center


M
issed their dose within
48 hours

15

Electronic Report
ing
System

Online SMS
Server

Health Worker &
Program Manager

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

How eCompliance Works

Implementation


Lessons Learned

Patients
are not hesitant to give their
fingerprints


Patients
perceive
technology as a sign of the quality of
treatment


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)


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)

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
www.opasha.org

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.