Expert Panels [ARCHIVED] Lessons Learned in India: E-Compliance for TB Treatment by Operation ASHA

When: July 8, 2013 - July 12, 2013 | Where: Virtual, online panel at GHDonline.org Communities: Health IT, MDR-TB Treatment & Prevention

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Panelists of Lessons Learned in India: E-Compliance for TB Treatment by Operation ASHA and GHDonline staff

The World Health Organization first introduced the DOTS (Directly Observed Therapy) model for tuberculosis treatment in 1993 in order to prevent multidrug-resistant tuberculosis (MDR-TB), which develops when patients stop treatment before its full course. Although DOTS has drastically improved TB treatment, anti-TB drug resistance has become a major public health problem that threatens progress made in TB care and control worldwide. Among the 12 million prevalent cases of TB in 2011, there were an estimated 630,000 cases of MDR-TB and XDR-TB. (WHO. 2012) India bears the largest burden of TB deaths worldwide with 300,000 deaths per year, close to 1/3rd of the world's TB deaths.

From July 8-12, we are delighted to host Shelly Batra, MD, founder and president of Operation ASHA, and Abhishek Sinha, Asha's chief technical officer, to discuss their e-Compliance initiative, a biometrics monitoring system for TB patients.

Today there are 58 centers with e-Compliance terminals operating in India with over 175,000 visits logged. How do you plan for an e-Compliance system? What are the pros and cons of using biometrics and what does it cost in India and elsewhere? Are there other systems out there and how do they work?

Those are some of the questions that will be addressed in this virtual expert panel discussion. Dr. Batra and Abhishek Sinha will also share their plans and hope for the future of TB treatment in India, Cambodia, and elsewhere as they expand their work.

Fraser Wares, MD, World Health Organization, will join to share thoughts on TB control in India. Wares spent around 12 years working for various NGOs in Afghanistan, Ethiopia, India, Nepal, PR China and the Russian Federation before joining the WHO in India as the Medical Officer for TB from 2002 to 2010. He is now with the Laboratories, Diagnostics and Drug Resistance Unit of the Global TB Programme, WHO Geneva.

We look forward to the discussion. Feel free to post questions now for our panelists to respond to on Monday.

Thank you, Sophie

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Background information on Operation Asha and the e-Compliance Initiative:

Shelly Batra, MD, established the NGO Operation ASHA in India in 2005, and started TB education, active case finding, DOTS expansion, and default tracking in 2006. Today, Operation ASHA serves more than 6 million slum-dwellers and rural people in India and in Cambodia. Its model, including e-Compliance, has been successfully replicated in Uganda by Columbia University & Millennium Villages.

Dr. Batra explains that Operation ASHA has taken TB treatment “to the doorsteps of slum dwellers” with local community health workers (also known as DOTS Providers) “so no patient misses work or wages in order to get the medicine.” DOTS centers are open early morning and late night, in temples, shops and clinics of quacks, near major bus-stops or factory areas, and counselors are in charge of visiting patients in their homes and making sure they take their medicine as part of DOTS.

But Dr. Batra quickly wondered if providers were actually going to patient’s houses or just declaring they were to get the incentives. So in 2009 they partnered with Microsoft Research to develop the e-compliance initiative, which is a biometric terminal. The terminal has 3 off-the-shelf components, a netbook, a fingerprint reader, and a modem to send electronic messages. E-compliance terminals are kept both in the DOTS centres and carried by counselors. With every new patient enrolled, a record is saved with their fingerprints. At the time of swallowing the medicine, the provider identifies the patient with the fingerprints saved in the system. If patients miss doses, text messages are sent at the end of the day to the appropriate counsellors, the system was piloted in 4 clinics in 2009. In 2010, they did a large scale pilot with 1500 patients enrolled on the ecompliance, and found unprecedented results. eCompliance system is highly interactive and easy to use even for semi-illiterate health workers and illiterate micro-entrepreneurs.

eCompliance is linked to an Electronic Medical System (EMR) at the back-end, which allows automatic generation of all reports, improved transparency and reliability, increased productivity and elimination of human error. There are now 58 centers with eCompliance terminals operating in India with over 175,000 visits logged. Nearly 1600 patients are tracked by the system. The eCompliance initiative has reduced the default to 3%, a rate 3-20 times lower than usual.

Cost Effectiveness & Financial Sustainability:

The cost of eCompliance is very low because it uses standardized off-the-shelf components. It comes to $145 per year when amortized over life of three years. The cost of tracking a patient of DST/ normal TB for the entire regimen is $3. The cost of preventing an MDR case, by reducing default is $200, at least 15 times lower than the cost of treating each case.

 
Dr Kingsley Ukwaja
Replied at 5:38 PM, 5 Jul 2013

Thank you very much. "The costs of the eCompliance @ $145 amortized over life of 3 years. The cost of tracking a patient of DST/ normal TB for the entire regimen is $3. The cost of preventing an MDR case, by reducing default is $200, at least 15 times lower than the cost of treating each case".

These appear to be expensive to implement under programme conditions in very low-income economies in Sub Saharan Africa. I will be interested in how this eCompliance system could be scaled-up in other to monitor the underserved TB and TB/HIV patients in rural and remote settings.

Xeno Acharya
Replied at 11:06 PM, 5 Jul 2013

Operation ASHA's model of close follow-up using community workers (field staff) is already a financial challenge. However, the fact that it is currently operating 257 treatment centers with its current stream of funding speaks for itself--there are resources available if used effectively. I agree with Dr. Ukwaja that the gadget used for eCompliance is expensive, but looking at the reduction in treatment cost, it does seem a feasible solution. I am excited about the prospects of this model and would love to participate in the panel discussion!

Sandeep Ahuja
Replied at 7:12 AM, 6 Jul 2013

I would like to reply to the comments by Dr. Kingsley Ukwaja and Xeno Acharya. I appreciate the concerns about costs. The cost of eCompliance is EXTREMELY low compared to alternative methodologies. Additional cost of $3 is tiny compared any of the following.
1. The cost of treating a single case of TB is between $400-$1900 in Cambodia according to an article published last year in the reputed journal IJTLD.
2. Three years ago, a large project in India run by PSI incurred a cost of $567 per patient.
3. Under TB Reach funding stream of Stop TB Partnership, the cost of DETECTION ALONE for grants in 2011 was $852 per detection. This includes many projects in Africa.
I think there is a need for wider dissemination of cost involved in TB treatment. More information also needs to be disseminated about highly cost effective strategies like eCompliance.

A/Prof. Terry HANNAN
Replied at 8:41 AM, 6 Jul 2013

Sandeep, your comments regarding actual costings of the eCompliance are very important. They provide a 'measure' by which the project can be evaluated and compared to other regional projects. I believe there are "similar" costings for e-projects but for different parameters (e.g. costs/pp under PEPFAR in Kenya using AMPATH and Andy Kanter's Millenium Villages Project for supplying resouces at $/pp). Also Hamish Fraser and Joaquin Blaya were able to show benefits in costings as well as beneficial clinical effects with the e-Chasqui project. Terry Hannan

Dr Kingsley Ukwaja
Replied at 3:25 PM, 6 Jul 2013

Thank you Prof Hannan and Sandeep for the comments. I am passionate about costs associated with tuberculosis care both from the patient and health systems perspectives. I believe the eCompliance project is a very innovative and potentially cost-effective project. But, I am concerned about its applicability in lower income economies and sub Saharan Africa (SSA).

At an additional costs of $3 per to track a patient through out the TB treatment in India...it may be cost-effective? But considering our situation in SSA countries like Nigeria, perhaps it may be targeted to individuals at risk of treatment default and treatment failure...these are some of the issues I am worried about...And I cannot wait to raise them during the Expert Panel...

Thanks you...

Kingsley

Ruth MCNERNEY
Replied at 7:32 PM, 6 Jul 2013

Some costs of TB care from South Africa XDR TB USD 26,392; MDR-TB USD 6,772; drug-sensitive TB USD 257
Full article available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0054587


However, I think we should not focus on costs, but rather on the outcomes. In sub Saharan Africa many people living with HIV now have access to drugs and medical care that everyone thought was completely impossible just a few years ago. TB treatment and care is so much more cost effective than HIV care where people are never cured. TB is curable so let us get on and cure it. If the political will is not there then we should create it like they did for HIV and malaria.
There may be adjustments to the program needed in different regions. For example caring for someone with TB where it is part of AIDS may require support from people with medical expertise.
A question – what advice and monitoring is given to the DOTS providers regarding infection risks. Do you allow persons living with HIV to be DOTs providers?

thank you

Biao Xu
Replied at 8:43 PM, 6 Jul 2013

When talked about DOT, a couple of years ago, a study carried out in Chongqing, one of the most popularity cities showed that only 16% of studied patients reported being directly observed whenever they took medicine; less than 5% were observed by health staff and direct observation was neither well understood nor thought to be necessary (Hu, et al. Health Policy Plan 2008). In high burden countries, especially in mountainous areas, DOT is not practical. But patients' compliance is the key issue for treatment completion. Thus, e- E-Compliance is a good solution. The cost is not high compared to the DOT by health providers in person. What we need to think about later is how to address the frequently happened side effects of anti-TB drugs under the E-Compliance practice; how to trace patients under the more and more polular domestic migration, and how to protect healthcare providers from TB infection when they work in the community where TB is epidemic.

Phindile Shangase
Replied at 12:27 AM, 7 Jul 2013

Many thanks to Ruth for providing costs of TB care. India's innovations on e-compliance are also of much interest to me as I'm based in South Africa. This information is useful to me as I'm currently reading for PhD in Public Health with TB as the main subject. Otherwise all contributions are much valued. Phindile

Roger Paul Kamugasha/Maridadi
Replied at 1:37 AM, 7 Jul 2013

Thank you for this highlight, it is indeed crucial to emphasize infection control in DOTS providers,in this era where we are focusing more on TB/HIV integration at the community level those  with HIV are encouraged to test for TB,and those diagnosed with TB encouraged to take an HIV test.
True,there is need to share best practices with the malaria and HIV constituences so that TB can adopt the same,because  TB is left behind as a reason of poor advocacy.

Roger Paul Kamugasha

Biao Xu
Replied at 1:57 AM, 7 Jul 2013

We are still the country with a low prevalence of HIV infection.  DOT providers in China are mainly health care providers including village health workers (the former barefood doctor), health workers in community health center and upper level health facilities. Currently we encourage family members' involvement into the DOT. Village and cummunity health workers should visit patients when the treatment starts, this calls concerns on the risk of infection.  In rural, sometimes wearing a mouth mask to patient's home is not acceptable for the considerations of patient's privacy and culture.

Lucica Ditiu
Replied at 5:53 AM, 7 Jul 2013

Dear all, this is a verz good and timelz discussion so thatnk you all for the topic, the richness and the debate. Few things to add:
1. We are getting more and more visibility, support and commitment for TB interventionsand what is very important is to haveambition at the country level, NTPs and governments for full scale up and increased coverage of all our interventions. Cist effectivenss of what we want to do will play therefore a big role.
2. Funding - in GF eligible countries is and will be available - if plans are done properly. if anything - the overall TB community will be faced in the comming months - by the end of 2014 - with a larger than usual amount of funding from the GF approved proposals in round 9,10 - and all funding should be used and interventions scaled up. we should have NO countries returning their funding or being un able to spend 100% of their TB enveloped from GF.
3. when finding ADDITIONAL TB cases in vulnerable and poor populations - expect the budget per case detected and treated to increase - as additional efforts should be done to find the additional cases, engage them in diagnosis and treatment and follow up.
4. There are current significant efforts in SA with the engagement of the private sector to ensure a good tracing electornic szstem for patients - based on fingerprinting - to ensure proper follow up and monitoring.
very very good discussions, excellent points raised, thank you Op ASHA for staritng it and the great work!

Esmerelda Jelbart Wallbridge
Replied at 6:19 AM, 7 Jul 2013

Members of the panel may be interested to watch this 5 minute explanation of the eCompliance system: http://www.youtube.com/watch?v=OUaNhdXtm-4

Please note that eCompliance:
* is a tool designed for use by Community Health Workers to support their provision of directly observed TB treatment (not for use by patients themselves)
* verifies each patient visit to a DOTS centre
* notifies CHW when a patient has missed a scheduled dose (who can then visit the patient to give medicine/counseling in a remote setting such as the patient’s house)
* creates, maintains and archives patient data electronically
* improves transparency and eliminates human error

Operation ASHA has found that a decentralised community-based model of TB treatment delivery that utilises the eCompliance system can reduce default rate to between 1-3%.

Preventing missed doses or incomplete treatment is crucial in the fight against MDR and TDR TB.

Roberson Gede
Replied at 9:27 AM, 7 Jul 2013

c'est incroyayable,comment on va subvenir pour les patients du tiers monde,pour les pays a faible moyen,c'est absurde,c'est tres couteux.la ou je suis j'ai une multitude,non seulement resistants aux quimiotherapie mais egalement associes a VIH/SIDA,je suggere qu'il serait bcp mieux de penser a nouveau.

Michelle Colder Carras
Replied at 8:40 AM, 8 Jul 2013

Maybe my translations skills are faulty, but is this message saying that it's not worth it economically to address this in a third-world country where drug-resistant TB is common? I think the whole point is that when evaluated at a population level, the up-front costs associated with providing community health workers with a mobile health solution that would increase the effectiveness of DOTS would be offset by savings in the cost of treating MDR/XDR-TB. I would really appreciate a better translation (than Google translate) as I'm not sure what this last comment is trying to say.

Michelle Colder Carras

Michelle Colder Carras
PhD Student | Johns Hopkins Bloomberg School of Public Health

Sophie Beauvais
Replied at 11:13 AM, 8 Jul 2013

Dear All,

Welcome to this week’s virtual Expert Panel on the E-Compliance initiative for TB Treatment by Operation ASHA. But first of all, please note the important email notifications information as some have asked to not receive emails:

-This virtual Expert Panel is available to members of both the MDR-TB Treatment & Prevention and Health IT communities using our new hosting system. This means that if you are a member of one of these communities, you automatically receive email notifications.

- If, for any reason, you would like to not receive emails for this panel, please do not reply to the discussion via email but instead sign in to http://www.ghdonline.org and go to your profile.

- Anyone can join the panel and anyone can be invited so feel free to send the link to the discussion http://www.ghdonline.org/e-compliance-india/discussion/lessons-learned-in-ind... or send an invitation online and post to social media websites.

- Please remember that as a member of the GHDonline communities you are able to add/remove communities and panels as well as change your email preferences by signing in and editing your profile. There’s a lot more you can do when you sign in, you can read more about this here: http://www.ghdonline.org/about/

- Last, and as always, we want to know what you think so email us your thoughts on panels, communities, etc. at or by using the contact form http://www.ghdonline.org/contact/

Since we first launched the GHDonline communities in 2008 Dr. Batra and her team at Operation ASHA have been at the forefront of knowledge sharing so we’re delighted to have them with us “virtually” this week. Take a look at the following publications and videos and post questions and thoughts on biometric monitoring systems for TB treatment now!

Thank you, Sophie

Attached resources:

Roger Friedman
Replied at 12:09 PM, 8 Jul 2013

Maybe I have not read all the materials, but it looks as if the community health workers have to carry around e-compliance terminals containing personally identifiable information (e.g. patient name and address) as well as biometric information. How are these terminals and their data protected?

How are pediatric cases handled? Are fingerprints reliable for growing children? How are consents maintained for minors?

I don't see the workflow where regimens are assigned to patients, it implies a reverse flow from the facility at which the therapy is assigned to the e-compliance terminals.

Note that in addition to daily observed therapy, the DOTS protocol calls for a monthly physician visit, follow-up testing, and a change of regimen between treatment phases. I know that in India community health workers are trained to make TB smears, so the terminal should allow the association of a fingerprint with a scanned specimen label. Contacts are also supposed to have monthly tests, so this is another task for the e-compliance terminal.

Nor do I see a description of the data flows between facilities. Does a patient always have to receive treatment from his/her neighborhood facility or a community health workers connected to it? Given the long waits for service at most health facilities and the mobility of people, especially those susceptible to TB, such a requirement would make e-compliance not scalable.

Sophie Beauvais
Replied at 4:59 PM, 8 Jul 2013

@ Michelle Colder Carras
You are correct in your understanding of Roberson Gede's comments who basically says that in poor countries with limited resources/funding, it is not feasible, too expensive and "absurd" to do something like eCompliance for all patients especially as drug resistance is compounded by HIV/AIDS co-infection. He suggests we think again. I'm asking him now what he sees being done in Haiti (where he is based according to his profile) for patient monitoring and TB support and what the costs are.

Anyone else has thoughts on the costs of this compared to other systems or to detection alone or treatment cost per se? Especially take a look at Asha's Sandeep Ahuja's response here: http://www.ghdonline.org/e-compliance-india/discussion/lessons-learned-in-ind...

@ Roberson Gede
Cher Roberson Gede, j'ai traduit votre commentaire le mieux possible mais j'ai une question pour vous: comment se passe le suivi des patients tuberculeux en Haiti? Les patients recoivent-ils un soutien de la famille ou de la communaute pour verifier qu'ils prennent bien leur traitement?

Une autre question pour vous et la communaute de professionels en Haiti et pays francophones:
Ruth McNerney demande si les personnes sero-positives sont autorisees a etre des accompagnateurs de traitement TB considerant les risques d'infection?

Merci par avance, Sophie

Ruth MCNERNEY
Replied at 4:21 AM, 9 Jul 2013

The E compliance tool is being used successfully to improve compliance to TB treatment in areas of the world where drug resistance is emerging at an alarming rate. It aids community based persons to deliver TB drugs discreetly and efficiently. It is being used to support patients in communities where access to health centres is not optimal and where formal health services do not reach.

DOT providers are not necessarily the same as community health workers who often have a wider role, and they may not be in a position of trust - particularly in disadvantaged communities or the socially excluded. DOT providers provide treatment once a person has been diagnosed, they do not undertake the diagnosis themselves and are not usually trained to give complex medical advice.

For community health workers who deal with a myriad of health problems alternative etool solutions may be found to assist them. The devices are becoming smaller and lighter and cost is dropping rapidly. Diagnostic test manufacturers are already building the technology into their devices which if used appropriately may aid recording and registering patients as well as monitoring and surveillance activities.

In countries such as India people frequently choose not to engage with the formal health sector. The reasons are many and may include a lack of confidence in health care services or lack of access for geographic and other socioeconomic reasons. In India TB is more highly stigmatised than many other parts of the world. The disease is seen as casting a shadow on the family, it is grounds for divorce, your daughter may not marry well and if people think you have TB you may lose your job/livelihood. These are real issues that work against compliance. The etool has enabled slum dwellers to provide effective treatment to other slum dwellers. It may not be provide the answer for everyone and there will need to be some flexibility (e.g. a mother would register on behalf of a young child) but in a country with so many cases of MDR and XDR TB and where strains of TB have recently emerged that are resistant to all TB drugs tested this initiative should be applauded.

Thomas Mohr
Replied at 6:38 AM, 9 Jul 2013

Does the e-compliance tool being used in India utilize the strips which can detect TB drug levels in the urine which when used and then provide a number which the patients SMS back to the responsible health center? This is a variant I recently learned about that was used at the Indus Hospital in Pakistan as a part of the TB REACH project. The "X-out-TB" technology used in the project uses strips that reveal a code when exposed to urine of patients who have taken TB medications. The project also used other incentive schemes and it was reported that these pushed adherence to over 90%, at a lower cost per patient than the usual system.

We are looking into Mobile health solutions for the region where I am working as well (Central Asia) which has similar stigma and discrimination issues, so please continue sharing your experience as all of these discussions provide valuable ideas and lessons learned. Certainly, there is great potential here to achieve a lot and more patient centered care by employing new mobile solutions.

Thomas Mohr
Replied at 6:55 AM, 9 Jul 2013

Excuse me- I had missed the initial message at the top of this discussion and realize that the "X-out-TB" technology was not used in the aforementioned e-compliance tool used projects mentioned above. Still this variant is very intriguing for situations where it is hard to confirm if the patients are really taking their medications or not. It would be nice not only to compare the adherence results but also full cohort results.

Sophie Beauvais
Replied at 7:42 AM, 9 Jul 2013

To those who want to be "removed from the list" -- again please note that this virtual panel is part of one of your communities on GHDonline and you can thus change your email notifications settings in your profile. Please do not reply to this email as it sends a response to everyone discussing the eCompliance initiative as part of the Expert Panel. Thank you, Sophie

Abhishek Sinha
Replied at 8:19 AM, 9 Jul 2013

Yes, "X-out-TB" technology was not used in eCompliance. "X-out-TB" technology is mainly for non-DOTS protocol which eCompliance is designed for DOTS protocol but can handle non-DOTS with minor modifications.

I think the problem they had is that they were unable to guarantee that only one strip was dispensed per day. So, a patient could adhere to medication on the first day and expose all the strips at once.

Shelly Batra, MD
Replied at 10:29 AM, 9 Jul 2013

Thank you all, for your valuable comments.
Let me explain OpASHA's model a little further. The challenge in DOTS therapy is that existing centres( run by the government or other NGOs), are few and far between, and patients are forced to spend the better part of the day commuting, waiting in lines etc. These patients are the poorest of the poor, often these are the ones living in absolute poverty as defined by the World Bank ( ie earning less that $1.25 a day). So if they go for TB medication, there is no food for the family that day. The social stigma is so high that if anyone gets to know that have TB, they lose their jobs, which makes things worse. Another issue is, where is the bus fare coming from? And so on and so forth. We can continue talking ad infinitum about the challenges in DOTS therapy, but let me go on......
We decided to take TB treatment to the doorsteps of the needy, so no -one has to miss work and wages in order to access their medicines. So we have hired and trained Providers from the communities they serve. This ensures better rapport, also Providers can navigate the the informal geography of slums and shanty towns. These Providers are given a fixed basic salary, plus cash incentives for tracking patients who have missed their dose.

Now how do we ensure that Providers are doing their job. We thought of hiring another layer of Supervisors. Not a good idea at all, because costs go up, and Supervisors and Providers can be hand-in-glove with each other! So we though of technology. SMS was not the solution. SMS sent to a patient does not ensure that the medicine has been taken. Also, patients often do not want to recieve an SMS reminder because of the social stigma, which is so great that 100,000 women are thrown out of their families each year if they have TB,to die of disease and starvation in India.
The only solution was to ensure Provider-patient interaction, and a fingerprint is indisputable proof of visit. Also a fingerprint cannot be fudged, which makes the system very attractive to some ( and not at all attractive to others, if I may be permitted to say so!)

Regarding workflow with the eCompliance. Before treatment is started, the patient gives his fingerprint, and is thus enrolled in the system. Whenever the patient goes to a DOTS centre( which could be a temple, shop, anything convenient regarding hours of work and location), the patient has to give his fingerprint, the screen turns green, the computer says "Patient X logged in." Only then is the dose given.
Providers and the concerned managers get a daily SMS from the eCompliance about those patients who havent come to the DOTS centre. Now they have to take action. the Provider goes to the patients house, repeats the TB education, takes the finger print, and gives the medicine. The visit is camouflaged as a health visit because the Provider carries OTC drugs such as painkillers or antacids. This way, the patients are tracked in remote setting, but their privacy is maintained.

With eCompliance, our default rate is less than 3 %. Naturally. Incentives work. But we are ensuring that incentives do not become a way of 'gaming' the system. This is where eCompliance has tremendous value.

Shelly Batra, MD
Replied at 10:54 AM, 9 Jul 2013

@Dr Kingsley Ukwaja. I agree that its very important to keep costs low, esp as we are working in resource limited settings. The best thing about eCompliance is that it 'pays for itself' , so to speak, because the cost is more than offset by increased productivity of our staff, both the field staff as well as the office staff, who would previously spend 33% of their time in preparing reports for the government and donors. The eCompliance is linked to the EMR at the back end, which generates reports accurately and at the drop of a hat. Our Providers have now been given more patients to serve and bigger areas to cover, and we are saving on office space and salaries of office staff.
Now we switching to Android phones rather than using Netbooks. So cost will come down further by 40%, a great saving indeed and this saved money will be pumped back into the core program. This is very big need in TB, where funding is not excessive.
I may add that OpASHA is one of the most cost effective programs in the world. We do active case finding, TB education, de-stigmatising TB, treating patients fully, default tracking,using community empowerment and eCompliance, and our cost for all this is only $80 per patient.

Mona Duggal
Replied at 11:00 AM, 9 Jul 2013

Dear Dr. Batra,
Congratulations on setting up this system.I feel its an excellent use of technology. I think all those concerned with costs really need to understand the number of MDR tuberculois that are averted for every single patient correctly treated and how many new patients were averted.This is a modelling question. Its a model that can be modified and used in other chronic infectious disease models where adherance is an issue like HIV . A centralized control for the number of visits missed will help the providers to concentrate on the patients that require more intense follow up. Its a brilliant idea which can be modified, adapted and further refined as required.

Shelly Batra, MD
Replied at 11:13 AM, 9 Jul 2013

@Xeno Acharya. You have stated "Operation ASHA's model of close follow-up using community workers (field staff) is already a financial challenge". I wonder how you made this analysis?
Using community health workers as DOTS Providers is the best way to ensure the 'last mile connectivity' at low cost. Providers are from disadvantaged backgrounds, they get a market salary, which is much less than highly qualified workers would charge. Also, we do not hire clinics, rather we 'rent' space from micro-entrepreneurs in slums. Again, a cost saving device.
The Investment Manager of a large Venture Philanthropy firm recently said, "OpASHA's cost is at least 19 times less than its nearest competitor."
Ours is a low cost, high impact, scalable and replicable model, that gives a high leverage and SROI (Social Return on Investment) of 3217% because of increased productivity of treated patients, saving of indirect cost to the Indian economy, and job creation for the needy. Hope this helps. For more info, write to me at

andrew wyborn
Replied at 11:36 AM, 9 Jul 2013

Hi Dr Batra, this looks like an excellent initiative. I'm interested in the technology component and wondering how the back end EMR is updated when a new patient registers at a center? This is obviously important if a patient registers at one center and then visits a different center for treatment at a later date. Do the centers have internet connectivity? Many thanks, Andrew Wyborn, Greenmash, www.greenmash.com

Abhishek Payal
Replied at 12:09 PM, 9 Jul 2013

@Dr.Shelly Batra - that was an enlightening comment on the workflow of OpASHA. What has been your main challenge in implementation and expanding this service so far?

Roger Friedman
Replied at 12:34 PM, 9 Jul 2013

So it doesn't sound like the system is displaying the drugs to be dispensed, which it should. It doesn't sound like the Providers are prepared to deal with adverse reactions. And it doesn't sound like there is any follow-up testing being done. Is any syndromic evidence of possible treatment failure gathered?

While there are limitations as to how much can be done in underfunded, underserved, poor communities, we have to act as medical providers and not gadget-fixated technologists or nursing sisters helping their patients into the next world. This means that we make diagnoses and prescribe therapies according to evidence and science-based practice. This is not to say that we can't vary modalities of service delivery or recordkeeping, but that we must have a standard of care. DOTS alone, without testing, without adverse event response, without contact tracing, without prophylaxis, does not meet a minimum standard of care. It creates a risk of drug resistance through insufficient dosage or patients abandoning treatment due to side effects. It does not identify MDR or XDR cases, leaving those patients in the community to spread the disease. It does not deal with the most frequent co-morbidity, HIV.

With respect to stigma, it is a human problem, not a technological one. Quite often one hears requests to set up application security so that only providers in the patient's home HIV or TB clinic can see those records. This creates tremendous problems with reporting and cancels out the benefit of making relevant records available to all treatment providers. Meanwhile, the facility is using paper records which make this private information quite public, and facility managers fail to take disciplinary action against employees who access patient records without authorization or who spread patient information beyond those with a medical need to know. So the first place to start dealing with stigma is with providers, clinical and non-clinical.

As for stigma in the community, there is a need for public health campaigns. While the bacillus is quite widespread in the population, active TB is a disease of the malnourished, the sickly and the immuno-compromised. And TB is curable. This is a message that needs to be spread. Further, the evidence from HIV in Mozambique that I've seen is that patients, even those who use alternative medicine, don't fear the stigma of being identified as having the disease as much as they fear dying of the disease without medication.

Just to be clear, I think ecompliance is interesting as a technology and OpASHA's efforts to implement it praiseworthy. But as a medical intervention, it's not ambitious enough to meet basic requirements.

Roger Friedman
Replied at 12:44 PM, 9 Jul 2013

For the record, my comments in this forum represent my personal opinions and not those of my employer or any organization or agency with which I am affiliated.

Abhishek Sinha
Replied at 12:59 PM, 9 Jul 2013

Hi Andrew! Good to know that you are interested in the technology component.

In our model, patients registered in one center always go to that same center for medication and this is because of the fact that patient's medicine box is kept at this center.

Once a patient is registered at the center, his/her data is converted into an encrypted SMS, which is later sent to our SMS Server automatically by the client machines using SMS Dongles. Our EMR imports these SMSs and convert the SMSs to the database for Analysis and Reporting.

Shelly Batra, MD
Replied at 1:53 PM, 9 Jul 2013

Dear Roger,
Nice to meet you on this forum! You have raised some very relevant points.

Let me begin by saying that OpASHA is working as an extension of the national TB Control program, where internationally accepted guidelines for diagnosis and treatment are followed. TB suspects are diagnosed in the public Microscopy centre, then go to the Tb specialist in the public hospital for a check up, where the entire 6 month box of medicines is handed over to the nearest DOTS provider.
Our Providers keep the boxes of medicines in the nearest DOTS centre, which is open at convenient hours. But before the first dose is given the provider goes to the patient's house to educate the patient and family about TB, and the risks of MDR-TB setting in if the patient were to leave treatment halfway. This is no doubt difficult, but when patients are told that if they default, they will, in all likelihood, get MDR TB and spread the infection to their loved ones, they are more prone to adhere to the treatment protocol.

The national TB Program carries out all relevant tests at regular intervals. This includes testing for HIV, after taking the patients consent. Our providers are trained to dispense OTC drugs to treat/prevent side effects of TB medicine.All OTC drugs, ie painkillers, anti-emetics and antacids are kept in color-coded jars in the DOTs centres for ease of use. In case of serious side effects, the providers facilitate the patient's trip to the public hospital where treatment was started,so that the TB specialist can diagnose and treat accordingly. So you see, we have a high standard of care, with regular testing, with adverse event response, with contact tracing of family members (for which the Providers get cash incentives,) with regular and repeated TB education to prevent spread of contagion, to de-stigmatise TB, and to solve day to day problems of TB patients. (for example, I have one blanket for 5 persons and one has TB, what do I do?)

Technology can never take the place of humans. It can add the extra dimension. It can substantiate the work of humans, who are prone to making mistakes, carelessness and even deception. By minimising default, eCompliance has a tremendous benefit from the public health perspective, that of preventing MDR TB, which is the next plague that shall wipe out millions. Let us not miss the writing on the wall.

Shelly Batra, MD
Replied at 2:12 PM, 9 Jul 2013

@Abhishek Payal.
you have asked about challenges in implementation and scaling. Let me begin by saying that whenever we add a new dimension that will monitor the work of field staff, there is bound to be some initial resistance. When we established the ecompliance terminals initially, the providers were a little resentful, because they realised they could no longer have an easy time and do little work! This because they had to swipe their fingerprints on the e compliance at the time of arrival to a DOTS centre and on leaving. Neither could they declare that they are going on house visits to do tracking of missing patients, because these visits had to be 'proved' by the patients fingerprint in remote setting. It is only later that they realised the benefits, which were
1. They were learning a new skill
2. the fact that they carried computers added to their respect in the community
3. they were saving time, for they did not have to sift thru paper records to find which patient hasnt come for treatment. Also, there were less chances of errors
4. Counselling became easy. In case of a stubborn patient who refuses to come to the DOTS centre,they could appeal by saying that the technology device will monitor all this and they will lose incentives.

Other challenges were at computational level. Abhishek, could you comment on this?

But by and large, implementation and replication has been easy. In Uganda, Operation ASHA's model and eCompliance has been replicated by Columbia University and Millenium Villages successfully, with outstanding results: death rate is down to zero from 16% in Ruhiira cluster.And the technology transfer and training was done remotely by Abhishek and his team.

Shelly Batra, MD
Replied at 2:27 PM, 9 Jul 2013

@Roberson Gede. Your comment is "in poor countries with limited resources/funding, it is not feasible, too expensive and absurd to do something like eCompliance for all patients."

My take on this: eCompliance is a necessity because resources are limited, and the threat of MDR & XDR looms high on the horizon.
May I begin by telling you what is the cost of treating MDR TB? Drugs alone cost anything between $3000-10,000. Cost per patient to NGOs go up at least 8 times, because treatment lasts for 2 years so providers have to work longer, training is more intensive, we have to pay a nurse/informal healer anything from 10 cents to 50 cents for each injection for 6 months, and then there are regular trips to the public hospital for getting tests. All this costs money.
Apart from that, there are indirect costs, costs of communication and advocacy and so on.

According to the Stop-TB Partnership, by 2015 there will be 1.3 million cases of MDR TB, requiring $16 billion. Where is the money coming from?

So it makes sense to prevent MDR TB. Which is what e Compliance is all about. It minimises default and the threat of MDR, all at no extra cost to the program.

What I find absurd is the indifference to the plight of MDR-TB patients, and the lack-lustre, half-hearted approach to a problem that should be tackled on war footing.

Shelly Batra, MD
Replied at 2:37 PM, 9 Jul 2013

Article in Huffington Post on third party replication of eCompliance in Uganda.

http://www.huffingtonpost.com/dr-yanis-ben-amor/harnessing-new-technologi_b_2...

Attached resource:

Aaron Gordon
Replied at 2:57 PM, 9 Jul 2013

Dr. Batra,

It is absolutely fascinating to read about this new and innovative method of ensuring that the MDR-TB is mitigated. I was curious though about one thing. In your response to Mr. Friedman, you wrote that "TB suspects are diagnosed in the public Microscopy centre..." Does this diagnosis include investigating whether the patient is already resistant to the standard DOTS six month regiment? If one is already infected with MDR-TB, how does the system account for that? If not, does eCompliance or the providers have a way to quickly realize that the treatment is failing?

Thanks for your time!

Masoud Dara, MD
Replied at 3:31 PM, 9 Jul 2013

Dear colleagues,

In many parts of the world, we need to foremost improve compliance of health care workers and particularly physicians to diagnose early and administer appropriate treatment. From patients' side, we need to provide people-centered care and support patients' adherence. Although the terms compliance and adherence are often used interchangeably, but they are quite different. Both compliance and adherence are important. We need to use all available means including electronic adherence.

Gini Williams
Replied at 4:26 AM, 10 Jul 2013

Thank you, Dara, I could not agree more. Any means possible can be used to enable people to complete their treatment but they have to be part of a package of effective patient-centred care. From what I have read about this e-compliance project this seems to be the case. Directly observed treatment will never be the whole answer if it is used simply as a control mechanism. It has to be supportive and acceptable to the patient whatever means are used to record it. I would think finger-printing would have to be particularly sensitively handled - I am not sure if anyone has raised the issue of patient consent for the handling of their biometric data.
On another point, this discussion seems to have switched between talking about fully sensitive and drug-resistant TB. It concerns me that so much emphasis is being put on supporting adherence when people have MDR-TB (not necessarily here but in general). The fact that we have growing numbers of people with MDR-TB reflects the lack of support which has been available to people with fully sensitive TB. Our mantra has to be - "Cure first time, every time".
If we are talking about cost-effectiveness, someone should calculate how many people with fully sensitive TB need to be included within the e-compliance project to prevent a case of MDR-TB. When costing MDR-TB it should not only be the price of the medication but also the additional care required during the extended treatment period and most importantly cost to the patient and their family

Fraser Wares
Replied at 6:07 AM, 10 Jul 2013

Firstly I would like to congratulate Dr Batra, Abhishek and Operation AHSA on the innovative project to match the advances in information technology with the challenge of supporting TB patients through to successful completion of treatment in India. The challenge of creating effective patient centred care for TB patients in settings with limited financing is an immense one, and India certainly is one such setting. The use of modern IT to meet this challenge is to be welcomed. The end result of a 3% lost from follow up rate amongst patients is to be applauded.

However the replies raise a number of fundamental issues which need to be explored in much more detail in the current setting of restricted and even reduced funding, and where great emphasis is placed on the principle of value for money.

1. Is this system cost effective? How does it compare to alternative mechanisms? The national TB Programme of India (RNTCP) reported to WHO for the 2010 cohort of new smear positive pulmonary TB patients a lost from follow up rate of 6%. Does the investment that is required to operate the eCompliance mechanism deliver a worthwhile improvement? It is not just the cost and running of the IT system, but also the hiring of the community workers who provide the home based DOT (which is not part of the RNTCP DOT system). Please note that in the 2011 Annual WHO TB Report, the cost of treating a TB patient with first line drugs was estimated at just over USD 100 per patient. However the benefit of reduced transmission and prevention of drug resistant TB really need to be factored in to any full calculation, which is not easy.
2. If cost effective, is it affordable, reproducible and sustainable? India reported over 1.5 million TB patients being treated under RNTCP in 2011. Should the eCompliance system be expanded to all TB patients in India? Even if yes, could it be expanded?
3. Is the EMR system compatible with the existing information systems of RNTCP, or can it be so i.e. what is the level of interoperability of the EMR system employed here? It has been seen in many settings that different electronic recording and reporting systems are set up by different partners, but unfortunately they remain stand alone systems which cannot communicate with each other.
4. As raised by one commentor, what is the level of data protection included in the system? Is there consent from the patient prior to providing a fingerprint as in many settings this will be a major human rights issue?

And finally I would like to agree with others that the use of the word Compliance in the system is a double edged one. We would hope to support patients in their efforts to adhere to treatment. However, as mentioned by Masoud, maybe we do intend that compliance is sought from the health care providers!

My above comments are intended to create further discussion. And please note that my comments are being provided purely on a personal basis, and are not being provided on behalf of WHO.

Linda Hegarty
Replied at 9:44 AM, 10 Jul 2013

As a newcomer to the forum, I really appreciate this discussion. @ Shelly you talk about the initial resentment of providers to the compliance terminals...i would be interested to know how you managed to keep them engaged until they actually saw the value. Also, @ Abhishek would be interested to know how you developed and delivered the remote training programmes, and what were the incentives for providers to complete them. Thanks.

Sophie Beauvais
Replied at 10:15 AM, 10 Jul 2013

Hi Linda, Everyone,

Dr. Shelly Batra and Abhishek Sinha, Asha's chief technical officer, are now answering your questions live on Google Hangout on Air: Join here
https://plus.google.com/u/1/b/118398033629677073869/118398033629677073869/posts

We'll post the video later today. Thank you, Sophie

Lindsay McKenna
Replied at 10:59 AM, 10 Jul 2013

Thank you, Fraser Wares and Gini Williams, for raising the issue of data
and patient confidentiality protections, or lack thereof. The e-compliance
model minimizes paperwork and human error and appears to improve treatment
outcomes, but raises major concerns around patient confidentiality. I
recently had the privilege of visiting an Operation ASHA site in India. I
applaud the work they are doing and their success expanding the reach of
the RNTCP. However, beyond the apparent lack of protection of patient
information sent electronically, the boxes of medication were stacked in
plain sight with each patients first and last name written on the side.
Anyone who enters the health clinic can see who in their community is on
treatment for TB, which undoubtedly is a violation of patient
confidentiality and contributes to stigmatization of TB patients. While on
site I also learned that donors are able to track patient progress online,
which is another clear violation of patient confidentiality. I hope that
moving forward Operation ASHA and others who implement the e-compliance
model are able to better protect patient data and confidentiality.

Best regards,
Lindsay McKenna

Roger Friedman
Replied at 11:37 AM, 10 Jul 2013

I'd like to thank Dr. Batra for her open response to my posts. It's reassuring to see that eCompliance is embedded in a larger program which deals with other aspects of TB treatment. However, I think Dr. Batra can find some suggestions for extensions of the program in my comments.

Vicky Cardenas
Replied at 1:18 PM, 10 Jul 2013

I have visited over 30 DOTS centers in India. I can say that the display of patient names on medication boxes is not unique to OpASHA sites. All DOTS sites in India that I have visited do the same.
I am not suggesting that this makes it right; only that this is an issue that goes beyond OpASHA.

Mona Duggal
Replied at 1:47 PM, 10 Jul 2013

I agree, but at the same time most of the population that accesses this center is illiterate or have very low literacy levels. Concept of privacy,and patient rights are still in nascent stage and a very western concept in India. What might not seem acceptable in western medical system may be completely be acceptable in India or other resource limited settings.Probably that also gives the international health community flexibility to experiment and do research in these settings.

Shelly Batra, MD
Replied at 2:44 PM, 10 Jul 2013

Hi Linda. Yes, there was the initial resentment of providers to the eCompliance terminals. I am bringing this forth because it is important to realise that technology cannot be made in fancy labs and just dumped on field workers.
The initial resentment occurred because the providers had to cope with 2 systems of tracking patients and reporting. One was the paper system prescribed by the governtment, where each patient had a treatment card, where a tick had to be made at the time of giving DOTS. The other was the biometric system. So the providers felt that they were being made to do extra work. But very soon they realised that work has become simpler. One of the things they had previously found time-consuming and tedious was (as told by the providers themselves) going back to the DOTs centre late in the evening , to sift thru cards and try to ascertain which patient had not come for DOTS.This is the point where human errors would creep in. With eCompliance, in the evening, an SMS would come to the provider that so-and-so patient has not come, so they could go next morning to the patients house, give targeted counselling, take the eCompliance terminal , and use that to appeal to the patients to stay on course. The providers would say, the machines are monitoring our work and incentives, so please do take the med!

So we managed to keep them engaged by saying that this will simplify your work, make counselling easier, and will ensure that you get timely performance based incentives . Very soon the providers understood the value of eCompliance.

Lindsay McKenna
Replied at 2:50 PM, 10 Jul 2013

Dear Ms. Duggal,

I would like to make clear our position that ALL patients are entitled to
the same human rights and standards of privacy -- whether patients can read
or live in India or elsewhere is irrelevant. Additionally, the
international health community's "flexibility to experiment and do
research" in resource limited settings still requires IRB approval and
informed consent for ALL participants (as it should).

For more information on patient rights and ethics, please refer to the
Patients'
Charter for Tuberculosis
Care http://www.who.int/tb/publications/2006/patients_charter.pdf and
a WHO fact sheet on Ethical Issues in TB Prevention, Care and
Control http://www.who.int/tb/publications/ethics_in_tb_factsheet_28jan11rev.pdf
.

Best regards,
Lindsay McKenna

Shelly Batra, MD
Replied at 3:11 PM, 10 Jul 2013

Yes we must discuss privacy issues. We believe in maintaining privacy of patients. At the same time, we do not want ignorance and myths and misconceptions of TB, which are rampant among semi-literate and illiterate people, to be the reason for discrimination and ill-treatment of TB patients.
let us now discuss what is social scene.There are 2 types of TB patients. First are those who are petrified with fear, who hide the disease from each and every member of the family, Second are those whose family members know that something is wrong somewhere and already have some suspicion that this could be TB. Both the situations are not conducive to the patient getting any kind of TLC ie tender-loving-care from family members! So the solution is to involve the immediate family in the patients' management, while all the time keeping the patient protected from prying eyes and judgmental neighbours and others in the community.

This is done by the providers. Before treatment is started, the provider makes a visit to the patinets house, and, with the prior consent of the patient, discloses the diagnosis. This is the time the family is told that your patient need not infect others, TB is not a curse from the gods, your family is not doomed to die, TB does not spread by cups and plates, etc. Rather, the family is told, we will treat this patient together, we need your help in doing this, we will tell you how to prevent spread of disease, we will ensure that this patient becomes a useful member of the family. Thus we destigmatise Tb in a big way.
To maintain privacy, we open DOTS centres in temples shops etc, where anybody can go. We do NOT write the word TB anywhere. We camouflage our DOTs centres as health Clinics by distributing OTC drugs free of cost to all who need in the community. Our Providers never talk of TB when they go to patients house. Instead, they declare to the neighbours that the visit is to give some OTC drug or protein biscuits.

Now regarding privacy on the eCompliance. Abhishek has already given his comments. I must add that giving fingerprints is not an invasion of privacy in a country where fingerprints are freely used by the illiterate instead of signatures while doing legal transactions and government matters. A finger print is not a photograph, and patients do not hesitate at all in giving fingerprints. In fact they feel that the govt has set its seal of approval on the program. Most of them find the technology exciting & innovative, and definitely their faith in us has gone up tremendously !

I would hesitate to ask a TB patient for a photograph. But a fingerprint doesnt matter. To the untrained eye, all fingerprints look alike . Unless we are forensic experts.

And the last comment. All data is encrypted before being sent from the terminal . This again for privacy sake.

Shelly Batra, MD
Replied at 3:38 PM, 10 Jul 2013

Dear Lindsay,
I agree whole-heartedly. ALL patients are entitled to the same human rights and standards of privacy -- whether they live in India or elsewhere doesn't matter.

As clearly stated in the WHO ref, we need to strike a balance. This balance has to be between patients on one hand, and those who are at risk of infection on the other. Individual rights and liberties of suffering patients are important: and so is protecting the rights of contacts who could easily catch TB.

This delicate balance can be maintained, and we have done it successfully in OpASHA by taking consent from the patients before disclosing facts to other members of the family. I have always felt that the patient will be fed better, treated better, loved better , provided we can convince the family that your help and support is critical to the patients recovery and integration into family and workplace.
Another reason for disclosing the diagnosis to family members is that it will ensure that all precautions will be taken, so this way we can minimise spread of disease, and we can also persuade contacts to come forward for testing.

Acceptance by family members is high provided they are given the right inputs about TB as a disease. It is ignorance that leads to discrimination against TB patients. I am personally horrified by the sheer quantum of human rights violation that TB patients have to suffer.

Ethical issues can be discussed at length, and we must do so. This is an important aspect of our work. Thank you for having brought it up.

Shelly Batra, MD
Replied at 3:59 PM, 10 Jul 2013

Hi Aaron,
Yes, TB suspects are diagnosed in the public Microscopy centre. This is in accordance with the protocol laid down by the Indian TB Control program .
So this is just a simple smear to look for AFB, that's all. Rif resistance is not tested, so we never know whether the patient is drug sensitive or resistant. If one is already infected with MDR-TB, the system does not account for that. This is the unfortunate truth.
Once the diagnosis is made, the patient is sent to the public hospital where a doctor does the assessment and puts the patient in CAT 1 or CAT 2, and 6 months treatment is handed over to the provider.
It is only during the course of treatment that our providers take patients back to the public hospital, ie if there is no or little response, or if repeat sputum tests come out positive. Then the docs in the public hospital decide the line of management, and very often IP is continued for an extra month. OpASHA is not the deciding authority in these matters, but since our providers are meeting their patients on a regular basis, they are adept at assessing response , and have come up with valuable suggestions. More than once they have taken patients to public hospitals and requested that tests for MDR be carried out.

Shelly Batra, MD
Replied at 4:11 PM, 10 Jul 2013

Dear Ruth,
Awfully sorry, but I seem to have missed your q !

You had asked about advice to the DOTS providers regarding infection risks. We carry out 8 days training of all providers in our residential training academy in New Delhi. This is followed by a verbal and written test. The providers are taught very simple ways and means to prevent infection, They are told to ask patients to come to the door of their huts to take DOTS rather then entering huts. This is because often patients live in closed cramped rooms with no ventilation, where droplet nuclei go on circulating in the air. Providers are also told to maintain a physical distance from open cases, and encourage patients to cover their mouths while coughing. This is especially important when suspects are trying to bring up sputum for testing. Providers are also told to be alert to the symptoms of Tb in their own selves. And lastly, the sun and the wind are the best means for sterilisation and dispersion !

Do you allow persons living with HIV to be DOTs providers? No, never. This would be criminal.

Sophie Beauvais
Replied at 4:18 PM, 10 Jul 2013

Dear All,

This morning, the halfway point of our week-long virtual expert panel discussion on the e-Compliance initiative for TB patients, Dr. Shelly Batra, MD, and Abhishek Sinha joined on our Google page for a live Google Hangout on Air. Thank you very much Dr. Batra and Abhishek Sinha for taking the time to discuss, and thank you all for a constructive discussion here and for advancing TB prevention and treatment.

This topic has certainly proven more challenging and heated than I first thought. Some of the issues debated so far include: cost effectiveness, data protection, adherence vs. compliance, integration into medical records systems, and scaling-up and adaption to other countries and diseases such as diabetes.

In this 37 minutes video, Dr. Shelly Batra and Abhishek Sinha answer some of these questions. They also share the news that an Android version will soon be released and that adaptations in other countries and for other diseases like diabetes are in the works. They also call out for new partners.

Thank you all for a constructive discussion. I hope we can hear more from IT folks as well on the technology piece.

Best, Sophie

Attached resource:

Hoi Nguyen Thanh
Replied at 7:08 PM, 10 Jul 2013

Thank you very much for showing us your eCompliance system, it works very
well, especially in countries which are very shortage of human and
equipment resourses. With very small investment, but could apply for many
people, and could use even non medical staffs for health care system.
Could it be deployed in VietNam, I think, it can, and I do think that it
will work very well to help managers to control TB drug medication using of
all TB patients in TB prevention network
Thank you very much

Paul Robinson
Replied at 9:21 PM, 10 Jul 2013

Dr. Batra: Thank you for the opportunity to interact with you on the e-compliance technology. My organization (World Relief) operates a Community based TB detection and treatment support project in southern Mozambique. The patients do not visit the health centers to get their meds but they ingest their daily meds under observation in their homes. Can you suggest how e-compliance may be utilized at the community/household level? You mentioned android phone use may be a possibility in the future, in your video clip interview with Sophie B. Do you know of any research initiative that is being undertaken to explore such potentials? I'd be quite interested to explore possible utilization of such technologies at the household level in our rural Mozambique Community TB project

Junior Bazile
Replied at 12:10 AM, 11 Jul 2013

Thank you very much Dr Batra for such good explanation and inputs.
I have one question pertaining to the E-Compliance providers telling the patients " the machine is monitoring our work and incentives, please take the meds". Didn't you find patients asking providers to share their incentives with them? In some settings where Partners In Health work we have had issue with patients asking Community Health Workers (CHW) to give them money so that they can continue taking their drugs because they heard that the CHWs are getting lots of money on their behalf.
Also, I would like to hear your thoughts on how receptive and understanding are the clients / patients of the concept of E- Compliance that can be used to retain them into care.
Thank you.

Bazile

Emmanuel ANDRE
Replied at 3:42 AM, 11 Jul 2013

Dear all,

Thank you for sharing your experiences. My feeling at this point of the discussion is that eCompliance should integrate the standards of care, although some major challenges remain:

- The tool is still too complex (a laptop, a fingerprint recorder and a modem). I think IT companies should be able to create a more compact and cheaper tool that could be carried in a pocket, and would be less susceptible to robbery, loss or viruses.

- The people who perform this DOTs-supervision job must be of different profiles and located in each village. This should include not only health workers, but also (as done in India) small entrepreneurs, or (as we do in DRC) ex-TB patients. Incentives must be carefully discussed for each kind of profile (no extra-cost for professional health workers, volunteer work for ex-TB patients, small incentives for private businesses, ...)

- This system must be, from the beginning, be compatible with other tasks that community health workers have to perform in such settings (HIV follow-up, pregnancy follow-up, vaccination follow-up, ...). The data should be sent in a format that is common to all medical record systems so that any medical center could at any time download the data of a selected patient presenting for medical care.

Looking forward to participate to this revolution with you all!
Best regards,

Emmanuel

Junior Bazile
Replied at 5:32 AM, 11 Jul 2013

Thank you very much Dr Batra for such good explanation and inputs.
I have one question pertaining to the E-Compliance providers telling the patients " the machine is monitoring our work and incentives, please take the meds". Didn't you find patients asking providers to share their incentives with them? In some settings where Partners In Health work we have had issue with patients asking Community Health Workers (CHW) to give them money so that they can continue taking their drugs because they heard that the CHWs are getting lots of money on their behalf.
Also, I would like to hear your thoughts on how receptive and understanding are the clients / patients of the concept of E- Compliance that can be used to retain them into care.
Thank you.

Bazile

Abhishek Sinha
Replied at 6:01 AM, 11 Jul 2013

Dear Roger,
We have missed the point that you have raised regarding Pediatric cases. So far we have registered 581 pediatric cases on eCompliance, out of which only 6 had issues with fingerprint recognition. We are constantly upgrading our application to address any issues that we find in the field. In our next major upgrade (Android Version), this issue will be resolved by updating the fingerprint template on every successful log in by a patient.

Thank You.

Thomas Mohr
Replied at 7:37 AM, 11 Jul 2013

Dear Colleagues,

In relation to Bazile's concerns about patients wanting to participate in the incentives provided to the providers, I would just like to note that other such projects have been able to provide the patients additional time on their mobile phones as an incentive for adhering to treatment. This may be an option to consider. The positive point is that these days, even among the less advantaged, many people still have mobile phones.

Shelly Batra, MD
Replied at 7:42 AM, 12 Jul 2013

@Emmanual. We have deliberately chosen to integrate off-the-shelf components to make the eCompliance device, rather than get a device made specifically for us by a company. The reasons are obvious: low cost, easy availability across different countries , easy replacibility of one component if needed rather than the entire device. And most important, we are NOT dependant on the company. (there have been cases when companies collapse, and the entire exerices has to begin again, with great loss of time and investment)
we are now moving to Android phones instead of the netbook. The android will connect to a fingerprint reader. This will decrease, size, increase portability, and substantially decrease cost by 40%.

Shelly Batra, MD
Replied at 7:53 AM, 12 Jul 2013

Dear Masoud,
You have rightly said "We need to use all available means including electronic adherence". This is clearly mentioned in WHO guidelines, which say, Electronic data-sets are needed to facilitate transparency and analysis of data.
You will be glad to know that Operation ASHA believes in the truth, the whole truth, and nothing but the truth. Also on a measurable impact. Hence the emphasis on eCompliance.

Sandeep Ahuja
Replied at 9:02 AM, 12 Jul 2013

Dear Colleagues,
I am giving my comments on each of the issues that Shelly has not replied so far. This reply covers comments upto no 55.
Sandeep

COMMENTS: 1 & 5, 2, 13, 38 & 39 (Dr Kingsley Ukwaja,Xeno Acharya,Roberson Gede,Gini Williams & Fraser Wares)
ISSUE: Is eCompliance cost effective?
Operation ASHA’S RESPONSE: Absolutely, apart from the very low cost of $3 per patient, one very important aspect of technology is improvement in productivity. After introduction of eCompliance, the cost of field staff has gone down by about $8 per patient. So the additional cost of eCompliance is more than offset by increased productivity. Of course, increased accuracy, elimination of human error, reliable data, increased transparency are added bonus.
I will be happy to provide more details if need be.

COMMENT: 16 (Roger Friedman)
ISSUE: Providers carry eCompliance terminal containing personal identification no.
Operation ASHA’S RESPONSE: The information in eCompliance is well-protected which I have mentioned elsewhere. I would like to point out that this is much safer than the alternative system of carrying around paper records, which is a mandatory guideline issued by the government in India.

COMMENT: 29 (Roger Friedman)
ISSUE: One should not be gadget-fixated
Operation ASHA’S RESPONSE: Fully agreed. I would only like to quote Aleem Walji, Director, Innovation Lab, World Bank “I have found that Operation ASHA’s transformative innovation has less to do with the scanners and more to do with listening to patients so they can design more effective testing and treatment protocols and reduce transaction costs associated with treatment.” Read the full blog on (http://blogs.worldbank.org/dmblog/what-does-innovation-look-like)


COMMENT: 37 (Masoud Dara)
ISSUE: Early diagnoses
Operation ASHA’S RESPONSE: An upgrade of eCompliance system is being used by Operation ASHA to regularly track all contacts of sputum positive TB patients (of course with consent). It is improving detection. But that upgrade will be the subject of another discussion.

COMMENT: 38
ISSUE: Fingerprint is a sensitive issue
Operation ASHA’S RESPONSE: I have dealt with it elsewhere but would like to refer the readers to the reactions of patients that were brought out in a paper which can be made available if anybody wishes to.
One should also read the following blog which states that a mother gave a few “precious pineapples” to the provider to thank you for tracking every dose taken by her son on eCompliance and helping the son.http://www.huffingtonpost.com/dr-yanis-ben-amor/harnessing-new-technologi_b_2940865.html

COMMENT: 39 (Fraser Wares)
ISSUE: Does eCompliance need additional hiring for home based DOTs
Operation ASHA’S RESPONSE: This is a total misunderstanding that eCompliance needs any additional hiring of the field level staff by the government. I would like to reiterate that Operation ASHA works as an extension of the government TB Program. Government of India has appointed “accredited social health activists” in every village. Tens of thousands of them are already working as DOTS providers. They are the ones who need to be equipped with eCompliance. In urban slums also, Operation ASHA follows exactly the government system.
I am happy to inform this community that Operation ASHA and the National TB Program have put in place many innovations in the last few years, which experts outside India may not be aware of. That may have led to the misunderstanding in the first place.
I certainly want to thank Dr. Wares for proposing that eCompliance as a candidate for replication at the national level in India for 1.5 million patients. This is highly encouraging for Operation ASHA.



COMMENT: 39
ISSUE: Is eCompliance reproducible and sustainable
Operation ASHA’S RESPONSE: There is no doubt about it. I may mention that each eCompliance unit can handle upto 2000 patients. The backend is web-based and can handle unlimited data. Of course there will always be nay-sayers. I remember hearing once from a senior expert that “if Windows could crash during a demonstration by Bill Gates, how can computers be trusted’. But apart from such cynics, there is no issue about replication.

COMMENT: 39
ISSUE: Is eCompliance EMR compatible with the existing information system of RNTCP
Operation ASHA’S RESPONSE: Yes. Not only that, eCompliance and the EMR use standard technology (.net, MS Access and SQL). The system can already “speak” to RNTCPs IT system. It is so versatile; it can speak practically to any other EMR being used by government or other organizations across the world.

COMMENT: 39
ISSUE: Data protection
Operation ASHA’S RESPONSE: The protection level in eCompliance is very higher. It is protected both by a password and finger print of the provider. The latter provides very strong security and cannot be matched with the best non-biometrics system.

COMMENT: 39
ISSUE: Giving fingerprints is a major human right issue
Operation ASHA’S RESPONSE: No individual should be denied rights. The patients have a choice of accessing another center of another NGO or the government. Thus fingerprinting is not a mandatory requirement. The final choice rests with the patients as it should. However, like others have pointed out, the society has to strike a balance. This issue reminds me of the raging debate in the US five years ago whether full body scanners should be used at airport to improve security and thwart terrorists or not.

COMMENT: 39
ISSUE: Should patient be responsible for compliance or provider or both
Operation ASHA’S RESPONSE: Operation ASHA’s philosophy is that the primary responsibility of Compliance rests with the patient. However, in an environment where TB is still considered a curse from God and patients are extremely poor and the priority is earning bread for the family, non-compliance is not unknown. But in an infectious disease like TB where defaulters face risk of drug-resistance and infection others with MDR, responsibility cannot be left on the shoulders of patients alone. There is great social benefit in ensuring Compliance. This is the philosophy of Operation ASHA that “we are in it together”. Only that philosophy can improve TB care.

COMMENT: 42 (Lindsay McKenna)
ISSUE: Privacy
Operation ASHA’S RESPONSE: Vicky has replied to part of this comment at comment no. 44. Writing names of patients, their TB no. (allotted by the government) and date of starting the treatment is a convention laid down by the government. The government itself also follows this convention at its on centers. This needs to the changed. Operation ASHA has been requesting government for higher level of privacy. The advocacy and activist group also need to support this cause.

COMMENT: 42 (Lindsay McKenna)
ISSUE: Donors can track patients online
Operation ASHA’S RESPONSE: This is an option for individual donors who would like to support particular patients. Only one donor has utilized this facility to date. In this case, it was the donor who introduced the patient to Operation ASHA.
It was nice of Lindsay to have visited an Operation ASHA center. But I wish she and our team had more time together. Operation ASHA is a sophisticated program and a few hours are not sufficient to understand it. Of course, Operation ASHA remains open to suggestions.

COMMENT: 53 (Dr. Thanh)
ISSUE: Use of eCompliance in Vietnam
Operation ASHA’S RESPONSE: Dr Thanh, we are very keen on this. Can you please write to me on my email -

COMMENT: 54 (Paul Robinson)
ISSUE: Use of eCompliance at the household level
Operation ASHA’S RESPONSE: Please read the following blog by Yanis Ben Amor and Sarah Snidal that was published on the World TB Day this year. Their initial modal was, I believe, very similar to what you have mentioned. They adopted eCompliance last year. The results are a “staggering improvement”. (http://www.huffingtonpost.com/dr-yanis-ben-amor/harnessing-new-technologi_b_2...).
I will be happy to take up with you how you could adopt eCompliance. Please write to me on my email –

COMMENT: 55 (Junior Bazile)
ISSUE: Patients asking providers/ counsellors to share incentives
Operation ASHA’S RESPONSE: We have never come across this. I have forwarded the question to about 25 managers in the field and in case I get a different reply, I will post the comment later on GHDOnline. I may also mention that the incentive is too low to split anywhere. However, the incentive is strong enough to cause behaviour change and high compliance. J-PAL finished a randomized control trial on the success of Operation ASHA’s incentive salary model. They will come out with the final results soon.


Finally, I would only like to mention a comment made by Country Director of the World Bank after visiting Operation ASHA’s centers recently (http://blogs.worldbank.org/endpovertyinsouthasia/last-mile-last)
“I was fascinated: If this model could be rolled out everywhere where there is TB, we could stop multi-drug-resistant TB and save so many lives!
What Operation ASHA does is literally to deliver the elusive “last mile” in service delivery. The mile that lies in between well-intended government programs and results on the ground. And they do it with relentless focus and incredible efficiency. What if we could develop Operations ASHA for other problems as well? 90% efficiency and 19 times cheaper? It would be incredible!
For those of you who don’t know, ASHA means hope. Hope for millions of TB patients. But to me it can be even more: hope for millions of others who need services, all over the world. Our last miles must become cheaper and more efficient. ASHA’s results in applying the science of delivery give rise to real hope that this can happen.”
At the other extreme, many “experts” have criticized eCompliance for various reasons, even when I demonstrated it the first time four years ao, without asking a single question about utility, costs and other details. The reason is well-understood by all and is quite simple. Accuracy of data would expose massive fudging going on in certain areas and destroy the careers of those who were part of the “cover-up”. But good systems have their own way of finding supporters and growing. This is precisely the trajectory eCompliance is taking. We in Operation ASHA have no doubt that this is the system of the future that will change the entire landscape of delivery of public health across the world in the next decade.

Lindsay McKenna
Replied at 11:26 AM, 12 Jul 2013

Thank you, Sandeep.

Regarding your response to comment 39 pasted below, "striking a balance"
between human rights and public health is something reserved for pressing
circumstances in accordance with guidance laid out in the Siracusa
Principles http://graduateinstitute.ch/faculty/clapham/hrdoc/docs/siracusa.html
.

In addition, I would like to draw your attention to an
article http://www.ingentaconnect.com/content/iuatld/ijtld/2012/00000016/00000006/art... that appeared in the IJTLD June 2012 issue, which describes how judgmental
terms such as "suspect," "defaulter," and "compliance" can "powerfully
influence attitudes and behavior at every level– from inhibiting patients
to seek treatment to shaping the way policy makers view the challenge of
addressing the disease." We encourage Operation ASHA to avoid
inappropriate, coercive, disempowering, judgmental and criminalizing terms
-- a great first step might be to consider renaming "e-compliance" to
"e-adherence."

Best regards,
Lindsay

COMMENT: 39
ISSUE: Giving fingerprints is a major human right issue
Operation ASHA’S RESPONSE: No individual should be denied rights. The
patients have a choice of accessing another center of another NGO or the
government. Thus fingerprinting is not a mandatory requirement. The final
choice rests with the patients as it should. However, like others have
pointed out, the society has to strike a balance. This issue reminds me of
the raging debate in the US five years ago whether full body scanners
should be used at airport to improve security and thwart terrorists or not.

Rakesh Biswas MD
Replied at 12:33 PM, 12 Jul 2013

Thanks Lindsay, An even better and non-judgemental term in place of
compliance or adherence is concordance?

More here:
http://www.igi-global.com/viewtitlesample.aspx?id=52617&ptid=47799&t=from+com...

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387303/

Smitha Gudapakkam
Replied at 4:44 PM, 12 Jul 2013

Dr. Batra,

Thank you for being part of the panel. The public health impact of this program seems immense.

I would like to understand what challenges do you face within the healthcare eco-system that you operate in? What are your major pain points as an organization that is trying to implement the TB e-compliance program.

The motivation for this question is to understand where the gaps are and where other organizations can focus on innovating so that the TB compliance program has fewer obstacles.

Thanks!
Smitha

Sophie Beauvais
Replied at 5:25 PM, 15 Jul 2013

Dear All,

Thank you again to all who participated in this very productive virtual expert panel on E-Compliance for TB Treatment by Operation ASHA, and thank you so much to our panelists for being so forthcoming and sharing so many details and lessons learned with us. We will publish a peer-reviewed summary of the exchange soon. Please don't hesitate to post new replies with further thoughts on biometric monitoring systems for TB treatment.

Sincerely, Sophie

Sandeep Ahuja
Replied at 4:22 AM, 29 Aug 2013

I did not bother to reply to the comment at no 63 above because:
We care about patients, but not about arm chair consultants who think English is the lingua franca for poor patients in developing countries. Their job is not complete without developing acceptable vocabulary in 200 languages and 4000 dialects in India. We overcome that by using hiring locals who bring in considerable social capital and use locally acceptable language. Thanks so much for the advice Lindsay.

Rajan Arora
Replied at 9:24 AM, 29 Aug 2013

At the risk of digressing a bit, (apologies in advance but it struck a chord! ), totally endorse Dr. Ahuja’s views, there are too many of those aptly christened – Armchair Consultants. The donors and other agencies have been continued with them with good albeit misplaced intentions.
In the Indian context, the premise is that they provide “technical support” to the actual implementers, the assumption being that most of the implementers are not technically sound and need handholding if not with anything else than just to beat around the bush with the dictionary; confusing vernacular terminology generally utilized in patient care with that reserved for programme management and academic purposes.

While handholding was definitely needed in the past, in the present context the country has a much better technical capacity (certainly more than a chap with a few days training doling out advice)

Unfortunately, if this phenomenon is not curbed in time, it will result in those worrying about the patients being a diminishing tribe!

Thanks Dr. Ahuja for giving the group a reality check !

Again apologies for digressing and may be sounding a bit harsh, but yours truly has seen both the sides of the coin, hence the experience sharing!

Warm Regards
Dr. Rajan Arora

Rajan Arora
Replied at 9:28 AM, 29 Aug 2013

Sorry for the typo ! Please read continued as continuing in the above post !

Colleen Daniels
Replied at 10:27 AM, 29 Aug 2013

Dear Sandeep and Rajan,
Everyone is entitled to their opinion, however, if you are joining this
online discussion you should at the very least be professional and
respectful to everyone who is part of this discussion. Calling people who
work very hard 'armchair consultants' is disrespectful, derogatory and
unnecessary. You do a disservice to all the activists who work day in and
day out to get results. If you do not want to engage in an open discussion
where everyone is allowed and encouraged to speak openly why join this
fora?

To the GHD listserve facilitator please ensure that all contributions to
this discussion are professional.

Sophie Beauvais
Replied at 1:00 PM, 29 Aug 2013

Thank you for trying to further the discussion on the eCompliance system. I’d like to ask all those involved in the last few comments to “agree to disagree.” Clearly there is disagreement over the use of fingerprinting and biometrics technologies. We appreciate hearing the opinions of everyone but let’s remember that we’re all in this work to improve the health of populations, in our communities and abroad. We are very grateful to the organizations, professionals, and experts who agree to participate in our virtual expert panels to discuss their work, and we invite everyone who is willing and ready to do so to email us: http://www.ghdonline.org/contact/

As a reminder, this is in our philosophy (read full text here: http://www.ghdonline.org/about/):

> Our mission is to improve the delivery of health care worldwide, especially in areas with limited resources, by fostering the exchange of knowledge and critical information in expert-led, thematic, communities. Anyone willing to join us in this pursuit and involved in the delivery of health care can become a member.

> We seek to foster the respectful exchange of practices and “know-how” on issues that matter. Please avoid derogatory or disparaging comments, spam, and promotional comments.

Thank you in advance, Sophie

P.S. Comments from members in the GHDonline communities and panels are not subject to approval and are posted right away (i.e. no wait-time or filter) because we value speed, trust, and transparency. But please note that we reserve the right to remove replies not in accordance with our philosophy.

Dr Shanta Ghatak
Replied at 12:26 AM, 30 Aug 2013

It is difficult to stay out of the discussion as we are amidst a probable
rising pandemic of both DR and DS TB in several parts of the world
E compliance is a part of adherence strategy and it does work with a whole
lot of people
And of course it may not work in some hard to reach areas and difficult
populations for many diverse reasons.
E compliance as an advocacy tool has also proved itself over countries and
time ....many focal points have seen successful in upscaling efforts as
well

In today's world we are happy to be frustrated online which in some ways
are cathartic as well and get on with good work in the field , inside
offices , inside hospitals , inside sanatoriums , inside community care
centers, inside HIV shelters , inside prisons , for the many many patients
and their contacts who are still awaiting our help , our support - the
deliberate thrust is still awaited for the impact - to make their lives
healthier , stronger and improved

It hardly matters whether we are working from arm chairs or field level
facilities - the focus is to get on with improving lives , to move ahead
with a proper help and support , to be there with adequate medicines not
only for the patients but also for their families and contacts .....to
advocate for treating not only TB but the co morbidities as well !

Frustration will be fruitful only when we get a few more things done to
improve our quality of patient care ....and I do firmly believe
e-compliance is one mechanism in today's e world and will catch up in more
areas than we foresee

Happy reading !

Dr Maria Goretti Ametembun
Replied at 2:53 AM, 30 Aug 2013

Dear Dr Shanta,
it will be more frustated if the TB, moreover XDR or MDR TB infect us as medical doctor.
We back home to our family after close contact with TB patients.
Wow, to whom we can complain?

Pada 30 Agt 2013, pukul 11:44 AM, Dr Shanta Ghatak via GHDonline <> menulis:

Dr Shanta Ghatak replied to a discussion in Lessons Learned in India: E-Compliance for TB Treatment by Operation ASHA:
It is difficult to stay out of the discussion as we are amidst a probable
rising pandemic of both DR and DS TB in several parts of the world
E compliance is a part of adherence strategy and it does work with a whole
lot of people
And of course it may not work in some hard to reach areas and difficult
populations for many diverse reasons.
E compliance as an advocacy tool has also proved itself over countries and
time ....many focal points have seen successful in upscaling efforts as
well

In today's world we are happy to be frustrated online which in some ways
are cathartic as well and get on with good work in the field , inside
offices , inside hospitals , inside sanatoriums , inside community care
centers, inside HIV shelters , inside prisons , for the many many patients
and their contacts who are still awaiting our help , our support - the
deliberate thrust is still awaited for the impact - to make their lives
healthier , stronger and improved

It hardly matters whether we are working from arm chairs or field level
facilities - the focus is to get on with improving lives , to move ahead
with a proper help and support , to be there with adequate medicines not
only for the patients but also for their families and contacts .....to
advocate for treating not only TB but the co morbidities as well !

Frustration will be fruitful only when we get a few more things done to
improve our quality of patient care ....and I do firmly believe
e-compliance is one mechanism in today's e world and will catch up in more
areas than we foresee

Happy reading !

Ruth MCNERNEY
Replied at 3:50 AM, 30 Aug 2013

I would like to suggest a topic for a separate discussion sometime in the future. There is often frustration caused by lack of understanding and awareness of the use language by other cultures - it is not a new problem, and it is something that goes in both directions. When considering TB - on the one hand we have people wanting to help but not understanding the local context, on the other hand we have people who would like to access external resources brought by aid projects. Many aid organisations now work though local partners but others do not have this opportunity and recipients of external aid in developing countries often feel unable to discuss problems or embarrassment they experience because criticizing the people bringing or distributing resources is seen as 'biting the hand that feeds'. Please could we put our minds as to how to fix this. Are there practical things we could do for the mutual benefit of both parties? Could we improve access to awareness training?

Sophie Beauvais
Replied at 3:30 PM, 30 Aug 2013

Hi Ruth, many thanks for this idea and if you'd like to work with us to plan a virtual Expert Panel on this topic happy to work with you on this! Please email me at or http://www.ghdonline.org/contact/

To all, we're delighted to share with you the discussion brief summarizing this panel here: http://www.ghdonline.org/e-compliance-india/discussion/lessons-learned-in-ind... - available in html and pdf - just sign in on the web for download and sharing.

Best, Sophie

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Panelists of Lessons Learned in India: E-Compliance for TB Treatment by Operation ASHA and GHDonline staff