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
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.