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

You may use this brief for informational, non-commercial purposes with credit attribution: The Global Health Delivery Project, GHDonline.org, Aug 30, 2013. Please see our Terms of Use for more information.

The Use of a biometrics monitoring system for MDR-TB Treatment in India

Added on 30 Aug 2013
Last updated on 30 Aug 2013

Authors: By Elise Hoover; Reviewed by Sophie Beauvais

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.

This Expert Panel focused on the eCompliance system, a biometrics monitoring system developed and run by Operation ASHA in India in partnership with Microsoft Research and India’s National TB Control Programme since 2005.  The biometrics monitoring system uses a fingerprint scanner to track patient visits and treatment adherence, then encourages health care workers to seek out any patients who missed their scheduled treatments.  As the system is analyzed for potential on a global scale, questions arise as to cost effectiveness, data protection, the policy implications of the name itself, and the potential to widen use to other diseases such as diabetes.  Panel participants came from various organizations and countries such as Uganda and Viet Nam to discuss these questions with Shelly Batra, MD, founder and President of Operation ASHA, and Abhishek Sinha, ASHA’s Chief Technical Officer.

Key Points

What is eCompliance?

  • The technology is a partnership with Microsoft Research designed for easy patient follow-up in the context of DR-TB in rural India, as well as with impoverished populations such as slum dwellers
  • The program works through the DOTS Plus program to ensure accuracy of data
  • The fingerprint scanner technology tracks patients and allows for easy access to treatment regimens at health centers: Due to occasional difficulty reading the fingerprints from dirt or cuts on the patient’s finger, eCompliance would also record a secondary finger print for identification purposes       
  • According to Dr. Batra, the full cost of treatment using the eCompliance system is $80 per patient. This includes active case finding, tuberculosis education in an attempt to de-stigmatize TB for the patient’s family, treatment drugs, default tracking, community empowerment and the eCompliance technology itself
  • eCompliance is designed for use by community health workers, who are recruited directly from the communities they serve. The system notifies a health worker when a patient has missed their treatment dose, which triggers a home visit. This method simplifies the identification of those having trouble adhering to their treatment, as well as helps to minimize human error (ASHA has found that this reduces the default rate to between 1 and 3%). It is easy to disguise these health workers, especially in areas with high TB stigmatization, as they carry routine OTC drugs such as painkillers and antacids, which are generally given out free at local DOTS centers to the community separate from diagnostic status

Cost Effectiveness

  • Since the introduction of eCompliance, the cost of field staff in respective areas have gone down by $8/patient
  • The cost of using the system to track patient adherence is $3 per patient, and each system can contain information for up to 2,000 patients
  • The costs are considered especially low as eCompliance increases productivity for the local health workers in the context of the DOTS Plus system. Currently, ASHA is working to convert sites from Netbooks to Android phones, which will decrease costs by an additional 40%.
  • The goal of eCompliance is to ensure that health care workers comply with the necessary treatment requirements, as well as help patients to adhere to their medications. Other alternatives include hiring further supervision (which would be costly) or sending SMS reminders directly to patients (which is difficult due to social stigma associated with transparent methods)

Data Protection

  • Once registered at a health center, patients’ biometric and personally identifying data is encrypted into SMS and automatically sent to the main server.  Only then is in unencrypted for analysis and recording.
  • This is believed to be much safer and more efficient that transportation of records in paper form
  • The SMS encryption method uses the national data encryption standard in India
  • Fingerprints are already commonly used in India for legal and civic transactions due to low levels of literacy

Potential to expand ASHA’s program to cover other countries and diseases

  • The title of the technology was discussed in the panel, with a few suggesting it be named eAdherence or eConcordance rather than eCompliance
  • ASHA originally intended to name it eDOTS, however, the question arose: “Why just tuberculosis, and why just DOTS?” The intension is to eventually apply it to other diseases with long and complicated treatments, such as diabetes or epilepsy
  • eCompliance has a lot of potential for expansion to general TB cases, to prevent MDR/XDR-TB from developing in the first place.  However, this is difficult to implement in locations with poor health delivery systems and limited resources
  • Global programs using similar technology: Kenya, AMPATH; Millennium Villages Project; Peru, e-Chasqui

Key References