eDOTS: Demanding Reliable Results from Tuberculosis Treatment

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eDOTS: Demanding Reliable Results from Tuberculosis Treatment

India
Organization type: 
nonprofit/ngo/citizen sector
Project Stage:
Scaling
Budget: 
$250,000 - $500,000
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

Under the current state of the WHO DOTS program, there is no method to verify the reliability of an institution’s tuberculosis drug adherence. To remedy this, eDOTS uses biometric devices to monitor patients’ drug adherence on a daily basis by digitally logging a patient’s registration at an OpASHA clinic. At the end of each day, every clinic sends its attendance record through SMS to a central server, where the information is synchronized. When a patient fails to register at a DOTS center, a notification is sent to multiple levels of the organization, and a counselor delivers the medicines directly to the patient’s home with supplementary tuberculosis education. Through this system, defaulting patients can be quickly identified and educated about the dangers of drug-resistant tuberculosis

About Project

Problem: What problem is this project trying to address?

OpASHA is eradicating tuberculosis in urban slums. Tuberculosis (TB) was declared a Global Emergency by WHO in 1993. “TB has historically been one of the world’s biggest killers. Nearly one-third of over 11,000 (business leaders from across the world) expect tuberculosis to affect their business in the next five years”, states a recent report of the World Economic Forum. 13 million people suffer from TB worldwide of which 3.5 million are in India. Two Indians die of the disease every three minutes. TB also carries terrible social stigma and 100,000 infected women are abandoned by their families every year, to die of disease and starvation. 300,000 children are forced to leave school (Government of India). For fear of being ostracized, patients do not come forward for treatment and the disease, being highly contagious, spreads rapidly. TB bacteria is mutating and giving rise to Multi-drug resistant (MDR) and Extensively-drug resistance (XDR) forms, which are fatal. A sanatorium in Miami, USA has quarantined over 40 XDR patients. They are CONFINED so they do not infect others. There are many more in developing countries. The world is at the brink of an epidemic of MDR/XDR TB. TB is not only a medical problem. It has serious economic effects. It saps the strength of the patients. The underprivileged in India lose $300 million annually in wages. So those affected find it impossible to pay for medication. The Indian economy loses $3 billion annually (Government of India). Tuberculosis is not just a disease, it is a socio-economic issue, where patients lose jobs and face horrifying discrimination. OpASHA is one of the world’s leading NGOs in TB control. It uses parameters prescribed by the World Health Organization and Government of India to measure its performance. A few additional parameters have also been opted by OpASHA. A complete list follows. 1. Population served 2. Number of patients 3. Average distance of treatment center from the patient’s house 4. Detection rate per 100,000 persons 5. Cure rate 6. Default rate 7. Death rate 8. Cost of treatment of each patient 9. Financial leverage 10. Social Return on Investment

Solution: What is the proposed solution? Please be specific!

Operation ASHA’s eDOTS program enhances the existing DOTS program with reliable and up-to-date biometric data. No other TB control system has proved that it can eliminate drug default, especially in poor areas. In addition, eDOTS only uses “off-the-shelf” components: a fingerprint reader, a notebook computer, and a simple cellphone, making it an easily replicable and cost effective method of fighting drug resistant TB. Each time a patient visits one of OpASHA’s centers, the patient is required to confirm the visit on the terminal’s fingerprint reader. At the end of the day, each terminal will send the attendance log to an online server, where the data is imported into OpASHA’s Electronic Medical Record. Each time a dose is missed, the device sends a text message notifying the counselor, program manager, and office server that a patient follow-up is required within 48 hours. Since the counselor must acquire the patient’s fingerprint during the follow-up, drug default can be reliably prevented. Because the system alerts OpASHA to defaulting patients, tuberculosis consultation is targeted and individualized to the patients who need it the most. Since the records and reports are automatically generated, the system eliminates the chance of human error in data collection (both accidental and purposeful). This digitization has also freed up the time of OpASHA’s counselors, who can reallocate that time to finding new patients and spreading TB awareness.
Impact: How does it Work

Example: Walk us through a specific example(s) of how this solution makes a difference; include its primary activities.

The primary objective of eDOTS is to completely halt the incidence of drug-resistant tuberculosis. eDOTS uses biometric devices to monitor patients’ drug adherence on a daily basis by digitally logging a patient’s attendance at an OpASHA clinic. At the end of each day, every terminal will send its attendance record through SMS to a central server, where the information is synchronized. When a patient fails to register at a DOTS center, a notification is sent to multiple levels of the organization, and a counselor delivers the medicines directly to the patient’s home with supplementary TB education. As every missed dose is immediately followed with counseling, the adoption of eDOTS can produce near 100% adherence to medications.
Sustainability

Marketplace: Who else is addressing the problem outlined here? How does the proposed project differ from these approaches?

OpASHA works like an extension of the government’s Public Health Department in the slums. TB treatment, medications to address side effects, ORS, protein supplements, iron and calcium tablets for pregnant women, and contraceptives for child spacing are all provided to OpASHA by the Public Health Department. The District TB Administration provides office stationary and stock registers for inventory management. District health authorities provide funding for snacks and beverages to participants at Health Awareness Camps organized by OpASHA. These government partnerships mean that external donations are leveraged 5 times; i.e. for every dollar donated to OpASHA, the Government provides medicines, diagnostics and physician’s services worth . The government also provides a grant for each patient treated two years from starting a centre. In this way, each centre becomes self-sustaining within two years. OpASHA also works closely with businesses, NGOs and individual donors. It is also very active in civil society organizations including the National TB Partnership in India.
About You
Organization:
Operation ASHA
About You
First Name

sandeep

Last Name

ahuja

Twitter

@OperationASHA

About Your Organization
Organization Name

Operation ASHA

Organization Phone

09310298004

Organization Address

D-156, first floor Sarita Vihar

Organization Country

, DL

Country where this project is creating social impact
How long has your organization been operating?

More than 5 years

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Innovation
What stage is your project in?

Operating for 1‐5 years

Tell us about the community that you engage? eg. economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts.

OpASHA currently serves a population of 4.5 million slum dwellers in India, and approximately 50,000 in Cambodia. India is home to 25% of the world’s TB patients, many of whom live in highly populated areas as rickshaw pullers, rag pickers, sex workers, street children, or beggars. Their habitats consist of simple concrete or sheet metal walls and a roof, if anything at all. Additionally, these houses or apartments generally are not equipped with sanitary facilities or windows for sunlight, which kills the TB bacteria, allowing it to fester and grow. Because of the high population density and miserable living conditions in India, these individuals are especially vulnerable to contracting tuberculosis.

Once contracted, their disease is often hidden or ignored. Firstly, it is hidden due to the lack of education about the disease highly prevalent in these areas and subsequent social stigma attached to it. Secondly, it is ignored due to the need to continue to earn wages, which precludes them from travelling to a clinic every other day to receive treatment.

If they decide to seek treatment, clinics are scarce in these regions, and because DOTS requires patients to take their medicines in front of a health worker, they must often travel long distances. Because of various reasons such as TB ignorance, unbearable drug side effects or missed wages, individuals often default on medicines. To solve this gap, OpASHA has hired local counselors to run informal treatment centers in established locations such as homes, businesses, and temples.

Share the story of the founder and what inspired the founder to start this project

During a healthcare conference Dr. Batra discovered that the government of India was destroying millions of expired TB medications due to the lack of the proper channels for getting the medicine properly to the patients. Alongside her fundraising partner and today’s OpASHA CEO, Sandeep Ahuja, she conceived the idea of addressing India’s biggest problem in TB treatment: going the last mile by opening treatment centers directly in the slums to enable access to the patients within walking distance. From this conception in 2005, operations began with the first TB treatment center in 2006.

Sandeep and Shelly quickly found that a large amount of DOTS patients were defaulting on their regimen, and even institutions with good adherence records had been falsifying their reports. To combat this, they started the biometric initiative in 2010, which guaranteed accurate data. Microsoft Research and Innovators in Health joined the project and designed the software pro-bono. The pilot project launched by the end of the year, and by 2011, 17 eDOTS centers were operating in South Delhi.

Social Impact
Please describe how your project has been successful and how that success is measured

Although there are many indirect benefits to the eDOTS program, its primary measure of success is the ability to reduce the number of TB drug defaults (defined as two months of consecutive missed doses) and the actual number of missed doses. In areas that the project has been implemented, missed doses have been dramatically reduced and defaults have been completely eliminated. This rate is substantially lower than the 7% default rate published in the Government of India’s 2009 RNTCP Status Report.

The success of further eDOTS expansion will be measured by an independent study, which will compare the number of pre-implementation missed doses to the number of post-implementation missed doses. OpASHA’s preliminary data has shown that the introduction of eDOTS correlates with an initial spike in missed doses, which can be explained by the increased data reliability or the difficulties in training counselors to use the system. After this initial jump, the number of missed doses sharply declined, dropping below pre-implementation rates.

While a direct comparison is the best method to measure the effectiveness of eDOTS, the program has been successful in reducing the workload of health workers and focusing TB consultations to patients who have repeatedly missed doses. Because eDOTS utilizes technology, patients have felt confident in the quality of treatment they are receiving.

How many people have been impacted by your project?

1,001- 10,000

How many people could be impacted by your project in the next three years?

More than 10,000

Winning entries present a strong plan for how they will achieve growth. Identify your six-month milestone for growing your impact

The first six-month will focus on the expansion of eDOTS to OpASHA’s existing centers. Integrating new terminals and training counselors to use biometrics will be the primary activity.

Task 1

Biometric terminals will be delivered to Operation ASHA’s TB treatment centers and its counselors will be trained to use the system. This training is estimated to take 2-4 hours.

Task 2

The next step will be implementing the systems in the field. Coordination between TB counselors and database management staff will be the key obstacle in this phase.

Task 3

Towards the end of the six-month time frame, each eDOTS center should become completely self-reliant. Any new biometric training will be handled by the program manager.

Identify your 12-month impact milestone

Expansion of eDOTS will continue throughout OpASHA’s existing centers. Control trials will assess biometric effectiveness in areas where eDOTS has been implemented.

Task 1

Biometric terminals and training will be delivered to new areas where OpASHA works. An assessment will first measure the improvements in centers that were opened in the first six months.

Task 2

Second phase of biometric terminals will be implemented in the field. The assessment of the first phase will begin to compare project results with pre-project data.

Task 3

The second phase of biometric terminals will become self-reliant, and its program assessment will begin. Results from the first study will be published and used to acquire more funding.

How will your project evolve over the next three years?

1. All text will be removed from the biometric software to allow eDOTS to be adopted in illiterate areas. Although patient’s names will remain in the system, they will be identified by a unique symbol, which will correspond with the patient’s medicine box.

2. The biometric software will be modified so that a missed dose will send a text notification to the patient as well as the counselor, program manager, and office server.

3. When a counselor currently travels to a patient’s house to follow up on a missed dose, he or she must carry the laptop terminal. To make this process easier, the biometric software can be converted into an application for a smartphone.

4. The eDOTS program will be expanded to cover other regularly scheduled treatments such as immunizations, HIV ART, etc.

Sustainability
What barriers might hinder the success of your project and how do you plan to overcome them?

Since the primary objective of eDOTS is to ensure the reliability of data, unauthorized access to the system has been a major concern. In order to prevent unwanted registration or editing of events on the clinic’s netbook when the counselor is not present, the terminal requests that a counselor (or program manager) scan their fingerprint when registering new patients or editing patient data. Because the time and date of the access will be monitored, individuals who tamper with the data during off-hours can be tracked and confronted.

One hurdle of introducing eDOTS to new areas is the re-training of staff members. During the first months of the project, there may be some difficulties in the adoption of the terminals. Because of this, OpASHA will send a senior program manager to its centers to ensure proper training and implementation of the biometric system. When designing the software, OpASHA and Microsoft Research made a special effort to use a minimal amount of text so that the system was easy to use in illiterate areas.

Another potential problem is the fingerprint recognition software’s failure to recognize a patient, and thus failing to register their attendance. Impoverished populations are particularly prone to have cracked or calloused hands due to the large amount of physical labor. Operation ASHA plans to overcome this barrier in two ways. First, a wet pad is made available to all patients, which improves the chance that the fingerprint is recognized. If this fails, counselors have the option of scanning the left hand backup finger.

Tell us about your partnerships

The biometrics system behind eDOTS was co-developed with Microsoft Research and Innovators in Health. Their pro-bono work with Operation ASHA is valued at over $200,000, and has been essential to the eDOTS program’s success. They have also made the software open source so that it can be freely adopted by other TB organizations.

Another important partner has been MIT’s Poverty Action Lab, which has been conducting control trials with Operation ASHA to measure and improve its impact. After their work has been completed, a second study is planned to assess the effect of eDOTS in comparison to pre-biometric performance.

Other partners have been LGT Venture Philanthropy, who has given OpASHA considerable grants and has paid for highly qualified personnel; The Michael & Susan Dell Foundation; The Marshall Foundation; and the Sahayak Foundation. Many other organizations have provided additional financial and technical support.

The Government of India has also been an essential partner with OpASHA. Grants through the Revised National TB Programme have provided funding for recurring operational expenses in addition to the free medication, lab tests, etc. This scheme has been pivotal in OpASHA’s long-term sustainability.

Explain your selections

Two years after Operation ASHA cures a patient of TB, it is awarded a small grant from the Government of India. The lag time means that outside funding must be acquired to start-up each clinic. However, after two years of operations, the clinic becomes fully sustainable through the grant. The initial start-up costs are funded by individuals, foundations, and businesses as a one-time expenditure.

The eDOTS program supplements Operation ASHA’s existing procedures, and is primarily funded by private donations and grants. Implementing biometrics costs about $2.50 per patient, which is a small fraction of the estimated $900 it costs for the overall TB treatment. Because eDOTS also increases the productivity of OpASHA’s health workers, counselors can cover more patients in the same amount of time. Thus, a portion of the government grant can act as a secondary support for biometrics.

As previously mentioned, Microsoft Research and Innovators in Health have played a major role in developing and maintaining the biometric system. Their assistance has made eDOTS a reality.

How do you plan to strengthen your project in the next three years?

The eDOTS project will be further developed (see 3-year plan in Development & Prosperity), but geographic expansion will be the primary method that the program is strengthened. Biometric systems will be introduced to all of OpASHA’s centers, and proper effectiveness assessments will be carried out.

However, geographic expansion does not necessarily mean the expansion of Operation ASHA. eDOTS can be replicated by other TB control institutions, and so educating other organizations to utilize biometrics with Directly Observed Therapy will be an important method of expansion.

Biometric tracking can also be used by non-TB institutions. To show its true capabilities, OpASHA will help develop its software to compliment other lines of work, such as neo-natal care and vaccinations.

Challenges
Which barriers to health and well-being does your innovation address?
Please select up to three in order of relevancy to your project.

PRIMARY

Lack of physical access to care/lack of facilities

SECONDARY

Lack of access to targeted health information and education

TERTIARY

Limited human capital (trained physicians, nurses, etc.)

Please describe how your innovation specifically tackles the barriers listed above.

Operation ASHA brings tuberculosis treatment to areas that have no access to government care. It overcomes this gap by establishing treatment centers within established community institutions (homes, businesses, temples, etc.) Because there are few health workers in these areas, OpASHA hires individuals from each community and trains them to specialize in TB care.

The eDOTS program specifically targets the absence of proper health information by digitizing patient records and treatment attendance. Since the system also ensures the presence of the counselor, the innovation prevents health worker absenteeism.

How are you growing the impact of your organization or initiative?
Please select up to three potential pathways in order of relevancy to you.

PRIMARY

SECONDARY

Influenced other organizations and institutions through the spread of best practices

TERTIARY

Grown geographic reach: Multi-country

Please describe which of your growth activities are current or planned for the immediate future.

Operation ASHA currently provides TB treatment to over 4.5 million individuals in six different Indian states. Already, it has begun operations in Cambodia with plans to expand to other Asian and African countries. eDOTS, however, was designed to be replicable and scalable, and so educating other organizations to adopt the model is a high priority. Biometric monitoring should become standard practice for all tuberculosis control programs.

Do you collaborate with any of the following: (Check all that apply)

Government, Technology providers, NGOs/Nonprofits, For profit companies, Academia/universities.

If yes, how have these collaborations helped your innovation to succeed?

Government TB programs have been the sustainable backbone of Operation ASHA by providing grant money for each patient cured. It is not OpASHA’s goal to replace these programs, but to provide treatment in areas that they cannot properly reach.

Without the pro-bono work of Microsoft Research and Innovators in Health, eDOTS would have never made it past the concept stage of an innovation. Their continued maintenance and improvements to the system have been invaluable.

Funding from NGOs and for-profit companies has guided the project through its pilot phase, and towards expansion. These funds have been guided by external academic institutions, which have evaluated and contributed to OpASHA’s model and innovations.