Operation ASHA provides last-mile delivery solutions for health, serving the poor in urban slums.
Tuberculosis (TB), a curable disease, has now become a global pandemic. 10.4 million people contract TB annually; 1.8 million die. In India, 100,000 women are abandoned and 300,000 children forced to leave school annually because of stigma. India has the highest TB burden in the world. People lose jobs; loss of wages isThe world will lose $3.4 trillion because of TB in the next decade. Incomplete treatment has led to Drug-Resistant TB, which has the potential to wipe out millions.
Challenges faced by TB patients:
1. Last mile delivery is missing: In the WHO sponsored TB treatment program, patients are not given medicines for home consumption. They must go daily for 6-9 months to a designated centre and take every dose under supervision. Existing centres are few and far between, and open the usual business hours. Patients have to choose between work and wages on one hand, and TB medicines on the other. They naturally prefer to work and feed their families, so they continue to suffer and die, and infect others. Each untreated TB patient infects 12 others, thus spreading the disease in poorly ventilated, overcrowded shanties. Malnutrition further lowers the immunity and makes slum-dwellers susceptible to TB.
2. Incomplete treatment: Patients stop treatment midway because of inconvenience, stigma, out-of-pocket expenses, fear and myths. This leads to Drug-Resistant TB which is difficult and costly to treat.
3. Informal providers: In urban slums, quacks or informal providers are the first point of contact for patients. They lack the expertise to treat TB, and give incomplete, irregular treatment which leads to Drug-Resistant TB.
4. Fear and stigma: Patients live in fear and denial, even those who have been coughing up blood for years. TB is a disease of darkness. There is no help.
5. Lack of support: There is no one to track missing patients, to take care of day-to-day problems, to treat side effects of medication, or to persuade them to take their treatment. Marginalized patients are intimidated by government infrastructure.
Our community based solution addresses all these issues. We have a low-cost, high-impact, scalable and replicable model for TB detection and treatment. We collaborate with National TB Programs that provide free medicines, diagnostics and physicians' services. We hire and train local slum-dwellers as Community Health Workers (CHWs), thus empowering them with dignified jobs and respect. Our doorstep delivery model has treatment centres within community premises. We identify Community Partners such as shopkeepers, housewives and priests (who give us part of their premises to establish treatment centers). These are open at convenient hours so no patient has to miss work and wages. Where patients are scattered, as in the periphery of cities, CHWs go on foot, bikes or motorcycles. They carry out awareness, counselling, and address stigma and myths. They carry sputum samples from people with symptoms of TB, and facilitate testing in government laboratories. They facilitate the checkup of TB patients by doctors, and collect the entire 6 month course of medicines for each patient, to be kept in the centres. Patients come early morning or late night to get their medicine. CHWs give supervised daily doses and use eCompliance, (fingerprint/iris scans) on each visit to ensure adherence and prevent ‘drop-out’. This prevents Drug-Resistant TB. Technology ensures accuracy; a fingerprint cannot be fudged.
CHWs belong to the communities they serve, they speak the same language, eat the same food, and worship in the same way. They get market salaries and tremendous respect. They educate patients and communities. Our community partners are benefited greatly. Their income is augmented by 25%. We give them over-the-counter drugs for patients who suffer fever, vomiting and acidity, and also to be given free of cost to anyone in the community. This camouflages the centres and general health clinics, which is necessary, considering the stigma related to TB>
Technology: We implement the following technology applications, among others:
1. eCompliance: This is an innovative biometric system created by Microsoft Research. It uses fingerprint/iris scan verification at the time of each dose, and gives real-time information of missed doses, which result in prompt action by CHWs, thus preventing drop-out.
eCompliance terminals are kept in treatment centres in slums, and also carried by CHWs in their backpacks. At each visit, the patient and CHW scan their finger/iris, only then is medicine given. At every missed dose, a text message alert is sent to the CHW, who must meet the patient within 24 hours to administer the medication and take the fingerprint/iris scan as proof of visit. Each terminal consists of low cost, off-the-shelf components. There is an Android Tablet and a Fingerprint Reader/ iris scanner. Terminals work offline.Internet is needed only to access reports. The biggest benefit of eCompliance is ‘turning the tap off’ on Drug-Resistant TB. There is accurate, secure, and timely patient data tracking. Each transaction is recorded in the Electronic Medical Record (EMR), which collates the data in formats designed by various governments/organizations. All data is encrypted to ensure patient privacy. Terminals send updates to a central database every 15 minutes via the SIM card. Technology improves impact measurement and decision-making. Government/managers can use reports to analyze and improve performance, and make policy and budgeting decisions. There is great ease of use and portability. The software is user-friendly and can easily be installed.
2. eDetection: This is a screening application loaded on the same tablet, with a series of questions based on the symptoms of TB. CHWs screen contacts of existing patients, and also go door to door in slums. The application guides CHWs to ask relevant questions, and based on the answers, the algorithm directs the CHW to give proper advice to the client. This helps improve detection and productivity. The results of eDetection are outstanding. A team constituted by Government of India found that all TB patients detected by Operation ASHA were expeditiously enrolled in treatment with zero initial default. This means that no patient was allowed to go on infecting others. (Initial default across India is 18% according to a paper co-authored by Director-General, Indian Council of Medical Research)
3. Counselling videos: We have 24 animation videos for education to prevent stigma, ensure full treatment, and prevent spread of infection.
4. eQuality: This is an application used by our auditors to ensure best results and outcomes, and to get feedback from patients.
Our results that far exceed country averages, as shown by third party evaluations by Ivy League and other universities, and the Government of India. All this has been achieved at a cost that is 32 times less than others, as shown by the Centre for Strategic & International Studies .
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