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A Game-changer that can scale TB care
internationally & prevent MDR TB
© Operation ASHA 2014
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Operation ASHA: delivers healthcare services
Serving more than 6.1 million people in India & Cambodia
• Local, deep, cost effective and high impact model
• Believes in measuring impact and outcome
• Ranked by The Global Journal as 48th among top 100 NGOs in the world
Cambodia Operations
 Presence – 5 Health Operational
Districts (2 in Phnom Penh, 3 in
Takeo Province)
 Health Centers covered – 57
 Coverage – 1.1 million people
 Total Staff – 57
 Patients enrolled – 7,378
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Overview: TB is a disease that eclipses all other
pandemics
In the past 200 years:
• 1,000 million men, women and children have died of TB.
• Only half as many (490 million) died because of all other major pandemics (AIDS,
Small Pox, Black Death, Spanish Flu & Cholera) put together.
Source: World Health Organization
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TB: The only disease declared a Global Emergency (WHO
1993)
Tuberculosis (TB) is a global pandemic
• fully curable infectious disease
• 9 million new TB patients worldwide every year
• 1 million patients die of TB every year
• TB has caused 10 million orphans
Horrifying Predictions:
• “We are on the brink of another epidemic and it has no
treatment. If Totally Drug Resistant spreads, we will go back to
the dark ages” – TIME Magazine, March 4, 2013
• By 2015: 1.3 million drug resistant cases, needing $16 billion
to treat
• "The total economic burden of TB between 2006 and 2015 for
22 high burden countries is estimated to be about $3.4 trillion”
– GBC Health
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TB is highly infectious: leads to geometric progression of
patients
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TB is a pertinent issue in Cambodia
Among 22 high TB burden countries,
• Cambodia has the highest mortality rate
Global
Cambodia
9,300
940,000 Mortality
Cases
Cases
• Cambodia has the second highest TB prevalence
Global
Cambodia
12,000,000 Prevalence 110,000
Cases
Cases
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Why is TB so common in Cambodia?
• Historical context
• Infrastructure
• Difficult terrain
• Poverty
• Poor health
• Low awareness
• Poor health seeking behavior
• Preference for traditional healers
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Mobile DOTS model: avoids duplication, optimizes use of
existing Government infrastructure
With support from MOH, CENAT, PPMHD, PHD and NGO partners
• Diagnostics
• Sputum delivery
• Medication supply
• Service audits
• Consultation
•
•
•
•
•
Counseling
Contact tracing
Active case finding
Treatment
Raise awareness
Across water
Health centres
Field Supervisors
VHSG
Field Auditor
+
On land
Result:
An effective, closely knitted and dedicated
network of mobile field supervisors bringing
TB cure to the doorsteps of people who
otherwise don’t have “practical” access to
medical care.
Field Supervisor 2
Field Supervisors
Random service audits of field supervisors
VHSG refers to Village Health Support Group. They are community volunteers in the villages
appointed by the Government.
DOTS refer to Directly Observed Therapy Short course. WHO recommended guideline for standard
TB care where a dose is observed by healthcare workers when taken.
VHSG
+
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Field Supervisor
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Operation ASHA’s solution: local, deep, high-impact &
cost-effective model that empowers local communities
Accessibility
• Doorstep access to full suite of TB care
• Good knowledge of local terrain, culture,
custom
• Performance based incentives for field team
Quality
• Regular audits to ensure consistency of care
• Comprehensive and innovative use of
technology
Community
• Work with TB patients and formal/informal
grassroots network for detection and
awareness building
Knowledge
• Training of field and public health care staff:
• Active case finding, awareness, adherence to
treatment
• Improve treatment outcomes and
collaboration
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Personal connection with technology
Start
Referral
Screening
Diagnosis
Treatment
Community
+
Field Supervisor
Contact Tracing &
Case Finding App
Lab Alert +
SMS
Biometrics
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Screening: contact tracing & case finding
Community
Methodology:
To look for symptomatics of TB through community
screening and tracing of contacts of positive TB patient.
+
Field Supervisor
Objectives:
Identifying patients early, enrolling them in treatment and
reducing chances of infection to others in the community.
Advantages:
• Aid screening at community level
• Ensures follow-up of patients according to protocol
• Locate hotspots in the community
Results:
• Implemented in 6 HC (83 villages)
• Screened 6931 people; 474 selected for diagnostics
test, 142 positive
• Without the App, these patients will remain missing
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Diagnosis: lab alert + SMS
Methodology:
Manual Lab register is replaced with an electronic version
on a computer
Objectives:
Automatic SMS Alert facility: When Lab Technician enters
all details of patient’s Lab result, automatically, a SMS is
sent to cell phone of the patient and concerned OpASHA
worker. Message can be sent simultaneously to any
number of persons.
Advantages:
• Reduces time lag between availability of lab results and
enrolment by over 30%.
• Eliminates loss to follow up: All patients are enrolled;
none are lost.
Results:
• Implemented in 5 HCs (69 villages)
• Registered 465 patients; 55 were diagnosed with TB
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Treatment adherence: biometrics
• Aim: to track each dose taken and eliminate default and
generation of MDR
• Runs on commercially available, ‘off-the-shelf’ components:
o Netbook
o Fingerprint Reader
• Software developed by Operation ASHA, with initial support from
Microsoft Research
• Minimum initial and running costs
Netbook
Fingerprint
Reader
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Objectives of biometrics
• Attendance logs quickly inform health workers of patients who
still need to take the dose
• Tracks missed doses, improves treatment adherence
• More efficient than from manual monitoring system
• Accurate & real-time reporting
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Benefits of eCompliance
•
•
•
•
•
•
•
The simple interface uses a minimal amount of text
Can be easily translated into other languages
Color coding makes them easy to use even for semi-literate
workers
High accuracy
Elimination of human error
Increased transparency
Prevents tampering
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Workflow of eCompliance
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Biometrics: spread across the world
Results in Cambodia
• Implemented in 4 HC (64 villages) in Dec 2013
• Default: 0% (with technology)
• Enrollment: 217 patients; Completed: 120; Active:
97
159 Terminals installed in India
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Terminals installed in Cambodia
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Terminals were installed in Uganda in 2012
1
Terminals were installed in the Dominican Republic in 2012
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Achievements (Dec 2010 - Mayie2014)
93.6%
Treatment
Success Rate
7,378 patients
enrolled
Total patients enrolled by Operation ASHA (OpASHA) and Health Centers (HC)
350
300
250
200
131 159
150
50
4
0
2
0
1
0
8
10
0 13
2
0
7
13
6
1
7
5
185 215
179
31 34 28
239
196 196
158
156
193
196
OpASHA
231
213
247
177
169
162
21 11 23 94
7
18
184
195
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Pilot phase
100
0
208
56 82
80
234
204
268
234
HC
186
147 142
82 74 73 81
59 62
84
36
65 67 68 71 52
93
32
52
31 30 37
53
69
38 28
18 25
HC refers to Health Centers (i.e. facilities providing primary care) operated by the Government
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For more information
• Website: www.opasha.org
• Like us on Facebook:
https://www.facebook.com/operationasha
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OpASHA: awards, partners and media coverage
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and many more…