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A Game-changer that can scale TB care internationally & prevent MDR TB © Operation ASHA 2014 1 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 2 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 3 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 4 TB is highly infectious: leads to geometric progression of patients 5 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 6 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 7 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 + 8 Field Supervisor 1 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 9 Personal connection with technology Start Referral Screening Diagnosis Treatment Community + Field Supervisor Contact Tracing & Case Finding App Lab Alert + SMS Biometrics 10 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 11 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 12 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 13 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 14 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 15 Workflow of eCompliance 16 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 4 Terminals installed in Cambodia 3 Terminals were installed in Uganda in 2012 1 Terminals were installed in the Dominican Republic in 2012 17 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 30 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 18 For more information • Website: www.opasha.org • Like us on Facebook: https://www.facebook.com/operationasha 19 OpASHA: awards, partners and media coverage 20 and many more…