Empowering States & Districts & using biometric technology to deliver healthcare to the doorsteps of the poor

Empowering States & Districts & using biometric technology to deliver healthcare to the doorsteps of the poor

Overview- What gets measured, gets done Operation ASHA -serving more than 54 Lakh people in India & Cambodia A local, deep, cost effective, high impact model believes in measuring impact & outcome Operation ASHA s transformative innovation has to do with listening to patients so they can design more effective treatment protocols and reduce transaction costs Aleem Walji, Director, Innovation Lab, World Bank 2

Problems India has much higher Infant Mortality and Maternal Mortality Rate than Bangladesh, which is otherwise far poorer than India in more aspect than one India s TB burden is more than double that of secondranked China It is a shame that we have reached Moon and Mars. We are a nuclear power. But a person dies of TB every two minutes, a disease that takes only Rs. 5,000 per patient in additional cost and should have been eradicated long ago. 3

Tuberculosis in India: The biggest public health crisis India has 2.8 Million TB patients, 31% of world s total burden 64,000 estimated cases of MDR- TB in India, only 16,588 cases diagnosed. (Source: Global TB report, WHO 2013) TB kills one 1 person in every 2 minutes in India & 750 people every day 300,000 children drop out of school because they, or a parent, have TB. (Source: TB India 2008) Lost wages: $300 million/ year; Total loss to Indian economy: $23 billion/ year.* 100,000 infected women are thrown out by families to die of disease and starvation (Source: TB India 2008) 4

Challenges in delivery of health services and prodcuts 1. Inaccessible Centers- Existing public infrastructure lacks the last mile connectivity 2. Limited/ Ineffective Education or counseling 3. The Quacks - incomplete, irregular, inadequate treatment 4. Negligible follow-up of defaulting patients 5. High cost of implementation for most other NGOs 6. Program level lack of electronic data, inaccuracy and human error

India s Healthcare program District Hospitals: Adequate CHC Hospital/ Warehouse Government facilities providing comprehensive diagnostics and treatment recommendation CHC CHC CHC District Hospital CHC CHC CHC: Adequate CHC CHC PHCs: Inadequate in slums and villages Local last mile centers CHC Inadequacy of PHC facilities results in poor health and crowding of District Hospitals. * Directly Observed Therapy - Short Course 6

OpASHA s Solution: Fill the Gaps: Community Empowerment: examples for TB Strategically located TB Centers Partner with local micro-entrepreneurs, priests etc. based in convenient, high-traffic areas Centers open at convenient hours No patient needs to miss work/wages or pay for bus fare to access treatment Local Community Members Hired as Counselors & Providers Work to treat TB, detect new patients, education camps, default tracking Familiarity with local customs, geography, and informal address systems Much more cost efficient than MD doctors Performance-based salaries for field workers & supervisors Specialized Training For active case finding Conduct health awareness programs Provide counseling to ensure adherence and prevent MDR To destigmatize TB 7

OpASHA: Results for TB 8

ecompliance: A New Idea. DOTS alone is not sufficient to curb the TB epidemic in countries with high rates of MDR- TB. - Stop TB Working Group Electronic datasets are needed to facilitate accuracy and analysis of data. - World Health Organization (2011) 9

ecompliance: Implementation Results Default: as low as 0 Over 9,000 patients enrolled so far Over 19,700 visits logged every month Total number of transaction (Supervised Dose Only) from both systems - 207,504. Total number of doses (Supervised, Unsupervised and Self-Administered) - 383,167 178 Total no. of terminals installed by the end of Nov 2014 10

Cost Effectiveness Component Cost Tablet 8500 Fingerprint Reader Rs. 4000 Installation cost Rs. 800 Internet Plan (per month) Rs. 200 The total cost of each ecompliance terminal = Rs. 13,500 Cost per patient = Rs 386, which is expected to be offset by increased productivity (each unit will treat 35 patients over 18 months) 11

Key Benefits of ecompliance PATIENT AND COMMUNITY LEVEL Positive impact on the psyche Improves motivation Seen as dedication towards quality treatment AT LEVEL OF FIELD STAFF Ensures integrity of DOTS: eliminates unsupervised doses Eliminates human error Improves skills Makes counseling easy, i.e. easier to convince patients Accurate reporting and up-to-date intelligence Saves time that would be otherwise spent in going through paper records Target counseling to patients who regularly miss doses 12

Key Benefits of ecompliance (contd.) MANAGEMENT LEVEL Comprehensive Electronic Medical Record System. Accuracy of records Multi-level accountability and transparency An accurate platform for monitoring Eliminates absenteeism, late coming Prevents tampering Transparent treatment supervision Ensures accuracy of incentives THE PUBLIC HEALTH PERSPECTIVE Ensures DOTS is being delivered Prevents MDR-TB CAN BE UPGRADED FOR Daily dose regimen Adherence for MDR-TB, HIV treatment Diabetes Mid-day Meal schemes 13

ecompliance Web-based reporting system: sets supplied/ installed in Madhya Pradesh 14

Expansion in India & Cambodia Jharkhand Treatment Centers 400 Cambodia 350 300 Orissa Maharashtr a Chhattisgarh Rajasthan 262 315 384 250 MP 200 Punjab UP 190 150 100 97 50 24 0 11 15

Impact to date 38,118 2,28,708 $4,000 Cost of creating a job Total enrollments 86.9% Treatment success rate <3% Default rate Infections averted 103 Jobs created for Semi-literate youth 161 Microentrepreneurs/ community partners who earn additional income in disadvantaged communities that serve as locations for Operation ASHA treatment centers SROI 3,217% 16 16

Replication in other countries Operation ASHA has successfully replicated its model in: 1. Uganda 2. Kenya 3. Dominican Republic 4. Cambodia 5. Discussions going on in 8 other countries 17

Replication in Other Countries (contd.) UGANDA- Replication of e-compliance by Researchers at Columbia University & Millennium villages {third party replication} e-compliance started in June 2012 Outstanding results: Death+Default rate down to ZERO from > 16% in the preceding year The results of Ruhiira are a staggering improvement. They mean better TB care worldwide Huffington Post, World TB Day CAMBODIA Expansion/ Replication of the entire model by OpASHA since 2010 Serving 6% of the population and 8% of the patients Working in 5 Operational Districts, in 2 provinces; Detection rate increased by 70% 18

PRESSING ECONOMIC AND HUMANITRARIAN RATIONALE FOR EXPANDING OPERATION ASHA ACROSS THE STATE India MP Ratio Population (Lakh) 12471 429 3.4% Deaths pa 270000 9287 3.4% Prevalence Patients/Lakh) 216 Total patients 92664 Patients enrolled by RNTCP 45269 Missing Patients 47935 Proposed Expenditure (In Crores) 42.9 Proposed prevention of deaths 9287 Proposed additional detection 47935 Cost per life saved (Rs.) 46193 Number of additional detections for Rs. 46193 4 Increase in earning per patient treated (Rs. Lakhs) 8.36 Total increase in earning (Rs. Crores) 4007 Prevention of economic loss per patient treated (Rs. Lakhs) 7.34 Total prevention of economic loss (In Crores) 3518 Total economic benefit to the state (Rs. Crores) 7525 Economic benefit per Re invested by the State 175 Number of jobs created 2145 So, each investment of 2 Lakhs SAVES 4 LIVES, TREATS 16 ADDITIONAL PATIENTS AND GENERATES RS. 3.5 CRORES IN ECONOMIC BENEFITS AND CREATES 1 JOB 19

How Government and Operation ASHA work together Alternatives: Operation ASHA can run the project on its own and deliver all services with its staff Train a local autonomous body or local NGO to replicate our work Train Government appointed ASHA workers or any other cadre in improving TB care Funding: One time expenses, software and expertise will be brought in by Operation ASHA Government will provide funding for recurring cost under GoI s Guidelines for TB Program/ RNTCP or any other GoI/ State Scheme 20

Request Allotment of entire state or at least all 5 districts in full + tribal or Maoist affected districts, to turn them into model districts with measurable indicators like Finding missing cases/ Improvement in detection Improvement in Treatment Success Rate Reduction in mortality rate because of TB Operation ASHA distribution channel can deliver other products and services to improve lives of the people who are marginalized. We can help in vaccination, malnutrition and better care of pregnant women thereby increasing institutional deliveries. 21

OpASHA : Awards, Partners and Media Coverage 22 and many more

NSP Cure Rate 2Q10 Before & After Validation of Data - 8 Districts 100% 90% 86% 86% 89% Target - 85 % Cure Rate 80% 70% 71% 81% 69% 81% 75% 79% 60% 50% 40% 30% Significant Drop in Cure Rates (32%) Found after Validation of Data 2Q10 60% 34% 28% 25% 25% 25% 32% 20% 10% 0% 1% 0% Kanker Durg Mahasamund Dhamtari Narayanpur Bastar Dantewada Bijapur Total (8 Districts) District Reported NSP Cure Rate (2Q10) TB Register NSP Cure Rate after validation of reports (2Q10)