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    Date submitted
  • 26-Aug-2017

Technology for best health outcomes

Abstract

Operation ASHA is a non-profit organization that is focused on Tuberculosis (TB) detection and treatment by providing a last mile delivery solution to the poorest of the poor in slums, villages and tribal areas. Though fully curable, TB is the biggest health crisis in the world. 10.4 million people fall sick ill with TB annually, and 1.8 million die. It is estimated that the world will lose $3.4 trillion in the next decade due to TB.

Operation ASHA has achieved an unprecedented treatment success rate, at a cost that is 40 times less than other NGOs. It began in 2006 in one slum in South Delhi. Now it serves close to 18 million people in India and Cambodia. Its model has been replicated in Uganda, Kenya, Peru and Dominican Republic, Tanzania, and Afghanistan.

We works in collaborations with governments, which provide medicines, diagnostics and physicians’ services for free. We have devised a new methodology with patient convenience as the focus, bringing the TB treatment right to the doorsteps of the disadvantaged. Patients are diagnosed in the public hospital. Then we are given the box of medicines for the entire 6 months. For TB treatment, patients must go daily to a designated centre and take medicine in the presence of a trained worker. In order for these to reach the unreached, we utilize space in the premises of local doctors, chemist stores, temples, tea shops, grocery stores etc to set up treatment centers. These are manned by locally hired and trained youth- who work as Community Health Workers (CHWs). Centres are situated in convenient places and open early morning and late night too, so no one has to miss work and wages in order to get the medicine. CHWs also carry out education of families, de-stigmatisation, case detection, and full treatment to prevent drug resistant TB.

CHWs are all local people, so they are well aware of the informal topography, neighborhood groups, prevailing myths about the disease etc. These CHWs are empowered with portable technology- a biometric fingerprinting system that is attached to a tablet loaded with an application called eCompliance to track medication adherence. Each dose is monitored by the finger print, and in real time we know if patients have missed their dose, so missing patients can be tracked by CHWs. eCompliance was developed with research and advisory support from Microsoft Research. In remote areas, where patients are scattered in far off villages, our health workers go on bikes, motorcycles and even on boats to visit patients in their homes and give the medicine under supervision.

So far, we have treated over 75,000 patients since starting operations in 2006. This model has been able to achieve a treatment success rate of 87% and an extremely low default of 3% thus preventing progression and spread of the disease.

We are the most cost effective organization in TB care. Our total cost of detection and treatment per patient is only $80, as compared to several thousands by others. According to CSIS, the Centre for Strategic and International Studies, which is the world's top bi-partisan international security think-tank, the cost of TB detection alone by other NGO's is $852.

https://www.csis.org/blogs/smart-global-health/achieving-tb-milestones-through-last-mile-delivery-india

We give a Social Return on Investment of 3217%. On treatment, patients earn an additional $13,935 through reinstated productivity, and the economy saves $12,235 in indirect loss (Annual TB Report 2013, Government of India). So our patients and the countries economies have saved huge amounts.

We have achieved sustainability in many ways. We give a leverage of 4 times to the donor because of the free medicines and government infrastructure. We have created a sister concern, mASHA Technologies Private Ltd, which develops technology for third parties such as governments, NGOs, and even the UNHCR. We also get funds from the government under government schemes, which take care of 27% of the field costs.

We also carry out detection, management, awareness building for diabetes, hemophilia and cardio- vascular disorders, and delivery of nutritional supplements, vitamins, and Oral Rehydration Salts. We provide vocational training to TB patients to support their family income. We create hundreds of jobs at a low cost. Our delivery model is truly turning into a delivery pipeline for disadvantaged areas/ Bottom of the Pyramid markets.

Onno Ruhl, Country Director World Bank for India, wrote a blog entilted – The last mile, at last, which says:

“I was fascinated: If this could be rolled out everywhere where there is TB, we could stop multi-drug-resistant TB and save so many lives!

What Operation Asha does is literally to deliver the elusive “last mile” in service delivery. The mile that lies in between well-intended government programs and results on the ground. And they do it with relentless focus and incredible efficiency. What if we could develop Operations Asha for other problems as well? 90% efficiency and 19 times cheaper? It would be incredible!”

http://blogs.worldbank.org/endpovertyinsouthasia/last-mile-last

An immediate need is to scale this model worldwide to provide access to health care at a low cost. eCompliance must be used wherever adherance is an issue, such as treatment of HIV/AIDS, non communicable diseases, immunisation and maternal and child care programs. technology is the ultimate solution to solve the public health problems of the world, and if used in tandem with local deep models using local people, can give outstanding results, as have been proved by Operation ASHA.

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Additional Questions

Who is your customer?

Operation ASHA, founded in 2005, delivers high quality healthcare services with a focus on tuberculosis (TB) to the poorest of the poor in slums, villages and tribal areas. It has achieved an unprecedented treatment success rate, at a cost that is 40 times less than other NGOs. Though fully curable, TB is the biggest health crisis in the world. 10.4 million people fall sick ill with TB annually, and 1.8 million die. Each year 1 million children worldwide contract TB and 170,000 children lose their lives. Over 95% of TB deaths occur in Low and Middle Income countries. TB is not just a disease, it’s a socio economic problem. Entire families sink into poverty because of loss of jobs and productivity due to TB. It is estimated that the world will lose over US$3.4 trillion because of TB in the next decade. The stigma associated with the disease leads to terrible deprivation and violation of human rights. In India alone, 100,000 women are thrown out their homes each year to dies of disease and starvation if they have TB. 300,000 children are forced to leave school for the same reason. ( Govt of India, 2008) In 2015, globally an estimated 480,000 people developed MDR- TB ( Multi Drug Resistant TB), a horrifying disease where conventional drugs become ineffective, and mortality is almost 80%. MDR TB, which occurs due to incomplete treatment, is the emerging man made epidemic that can wipe out millions. Operation ASHA began in 2006 in one slum in South Delhi. Now it serves close to 18 million people in India and Cambodia. Our model is highly scalable and replicable. It has been replicated in several countries. Third party replication has been done by Columbia University, NYC, in Uganda and Kenya, and by local NGOs in Peru and Dominican Republic. Replication has started this year in Tanzania, where 2600 TB patients will be put on eCompliance, the technology device for adherence. In Kabul, Afghanistan, we are collaborating with the country’s National TB Program and a local NGO to open 20 TB treatment centres. Operation ASHA is the biggest TB control NGO in India and third biggest in the world. Over 65,000 patients of TB, 205 patients of Multi-Drug Resistant TB and one patient of Extensive Drug Resistant TB have been treated by us. We are enrolling 15,000 patients each year. In Cambodia, where we started work in Dec 2010, we are serving 16% of the population and 16% of all TB patients. Recently we have trained more than 3000 local village health workers to carry out TB detection and treatment, at the behest of the government. TB has now become a global pandemic. It has staged a comeback in the West, from where it had been eradicated. An immediate need is scale operations worldwide.

What problem does this idea/product solve or what market need does it serve?

Our community model and technology are focussed towards Tuberculosis (TB) treatment and prevention. TB was declared as a global emergency in 2009 by WHO. Unfortunately the enormity of the problem is yet to be understood and accepted by global leaders. It is expected that the world will lose $3.4 Trillion because of TB India has more than 27% of the global burden of TB. The economic costs incurred equate to $300 million USD in lost wages per year, and a $23 billion USD indirect cost to the Indian economy due to staff absenteeism and lost productivity. TB is a disease of the poorest of the poor, who face the following challenges: 1. last mile delivery is missing: Govt programs worldwide provide free meds, diagnostics and services of physicians to the poor. Though available to all, accessibility is a key challenge. In the WHO sponsored DOTs program, Patients are not given medicines to consume at home, rather they have to go daily for 6 months to a designated centre and swallow the meds in the presence of a trained provider. 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 meds on the other. They naturally prefer to earn their daily bread, so they continue to suffer and die and infect others. 2. Incompklete treatment : Even if tpatinets start treatment, they drop off because of many reasons, such as inconvenience, stigma, out of pocket expenses for travel, fear and myths and so on. This leads to treatment default, which gives rise to a much bigger problem- that of drug resistant forms of TB which is much more difficult and costlier to treat. 3. Informal providers _ Patients often opt for treatment from quacks or informal providers in the private health system- who are either not qualified or not trained enough to tackle TB cases. Incomplete and irregular treatment further aggravates the problem of MDR TB. 4. Fear ans stigma: There are patients who have been coughing up blood for years, but they live in denial. TB is a disease of darkness. Patients live in constant fear and there is no one to help. 5. Lack of support - There is no one to track missing patients, to take care of day to day problems, to find solutions for side effects of medication, or to persuade them to take their treatment. Nor is there anyone to facilitate the testing and treatment in public hospitals. Marginalized patients are often intimidated by government infrastructure.

What attributes will make this idea/product successful? Why do you believe that those features will create success?

There are many organizations trying to work in the TB space. But unfortunately,they are not geared towards outcomes and impact, and therefore do not give results. In comparison, OpASHA’s focus is the last mile delivery system that has taken services out of the realm of specialists and hospitals to the absolute last mile, where the poorest of the poor live. We are focused on results and believe in measurable impact. We are better, faster, cheaper that others because we have a local, deep, low-cost, high-impact scalable and replicable model, utilizing local communities and empowering them with technology. Our model is: • We work as partners with governments, which gives us free medicines, diagnostics, and services of physicians. We utlilise existing govt infrastructure, which provides a leverage of 100% to the donor • We solve the problem of last mile by establishing treatment centers in deep and disadvantaged areas, open early morning and late night so no one has to miss work or wages. • Where patients are scattered, TB Health workers (Providers) go on bicycles and motorcycles and even on boats right up to the doorstep of patients. • Providers are given OTC drugs to take care of side effects of medicines and to camouflage TB. • Providers and centers have eCompliance, the biometric fingerprinting device created by Microsoft Research that ensures every dose taken by fingerprint, prevents default and MDR-TB. • Quality audits and a robust feedback loop are an important aspect. • There is absolute accuracy regarding work done and data collected. A fingerprint cannot be fudged. There is no manual entry. • We leverage the trust of community leaders. • We do not hire doctors and nurses, we bleiev in hiring and training local people as TB Providers • We use technology to ensure accuracy ”Operation ASHA’s work involves all kinds of innovations. Their service provider is not a doctor, but a community health worker, which dramatically reduces the cost of treatment. They have non-descript clinics without signs that mention TB to reduce social stigma, which makes it safer, particularly for women, to seek treatment. They have also identified ways to increase treatment compliance for a disease that is traditionally difficult to treat because people don’t constantly take their medication for the necessary six to nine months. These are powerful innovations, developed in partnership with patients and target communities" (Aleem Walji, Director, Innovation Lab, World Bank). OpASHA has reinforced these innovations with highly effective technologies: the World-renowned eCompliance, developed initially in collaboration with Microsoft Research. This partnership was tweeted by Bill Gates on Dec7, 2012; Other applications include eDetection, which helps detect every patient and stop the spread of infection; eQuality, to improve service delivery; eTraining, to improve training and eCounselling to improve education and counselling. These innovations empower community health workers (CHWs) to implement high-quality programs in addition to providing real-time, transparent reporting, rigorous supervision of staff & tracking of patients. The Innovation achieves unmatched results in every aspect of the tuberculosis detection, treatment and prevention program. Detection rate reaches nearly 100% of prevalence; this means that every patient is detected and treated. This far exceeds the WHO benchmark of detection of 70% of prevalence. This is a critical indicator of success, because every untreated TB patient infects 12 others on an average and leads to a geometrical progression. 100% detection by OpASHA eliminates this geometric progression and prevents millions of infections.

Explain how you (your team) will execute to make this idea/product successful? What gives you (your team) an advantage over others already in the market or new to this market?

My team consists of highly qualified and dedicated people. Sandeep Ahuja, CEO and Co Founder, is an ex-IRS officer, with excellent government relations, and is skilled in finance and administration. The Technology team is led by 2 people with Masters degrees in Computer Engineering from the best universities in US, including GeorgiaTech, Atlanta. We have achieved success by our practical approach, as shown by the following Testimonials: 1. Dr. Yanis Ben Amor, Director of Tropical Laboratory Initiative, Earth Institute, Columbia University and Tuberculosis Coordinator, Millennium Villages Project has stated that “eCompliance, an electronic biometric tool is the right one that ensures health workers can accurately follow up with patients. Health workers do not have to waste time thumbing through individual records of each patient. Instead, they easily find their patients, administer therapy, and provide the educational support that is needed. It may be just the assistant that overworked doctors and health workers in disadvantage areas needed to easily, efficiently and successfully care for all of their at-risk patients including in the United States” 2. CSIS, has written a compelling article about India's TB problem, which says “OpASHA’s pragmatic, community-based approach enables patients to more easily adhere to their treatment regimens, and this has led to fewer than three percent of patients missing their doses each day, compared to 36 percent in the public health system” https://www.csis.org/blogs/smart-global-health/achieving-tb-milestones-through-last-mile-delivery-india