If Universal Health Coverage has to be achieved, there needs to be less dependence on DOT and greater acceptance of VOT and other patient-centric treatment modes for TB
After being diagnosed with tuberculosis (TB), Niyam Mohammed was asked to follow the standard Directly Observed Treatment Short Course (DOTS). In the beginning, he abided by the procedure, which meant taking the TB medication in front of a DOTS provider (usually a healthcare worker or volunteer). This was done to ensure compliance and completion of the treatment and also to prevent the development of drug-resistant tuberculosis (DRTB). But for him, visiting the healthcare centre for medicines and registration of compliance daily meant missing many hours of work. As a construction worker, Mohammed’s survival depended on his daily earnings and unable to afford this loss of income, he slowly became irregular, not just in his visits to the healthcare centre but also in treatment adherence. So, it wasn’t surprising when he was detected as having DRTB during a door-to-door TB screening programme in March. Realising that counselling and behaviour change was needed to get him back on track, ZMQ Global, a social enterprise using technology for development, which conducted the screening drive, took him under its wing.
Once the team understood that Mohammed was more likely to adhere to the regime if he didn’t have to miss work, he was given an innovative Patient’s Active Compliance and Treatment (PACT) tool kit, a patient-centric mobile solution designed especially for people with DRTB. By using PACT, the construction worker didn’t have to miss work to access treatment because he no longer had to present himself in front of a healthcare worker daily. Instead, he could show that he was following the regime by clicking a video while having his medicines and use the app to send the video to the TB unit located in his primary healthcare centre.
Just as Mohammed began his treatment using Video Observed Therapy (VOT), a countrywide lockdown due to the Covid pandemic was announced. But the worker knew that he didn’t have to worry about access to treatment and care because he had been given medication to last for two months. More importantly, the patient knew that he could use the app to consult the doctor via tele-conferencing if he had any problems.
At a time when 51 per cent TB patients in India, who were surveyed by the Global Coalition of TB Activists, said that they were less likely to seek care during the outbreak because they feared contracting the Coronavirus, ensuring continued access to DRTB care and management is critical. By leveraging tele-medicine and patient-centric mobile tools to put treatment and care directly into the hands of patients, PACT has been able to enhance adherence support.
It was after extensive research and trials that ZMQ Global hit upon a three-pronged strategy to address the issue. Using its expertise in developing technology solutions, it first created a patient tool kit. This comprises a component which reminds DRTB patients of the need for taking their medication daily and adherence reporting through the VOT technology. It has customised data of the patient with personalised details like the history of previous illnesses, the treatment regimen, test reports and so on.
This ensures that all information is accessed seamlessly by the healthcare providers and the patients, too, have access to their treatment history and follow-up schedules. Second, the app allows patients to remotely connect with the TB Unit (TBU) or Senior Treatment Supervisor (STS) for consultation or emergency care using the video connect tool. This means that visits to the TBU can be substantially reduced and with the pandemic showing no signs of slowing down in India, this can be a life-saving feature for immunity-deficient TB patients.
The third strategy to boost treatment compliance was to incorporate digital behaviour change communication and motivational content for DRTB patients. Interesting digital stories, learning tools and messages have been developed in the local language and attractively packaged in the form of audio-visuals to connect, engage, inspire and motivate patients. In this way, even those with low literacy levels can use the app with ease.
At present, PACT is being rolled out in Nuh (Mewat), Haryana, which is just 100 kilometres from the national capital Delhi and considered the most backward district in India. In 2018, it was included in the Niti Aayog’s list of “aspirational districts” or backward districts demanding special attention for its poor healthcare and development indicators. This happened after a study by Sehgal Foundation, a not-for-profit, found that the district lagged behind other areas in Haryana.
Nuh has a TB load of over 2,800 patients every year. With the treatment initiation of DRTB patients being 24 per cent and the success rate of treatment being only 35 per cent, it was decided to implement PACT in Nuh first. Planners believe that anything which works in this district has the potential to be scaled up to 114 other aspirational districts of India.
It has just been seven months since the initiative was launched but there are already signs that the PACT is boosting adherence and compliance. Mohammed, one of the 120 DRTB patients in Nuh, has recorded 85 per cent treatment adherence using the VOT technology. He returned to work after the lockdown was eased and hasn’t let that come in the way of completing his treatment. He sends videos to his designated healthcare centre to show his intake of medicine from the construction site even now.
Although Mohammed is considered a successful case because he changed his behaviour and adhered to his treatment, the team continues to monitor him. Since he has DRTB, he will have to undergo a longer and more arduous period of treatment. The team wants to ensure that the worker remains vigilant till the end, so it will continue to monitor him over the next six months as all patients under PACT are monitored for at least a year.
PACT, in fact, was specially designed to ensure continuum of care for those diagnosed and undergoing treatment for DRTB in the wake of the contagion. It recently won the Drug Resistant-TB Lifeline QuickFire Challenge instituted by pharmaceutical major Johnson & Johnson’s Global Public Health and Johnson & Johnson Innovation. According to Hilmi Qurashi, co-founder of the not-for-profit, they focussed on making the solution patient-centric. Since they have been engaged in providing mobile technology solutions for TB and other health issues in other parts of India and Africa, they adapted from their existing bottom-up technology- linked model to provide appropriate tools in the hands of the patients.
This could not have come at a better time as recently the World Health Organisation in its global report sounded a warning that the pandemic would cause an excess of 1.8 million TB deaths in 2020. India is among the countries expected to bear the maximum burden of these casualties.
The need for innovation has also been flagged by the ongoing 51st Union World Conference on Lung Health convened virtually by the International Union Against Tuberculosis and Lung Disease (The Union), the world’s first global health NGO. Failure to invest in the health of citizens and defeat preventable, treatable and curable diseases such as TB would enhance exposure to the Novel Coronavirus and future pandemics, said José Luis Castro, Executive Director, The Union.
With 75 per cent of TB researchers saying that they do not have the necessary resources, the need to protect existing ones becomes vital. The concern that TB medicine, tests, vaccines, even sputum cups may not be available has been expressed by Dr Madhukar Pai, director, McGill University TB Centre. This makes the new tools for TB prevention and care, like PACT, even more necessary. Never has this innovative tool kit been needed more, considering the necessity to reduce visits to healthcare centres and contact with healthcare workers in the Corona era.
If Universal Health Coverage has to be achieved, there needs to be a reduced dependence on DOT and greater acceptance of VOT and other forms of innovative patient-centric treatment modes for TB.
(The writer is a senior journalist)
