A team from Columbia University’s Earth Institute adapted the Operation ASHA strategy for a rural African setting in Uganda. In that context, patients no longer go to the clinic while on TB treatment, but rather a community health worker goes to the patient’s home with an eCompliance system to observe the patient taking the drugs and record the drug intake.
Our team implemented three systems (notebook + fingerprint scanner) in the Millennium Villages Project in Ruhiira, in the rural southwest of Uganda and trained three community health workers (CHWs) on the process of eCompliance. Some changes in the system were necessary to adapt to local constraints. For example, unlike urban India where the systems were clinic-based, the CHWs have to ensure the system’s battery is always fully charged since electricity access is often not readily available and road quality or lack thereof means travel can be long and difficult. Yet, even with these added challenges, the system has proven to be successful. Now the CHWs are able to easily and accurately identify when a patient has missed a dose and have a conversation with them to ensure that they do complete treatment, instead of missed doses going unnoticed and resulting in loss to follow-up. That is not to say that a patient never misses a meeting for observation, it is impossible to avoid all obstacles in a six-month plus period; events such as funerals or patient travel occasionally lead to a missed record.
The results in Ruhiira are a staggering improvement. The cluster of villages has a population of about 50,000. In 2011, the most recent year with full data, there were 52 TB cases diagnosed and placed on treatment and eight patients died. The eCompliance compliance system was implemented in July 2012; since then, 31 patients have been enrolled in the system, none of those patients have been lost to follow-up, and none have died.
Perhaps more importantly, the community and the patients are excited about the system. When the project was first implemented, the mother of one patient said she could not thank the eCompliance team enough for taking care of her son. She insisted that they take a few valuable pineapples as a gesture of her appreciation. Another health worker reported that community members told him how much they appreciated both him and the system. Now they can rely on him to always check on the health and treatment status of patients. In areas of the cluster where the system doesn’t yet reach, patients are asking when they will get the new technology.
These results are remarkable, and mean better TB patient care not only for the Ruhiira village cluster, but also for TB follow up rates worldwide. If systems like eCompliance work in areas as different as dense urban Indian slums and sprawled rural Ugandan villages, we may be able to halt the increased incidence of drug resistant cases.
Stopping the incidence of drug resistance in India or Uganda may seem like an issue that is not relevant to those of us in the United States. But today it is more true than ever that TB anywhere means TB everywhere. The American lawyer likely picked up MDR-TB while doing development work. But the transfer of TB can be even more indirect. As globalization grows, and the number of people travelling increases, it is more important than ever to stop TB drug resistance and stop the spread of this deadly epidemic.
eCompliance may be just the assistant that overworked doctors and health workers in disadvantaged areas need to easily, efficiently, and successfully care for all of their at-risk patients, including in the United States.
