Achieving TB Milestones Through Last Mile Delivery in India

By Deen L. Garba

India has the world’s largest burden of tuberculosis. The government has recently committed to raise TB as a national priority. With such a colossal burden, India may do well to scale up its promising health innovations. In this GHPC blog, Deen Garba describes how one organization in India has used last mile delivery to make gains in TB.
The magnitude of India’s tuberculosis crisis is staggering. India has the largest burden of tuberculosis globally, with an estimated 2.8 million cases, and TB is the number one cause of death among its citizens. Recent signs suggest that the government of Prime Minister Narendra Modi appreciates the gravity of the situation. During the WHO Southeast Asia Regional Meeting in March, India’s Minister of Health JP Nadda pledged to end the country’s TB epidemic by 2025, and said an aggressive strategy to do this was being finalized. If India is to achieve such a lofty goal then a bold, disruptive approach to TB will be required; one that addresses the threat of Multidrug-Resistant (MDR) TB and finds ways to navigate India’s fragmented health system. In late March, I traveled to India with CSIS to explore how India’s rapid economic growth has led to significant health gains and discovered how one organization is achieving results in TB by taking treatment directly to patients.
India has more than 27 percent of the world’s 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. Patients are often deterred from seeking treatment by social stigma and poor access to quality services in the public sector. Most patients opt for treatment from formal or informal providers in the private health system, but because this sector is largely unregulated and data gathering is poor, tracking patients throughout their course of treatment is difficult.
Government policies place additional barriers in the way of treatment.  Patients with MDR-TB were given hope when a new drug, Bedaquiline, was approved for use but limited stocks mean the drug is only available in six states across the country, and patients must have lived in one of these states for three years to be eligible for treatment. (These regulations faced a legal challenge in January, when the high court in Delhi ruled that an exception must be made for a seriously ill MDR-TB sufferer who did not meet the residency requirements). 
A handful of Indian health experts are finding creative solutions to tackle the TB crisis. Located in the South Delhi neighborhood of Sarita Vihar, Operation ASHA (OpASHA) is an NGO that has provided TB treatment and educational services to 14.6 million people worldwide since 2006. How? By taking the World Health Organization’s standard TB treatment model, DOTS (Directly Observed Therapy Short Course) directly to the hearts of the slums through its mobile clinics. 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.
For years, the number of projected TB cases in India has increased, while detection has remained low. This can largely be attributed to the fact that patients from the country’s urban slums and rural communities often do not elect to enter the public healthcare system. Faced with a choice between traveling to distant health facilities to take a single dose of medication and going to work to provide food for their families, patients naturally tend to choose the latter. We met with Dr. Shelly Batra, President of OpASHA, who explained that their approach saves time and money for patients by delivering medication directly to their doorstep or to accessible collection points in their neighborhood.  
OpASHA has also partnered with Microsoft to develop “eCompliance,” a monitoring system to help ensure adherence to TB medication. Under this method, treatment can only be administered when both the health worker and patient provide their fingerprints on a mobile reader. The eCompliance system has reduced the default rate—the number of patients failing to complete treatment—to less than 1 percent.
These costs compare favorably to more traditional approaches. The United States Agency for International Development (USAID) has helped procure GeneXpert machines, known locally by the non-proprietary name of CBNAAT (cartridge-based nucleic acid amplification test), for the rapid diagnosis of TB across India. Yet, despite being lauded as the preferred diagnostic for TB, each machine costs roughly $20,000 USD. Simply purchasing more machines to place in urban slums is not the most cost-effective solution, despite the relative success of CBNAAT as an initial TB diagnostic in Indian public health facilities.
Globally, NGOs spend an average of $852 USD detecting each patient. By contrast, Operation ASHA spends $80 USD on both detection and treatment, with an eCompliance per-patient cost of $3.55 USD, or 162 Indian Rupees. Not only are costs substantially reduced through eCompliance, but the technology can also be adapted for other purposes. Several states in India have repurposed it to track everything from school attendance, treatment for hypertension, and the detection and management of diabetes. 
Our trip to India illuminated some of India’s most promising health innovations. Over 80 percent of India’s citizens continue to rely on a virtually unregulated private healthcare system. Instead of having patients travel to such clinics, Operation ASHA’s model seems practical: treatment should be taken directly to the patient. While this approach is certainly not the only solution to a TB epidemic that requires a multifaceted approach, it does offer a compelling example of how last mile delivery can be a financially pragmatic approach to treating those with TB in the world’s most difficult-to-reach locales. Additional innovations such as OpASHA that prioritize last mile delivery could prove effectual in realizing India’s ambitious hopes of eliminating TB by 2025.