Operation ASHA

Operation ASHA (OpASHA) is a non-profit organization founded in 2006 to bring tuberculosis (TB) treatment at economically feasible rates to disadvantaged communities. The organization’s primary work is detecting and curing TB and preventing and treating Multi-drug-resistant tuberculosis (MDR-TB) in India and Cambodia. Operation ASHA specializes in last-mile connectivity, bridging the gap between government medicine distribution centers and the communities of patients to deliver treatment at the doorsteps of the under-served. In addition to detecting and curing TB, OpASHA's community health workers also educate the community about TB and its symptoms thereby helping to reduce the stigma there is regarding the disease even in today's day and age. In addition to TB, Operation ASHA's model and technology has been used in many other diseases such as diabetes, hemophilia and mental health.

Logo of Operation ASHA

Operation ASHA was founded by Dr. Shelly Batra and Sandeep Ahuja. In India, Operation ASHA works under the Revised National Tuberculosis Control Program as a private-sector DOTS-provider. Operation ASHA is a member of the Stop TB Partnership’s Coordinating Board. In 2010, a collaboration with Microsoft Research developed eCompliance, a biometric terminal for monitoring TB patients.

Founders' Bios

Dr. Shelly Batra is the President of Operation ASHA since 2005. She is Schwab Foundation's Social Entrepreneur of the Year 2014, renowned Senior Obstetrician and Gynecologist, Advanced Laparoscopy Surgeon. She is a powerful advocate for better policies in TB across the world.

As CEO, Sandeep has led the organization since 2006. He was member of the Board of the Stop TB Partnership from 2009-2012 where he represented NGOs of developing countries. Before founding Operation ASHA, Sandeep served for many years as additional commissioner for the Government of India.

Social model

A community health worker for Operation ASHA gives a child medication for TB treatment at a TB Treatment Center in Haryana, Gurgaon.

Operation ASHA has established DOTS (Directly Observed Therapy, Short-Course) clinics in existing and accessible locations such as businesses, temples, and pharmacies where field staff supervise treatment. Going to these common places, rather than a separately established clinic, allows patients to avoid the negative stigma associated with TB. In rural areas, Operation ASHA uses mobile delivery, where a community health worker travels from village-to-village on a motorcycle/scooter carrying with him anti-TB drugs, supplies and equipment. TB patients in the slum are generally daily wagers. They cannot afford to miss an entire day's wage by going to a public hospital to get their medication. Hence Operation ASHA's centers are located in the community of the patients themselves and are open at a time convenient to them like early morning and late night so that they do not have to miss work in order to go and get their treatment.

Operation ASHA stresses upon employing and training disadvantaged youths from the local community who understand the local culture and customs as TB-specific health workers. Two-thirds of Operation ASHA's staff is semi-literate/illiterate. Currently, Operation ASHA serves over 15 million people in India and Cambodia, with a team of over 250 field workers, 150 community partners, and over 4000 village workers.

In addition, people are employed in India in the field of Haemophilia detection and care.

Technologie

eCompliance

One of the key problems in TB is determining if the patient is actually taking the prescribed medication and this process is simplified with the help of Microsoft developed eCompliance, which is a biometric terminal that can be downloaded on a simple seven-inch Android tablet with a SIM card. It works in conjunction with a fingerprint reader and/or an iris scanner. The tablet is connected to a central server through internet and updates that server whenever synced, allowing data to be easily accessed from a central server. The device records electronic fingerprint from patient and community health worker to verify the treatment has been given and every evening data is uploaded to the server which helps in identifying missed treatments and allows follow-up with patient, health worker and Operation ASHA supervisor. It can hence work offline as well. eCompliance technology also advises community health workers to carry out pre-treatment counseling.

All TB patients must register with eCompliance using a fingerprint scanner and/or an Iris scanner. From then on both the patient and their provider (community health worker/DOTS provider) will have to use the scanner before the patient receives treatment to create accountability. Using an alert system, eCompliance ensures that the patient took his/her medication and keeps track of missed doses, and is an invaluable tool to ensure proper administration of the medicines for patients with TB in India. The health worker is then required to track down the patient within 48 hours to give the medicine and further counsel the patient, encouraging them to stick with their treatment. This monitoring system, now established in 217 of Operation ASHA's centers, has reduced the percentage of patients who fail to finish treatment to 3.1 percent. The system is currently being used in 78 ASHA TB treatment centers spanning Delhi, Korba, Indore, Mumbai, Bhopal, Raipur and other places.

Replication of eCompliance in Uganda was done by Columbia University, Earth Institute, and the Millennium Villages. Professor Yanis Ben Amor describes the system as "a staggering improvement". Replication was also accomplished in Kenya, Peru, Uganda, Dominican Republic, Afghanistan and Tanzania.

eDetection

eDetection is an algorithmic questionnaire designed to track down and diagnose tuberculosis. Using a decision-based algorithm, eDetection analyses a patient's responses to identify TB suspects, who are then tested for the disease. The guided diagnostic process is simple and easy-to-follow, which is necessary for disadvantaged communities where many persons are illiterate. The technology is easily downloaded and accessed using 3G connection and responses are systematically archived and are sent to the EMR on a central server at the time of syncing of the app. With a highly infectious disease like tuberculosis, it is important to locate new cases. By putting positive patients on the geo map using GPS, eDetection locates communities with greater numbers of infected patients.

eDetection has also been adapted for Haemophilia diagnosis.

eQuality

Quality audit has been a key part of Operation ASHA’s methodology since its inception. eQuality was developed into an app that could be downloaded on an Android tablet.

To ensure quality audit, an auditor visits a treatment center that is supported by Operation ASHA, or travels with a community healthcare worker (CHW). In observing the work of the center of the CHW, the auditor asks questions and interviews patients. Based on these responses, the auditor awards a score to the center of CHW. This score determines if the CHW receives a payment incentive every month.

This works in conjunction with Operation ASHA's other applications (i.e. eCompliance, eDetection, eAlert) to ensure that CHWs deliver high quality healthcare to local communities.

eAlert

End users, mainly lab technicians, enter patient contact details and lab results onto the system which then sends the information over the internet to a central reporting system. An SMS message is sent to concerned health workers who inform patients of their status. Lab Alert System delivers lab results more quickly and efficiently and can be installed on any tablet. This decreases the delay in enrolling patients in DOTS, minimizing the chance of spread of the disease.

eCounseling

eCounseling ensures high quality counseling of each patient treated by Operation ASHA and their immediate circle. This is done through a series of short videos and question answers. A patient's treatment cannot be started without completing Operation ASHA's counseling model.

Electronic Medical Record System

Electronic Medical Record compiles data from all of Operation ASHA's applications, including eCompliance, eDetection and eAlert. EMR is downloaded onto tablets, which have internet or SMS connectivity. All data are uploaded onto a server, which collates it into various reports. Data is regularly analyzed by supervisors within Operation ASHA. EMR has eliminated the staff needed for data collection, collation and analysis and reduced supervisory and administrative costs.

The data from EMR has also been analyzed by research organizations including University College London. They will publish the results soon in a leading journal.

eCompliance+

Tracks MDR-TB patients continuously throughout the treatment course for a span of 2 years.

Rural Outreach

Operation ASHA team travels long distances to reach rural villages and its community health workers visits places three times per week to identify and treat individuals with TB in India. As they have to cover rough terrain in many places and travel long distances in addition to unique cultures of many villages, operation ASHA trains and hires villagers to work as community health workers. The hired health workers from within community know local languages, customs, religions which helps being friendly with patient's and also provides much needed job assistance to local villages. In urban slums of India and Cambodia, ASHA team serves around 3.5 million people who previously had no access or minimum access to TB treatment. The organization facilitates treatment through shops, homes, health clinics, temples and other public utility places making them as their centers and each of these places serves between 5000 to 25000 people within a 1.5 kilometers radius. This system also helped patients to avoid time and money on travel during the course of treatment and get medicine in convenient way unlike earlier where patients had to travel around 8 kilometers requiring around 6 hours both ways in order to get medicines. The facility has helped by making patients to travel hardly for 10 minutes from their home to get treatment.

Impact

Operation ASHA increases TB-detection rate by 50-400% within 6-18 month of starting work in any area. Also, DST-TB treatment default rate has been maintained at 3%, compared to 32% in a triangulation study in India.

As of 2016, Operation ASHA has treated a total of 75,719 patients of DST-TB in India (including 9,003 patients in Cambodia), 366 patients of MDR-TB, two patient of XDR-TB, and one patient of XXDR-TB. Another XDR-TB is also undergoing treatment in India. 342 Haemophilia patients have been detected and started on treatment. Operation ASHA has also detected thousands of patients of diabetes, heart disease and mental depression, and is helping with the management of their health issues.

Following treatment, patients earn an additional $13,935 (Rs. 8.36 Lakh) on average through reinstated productivity in their lifetime (Annual TB Report 2013, Government of India). Thus, treated patients have benefited by a whopping $843 million (Rs. 5,485.3 Crore). Also, with treatment of each patient, the economy saves $12,235 (Rs 7.34 Lakh) in indirect losses (Annual TB Report 2013, Government of India). Thus, the Indian and Cambodian economies have saved a total of $740.9 million (Rs 4,816.1 Crore) for patients who have successfully completed the treatment.

Operation ASHA has also distributed millions of analgesic, antacid, antiemetic, iron and calcium tablets, condoms, Oral Rehydration Salts, protein supplements, in addition to 8 tons of food and 9000 blankets.

Till January 2021, a total of around 4930 patients had been enrolled and more than 1,05,550 supervised doses had been logged through eCompliance. The default rate had also been reduced to 1.5 percent, which is much less than that of other institutions. Additionally, the total cost of treating a patient is $80 in comparison to $300 among other NGO's. In year 2013, Operation ASHA's President, Dr.Shelly Batra, was chosen as Social Entrepreneur of the Year, in recognition of this innovative and effective methodology. In addition to combating tuberculosis and simultaneously addressing the effects of global poverty.

Operation ASHA in India

In India, Operation ASHA serves 5.1 million people of the population, operating in the following Indian states for tuberculosis:

Delhi NCR (East Delhi, West Delhi, South Delhi), Madhya Pradesh (Bhopal, Khargone, Barwani-district, Indore, Khandwa, Vidisha, Gwalior), Maharashtra (Bhiwandi, Malegaon, Vasai), Odisha (Bhubhaneswar), Rajasthan (Jaipur), and Himachal Pradesh (Solan, Sirmour, Kullu, Mandi).

Operation ASHA's hemophilia centers are located in Haryana (Bhiwani, Hisar, Fatehabad, Sirsa) and Uttar Pradesh (Aligarh, Meerut and Lucknow).

Operation ASHA in Cambodia

In Cambodia, Operation ASHA works closely with the National Tuberculosis Program, operating in 14 Operational Districts across 6 provinces and working with a total of 164 Health Centers. Overall, 15% (2.3 million) of Cambodia's population are provided with services by Operation ASHA.

Since starting operations in Dec 2010, when Operation ASHA opened its first short-course (DOTS) center in Phnom Penh, Cambodia, it has enrolled more than 11,500 patients for Tuberculosis treatment. Health care workers travel to villages on motor-bikes, carrying drugs and supplies. Health care team members approaches community members who exhibit Tuberculosis symptoms and administer medicines to patients in their homes.

Operation ASHA Cambodia Website: http://opashacambodia.org

Forschung

In collaboration with Johns Hopkins-Economic Department and MIT-J-PAL, Operation ASHA studied incentivizing community health workers to determine if monetary rewards for finding new TB suspects will result in health workers identifying more TB patients that can then be treated, as well as preventing patients from default.

Operation ASHA worked with University College London (UCL) to study the detection of depression in TB patients and family members. If a correlation between adherence to treatment and depression is found as suspected, an intervention program similar to one used in the UK can be developed for India and implemented at a later stage of the study.

Operation ASHA was involved in a research project with University College London wherein TB specialist Dr. Marc Lipman and his team analyzed the eCompliance data for two years. It was accepted for a poster presentation for the International Union Against Tuberculosis and Lung Disease Conference 2016. There has also been a poster presentation at the British Thoracic Society on eCompliance titled ‘Utilizing Community Empowerment and Biometrics to Facilitate DOTS in Delhi Slum Populations: The Operation ASHA Model’.

Operation ASHA conducted a randomized control trial (RCT) with MIT JPAL on whether use of biometrics give improved outcomes when used by community health workers or not.

Operation ASHA, Johns Hopkins, University of Maryland and University of Chicago are conducting an RCT to determine whether giving cash incentives to existing TB patients will encourage them to find others with symptoms and refer them to our program.

With support from the Bill and Melinda Gates Foundation, Operation ASHA and Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health of University of Chicago are conducting workshops with underprivileged teens in Lucknow, Uttar Pradesh, India. Through games and storytelling, we will better understand the social determinants of adolescent health and well-being. The goal is to empower youth to develop strategies for improving gender equality and sexual and reproductive health.

TB and diabetes: Through a six-month pilot, Operation ASHA investigated the potential ways and means of establishing a sustainable model for diabetes management among TB patients.