In Sarita Vihar, a residential colony in South Delhi, quite far from the traditional hangouts of the development community in the city, Operation Asha – one of the biggest TB treatment NGO in the world – has its headquarters.

 

A handful of technology enthusiasts monitors data from service delivery in nostalgic 90s PC. Mohan drives us to an austere office where Dr Shelly Batra is waiting for us. Nonchalantly, we enter into her work as practitioner, doctor and global opinion leader. She is the president and cofounder of Operation Asha, a Senior Obstetrician and Gynecologist, 2014’s Social Entrepreneur of the year and an Ashoka Changemaker.

 

When the chai is eventually over, we ask abruptly: What is Tuberculosis?

 

A: TB is the biggest infectious disease killer in the world today. Tuberculosis is simply an infectious disease, it happens because of a bacterium, and that bacterium is exiled in the breath and goes on circulating in the air, so anyone can get the disease. Actually, it is not just a disease. It’s a socio-economic problem: people lose jobs, women are thrown out of home. Young girls find difficult to get married. Children have to leave schools.

 

Q: Evidence shows that the lost to the world will be an unbelievable 3.4 trillion dollars in the next decade because of the huge number of TB cases, especially among the poorest ones. Who will be the most affected?

 

A: Typically, TB attacks those with low immunity. Think of people who are malnourished, think of people with HIV/AIDS or diabetes, they are the ones who are more prone to get TB. At the same time let’s think of the disadvantaged. Those who live in crowded conditions. Imagine a room six feats by 6 feats. There is no ventilation, there are six people crammed inside, if one has TB, they all have TB. Moreover, global travels, migrations and many other factors have brought TB all around the world. As this were not enough, drugs don’t act anymore, the disease is back in a more deadly avatar, that of Drug resistant TB. That happens because of incomplete treatment.

 

Q: What do you mean?

 

A: More than 90 countries have reported advanced cases of drug resistant TB. India reported 12 cases of TDR, totally drug resistant TB, for whom we have no cure.

 

Q: You introduced the case of India. India has the biggest tuberculosis burden in the world. Twice as many cases as China. At the same time, India has TB control programmes. The government, international organizations and local NGOs have laid down a great infrastructure against this pandemic. So, what is missing?

 

A: It’s true. Two million people get TB in India every year. We also have good doctors, we have the specialists, we have the medicines, we have diagnostic facilities, everything is there. Everything is available. But, I will tell you what is missing in India: the accessibility. Everything is available but not accessible. Here lies India’s challenge: to provide the last-miles connectivity with the poorest of the poor.  Funds should be directed to the poorest of the poor. What is the point of millions of dollars being given to countries and governments if the benefit doesn’t trickle to the beneficiaries? So I think there is a lot that needs to be done, we need all our hands on tech number one, we need families, foundations, governments, multilateral and bilateral agencies all to think and redefine our strategies against Tuberculosis.

 

 

Q: Why are TB patients so hard to reach?

 

A: There are two reasons: number one, they can be living in hard-to-reach-areas. Our tribal patients live in areas, which we can access only on foot. You have to walk and walk for miles, and then you will reach the patients. Then we have patients in conflict ridden zones, again difficult to reach. We have patients in the mountains, in the desert, and far away from the cities. As this were not enough, there is another problem. We have patients who are hard to reach, because of a self-imposed isolation, born out of fear and insecurity. There is fear of death; there is fear of infecting your loved ones. There is social stigma. Moreover, there is very little education in this respect. People simply do not know about the existing TB programmes. They cannot read and write sometime.

 

Q: Here is where Operation Asha steps in. Right?

 

A: Exactly, operation ASHA was born in order to fill the gap in the delivery chain. We developed a doorstep-delivery-model by bringing together community and technology. We brought TB centres where patients live. Think of a Hindu Temple. Before going to school, children get their medicine after the first pray at 6.30 in the morning. Factory workers get the medicine on their way back home.  In places where patients are scattered, we have mobile DOTs. Providers go door to door, they carry the strips of medicines with them, they also monitor whether medicines are swallowed.

 

Q: That’s impressive. But, it seems that you place a very high burden on service providers. How do you monitor their work?

 

A: In TB treatment centres, a fingerprint scan gives us information about the patient in real time. We also give our providers cash incentives. It’s very important that they have adequate incentives to go the extra miles into their work. To give you an idea, it has been found that, out of nine million new cases in the world, three million are not detected, so active case finding, improving detection is an immediate need. For this reason, we pay our providers 3 dollar for every patient detected and enrolled into the TB treatment programme. We also give our providers incentives to make patients complete the treatment. If a patient misses a dose, the provider has to go to the patient house within 24 hours and take the fingerprint as a proof. She repeats the counselling and tells them how important is TB medication. Then, there is a multilevel accountability: GPS tracking shows whether the provider actually goes where he is supposed to go.

 

 

Q: This sounds like a manual of service delivery: technology, community-based approach and social empowerment.

 

A: Technology has a positive impact on the psyche of the patients. It also improves the skills of our health workers. They are learning something new. They are learning how to use computer in the office and even in remote settings.

 

Q: So, technology, technology, and technology…

 

A: Technology saves time of the providers. It brings down costs and helps to have a wider reach. Ideas like eCompliance and fingerprints are low-cost and simple. However, in order to be so successful, they have to look at people’s needs first. We developed our system in the field. Health workers and people’s everyday challenges were an integral part of the entire development process. All in all, when each village has a different character, it’s all about local people. We have to train local people, they are the best ones to understand local needs. Technology will help them to make their work better by ensuring reliable data, accuracy and scalability.