New DOTS (IDEAS Competition Prize-winner $5,000)
The TB Problem
One-third of the world carries tuberculosis (TB) and within that group, 14.6 million people have an active case. These numbers are both shocking and tragic because there is an effective treatment for the disease. However, unmonitored patients often forget or avoid taking their drugs because the treatment is long (six months), complicated (consisting of a multiple drug regimen), and can cause uncomfortable side effects and alleviation of symptoms (but not the actual infection) before the treatment period is over. The result is that in most developing settings only 15% percent of patients who begin treatment will finish it unless they are closely monitored. Thus the global TB problem is spiraling out of control and drug-resistant TB is becoming more prevalent, leading to fears of widespread outbreaks of TB super-strains.
The best solution to have yet been found for this problem is the Directly Observed Therapy, Short-course (DOTS) system, which is the primary plank in the World Health Organization's tuberculosis eradication program. This system achieves high rates of treatment adherence (around 85%) because healthcare workers observe patients take their drugs every day. However, DOTS is extremely expensive - between $70 and $150 per patient - and human resource intensive. The high costs and deficit of trained health workers mean that the most rural and poor areas have low rates of DOTS penetration, with little hope that DOTS can feasibly be extended to those areas . Thus, DOTS coverage varies significantly by country and, in 2002, was available only to approximately 37% of people with TB. Within countries there are also huge regional variations. For example, coverage in India is relatively extensive, with optimistic measures estimating 84% percent of the population is covered by DOTS, but those remaining 16% percent are in extremely rural and poor areas where there is neither money nor human resources for DOTS.
Our system is a combination of a novel remote monitoring device and microfinance-based incentives:
- Novel urinalysis test strips check daily that patients have taken their drugs (reducing forgetfulness and procrastination);
- Reporting using widespread cell phone technology reduces the need for human resources (eliminating the issue of health worker absenteeism and lowering the cost to half that of DOTS); and
- Customized microfinance incentives reward compliant patients with progressively increasing benefits (encouraging them to continue treatment even when side effects cause discomfort or symptoms are alleviated but infection persists).
The New Dots system allows penetration of tuberculosis monitoring into disadvantaged areas where lack of infrastructure makes DOTS extremely difficult, if not impossible, to implement. Furthermore, we expect that our system will be so much more inexpensive and effective that it will be an attractive alternative for almost every organization that uses DOTS.
New DOTS (PDF)