“Our unique doorstep delivery model goes beyond health”

Operation ASHA has emerged as a last-mile healthcare delivery organization and the third-largest tuberculosis-control NGOs in the world. It has expanded its healthcare delivery pipeline to the doorsteps of nearly 10 million people in India and Cambodia and has treated over 100,000 TB patients. It also provides treatment and amelioration of other diseases including diabetes, haemophilia, cardiovascular diseases, menstrual and adolescent health issues.

In an exclusive Chat with BioVoice, Sandeep Ahuja, the CEO and Co-founder of Operation ASHA shared details about how highly cost-effective, resource-efficient, and patient-centric model developed by his organization have been replicated in seven other countries. Mr Ahuja also talked about the use of BCG vaccine against COVID-19, on the ground experiences and much more. Read on:

Take us through the foundational philosophy of Operation ASHA. What is the vision behind the initiative and how is it different from the crowd?

Operation ASHA is so different from the crowd that it is cited internationally as a model of innovation by not one, but many world-renowned experts. I would like to quote what Director Innovation of the World Bank said about our organization. “Operation ASHA’s work involves all kinds of innovations which dramatically reduces the cost of treatment. They reduce social stigma, which makes it easier, particularly for women to seek treatment. They have also identified ways to increase treatment compliance for a disease that is traditionally difficult to treat because people don’t constantly take their medication for months.”

For us, there are many reasons for developing such powerful innovations. First is the vision of scaling its model to the entire developing world and eradicating TB globally, against the usual ‘vision’ of most NGOs to serve a cluster of villages. Second is to make the model so cost effective that developing countries can adopt it at scale. As a matter of fact, the model is so inexpensive that it will reduce costs multiple times in developing countries so the program can be expanded to vast areas without increase in national budgets. Thirdly, the model has robust in-built feedback loops and quality assurance, which are often overlooked in public health models, especially those run by NGOs. Finally, the model is highly patient and community centric. So, it finds easy replicability across linguistic, geographical and national boundaries.

No wonder, Operation ASHA is one of the youngest NGOs to reach the top 100 worldwide. Not only that, but it is also the one with the LOWEST Operating budget in that class. A comparison would be useful. Global Fund, which is just one rank below Operation ASHA, has a budget of billions of dollars, which exceeds Operation ASHA’s budget by more than 1000 times. Unbelievable but true.

Tell us a little more about the model of Operation ASHA

We have devised a unique doorstep delivery model which goes beyond health. It is low cost and efficient and can be used to provide any service to the disadvantaged even in inaccessible and remote geographies. It has been deemed as one that can deliver any health service. In the past 8 years, Operation ASHA’s model has been replicated in six other countries. Apart from TB, we are currently also providing treatment, education and prevention for hemophilia, diabetes, hypertension, heart disease, and adolescent and menstrual health, serving 15.6 million people in over 5000 slums and villages of India and Cambodia. The model works seamlessly as we empower community health workers with technology.

Since 2006, Operation ASHA has been successful in taking tuberculosis treatment to the doorsteps of individuals living in disadvantaged areas across 9 countries at economically feasible rates. This has been a significant achievement for us. We remain committed to making healthcare services further affordable and accessible to millions of others.

In your view, where does India stand currently in its fight against tuberculosis? Are we doing enough? 

Tuberculosis still remains the biggest infectious disease killer in India. According to the India TB Report 2020, India recorded 24.04 lakh TB cases, and 79,144 deaths in 2019. The report also highlighted that the treatment success rate of TB patients has risen from 69% in 2018 to 81% in 2019. This demonstrates that India is moving in the right direction. The improvement in performance of the private sector’s in TB treatment in India has helped greatly in treatment to TB patients.

India is also on the path to bridge the gap between the number of tuberculosis cases estimated and those detected, and it could soon find all its “missing million” TB patients. We have been able to find 7.81 lakhs missing cases as against 10 lakhs in 2018. These numbers suggest the success of India’s drive to eliminate tuberculosis.

Our aim as a country should be to cater to the patients who fall through the cracks due to remoteness or discontinue their treatment once the symptoms stop showing. Technology can be an effective tool that can enhance our healthcare services.

At Operation ASHA, we use local health workers in areas with high TB to set up local or mobile treatment centers integrated within existing community resources, like temples and shops. We empower them with technology such as portable fingerprint, retina or face-identification system that tracks and compiles patient adherence data and alerts health workers to follow up with a patient within 48 hours of a missed dose. As a result, we have 100 percent detection rate and treatment success rate of around 87%. Also, technology helps us in maintaining electronic record and there are no chances of human error or inaccuracy.

Is the goal of eliminating TB by 2025 a realistic one? What do you consider as challenges in the way of eradication of TB in India?

The Indian government has said that the country would reduce new TB cases every year to 44 per 100,000 by 2025. The National Strategic Plan 2017 – 2025, sets out the government plans of how the elimination of TB can be achieved with four strategic areas of Detect, Treat, Prevent & Build. With more investment in healthcare and improvements in detection and treatment, the Revised National TB Programme and free treatment, and the improvement in treatment by private players, India is moving closer to its goal of eliminating TB. While it seems difficult to achieve the goal, it is not impossible.

Currently, the biggest challenge in providing TB treatment is the lack of last mile connectivity. Even though the government provides free treatment for tuberculosis, the average cost of commuting to hospitals and labs is more than 500$. The high cost makes it unviable for patients to undertake long term treatment as majority of them are daily wage earners. And to contain the spread of the disease, it is essential for patients to complete the entire course of the six-month treatment. TB treatment is thus rendered difficult in India due to remoteness, lack of access and high cost of treatment.

At Operation ASHA, we address the issues that TB patients face by making continuous efforts to reach all our patients even in the remotest villages in the country with the help of community health workers and volunteers. The community health workers are familiar with local customs and languages which help us in communicating and educating masses about the disease. This also helps break all the stigma and myths around TB. In case of disease management, workers collect samples and return results in the vicinity of the patients’ house after transportation to labs. Most importantly, they are essential for active case finding (ACF). Additionally, the patients are tracked with our electronic applications coupled with GPS, finger print and retina scanner which improves the attendance of our patients and helps us keep a track of their progress

How is the Operation ASHA playing a role in the End TB campaign and advancing progress towards ending the disease in line with the SDGs?

Operation ASHA works in collaborations with governments/ public health departments as well as private hospitals, which provide medicines, diagnostics and physicians’ services mostly for free. It also advocates with all stakeholders to improve lives of patients. We have developed an effective and highly innovative patient-centric, community driven, deep, low cost, last mile delivery system that is scalable and is heavily supported with technology.

In terms of number of patients served, Operation ASHA is the biggest TB control NGO in India and third biggest in the world. Not only that, we have achieved an unprecedented treatment success rate, at a cost that is 32 times less than other NGOs, which do similar work. We have detected and treated over 1.1 Lakh TB patients till date. Our CHWs raise awareness, scour the communities for symptomatic, ensure testing, link them to high quality medical practitioners and finally provide treatment and ensure adherence. Since our inception, we have managed to achieve a treatment success rate for drug sensitive TB of over 85%. The second best recorded success rate, after evaluation by a third party is 77%. Our loss to follow up rate is of less than 5% in treatment of DS TB, which is many times lower than comparable programs across the world. To put it in context, one report states that certain programs have reported as much as 46% loss, meaning that 46% patients never complete treatment. This is 9 TIMES worse than Operation ASHA’s performance. We have also sensitized and screened nearly 7.7 million families, including contacts of TB patients for symptoms out of which nearly 1,000,000 persons have been tested for TB. We have also generated employment for nearly 500 semi-literate disadvantaged youths.

We are working tirelessly towards fulfilling the United Nation’s Sustainable Development Goal 3: Good Health and Well-being. We believe in justice and inclusion, thus also fulfilling the Sustainable Development Goal 10: Reducing Inequalities. We serve the poorest of the poor irrespective of religion, colour, caste, political or religious beliefs, or sexual orientation. A Randomized Controlled Trial by J-PAL showed that 60% of our patients belong to the backward classes, and most are illiterate. We work extensively towards gender equality and serve as many women and children as possible and persuade their families to treat them with compassion. 30% of our health workers are women which also helps them get added respect from their communities and live with dignity.

How has the COVID-19 crisis impacted your work?

The shutdown subsequent to the COVID-19 pandemic brought new challenges. We were worried about massive reduction in detection because the government put a halt to active case findings. Also, due to social distancing, our face-to-face interactions with the patients has become staggered. But, to our surprise, our community workers have more than met the challenges. We have still been able to get 50-90% of the patient numbers against expected reduction of over 50%. Not only that, but our workers have also been in constant touch with our patients telephonically throughout the lockdown. Our community health workers have also been keeping a track of our patients and their medicines. Instead of providing a week’s medicine, we are providing one month’s medicine in advance to all our patients. We have also provided funds for food rations and rent etc. to those in need so they do not migrate to villages which will lead to an interruption in TB treatment. This has helped us achieve an unprecedented treatment success rate of 93%. Had anyone asked me last year, I would have said none other than God can deliver this kind of results.

In short, Operation ASHA is one program which has converted the shutdown into an opportunity. A great change from the usual grim stories one gets to hear during these times.

Are the tuberculosis vaccines effective for the frontline workers and medical staff during the corona crisis? How?

Even though COVID and tuberculosis both affect the lungs, there is no verified evidence that the vaccines that are effective for treating TB can be beneficial for coronavirus patients. Also, even the BCG vaccination cannot prevent natural tuberculosis infection of the lungs and its local complications, although it reduces the complications of primary infection, thus it is not proven that it can treat coronavirus. Randomized controlled trials using BCG vaccine are underway to find out whether the vaccine can reduce the incidence and severity of COVID-19 among healthcare workers.

While there have been a few countries where BCG vaccine has been provided to frontline workers and elderly people to see whether it can provide some kind of protection from COVID but we are yet to see any success on this.

 Would you like to share a few unique ground-level experiences during the efforts to contain TB in India?

 The on-ground situation is different with every patient. As there is a lack of awareness in people about TB, many people suffering from the disease and even those around them are unable to identify the symptoms. They are often ostracized from the society and lose their jobs due to the disease. Often, we have to convince patients to continue their treatment.

We come across various experiences in the rural parts of India. One such case was of Nababa, one 40 year old patient from rural Madhya Pradesh. This person was a daily wage earner who was forced to remain at his home since he was not in a condition to work. The whole family had abandoned him because of the fear of disease as TB in rural areas has a stigma around it. We wish that he should be fine and be able to return to work, earning his daily wage and caring for his daughter. However, there is no instant cure, no instant relief. Nababa has months of drug therapy ahead.

This is what usually happens with a lot of daily wage earners who get TB. Their source of income is effected, even if we give the medicines for free, due to malnutrition it takes a lot of time for them to properly recover.

During the pandemic, we were more careful about our patients as there is a higher chance of TB patients contracting COVID because both damage the lungs. TB patients are also quite poor and so malnourished. So, they would be more prone to COVID. However, of the 2200 patients on TB treatment in India and 4500 in Cambodia with Operation ASHA, none has contracted COVID This raises another possibility that TB drugs reduce the risk of contracting the virus. This is another research question ICMR and other research agencies should investigate.

Do we have enough funds available for the defined goal? What have been the immediate priorities and long-term goals of your organization? 

Over the past 5 years, the Central government’s TB program’s budget estimates have increased a lot, according to the annual TB report 2020. Since 2017, the government has allocated Rs. 16,649 crores for TB treatment. Considering the total number of cases in India that are in our radar, the funds might not be adequate for TB elimination currently. We expect the government to invest more to achieve our goal.

The immediate priority for Operation ASHA during the pandemic is to continue the treatment for all our patients. In the long term, we are working towards eradicating TB from India as well as reducing TB related mortality rates. We envision a world without TB.