Operation ASHA

Using technology to strengthen screening, improve early detection, and increase access to prompt treatment for tuberculosis (TB).

Tuberculosis (TB) is a preventable, curable disease but, globally, there are 10.4 million new cases of TB every year. A quarter of those cases are in India alone. Moreover, TB is not just a disease, trapping people in the vicious cycle between poverty and disease. Due to stigma and ill health, TB patients often lose their livelihoods and the support of their community.

Although the Revised National Tuberculosis Control Program (RNTCP) program of India provides free medicines, diagnostics, and physician services to patients, getting these products and services to patients at the last mile remains a significant gap. For instance, it is estimated that initial default is 18%, i.e., 18% of TB patients in India are “lost” despite getting diagnosed in RNTCP TB labs. These patients never start treatment in spite of being diagnosed and go on infecting others. Their own condition also worsens, leading to complications and avoidable deaths.  

Treatment adherence is also a big concern. Patients who do start treatment may not complete the standard 6-month regimen, whether because of lack of access, stigma, or side effects. Of those who default (dropout of treatment), around 50% will get Multi-Drug Resistant TB (MDR-TB), which is not only difficult to diagnose and treat but, if left untreated, has a mortality of 80%.

Historically, data accuracy has been another issue in the RNTCP, with the Treatment Success Rate (TSR) found to be 75% (previously reported as 89%) and default or dropout rate is nearly one-fifth or 20%, (though it was previously reported as 6%). (Source:

http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002149).

Operation ASHA (OpASHA) is able to solve for all of these problems. OpASHA provides last-mile delivery of screening, treatment, and care while both maintaining data integrity and improving adherence to and completion of treatment.

OpASHA uses a unique combination of 3 main things: (1) in-house software and low-cost off-the-shelf components (biometric technology and Android tablets), (2) hiring and training local community health workers (CHWs) to provide end-to end TB services, and (3) establishing long-term support from local governments -- all to to achieve unmatched outcomes at unmatched costs.

We leverage the trust of community leaders wherever we work. Our CHWs provide medicines to the patients at their homes, from early morning until late night, so no one has to miss work or wages to take treatment. We train and equip CHWs to use eCompliance, which validates directly observed treatment (DOTS) and every dose taken by fingerprint. This not only reduces default and MDR-TB, but also ensures absolute accuracy regarding work done and data collected.

With grant funding from Solve, we propose to work in one large city of Maharashtra, called Vasai-Virar Municipal Corporation, covering a population of 300,000 people in urban slums.

By expanding Operation ASHA’s technology and CHW-driven model in India, we can make a significant dent on this devastating disease, TB. Our solution will help move the world -- toward a world without TB.

OpASHA’s model is designed around patients and CHWs, while also positioning us to reach the degree of scalability required to control an extremely infectious disease like TB. Not only do we achieve one of the highest TB TSRs in the world, but our cost to treat one patient is only $80 -- 19x less than the next comparable NGO.

We have developed our suite of Android applications (eDetection, eCompliance, and eCounseling) to empower CHWs. For example, our user interface utilizes color-coding and minimizes text for ease of use by semi-literate CHWs and enables them to provide extensive patient counselling throughout treatment.

OpASHA’s Android applications are deeply embedded in our model and designed to work offline in low-resource settings. These applications include: 

1. eDetection -Built-in surveys and algorithms enable semi-literate CHWs to perform active case finding and contact tracing, identify TB symptomatics, and get symptomatics tested.

2. eCompliance -Fingerprint verification tracks every dose taken and enables follow-up with missing patients; automated messages are sent to CHWs, their supervisors, and patients, when patients miss a dose.

3. eCounseling -Embedded, animated video series supports proper education and counselling.  

Collected data is synced daily, stored in the cloud, and subsequently synthesized for transparent, strategic decision-making.

With $10,000, we plan to appoint 6 CHWs and 1 Program Manager to cover 300,000 people living in the urban slums of Vasai-Virar Municipal Corporation in Mumbai. These employees will work through 12 mobile centers to provide TB screening and treatment services in these communities, reaching 651 TB patients over the next 12 months. Based on the results of the first year, we believe that the program can and will be adopted by the government, leading to in-kind grant-in-aid from the RNTCP that will enable the program to grow sustainably in this region.

In India, we are in the process of expanding our services across entire states. Over the next 3-5 years, we hope to also expand our work in Cambodia, where we currently treat 16% of all TB patients. By covering the entire population of a highly populous state or country, we hope to systematically eliminate TB in that region and develop a replicable, larger-scale approach to eliminate TB not just throughout India, but around the world. This work in Mumbai will support the adaptation of our model throughout India and our race against the rapid rise of drug-resistant TB.

CHWs form the backbone of the entire program. OpASHA will appoint and train a cadre of CHWs who will be recruited from the communities. These CHWs will do active outreach in the community, actively finding cases of TB by referring identified symptomatics to government testing labs. CHWs subsequently follow up with identified patients to provide treatment and counselling services with support from our technology. In urban areas like Vasai-Virar Municipal Corporation in Mumbai, treatment is provided in times and locations that are most convenient and least stigmatizing for patients, e.g., within existing pharmacies or at home.

Operation ASHA currently serves a population of 15.6 million people across India and Cambodia, where we were able to treat 12,480 TB patients. Successful treatment of TB patients also prevents further transmission to others.

Additionally, through third party replication, we are able to expand the impact of our model in 6 others countries. In Afghanistan, we collaborated with a local NGO (that is working with the government) to establish 22 centers in Kabul. In Tanzania, 3000 TB patients are being treated with eCompliance support in collaboration with a local NGO that is working with the government’s TB control program.

In Vasai-Virar Municipal Corporation, we plan to achieve a TSR of 85% (for standard TB), as we have elsewhere. In the first 12 months, we expect to reach 651 TB patients which includes the process of case finding, diagnosis, counselling, and treatment. Moreover, based on prior experience, we anticipate that we will increase the detection rate of TB patients by 50-400% within 6-18 months of starting work in this area. Within 3 years, we hope to both expand our impact throughout Vasai-Virar Municipal Corporation as well as to neighbouring communities where the TB burden is also high.

Dr. Shelly Batra, MD, President & Co-founder, is a physician who brings several decades of clinical experience and medical skills to this project. Sandeep Ahuja has an MPP from the University of Chicago. He is our CEO & Co-founder and is a management and strategy expert. Sonali Batra has a Masters in Computer Science from Georgia Institute of Technology . She is our CTO & Director Development.The technology and the field operations teams have a lot of experts and experienced people who have successfully completed many projects.

Operation ASHA does not generate any revenue as it is purely a not-for-profit entity. 

Solve gives us an opportunity to make what we are already doing better. The experienced team and mentors from Solve-MIT will be a great benefit for the project with their suggestions and ideas which will make the project much better.

Some of the key barriers are risks around ensuring the supply of pharmaceuticals, lab reagents, etc. However, in the past the RNTCP has demonstrated strong supply-chain management, delivering every necessary product/service consistently over the last few years, so we believe that this risk is not very high.

Generally, OpASHA has experience working in similar geographies before and has successfully achieved its targets in those communities, so we do not foresee any other major; Solve can help by ensuring that momentum for this project and our solution continues to grow.