Digital Pulse - Chap 3 - Sec 4 - The Compliance Service

Development Issues: Health, Tuberculosis, Technology, HIV/AIDS

Programme Summary

Cape Town, South Africa, has one of the world's highest incidences of TB, largely due to socio-economic and climatic factors. TB patients must strictly follow a difficult drug regime -- four tablets five times a week for six months -- and they often forget to take their medication. Non-compliance with the drug treatment has exacerbated the high occurrence of TB and has created difficulties for the local, overburdened healthcare service. Medicines are wasted when people do not take their medication on schedule, and non-compliance causes the TB virus to become increasingly drug resistant.

After much research Dr. Green, a consultant in Managed Care, Disease Management and Information Systems, came to two important conclusions. Firstly, he observed that interventions designed to prevent non-compliance of treatment were not effective because they were applied indiscriminately. He concluded it was necessary to identify those patients who were non-compliant and find out why they were not taking their medication. Secondly, he was struck by the overwhelming literary evidence that suggested people were not taking their medication simply because they forgot.

Dr. David Green developed a service in South Africa that uses the Short Message Service (SMS) to alert tuberculosis (TB) patients to take their medication. The initiative has led to a significant increase in the recovery rate of patients and could lead to savings for healthcare authorities. This project is being extended nationally and considered for HIV medication.

Summary of ICT Initiatives

Evidence suggests that TB patients often do not take their medication simply because they forget. So, Dr. Green uses SMS (Short Messaging Service) – text message service that enables short messages of up to 160 characters to be transmitted between cell phones – to alert patients to take their medication. Healthcare professional were sceptical whether the uptake of cell phone technology was high enough to justify the project. However, Dr. Green found that over 50% of people in the Cape Peninsula had access to cell phones. At the clinic where the pilot study was conducted, 71% of TB patients had access to a cell phone.

Dr. Green enters the names of TB patients onto a database. Every half an hour his computer server reads the database and sends personalized messages to the patients, reminding them to take their medication. The technology that he uses to send out the messages is extremely low-cost and robust: an open source software operating system, web server, mail transport agent, applications, and a database. Currently Dr. Green charges the City of Cape Town R11.80 per patient per month to send out SMS messages. Initially the SMS message sent to patients read: "Take your Rifafour now." When patients complained about the boring message, Dr. Green sent them a variety of alerts, including jokes and lifestyle tips with the result that he now has as database of over 800 messages that he changes on a daily basis. Of the 138 patients involved in the pilot, there was only one treatment failure.

Observations

The Medical Research Council (MRC) of South Africa and the University of Cape Town has now embarked on a Randomized Control Trial to compare the cost-effectiveness of the SMS-reminder service against the cost of non-compliance to TB treatment. In the interim, the World Health Organisation has cited the project as an example of "international best practice". The City Council of Cape Town has decided to extend the pilot project to other City clinics where the cell phone ownership of patients are high, while the South African Government is considering the technology for nationwide use. The system is also being investigated for use with HIV treatment.

Other organizations involved in best practice evaluations and analysis have also looked at Dr. Green's project. The following is an evaluation that was done based on bridges.org's 7 Habits of Highly Effective ICT-for-Development Initiatives and asks the question of whether or not this project has had a Real Impact on the ground.

1. Implement and disseminate best practice. - Dr. Green did a lot of research on compliance and adherence to medicine that led him to the insights on which this project is based.
2. Ensure ownership, get local buy-in, find a champion. - Dr. Green convinced the City of Cape Town's health directory to run a pilot at one of the City's clinics and so spurred on the public use of his technology. He ensured buy-in for patients by acting on their feedback.
3. Do a needs assessment. - Dr. Green was aware of the need for interventions that increase TB medication adherence, and especially so in Cape Town, which has one of the highest rates of TB infection in the world.
4. Set concrete goals and take small achievable steps. - Dr. Green first tested the reminder messages on his mother, who was taking medication for hypertension. He then convinced the City of Cape Town to run a pilot at one clinic. On the back of that success a Randomized Control Trial has been launched, involving South Africa's Medical Research Council (MRC), the University of Cape Town (UCT) and Dr. Green.
5. Critically evaluate efforts, report back to clients and supporters, and be prepared to adapt. - MRC and UCT are providing a critical, independent review of the pilot project. The outcome of the trial will be published in four research papers that will be subjected to peer review.
6. Address key external challenges. - The biggest external challenge that Dr. Green had to face was the preconceived ideas of health professionals regarding the uptake of cell phone technology in Cape Town.
7. Make it sustainable. - Dr. Green's company, The Compliance Service, is based at the UUNET Bandwidth Barn, which provides small IT businesses with affordable office rentals, shared office facilities, and reduced Internet connectivity costs. He deliberately kept the price of his service low so that more people can use and benefit from the technology. His choice of technology has enabled him to provide his service at a very affordable price.

The initiative not only uses technology to address a real need effectively, but it does this in a simple, affordable and flexible way. Dr. Green uses a server, free software and a bulk SMS provider to send out the SMS messages. His system costs very little because he uses freely available open source software.

Partners: City Council of Cape Town, U of Cape Town, South African Medical Service Council

Source: Bridges.org ICT-Enabled Development Case Studies Series: Africa and the Compliance website: On Cue, Automated SMS Scheduling and theEldis ICT for Development Resource Guide.

For More Information Contact:

Dr. David Green

The Compliance Service

Tel: +27 21 790 4521

david@on-cue.co.za