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AFRO-NETS> Impressive use of cell phones for TB compliance

  • Subject: AFRO-NETS> Impressive use of cell phones for TB compliance
  • From: Leela McCullough <leela@usa.healthnet.org>
  • Date: Fri, 24 Jan 2003 11:10:40 -0500 (EST)

Impressive use of cell phones for TB compliance

[From the Moderator: If you want to contact Dr. Green directly,
mailto:david@on-cue.co.za as he is not on the AFRO-NETS mailing list.

An initiative of IICD and bridges.org

The bridges.org/IICD Case Study Series on ICT-Enabled Development
sets out to illustrate how ICT contributes to development in Africa.
The aim of this series is to help ground level initiatives imagine
the possibilities of what can happen if they use ICT successfully to
overcome development obstacles, and to contribute to the existing
body of knowledge on the digital divide. For more information about
the case study series, go to:

The Compliance Service uses SMS technology for TB treatment

I. Overview

Initiative: Dr. David Green's Compliance Service uses the Short Mes-
sage 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

Implemented by:
Dr. David Green, a qualified medical practitioner and consultant in
Cape Town, South Africa, through his company The Compliance Service.

Field: Healthcare.

Funding or financial model:
Commercially driven. A pilot project has been sponsored by the City
Council of Cape Town.

Timeframe: Started in 2002.

Local context:
The population of Cape Town is divided along race and class lines.
White people generally have access to middle and high-income jobs,
good municipal services, and private healthcare, and they can afford
comfortable housing. Coloured, and especially black citizens of Cape
Town generally have low paid jobs or are unemployed, live in informal
settlements where housing is often substandard, cannot rely on good
municipal services, and have to use the overburdened public health-
care system. Cape Town's Mediterranean winters are cold and wet, and
this poses an additional health hazard for people living in informal
settlements. Large areas of these settlements are built below the wa-
terline and are flooded during the winter months. Due to this combi-
nation of factors, poor black people are more prone to contracting
TB. Unemployment countrywide is estimated at 41.5% and the GDP per
capita is estimated at US$ 8,500 (Global Insight, an international
research company).

The development problem/obstacle addressed:
Cape Town 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 occur-
rence of TB and has created difficulties for the local, overburdened
healthcare service. Precious medicines are wasted when people do not
take their medication on schedule, and non-compliance causes the TB
virus to become increasingly drug resistant.

How ICT is used to overcome the problem:
Evidence suggests that TB patients often do not take their medication
simply because they forget. So, Dr. Green uses SMS (Short Messaging
Service) -- a 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 skeptical 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 personalised
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 ZAR 11.80 (ca. 1.3 US$) 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 pi-
lot, there was only one treatment failure.

Next steps:
The World Health Organisation has cited the project as an example of
"international best practice". The City Council of Cape Town has de-
cided 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 sys-
tem is also being investigated for use with HIV treatment.

Geographical area targeted:
Currently Cape Town, South Africa, with the potential for future ex-
pansion across South Africa.

Contact Information:
Dr. David Green
The Compliance Service
Tel: +27-21-790-4521

II. Gauging Real Impact

Has this use of SMS messaging in the treatment of TB had a Real Im-
pact at ground level? How does it compare to the best practices es-
tablished by other successful initiatives? We used bridges.org's 7
Habits of Highly Effective ICT-Enabled Development Initiatives as a
framework to highlight what this initiative has done well.

1. Implement and disseminate best practice.
Dr. Green did a lot of research on compliance and adherence to medi-
cine while doing his PhD in Pharmacology which led him to the in-
sights 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, instead of selling the service to private doctors.
He ensured buy-in from 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 to take
her hypertension medication. He then convinced the City of Cape Town
to run a pilot at one clinic. On the back of that success a Random-
ised Control Trial has been launched, involving South Africa's Medi-
cal Research Council (MRC), the University of Cape Town (UCT) and Dr.

5. Critically evaluate efforts, report back to clients and support-
ers, 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 subject 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 of-
fice rentals, shared office facilities, and reduced Internet connec-
tivity 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 af-
fordable price.

III. The Story

A Cape Town doctor has dramatically helped the fight against tubercu-
losis (TB) by introducing a SMS service to remind patients to take
their medication.

Dr. David Green, a consultant in Managed Care, Disease Management and
Information Systems, became so frustrated when his mother constantly
forgot to take her medication for hypertension, that he started send-
ing her SMS reminders -- and it worked. Thanks to research he did for
his PhD in Pharmacology, he was able to take his idea further and ap-
ply it to public healthcare. Dr. Green's reading eventually led him
to two important insights. Firstly, he concluded that interventions
designed to prevent non-compliance of treatment was not effective be-
cause it was 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.

It did not take him long to make the connection between the effec-
tiveness that his SMS messages had on alerting his mother, the high
incidence of TB in Cape Town, and the possibilities that bulk SMS
messages could present. However, when he wanted to pilot his innova-
tive idea with TB patients at a local clinic in Cape Town, he met
with resistance. Healthcare professionals were skeptical about the
number of patients who would have access to cell phones. Not de-
terred, Dr. Green went back, did research and persuaded them with
statistics which indicated that over 50% of Cape Town residents have
cell phones. In addition, he found that 71% of patients at the clinic
he earmarked for the pilot had access to cell phones. The local
health authority eventually agreed and paid R11.80 per patient per
month to run the SMS reminder service. The results of the pilot have
been outstanding: of the 138 patients involved in the pilot, there
was only one treatment failure.

The Medical Research Council of South Africa and the University of
Cape Town has now embarked on a Randomised Control Trial to compare
the cost-effectiveness of the SMS-reminder service against the cost
of non-compliance to TB treatment. In the mean time, the pilot has
been so successful that the World Health Organisation has singled it
out as example of "Best Practice".

The initiative not only uses technology to address a real need effec-
tively, 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. In addition, his messag-
ing system is flexible. When patients complained that the initial
message ("Take your Rifafour now") was too drab, he added jokes,
pearls of wisdom, and tips about lifestyle management to light up
their day -- but it still reminded them to take their medication.

Author: bridges.org
Date: 23 January 2003

The International Institute for Communication and Development (IICD)
is an independent non-profit foundation, established by the Nether-
lands Minister for Development Cooperation. IICD assists developing
countries to realise locally owned sustainable development by har-
nessing the potential of information and communication technologies
(ICT). IICD works with its partner organisations in selected coun-
tries, helping local stakeholders to assess the potential uses of ICT
in development. For more information on IICD:

Bridges.org is an international non-profit based in South Africa with
a mission to help people in developing countries use ICT to improve
their lives. Its main focus is to enable informed policy decisions,
which affect people's access to and use of ICT. Bridges.org also gets
involved in ground level projects to study the effects of policy de-
cisions and relay lessons learned to the international development
community. It brings an entrepreneurial attitude to its social mis-
sion, and is committed to working with, instead of against, govern-
ment agencies and the business community. For more information on
bridges.org: www.bridges.org.

This initiative is supported by the Building Digital Opportunities
Programme (www.iconnect-online.org) which is funded by the UK Depart-
ment for International Development (DFID), the Directorate General
International Cooperation (DGIS), and the Swiss Agency for Develop-
ment and Cooperation (SDC).

Dr. Leela McCullough
Director of Information Services
30 California Street
Watertown, MA 02472, USA
Tel: +1-617-926-9400
Fax: +1-617-926-1212

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