CASE STUDY SERIES ON ICT-ENABLED DEVELOPMENT: AFRICA 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: http://www.bridges.org/iicd_casestudies/. CASE STUDY: The Compliance Service uses SMS technology for TB treatment I. Overview Initiative: Dr. David Green's Compliance Service 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. 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 healthcare 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 waterline and are flooded during the winter months. Due to this combination 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 USD $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 occurrence 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 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. Next steps: 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. Geographical area targeted: Currently Cape Town, South Africa, with the potential for future expansion across South Africa. Contact Information: Dr. David Green The Compliance Service Tel: +27 21 790 4521 Eml: david@on-cue.co.za URL: http://www.compliance.za.net II. Gauging Real Impact Has this use of SMS messaging in the treatment of TB had a Real Impact at ground level? How does it compare to the best practices established 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 medicine while doing his PhD in Pharmacology which 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, 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 Randomised 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 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 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. III. The Story A Cape Town doctor has dramatically helped the fight against tuberculosis (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 sending 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 apply 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 because 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 effectiveness 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 innovative 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 deterred, 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 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. In addition, his messaging 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 Netherlands Minister for Development Cooperation. IICD assists developing countries to realise locally owned sustainable development by harnessing the potential of information and communication technologies (ICT). IICD works with its partner organisations in selected countries, helping local stakeholders to assess the potential uses of ICT in development. For more information on IICD: http://www.iicd.org/about/. 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 decisions and relay lessons learned to the international development community. It brings an entrepreneurial attitude to its social mission, and is committed to working with, instead of against, government 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 Department for International Development (DFID), the Directorate General International Cooperation (DGIS), and the Swiss Agency for Development and Cooperation (SDC).