Digital solutions offer hope of a breakthrough on an age-old challenge
The regional programme ‘University and Hospital Partnerships in Africa’ supports partnerships between German and African university hospitals to jointly develop responses to priority health issues. Where multiple partnerships work on the same issue, they are encouraged to form networks to generate broader solutions for a lasting impact.
A research team at Gabon’s venerable Centre de Recherches Médicales de Lambaréné (CERMEL) were mortified to discover that after six months, only 53% of 201 tuberculosis (TB) patients they had been following had successfully completed their treatment, and only 8% could be considered cured. At Tanzania’s highly specialised Ifakara Health Institute (IHI), a team of Tanzanian and German researchers were struck by a communication gap between remote health facilities and tertiary-level hospitals which left many rural TB patients undiagnosed and untreated. In Madagascar, partners deplored the consequences of inefficient, paper-based data management for surveillance and treatment of TB patients and were frustrated by the lack of funds for daily operation of small treatment centres. Three situations, three complex issues calling for high-level scientific cooperation and operational research – could they be amenable to digital solutions?
Tuberculosis, an age-old problem
TB has been accompanying humanity since prehistoric times, and researchers have found evidence of TB in Egyptian mummies from 5000 years ago. Popularly known as ‘consumption’ during the 19th century, pulmonary TB’s main symptoms are coughing (sometimes accompanied by blood), fever and weight loss, typically leading to lingering illness and death, if untreated. Therapy consisted essentially of fresh air and rest (in mountain ‘sanatoriums’) until after the Second World War, when antibiotic treatments began to be applied to what is known as ‘the big cough’ in some African languages. Today, if treatment is taken continuously over months, most cases of TB can be cured.
Although significant progress has been made, according to the World Health Organization (WHO, 2020), in 2018 an estimated 10 million people worldwide fell ill with TB and approximately 1.5 million died. The latter figure includes 251,000 people with HIV/AIDS, whose emergence (by destroying patients’ immune defences) has contributed to a resurge of TB. Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent (before HIV/AIDS). Ending the TB epidemic by 2030 is among the health targets of the Sustainable Development Goals (SDG Target 3.3).
The African continent accounted for some 24% of new TB cases in 2018, with an estimated 2.45 million new patients. This is associated with Africa’s stubborn HIV epidemic. According to WHO (Ibid.), people who are infected with HIV are 19 times more likely to develop active TB. In 2018, there were an estimated 862,000 new cases worldwide of TB among people who were HIV-positive, 72% of whom (ca. 615,000) were living in Africa.
Control of these two infectious diseases confronts particular challenges in Africa, related to widespread poverty, low levels of education, poor hygiene and housing conditions and malnutrition, combined with weak health systems with correspondingly weak surveillance and patient follow-up. At the same time, African research institutions and NGOs working in health are emerging as a bright resource for tackling many of the continent’s health problems.
Hi-tech partnerships between university hospitals in Germany and Africa
It was to support the potential represented by high-level African research facilities t hat the regional programme ‘University and Hospital Partnerships in Africa’ (HKP), which is implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, was initiated in 2006 with a focus first on HIV/AIDS and later on patient safety by the German Federal Ministry for Economic Cooperation and Development (BMZ). HKP is part of the ESTHER Alliance for Global Health Partnerships whose chair HKP assumes on behalf of the BMZ until December 2020.
HKP provides substantial grants (averaging about 200,000 EUR for two years) to support partnerships on a specific topic between a German university hospital and an African university or teaching hospital. In its current phase, in line with BMZ’s ‘Digital Africa’ strategy, HKP focusses specifically on eHealth, and is supporting 13 partnerships in domains ranging from anti-microbial resistance, medical imaging at point of care and decentralised management of non-communicable diseases, to TB control and mother-child care. Promotion of equal opportunity, including training for African women in eHealth and leadership, is another priority of HKP and is a constant in all 13 partnerships.
In June 2019 in Berlin, HKP organised a ‘Matchmaking Platform’ between 40 representatives of university hospitals and a broad selection of IT service providers, aiming to galvanise digital solutions to the healthcare problems the partnerships focus on. In October of the same year, all 13 partnerships came together for an exchange forum at GIZ headquarters in Eschborn, Germany.
Enhancing partnerships’ effectiveness through a joint thematic focus
But the programme aims to bring the partnering momentum to yet another level, as Dr Kirstin Grosse Frie, Partnership Advisor at HKP, explains: ‘We encourage multiple partnerships working on different facets of the same topic to form a thematic network to enhance the scientific exchange, in view of further strengthening the outcomes and impact of the different projects, with the potential of jointly developing concepts that no single partnership might have envisioned. In our previous phase, a network coalesced around Anti-Microbial Resistance, and in the present phase we see much potential for a vibrant network between the three partnerships working on TB control.’
After a year of preparation (2019), the 13 partnerships were launched in January 2020. Though many planned activities had to be put on hold when the COVID-19 pandemic struck, research and reflection continued, including by virtual communication. After six months, in most of the partnerships the IT solutions had been defined, and the next step will be to put them into practice on a pilot basis (in some cases with remote support from Germany because of COVID), and ultimately to scale them up in the respective national health systems. As Dr Grosse Frie points out, ‘COVID was at once a challenge and an opportunity for the partnerships, clearly demonstrating the importance of digitalisation.’
From DOT to VOT: Video-observed treatment of patients through smartphones and apps in Gabon
Gabon’s Centre de Recherches Médicales de Lambaréné (CERMEL) is associated with the hospital founded by the legendary Dr Schweitzer. Employing 120 scientists, CERMEL has evolved into a major independent research institution, hosting Gabon’s national TB reference laboratory and a well-developed IT department. For over 20 years CERMEL has been partnering with the University of Tübingen’s Institute of Tropical Medicine, specialised in clinical development of drugs and vaccines for diseases such as malaria, schistosomiasis, Ebola, TB and now COVID-19.
CERMEL has long been researching TB, including the genetics of the different strains and drug resistance. In 2012 CERMEL initiated a survey on patients’ compliance with TB therapy. The standard treatment recommended by WHO consists of a 6-month course of 4 antimicrobial drugs that need to be taken daily by the patient, ideally under the supervision of a health provider, known as DOT (Directly Observed Treatment). The results of the study made it clear that nearly half the patients were not adhering to their therapy. In nearly 70% of these cases, daily direct observation was not taking place, particularly for patients living at a distance from their health facility. Without the daily reminder, many patients stopped taking their treatment. As Dr Bertrand Lell, Director of CERMEL, explains, ‘This is how multi-resistant TB strains emerge, obliging us to develop alternative, more expensive drugs to attempt to treat these resistant cases.’
This was an ‘Aha!’ moment for the research team, leading CERMEL to contact its partners in Tübingen with an innovative proposal that won a grant from HKP. Since DOT was not working, as the regular supervision of a health care provider is not available in remote areas or difficult to manage for patients, the partnership would replace it with VOT (video-observed treatment), taking advantage of the widespread use of smartphones in the general population, including cost-free internet message services such as WhatsApp and Telegram. Each day after filming themselves taking their medication, patients send the video to a nurse in CERMEL who keeps track of all patients, with the support of medical doctors who can ensure compliance with the regimen. The nurse sounds the alarm in case a patient does not send a video, and the patient is contacted.
Testing cash incentives for compliance
Supporting the pilot on behalf of Tübingen University, Dr Andrea Kreidenweiss explains, ‘The partnership has recruited 30 patients with TB. They pick their medication up once a month at the hospital. 75% of them have their own smartphone, and the partnership has lent phones to the other 25%. In general, the approach is well accepted, although there was some reticence about sending a personal video over the internet. The partnership is testing financial incentives with half the patients, paying 3 EUR per week for complete compliance – this is easy with telephone companies’ “mobile cash” programmes.’
Dr Lell interjects, ‘Ensuring confidentiality of data for this programme is a challenge we are working on with both a German consulting firm and a Gabonese company. Existing systems are expensive but our tech partners are working on a new tool that will be reliable and affordable and respects high data security standards. Once developed, the approach could also be used with HIV patients who need to take their ARV (anti-retroviral) daily.’
Connecting rural patients with tertiary-level care in Tanzania
The Ifakara Health Institute (IHI) is a long-time partner of the Berlin Charité hospital’s Department of Infectious Diseases and Respiratory Medicine, and is now associated with Tanzania’s tertiary-level St Francis hospital in a partnership entitled ‘Health Telematics for improving TB and HIV care in rural Tanzania’. The impulse for this Tanzanian-German partnership initiative is summed up by Dr Thomas Zoller of Berlin’s Charité: ‘What struck our team is that despite great technological strides in medicine and health research in tertiary hospitals and high-level institutes, too little trickles down to improve health outcomes for remote rural populations. Many hurdles, stand in the way of TB diagnosis and treatment, for instance: Will the patient with symptoms present at the rural health facility? Will the health provider have the equipment to take a sputum sample? How can the sample get to a well-equipped laboratory for analysis? At the laboratory, who will verify the sample? How will the result be transmitted to the rural health facility? To the patient? If positive, how will treatment be organised and followed up?’
The concept of ‘telematics’ reflects the notion of a continuum of care, from the first symptoms to completion of treatment. Everything is electronically documented, so that public health decision-makers can follow all the steps. All data will be fed into the district health management opensource software DHIS2 in Tanzania’s Ifakara health district, where the partnership activities are to be piloted.
‘Our project will move samples, not patients,’ explains Dr Zoller. ‘The patient just has to stay in touch with his or her local health centre or dispensary. Communication via SMS between the health centre and the tertiary level laboratory is critical. The health centre takes the sample and sends it to the lab which returns the diagnosis via SMS and continues to remotely supervise the treatment the health centre provides.’
Tanzanian partners including a doctor and a senior scientist are preparing to pilot this approach in two rural health centres plus 15 to 20 village dispensaries in their catchment area. For the IT aspects – developing the ‘health telematics’ app – the partnership plans to work with eHealth Africa, a company which members met at HKP’s ‘matchmaking’ event in Berlin in 2019.
eTB digitalises TB surveillance and money transfers to facilities in Madagascar
In Madgascar’s vast Atsimo-Andrefana region, the National Tuberculosis Programme’s network of 22 TB treatment centres has been functioning with great difficulty: The centres lack the petty cash to pay for medical consumables and petrol for their generator, and with their paper-based data management, patients’ records can take six months to reach the national programme’s headquarters. To tackle these challenges, the National TB Programme, the University of Toliara and the NGO Doctors for Madagascar are also partnering with the Berlin Charité hospital’s Department of Infectious Diseases and Respiratory Medicine.
The partners propose to adapt mTOMADY, a mobile phone-based platform for secure healthcare payments and data exchange developed by Doctors for Madagascar, Charité-Universitätsmedizin Berlin, and the Berlin Institute of Health, to the particular situation of the TB programme. Since its 2019 launch, mTOMADY has become the largest digital platform for healthcare-related payments in Madagascar. Building on this success, the ‘eTB’ project will digitise data collection and financial processes across the TB care cascade. With eTB, the national and regional levels will be able to electronically send small amounts of money to the individual treatment centres, which will shift to use of tablets for electronic entry and management of patient data.
The eTB software is being developed with support of the Berlin tech company ThoughtWorks, and a prototype is to be piloted – and adapted – in two centres starting in September 2020. Because of the size of the region and the long distances patients have to travel from their home to the treatment centre, directly observing treatment (DOT) is not feasible. VOT (video-observed treatment) is also not a viable alternative since many people in these areas do not have access to a smartphone or to the internet. Instead the centres send their patients home with treatment for two weeks, after which they must come back to renew it. As Dr Nadine Muller of Berlin’s Charité explains, ‘This digital tool will help the treatment centres keep track of their patients and know when to prepare their next batch of medicine. It is an opensource software which will be handed over to the National Tuberculosis Programme.’
Together, e-optimising the whole continuum of care
These three TB partnerships are already communicating with one another and comparing their different issues and approaches.
Claudia Aguirre, Head of HKP, sees an important advantage in the different focusses of the three TB partnerships: ‘We are supporting the three teams to work closely together as a network since each of the three is working toward an innovative digital solution representing different parts of the TB chain. Together, they have the potential to integrate solutions and move into scale-up.’
Representatives of the three partnerships emphatically agree. As Dr Nadine Muller observes, ‘We are all aiming for optimisation of TB care in African countries, with different strategies and domains of intervention: in Madagascar we focus on optimisation of data management and financial transactions, in Tanzania it’s the link with the community and in Gabon directly observed care. Together, this improves the entire continuum of care and could become a blueprint for a global digital TB care strategy.’
Dr Mary White-Kaba, September 2020