Tanzania is one of 30 countries to be recognised by the World Health Organization as a tuberculosis (TB) ‘hot spot.’ The impact of TB on individuals and communities is very significant. Annually, about 154,000 people suffer from the disease, but only about half of them are detected, and many die before they receive or complete treatment. A lack of accurate diagnostics, complications from co-infection with HIV, systemic shortages and management of essential equipment, supplies and health professionals, and stigma surrounding the disease all exacerbate this.
In 2002, the global non-profit organisation APOPO began testing the ability of African giant pouched rats to reliably detect TB as a response to the high burden of the disease in Tanzania. Since 2007, APOPO in partnership with the Sokoine University of Agriculture (SUA), the National Institute for Medical Research (NIMR) and the National Tuberculosis and Leprosy Programme (NTLP) has been scaling up its efforts to support national clinics and help significantly increase detection rates. The rats, which are also known for their ability to detect landmines and other explosives, are now appropriately referred to as ‘HeroRATs.’
APOPO has established an innovative TB case detection approach which involves a rapid re-evaluation of human sputum samples collected from partner clinics using the trained rats followed by an approved confirmation test and return of confirmed results to clinics.
Since 2017, with support from HDIF, APOPO and its partners have been working together to design and adapt their original model to allow the team to expand their same-day TB detection algorithm to labs and clinics based in Dar es Salaam from their original base in Morogoro. APOPO has also been scaling up direct observed therapy (DOT) and tracking hardto-reach patients in peri-urban and urban slums of the capital.
APOPO has achieved remarkable success in two of its primary indicators: increased detection and treatment initiation. In 2017, the model has increased case detection
by 32 per cent, completing 30,692 patient evaluations in the period January–December 2017, which is far greater than the target set. Initiation of treatment among those diagnosed with TB has increased to 81 per cent of those tested and diagnosed through APOPO’s diagnostic algorithm, compared to 71 per cent in 2016 prior to evaluating samples in Dar es Salaam, and even less prior to working with MKUTA, a community-based organization that recruits TB survivors and people living with HIV. APOPO and the team have ensured that 1,244 patients have been additionally detected and 1,005 initiated treatment – curing people and preventing potentially thousands of new cases
Gender equity and social inclusion
APOPO’s innovation is designed to benefit everyone within a TB-burdened community, including marginalised members such as women and girls, and people living with disabilities. Tools such as Operation ASHA’s eCompliance fingerprint technology are used to reduce clinic visits and cut down transportation costs while offering each patient a daily contact at home with trained community health workers who are often survivors of TB themselves
Principles for digital development
Design for scale: By expanding its operations and opening a new centralised testing facility in Dar es Salaam, APOPO has reduced the four-hour time lag of transporting samples to the original base in Morogoro for testing, which had undermined the efficiency gains of the detection algorithm. The project’s ambition to become fully operational in all 41 clinics and labs providing TB services in Dar es Salaam and periphery areas was realised in September 2017.
Among other things, the Design for scale principle suggests that innovators should identify institutional partners and make technology choices specifically to help them overcome the challenges to reach scale. By partnering with MKUTA, APOPO has gained entry to the communities where their model will have the most impact. By partnering with Operation ASHA, the organisation will be able to access the technological tools needed to extend its outreach and take the innovation to scale.
Reuse and improve: This principle advises that designers should identify proven technology tools that may already be in use and adapt them to the model that is being planned. For example, by applying Operation ASHA’s eCompliance fingerprint technology, the project has been able to quickly and correctly identify and track a patient and their drug regimen while reducing the cost of the digital devices required for the identification and tracking of patients.
With the project now in its final year of implementation, APOPO will draw on the experiences of other HDIF health grantees to understand how to evaluate the acceptability of its digital health tool, and look at how to scale up beyond the pilot area in Dar es Salaam and sustain the innovation beyond the scope of its current operations