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2007 muhammad yunus innovation challenge:
Increasing Adherence to Tuberculosis Drugs in Rural Developing Country Contexts

Adherence to medication regimens, or the extent to which patients take the drugs they are prescribed, is estimated at only 50% worldwide. This surprisingly common problem is the cause of both individual treatment failure and public health problems across a wide range of diseases and countries.

The focus of this year's Yunus Innovation Challenge is on tuberculosis (TB). TB kills an estimated 1.7 million people every year, yet the vast majority of cases are curable. Adherence to TB drugs is low and is a major driver of the epidemic. The most successful program geared to increase TB drug adherence, Directly Observed Therapy, Short-Course (DOTS) is relatively expensive and, in 2002, was available only to approximately 37% of people with TB.

background

The Yunus innovation Challenge IDEAS Award for 2007 will be given to the team that creates a system that solves as many of the problems as possible that cause non-adherence to TB drugs in rural, developing country contexts, for the smallest cost possible. The issues considered may include, but should not necessarily be limited to, those listed below. The system may involve a physical device, but this is not required. In judging between proposals, credit will be given for feasibility, acceptability within the community (i.e., likelihood of adoption), and supporting rationale for how it will address the problem of adherence. For example, the rationale could include reasoning on why the team decided to focus particular attention on solving one of the four issues. If a team decides that non-adherence is actually due to some other factor, supporting evidence should be given.

Because the challenge is to improve adherence where DOTS is not being implemented due to cost, systems should aim to come in at a significantly lower cost than DOTS in their entirety, including all costs of system administration and any manufacturing costs. Even below this threshold, cost will continue to be an important criteria in judging - i.e., the cheaper the better.

The system should be designed to operate in conditions prevalent in rural communities in poor countries as these present a major challenge for DOTS. Participants are encouraged to work on a design with a specific community or region in mind as this can be helpful in identifying constraints and providing context. One contextual issue that contestants should keep in mind is that medical personnel have very high rates of absence in rural (and often urban) settings across the developing world. This is not just a problem for medical service providers. Systems that require regular attendance of individuals that are not accompanied by good monitoring processes often fail in this context.

key considerations

Factors causing low adherence to TB drugs include:

  • Forgetfulness
  • Procrastination
  • Side-effects of TB drugs
  • Alleviation of symptoms before the end of prescribed course of treatment

The drug adherence needs of the poor are wide and varied, and it is not expected that proposed solutions will address all issues surrounding adherence to TB drugs. However, Yunus Innovation Challenge solutions should address a particular need and fill it well. Participants are encouraged to work on a design with a specific community or region in mind as this can be helpful in identifying constraints and providing context.

subject reading

There are additional sources of information (see bottom of page), but in particular participants are encouraged to read the following works.

the global burden of indoor tuberculosis

Tuberculosis is the second-leading cause of death by infectious disease in the world, behind only HIV/AIDS. Each year, an estimated 1.7 million people die of TB. Like HIV/AIDS and malaria, TB is also a "disease of the poor": 95% of people afflicted with TB and 98% of the people who die from TB are found in developing countries, and patients with TB in developed countries are disproportionately poor. The majority of TB sufferers are between the ages of 15 and 45 years of age, resulting in large economic costs in lost productivity from TB mortality and morbidity.

Preliminary readings include:

  • Vermeire, E., Hearnshaw, Van Royen, P., and Denekens, J. (2001) "Patient adherence to treatment: Three decades of research. A comprehensive review". Journal of Clinical Pharmacy and Therapeutics, 26: 331-42.
  • Haynes R.B., McDonald, H., Garg, A.X., and Montague, P. "Interventions for helping patients to follow prescriptions for medications". The Cochrane Database of Systematic Reviews 2002, Issue 2, article number: CD000011. DOI: 10.1002/14651858.CD000011.
  • McDonald, H.P., Garg, A.X., and Haynes, R.B. (2002). "Interventions to enhance patient compliance to medication prescriptions", Journal of the American Medical Association, 288: 2868-79.

tb and drug resistance

Poor adherence to TB drugs is a significant cause of the development of resistant strains of TB. Multi-drug resistant strains of TB (MDR-TB) are resistant to first-line TB drugs and strains of extreme drug-resistant TB (XDR-TB) are resistant to both first- and second-line drugs. Approximately 425,000 new cases of MDR-TB are identified each year, and alarming rates of XDR-TB have recently been reported. Treatment of MDR-TB is much more expensive than treatment of non-MDR-TB, and XDR-TB is particularly alarming because of the lack of treatment options for patients infected.

Preliminary readings include:

  • Annals of the New York Academy of Sciences, special issue: "Drug resistant tuberculosis: From molecules to macro-economics", December 2001: Vol. 953b, pp. 87-246.
  • Paramasivan, C.N. and Venkataraman, P. (2004). "Drug resistance in tuberculosis in India", Indian Journal of Medical Research, 120: 377-86.

the dots strategy

As a response to TB adherence problems, the World Health Organization (WHO) currently recommends the Directly Observed Therapy, Short-Course (DOTS) strategy. Part of this strategy is the direct observation of patients taking their medication by a health worker. DOTS has proven to be very successful in some contexts, such as China's rapid DOTS rollout in the 1990s. However, partly because of the relatively high cost of the program, in 2002 DOTS only covered an estimated 37% of reported TB cases. Scaling up of DOTS has a central role in the WHO's plan to combat TB to meet targets set by Millenium Development Goals by 2015, but many people infected with TB will not have access to a DOTS program for years to come.

Preliminary readings include:

  • World Health Organization publications on DOTS strategy
  • Volmink, J., Matchaba, P., and Garner, P. (2000). "DOTS and treatment adherence". Lancet, 355: 1345‚Äì50.
  • Khatri, G.R. and Frieden, T.R. (2002). "Rapid DOTS expansion in India", Bulletin of the World Health Organization, 80: 457-63.

procrastination and adherence

Research in economics has suggested that people may procrastinate because of a tendency to devalue the future relative to the present. Such procrastination may be an explanation for a patient's not taking his or her pills each day, or not going to the clinic to refill a prescription. There may be ways to reduce procrastination; for example, small financial incentives have been shown to increase the percentage of people who pick up their results from HIV tests in Malawi, and a simple planning intervention has been shown to cause a large increase the number of college students who show up for tetanus shots.

Preliminary readings include:

low attendance of health care professionals

Low attendance of health care professionals at clinics in developing countries has been widely documented. This low attendance may affect patient adherence directly: for example, a patient may be unable to get a refill of TB medication if a health care provider is unavailable. Moreover, low attendance of health care providers is an important factor to consider in any intervention that deals with medication adherence.

Preliminary readings include:

supporting initiatives

Opportunities are available for students who want to learn more about the Yunus Challenge and the context in which a solution should operate. Students are encouraged to apply for Public Service fellowships, internships and grants that provide them with the opportunity to work on a potential program and with communities to develop a feasible solution which takes local context into account. For more information, please contact Alison Hynd at hynd@mit.edu.

For additional support in gathering information about the local context, customs and conditions of a specific community or country, participants may leverage the expertise of D-Lab teams who have local partners in more than 20 countries. This year, some students enrolled in D-Lab will visit communities facing the challenge of non-adherence to TB medication in rural India. They will visit and work with a nongovernmental organization that has been dealing with these issues for many years. For more information, please contact d-lab-trip-leaders@mit.edu.

Participants also may enter proposals into the IDEAS Competition, where two special awards have been created to provide winning teams with funding to pursue their ideas. For more information, please contact Lars Hasselblad at ideas-admin@mit.edu. Further information on the IDEAS Competition as it pertains to the 2007 Yunus Innovation Challenge follows immediately below.

ideas competition criteria

The Yunus Innovation Challenge IDEAS Award for 2007 will be given to participants who create an innovative solution that solves as many of the problems as possible surrounding non-adherence to TB drugs for those living in poverty.

As the challenge focuses on non-adherence to TB drugs among the world's poorest populations, solutions should aim for a price point that makes intervention accessible to target communities (who are located for the most part in low-income nations with poor infrastructure) and allows for dissemination on a large scale.

As with all IDEAS awards, innovation, feasibility and impact will be important criteria in judging. Specific issues to address include, but should not necessarily be limited to:

  • Affordability
  • Acceptability within the community (i.e., likelihood of adoption)
  • Health impact
  • Environmental impact
  • Scalability

Credit will be given for supporting rationale regarding how the solution will directly address the issues faced. For example, this rationale could include why the team decided to focus particular attention on solving one aspect of the challenge. However, if a team decides that another factor is equally significant, supporting evidence for this factor also should be provided.

While not required, the solution may involve a physical device. The system should be designed to operate in conditions prevalent in poor households and communities where basic hygiene is limited. Again, participants are encouraged to work on a design with a specific community or region in mind as this can be helpful in identifying constraints and providing context.

Resources

A sampling of resources for participants about adherence to tuberculosis drugs follows. There are many more available, so please do not hesitate to ask!

For assistance in finding additional resources specific to your project, please contact an MIT librarian.

For more information on the 2007 Yunus Innovation Challenge, please contact Laura Sampath at lsampath@mit.edu