A tale of two Nobel Prizes

In 1943, Waksman and Schatz discovered the first effective antibiotic against tuberculosis (TB). This discovery led to medication that could cure TB in humans, for which Waksman received a Nobel Prize in Medicine. In 2017, nearly 70 years later, 1.7 million still died from the disease. Why are so many people dying despite effective treatment being available?

One of the main reasons is behavioural: patients do not take their medication. The implications are serious. Low adherence leads to failed or longer treatment and the development of new resistant strains of the disease. The financial costs of non-adherence in general are colossal, US$269 billion worldwide by one estimate, 57% of all avoidable healthcare costs.

In 2017, Richard Thaler was also awarded a Nobel Prize, this time in Economics. His number-one mantra is “if you want to get someone to do something, make it easy”. This seemingly simple insight had important implications for TB patients in Moldova.

What was the new approach?

The Republic of Moldova, which has the highest incidence of TB in Europe, follows a treatment strategy called Directly-observed therapy (DOT). Under DOT TB patients are required by law to come to a clinic daily to take their medication under the supervision of a TB nurse. The strategy was based on World Health Organisation (WHO) recommendations intended to improve patient adherence to treatment.

Adhering to a DOT regime, however, is often time-consuming and costly for patients to follow, in direct contrast to Thaler’s recommendation. Travelling to and from a clinic requires time and money and has to be done during clinic opening hours, making it difficult for patients to simultaneously hold a job. In addition, some feel ashamed going because of the stigma associated with TB.

In 2014, UNDP and BIT teamed up with Act for Involvement (AFI), Center for Health Policies and Studies (PAS) and the Ministry of Health in Moldova (MoH) to assess whether a behavioural approach could help support the TB programme. After two years of design and planning, our consortium piloted Virtually Observed Treatment (VOT), where, instead of having to travel to a clinic, patients could simply record a video of themselves taking the pills at a time of the day convenient for them.

“VOT is much better, I woke up in the morning and the first thing I would do was to use the tablet and take the pills” [ TB patient during RSTMH-funded qualitative study]

In addition, we created a social connection between patients and the observers. Patients were paired to the same observer each time and this observer sent videos back to the patient confirming receipt (daily) and offering feedback and encouragement (weekly). Both feedback and feeling the medical provider knows the patient “as a person” have been shown to be correlated with higher medication adherence. We wanted to ensure that these components were not lost in the movement from DOT and VOT, but rather improved and applied consistently.

TB or VOT TB? That is the question

The new approach was introduced in clinics in Moldova’s capital Chisinau and its impact was evaluated using an RCT with 178 patients. We measured adherence for four months after patients finished a two-month phase in hospital. For the DOT group, adherence was recorded by patients signing on a tablet computer every time they visited a clinic. This signature, including a timestamp, was then uploaded to an online database. VOT patients’ adherence was recorded using the videos sent.

The graph shows the main result: VOT almost doubled observed adherence compared to DOT.

Furthermore, we estimate that VOT patients spent considerably less time (23 vs 81 hours) and money for transport ($11 vs $42) over the course of 4 months. We also see evidence of VOT patients being slightly happier with their treatment and more side-effects being reported (at 10% significance). The latter could be because more medicine was taken or because VOT patients had to confirm the absence of side effects every day when submitting the video and were therefore more likely to also think about and report them during endline interviews.

Where next?

Experimentation in public policy-making has been gaining momentum but this approach is often more challenging in countries where governance and data collection systems are weaker. Our RCT shows that, despite certain institutional resistance and challenges with data collection, policy experimentation can contribute to systemic change.

The Ministry of Health will be rolling VOT out across the country through the National TB Program (NTP) with the support of local and international partners. More widely, this research and a similar study in London, recently published in the Lancet, support VOT being offered as a viable treatment option for TB around the world.