Voices from Eurasia


Fighting TB in Moldova: Moving beyond the nudge

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Meeting with a local doctor to discuss the new trial. Photo: AFI

Over a year has passed since we started discussing how to leverage behavioural insights to tackle tuberculosis in Moldova.

Back then Alex described how – together with BIT – we wanted to understand TB patients’ behaviour in order to identify the bottlenecks in adhering to treatment.

Looking back, this part of our journey appears exciting and simple.

What followed has proved to be both more difficult and more rewarding. Below are some of the takeaways:

Blending behavioural insights with tech

Initial research revealed two options available to ease patients’ treatment compliance:

1) VOT (video observed treatment)
2) Drug home-delivery

After weighing the pros and cons with the Ministry of Health, we opted for VOT.

We believed this would be less resource intensive and – with internet access spreading fast in the country – more effective

Our partners from Act for Involvement (AFI), conducted a survey among TB patients in Chisinau, which showed 38 percent of patients had access to internet and 36 had experience using Skype.

Using VOT, the patient would not need to make a daily visit to the clinic, but could simply take the pill in the front of their computer and send a video message using an app.

Setting up the trial

Moldova’s Ministry of Health showed strong interest in using the new approach nationally, should the outcomes prove positive.

So how we would know if VOT actually worked?

Our idea is to run randomized control trial dividing the pool of patients into two groups: those who use the new method and those who use the old.

We will compare results between two groups against a set of primary and secondary indicators including drug adherence and the treatment’s success.

We hit the snag: DATA

Now the issue we needed to deal with was somewhat unexpected: reliable data to measure adherence.

Current drug adherence rates are recorded through record sheets: simple tables with patients’ signatures upon intake of the meds.

The problem here is the whole system of rewards and targets is skewed so both patients and doctors are incentivized for high compliance. Misreporting is widespread and reliable data for drug adherence is hard to come by.

To run the trial and to have comparable and reliable adherence data for the “control group” (DOT), we had to sort this out.

In other words, we had to find an alternative approach to measuring treatment outcomes under the DOT.

At the same time, deploying a more reliable monitoring of DOT looked like a huge opportunity to have proper evaluation of drug adherence under the traditional approach.

So we called upon tech again: The polyclinics in Chișinău outside of treatment group will be putting signatures (time and date stamped) onto their tablet devices.

Ideas drive partnerships

To be frank the whole endeavor thus far proved a bit more difficult than we first imagined, but we have also have learned a great deal.

It also has been a demonstration of what can be achieved when you bring a fresh approach to solve a difficult problem. It’s here, we learned an important thing: support from the Ministry of Health isnecessary but not enough.

We needed someone from outside the system to run the trial, and so we found dedicated partners in Act for Involvement.

We also discovered the limited resources we had were not sufficient.

Luckily, PAS (one of the implementers of the Global Fund’s work in Moldova) joined us, bringing both new resources and additional knowledge.

Our private partner, Moldcell, has agreed to provide free internet for data transmission.

And BIT has proved to be a true partner in the project, providing advice every step along the way.

Now with the trials set up to start in the coming days we truly see what ‘working differently’ can bring.

Blog post Moldova Health Innovation

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