[OP-ED] Why we need to go an extra mile in development?
alex oprunenco.JPG
20 August 2015

Many development challenges Moldova faces are devoid of simple solutions. Indeed, at UNDP we have come to realize that TB treatment is not a matter of access to pills only, providing access to energy for people is not a matter of laying the pipelines and copy-pasting best practices in public service will not always make users happy. Furthermore, we often cannot be sure that this is exactly our new solution that improves the situation. What should we do differently to solve complex problems and how we measure the impact?

Our experience in supporting development of the new approaches to tuberculosis (TB) treatment shows our extra mile thus far.

TB remains a challenge for the public health despite the best efforts by all involved as Moldova failed to deliver on its commitments on MDG 6: according to WHO Moldova has one of the highest documented levels of TB and multi-drug resistant-TB in Europe (10.5 mortality rate per 100,000 persons). The Global Fund to Fight AIDS, Tuberculosis and Malaria ranks the country second among 110 countries by level of funds provided per capita. Among the primary concerns is the increasing rate of the multidrug-resistant tuberculosis , which is much trickier and more expensive to treat. One of the major reasons for this is the low drug adherence rate - people tend to discontinue treatment once they leave the hospital. With TB treatment basically free it is completely counter-intuitive that some people quit treatment and put their and others lives at risk.

This is exactly the issue where modern development agencies should help: not simply bring money and implement projects, but draw on the available expertise networks and build partnerships to work with the national counterparts to develop a solution relevant in Moldovan context. And this is how our joint work with the Ministry of Health and Behavioral Insights Team (formerly the UK Cabinet Office) has started. We began investigating why exactly TB patients drop out once they are released from hospitals?

Our ultimate hypothesis is that the way post-hospital treatment is organized, i.e. need to daily commute to clinic to swallow the pill in front of the doctor (so-called directly observed treatment, DOT), simply drives up the patients’ friction costs. That’s expensive, time-consuming, and furthermore since side effects of the drugs include nausea and fatigue, totally exhausting… One of the ways to overcome these frictions costs is video observed treatment (VOT), where patients swallow pills in front of webcam instead of daily commuting. VOT would make the lives of patients more comfortable and save doctors time by easing the flow of patients. It would also allow for covering more migrant workers and perhaps cut costs in the long term.

This has been our hypothesis and it would remain the hypothesis without a test. Indeed, we cannot advocate for changes in the existing national protocols without having robust evidence. How can we get it? We decided to set up the Randomized Control Trial (RCT). In a nutshell, idea is the following: we randomly divide a cohort of statistically similar TB patients in Chisinau in two groups: “control group”, which follows standard procedure, and “treatment group”, which follows our new VOT procedure. After the treatment period is finished we compare the results and if we see that drug adherence rate is higher in “treatment group” it means VOT procedure works and can become viable alternative to the standard DOT. And thus it can save many human lives and public money.

This is the first trial organized by UNDP and the first one in Moldova; moreover, while VOT has been piloted in some countries around the world and has never been yet evaluated through an RCT. In this ground-breaking experiment we are also joined by Act for Involvement, who are key implementers of the trial, Center PAS and Moldcell. With united forces and new knowledge we believe we can find a proper response to this development challenge our country faces.

Alexandru Oprunenco, for Ziarul de Garda

United Nations Development Programme (UNDP) Moldova, Policy Specialist

UN Partner Agencies