This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American
Imagine this: You are a doctor or a nurse in a developing country serving a community with a high rate of tuberculosis (TB). After taking a patient’s medical history and conducting a comprehensive physical examination that reveals the patient has TB, you prescribe a course of medication. You counsel the patient on why it is important to maintain a daily routine of taking the medicine. But you know that after the patient leaves the room, there is a good chance that they will not come back.
This is a reality in countries across the Global South. Even though doctors routinely advise patients with TB on the importance of following the prescribed regimen, many of them do not complete the treatment plan, which can last up to six months.
When patients stop taking TB medication, they risk developing multidrug-resistant TB, which is difficult and expensive to treat. In 2016, the median cost of treating a single patient in a developing country with drug-resistant TB was $9,529, and treatment could last for up to two years. New and shorter regimens of 9–12 months exist, costing up to $1,000 per person, but maintaining patient compliance for such long periods presents additional challenges.
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While treating those who have already developed multidrug-resistant disease and its complications is important, it is far cheaper and safer to catch patients early in the process. In India, for example, non-resistant TB can be treated for as little as $50.
It is not that these patients do not care about their health. Rather, they are saddled with economic constraints. Tuberculosis may be caused by a stubborn bacterium, but it is poverty that sustains it. The disease is more prevalent in people who wake up to an empty stomach every day and must earn their way to an evening meal. Treatment often means traveling long distances to a clinic and giving up a day’s wages.
For far too long, donor agencies and international health organizations have ignored the context for why people act the way they do. They focus on medical solutions—such as improved drugs and stricter regimens, or more investment in laboratory solutions.
But the answer may lie outside the medical world, in the creative thinking of the technology industry in addressing “pain points” that make consumers less than happy with a particular device. Case in point: In 2016, Apple released the iPhone 7, and removed the headphone jack. Many financial analysts at the time argued that this would turn off buyers. The opposite happened: iPhone 7 sales helped Apple reclaim the top spot in the global smartphone market. What the financial pundits did not understand was that Apple was addressing an existing pain point. Apple recognized that customers wanted a sleeker phone. Instead of trying to figure out how to narrow the headphone jack, Apple’s designers simply removed it, and that worked.
This concept of removing components that were previously considered necessary derives from a concept known as “design thinking.” Businesses and technology companies around the world use this approach to address the pain points they face in the consumer market. If we apply this same thinking to patient compliance in developing countries, we can find practical solutions.
One simple and highly effective method is incentivizing patient compliance. This can be done through conditional cash transfers, a policy commonly used in many other global health projects. In conditional cash transfers, money is paid to a patient on the condition that he or she behaves in a particular way—such as complying with the treatment plan. Indeed, conditional cash transfers would make it easier for patients to continue treatment since financial strain is a primary reason they are non-compliant in the first place.
A recent study from India demonstrated the efficiency of using this incentive in implementing policies that have historically low uptakes. The investigation reported significant increase in childhood immunization rates and in better reproductive health behaviors such as choosing to deliver babies at a hospital. Recently, researchers from Brazil investigated the effect of using cash transfer programs for TB, and reported reduction in incidence and improved response to treatment.
In global health policy, we need creative thinking and innovative solutions to address a disease that has kept vulnerable populations in lifelong poverty for centuries. We can treat more patients with the same money if we find ways to prevent drug-resistant TB.
We may not always have the best solutions, but if we think like Apple, perhaps we can change the problem.