Better treatment, better care: The promise of digital adherence technologies

November 10, 2021 by Evan Spark-DePass, Shibu Vijayan, and Kevin Kwong

Lack of adherence to medications has been a problem for decades. We may finally have the tools to do something about it.

A health care worker at the Vynohradiv TB facility in Zakarpatska Oblast, Ukraine prepares a smart pill box with a patient’s monthly supply of TB medication.

A health care worker at the Vynohradiv TB facility in Zakarpatska Oblast, Ukraine, prepares a smart pill box with a patient’s monthly supply of TB medication. Photo: PATH/ Volodymyr Kochanov.

Delivering medications to patients in under-resourced settings comes with many challenges. Supply chains can break down, the medication might not be affordable, or the product might not be high quality, to name a few.

In global health, when a product finally makes it into a patient’s hands, we often consider our job complete—the elusive challenge of access has been solved. In reality, the biggest hurdle to treating or curing a patient may still lie ahead.

Nonadherence is a human problem

People are not particularly good at taking medications consistently. Nonadherence is generally caused not by carelessness, but by unaddressed challenges.

In some cases, adhering to medication can cause unpleasant side effects. In other cases—for example, with hypertension—day-to-day symptoms are mild, so the impetus for adherence is lost.

This is not a problem specific to any region or socioeconomic group—nonadherence to medications is a human problem.

In the United States, which has some of the clearest adherence data available, a study of patients across eight chronic diseases showed that 50 percent or fewer remained on their treatment after one year.

The World Health Organization estimates that nonadherence is even more pronounced in the Global South, where patients may have less support or resources on which to draw.

The cost of all of this nonadherence is significant. Of course, medication is less effective when patients miss doses or discontinue regimens entirely. This leads to unnecessary morbidity and mortality, as well as community-wide impacts like increased resistance to critical first-line drugs.

Beyond health impacts, the financial cost of nonadherence is enormous. Unfortunately, data in low- and middle-income countries are limited, but in the United States, estimates attribute $290 billion in increased annual medical costs to nonadherence.

Thankfully, the expansion of digital technologies is giving rise to a new class of products designed to help patients adhere to medications and, in many cases, alert their provider when they miss doses.

These digital adherence technologies (DATs) are already used in many high-income settings to support elderly patients managing complex drug regimens, in drug trials where compliance is essential, and even for daily birth control.

PATH is working to bring DATs to more people and more countries, and to support patients in more disease areas that are affected by nonadherence.

Leading the way in Ukraine and India

Persons affected by tuberculosis (TB) are often faced with an impossible choice between their personal health and their livelihood. Historically, the standard of care for TB has been directly observed therapy, meaning that patients had to travel to a health facility daily to take their medication.

For many patients, daily trips can result in expensive travel costs and lost wages. Furthermore, health workers are not able to differentiate between patients who are regularly adherent to their medications and those who are not, resulting in the same level of care and support regardless of need.

Since 2018, PATH has pioneered the use of digital adherence technologies in Ukraine, where TB is endemic.

In an 18-month pilot, PATH collaborated with health workers to deploy a smart pill box to 950 patients. Smart pill boxes have battery-powered sensors and leverage mobile data connection. When a patient opens the box, it sends a signal to the health care worker. If the box is not opened, the health care worker can contact the patient to follow up.

The results were promising. Eighty-three percent of patients took more than 95 percent of their planned doses.

“The implementation of DATs in Ukraine is a crucial step toward human-centered TB treatment, which will allow better patient outcomes. We’re working to ensure both patients and health care workers have access to these innovative tools,” says Kateryna Gamazina, MD, PATH’s director of Eastern Europe and Central Asia.

“The implementation of DATs in Ukraine is a crucial step toward human-centered TB treatment.”
— Kateryna Gamazina, Director of Eastern Europe and Central Asia, PATH

India has the highest TB burden in the world, at 2.2 million cases annually. With PATH’s support, the country was the first to deploy DATs at scale.

Over the course of multiple DAT pilots since 2015, these products have proven to be a valuable optimization tool for Indian health workers. Critically, findings from these deployments show that the “cafeteria approach”—providing each patient with a choice of multiple types of DATs—led to more appropriate solutions tailored to individual contexts.

Once the DATs were in use, health care workers were better able to identify patients who required more support, enabling targeted and differentiated interventions across populations.

A global market to meet global needs

Currently, DATs are most widely used in a handful of specific cases. To establish a sustainable, global market for DATs, it is crucial to expand into other demographics that could benefit from adherence support.

For instance, though TB has been the test case for DATs in global public health, it is far from the only unmet adherence need across low- and middle-income countries. DATs have potential application for a range of infectious and noncommunicable diseases, reproductive health gaps, and pediatric support, to name a few.

Additionally, DATs are used when patients have access to cellular technology and network connectivity, thus limiting who can use DATs at present. Through DAT market sizing for TB, PATH led efforts to better understand how technological requirements impact various populations’ abilities to use the products effectively.

Uneven access to mobile phones and affordable network connections has created significant digital divides across and within countries. For instance, in many countries in Asia, smartphone ownership is high, while in most African countries, less than 30 percent of the population owns a smartphone.


Explore mobile phone penetration by country

The market size for DATs is limited by access to information and communication technology. This interactive infographic visualizes data on feature (basic) phone and smartphone penetration around the world.

Go to visualization

Even within countries, access to network connections varies widely. Around 78 percent of urban areas in Africa have access to a 2G connection (needed for calls and SMS). That figure drops to just 54 percent in rural areas.

As mobile phone ownership continues to increase, the market size for DATs will increase organically. However, in the near term, it’s critical to offer an appropriate range of DATs that suit the country or region.

The good news is that many DATs designed for high-income markets have extremely low technological requirements. PATH evaluated 19 adherence technologies as part of a market landscape, and found that roughly half of the DATs targeting high-income countries were designed to be low tech.

Finally, DATS are most often leveraged in public health systems. DAT use in the private sector is relatively low, even though in some countries with high TB burden, including India, Indonesia, and the Philippines, more than 40 percent of persons with TB are treated by the private sector.

Public-private collaboration offers yet another avenue for scaling up.

When more people have access to DATs, more people are able to receive high-quality, consistent care that meets their unique needs. To this end, PATH’s market sizing and product landscape constitute a roadmap for how to better meet patient needs around the world.