Drones Deliver Rwandans Cancer Treatment

PIH/IMB partnered with Zipline to deliver oral cancer medications to clinicians at health facilities nearest to the patient to effectively administer cancer medication nearest the patient during the COVID-19 pandemic. This reduces patient exposure to COVID-19 or any other highly contagious disease infection risk and mitigate risks and travel-related burden to patients accessing treatment and care at a remote cancer treatment facility.

More than half of new cancer cases and almost two thirds of cancer deaths occur in LMICs. Drone based solutions compliment larger efforts to strengthen the cancer care provision in LMICs and decongest cancer centers with unnecessary visits. Our solution may help reduce the risk of loss to follow up related to discontinuation of treatment amongst enrolled cancer patients and improve the patient experience. If this proves effective, other chronic care patients may benefit from this solution while saving patients and providers time in accessing and providing care.

Rwanda has ~18,000 people living with cancer and only two cancer centers: one in Kigali and Butaro Cancer Center of Excellence (BCCOE) in the North, which provides free cancer treatment to the most vulnerable. Due to poor road access, enrolled BCCOE patients spend a day using multiple forms of transport to reach care; they suffer nausea, headaches and muscle pain primarily associated with their toxic treatment, exacerbated by their difficult journey to care.

During the ongoing COVID-19 pandemic, cancer patients, with a heightened risk of contracting COVID-19 because of their weakened immune systems, are more likely to avoid travel and miss routine appointments. Those taking oral cancer medications were stranded in remote areas of the country, without refills.

Dr. Tedros, Director General of WHO, predicts at least 7 million lives could be saved over the next decade, by identifying the most appropriate science for each country situation, by basing strong cancer responses on universal health coverage, and by mobilizing different stakeholders to work together.

As stakeholders, Zipline and PIH/IMB worked together to launch a solution to one problem we could solve together: getting oral cancer drugs to 63 patients living across Rwanda who typically receive treatment at the PIH/IMB-supported BCCOE.

Zipline operates autonomous drones from distribution centers at the center of each region of service. Part medical warehouse, part drone airport, each distribution center can make 100+ deliveries daily to any point within a 22,500+ square kilometer service area.

This is how it works:

Step 1: PIH/IMB delivers oral cancer medication inventory to Zipline regional distribution centers

Step 2: Zipline receives an order by phone, text, or web form from a PIH patient navigator. Orders can be scheduled in advance or placed on demand.

Step 3: A Zipline operator immediately begins processing the product for delivery using packaging to maintain cold chain and protect fragile products during delivery.

Step 4: The drone is packed, prepped, and launched in minutes.

Step 5: The drone releases the package – using a small parachute - above a predetermined point convenient to the customer. After delivery the drone returns and is quickly prepped to fly again.

Step 6: A designated healthcare provider picks up the package and brings the medication to the patient and answers any questions the patient may have about the treatment.

Step 7: (future) Provider will record vital signs and send patient data to Butaro District Hospital Cancer Center of Excellence.

Partners In Health/Inshuti Mu Buzima (PIH/IMB) has been serving Rwandan cancer patients for the past eight years. Through task-shifting and partnerships with the leading cancer care experts across the world, PIH-IMB has created a cadre of empathetic and effective Rwandan cancer care providers, mostly based in a public district hospital- the Butaro Cancer Center of Excellence. Over the years, PIH/IMB has gained and understanding of patient needs through research and quality improvement projects. One of the most common complaints from our patients was the long distance and difficult journey required to receive medications in the Northern Province at the Cancer Center of Excellence. This solution will directly address this need by bringing the medication directly to patients with cancers treatable through oral chemotherapy, namely breast cancer, chronic myeloid leukemia (CML), gastrointestinal stroma tumor (GST), chronic lymphocytic leukemia (CLL), or small lymphocytic lymphoma (SLL).

The best way to prevent, detect and mitigate a global pandemic is to strengthen the public health system. This drone delivery solution for cancer patients, born out of necessity during Rwanda’s COVID-19 pandemic, provides a viable way to improve health care supply chains by bringing medications directly to patients living in rural areas. Taking away the unnecessary patient travel during a lockdown, decreasing patient anxieties, reducing risk for deferred treatment doses, and significantly reducing infection risk for chronic care patients with compromised immune systems, particularly those living in rural low-income areas, is critical to mitigate a pandemic of any kind.

1. Ability to send drones where it’s unsafe, challenging to reach and/or too far to send people routinely. Remote communities are least likely to be infected, but they are also least able to deal with an infection. Reduce risk by limiting visitors to those areas by leveraging drone delivery over vehicle delivery whenever possible. Eliminating vectors between affected and unaffected communities is vital to controlling disease spread.

2. More vehicles and fuel put towards fighting the pandemic. PIH/IMB used to cover transport costs for cancer patients around the country to reach cancer centers for treatment. While we still do this for patients needing IV chemotherapy, we do not need to use vehicles and fuel for transporting cancer patients needing oral cancer drugs anymore, which frees up our fleet to support with COVID-19 testing, tracing and treatment.

3. More capacity at the Cancer Center of Excellence to deal with patients in critical conditions and less travel burden on patients. When primary/secondary facilities have the supplies and treatments needed to refill oral cancer medication prescriptions, it reduces pressure on the hospitals, freeing up oncologist time for the patients who truly need them. For example, when we deliver oral cancer medications to district hospitals to treat oncology patients, we reduce their need to go to other facilities further away from their homes or tertiary facilities

Zipline’s reliability has earned the trust of health workers who have grown to rely on Zipline for delivery during emergencies, and the partnership of national civil aviation authorities, who collaborate with Zipline to operate a safe, modern airspace every day. Zipline is also integrated into national medical care through a direct partnership with the Ministry of Health, increasing the likelihood of long-term sustainability.

Safety is Zipline’s top priority at every stage, starting with the design of the vehicle. Zipline has built redundancy into all major systems like motors, power, communications, and navigation to ensure that drones can safely fly even if there is an unexpected failure. A parachute landing system that slowly lowers the drone to the ground can be deployed as a last resort. See additional video content above for more details.

Zipline is operating in different countries including Rwanda and Ghana to serve millions of people who need emergency service. Whereby with Zipline, the patients can easily get access on essential medicines and also help the country to reduce the expiries through centralizing stock that allow equitable distribution of stock at different levels. 

Our theory of change is built on the fundamental logic that a bringing medications to a patient by drone rather than making the patient travel to a distant cancer center for 6-12 hours will increase the patient's likelihood of continuing the treatment as prescribed, and reduce patient’s risk of contracting highly infectious diseases during a pandemic by avoiding a long, cross-country trip. 

With only two cancer treatment centers serving a population of 10 million people, drones allow cancer centers to extend their network of care to reach patients throughout the country, while removing unnecessary congestion from cancer centers by avoiding unnecessary visits. 

During a pandemic, safe and efficient transport of test sample kits and social support requires a larger vehicle capacity nationwide. Drone delivery of cancer medications can also reduce the use of vehicles and fuel for cancer patient transport, allowing fleets to be put to use fighting COVID-19.

The key assumptions in the theory of change are PIH/IMB’s continued provision of oral cancer medications at no cost to the patient, and the ability of Zipline’s drone infrastructure to continue to implement the delivery system they have put in place. 

Today 63 patients are receiving their oral cancer medications by drone.

Within one year, we will serve 217 patients in Rwanda (the entire # of Rwandan cancer patients who are taking oral cancer drugs).

With an increase in early detection of cancer, we expect that we will be delivering oral cancer medications to 1,085 patients over the course of the next 5 years.

Within the next year, PIH/IMB would like to reach all cancer patients in Rwanda who require oral cancer drugs by drone-delivery. Within the next 5 years, we plan to set up a health informatics component that will help oncologists at Butaro Cancer Center of Excellence (BCCOE) monitor their patients who are receiving refills by drone. We will train the health provider at the facility closest the patient to enter vital signs and other information into a tablet that will send the data to BCCOE oncologists, who will use that data to assess if the patient needs to come for an in-person visit.

If this model continues to prove successful, it may be expanded to support care for other patients in other chronic care programs. Within 5 years, our goal is to use an economic evaluation model to share the success of drone-delivered oral cancer drugs with other stakeholders looking to implement something similar in their context.  

Zipline is expanding the scope of the service and it’s aiming to increase the number of health facilities in Rwanda to serve the entire population by the end of 2021. Beyond serving the existing customers, Zipline is planning to expand to the new locations on the global with a plan of testing new delivery system such as home delivery that help the customers to easily access medications and consumables that they need. 

Patient feedback

Almost 50% of cancer patients are lost-to-follow-up each year, so getting patient feedback on how to make care delivery better is crucial for long-term success. In Rwanda there are less than 80 mobile subscriptions registered for every 100 people. This means that there are still rural patients that may be hard for us to reach in the case of missed visits or loss-to-follow-up, who cannot give feedback by phone.

Distance

Though we are bringing the treatment much closer to the patient by delivering it to the nearest health facility, there are still potential challenges that patients might face travelling that shorter distance between home and facility.

Research

Our patients have told us that the drone delivery has improved their well-being, by removing the long journey to the cancer treatment center, but we need rigorous qualitative research conducted to investigate this further. We are using less vehicles and fuel to transport patients who require oral cancer treatment, but we need rigorous quantitative research to measure the environmental and financial impact of this, and compare it to the business-as-usual approach.

Patient feedback

We will send tablets to all district hospitals with a form providers can fill out when consulting patients that will share their vital signs and other indicators with the patient's oncology care team at Butaro Cancer Center of Excellence. The results will be used to improve service delivery, help health providers flag when a patient needs to come for an in-person visit, and support follow up with individual patients experiencing problems with their treatment and care.

Distance

PIH/IMB and Zipline are eager to test new technologies like home delivery using the existing drone network. We also need to determine whether there are other aspects of patient treatment

aside from medications (lab tests, etc.) which can also be added to this solution so that patients will only have to travel when they need a clinical consultation with an oncologist. We will use the surveys mentioned above to incorporate patient feedback as we add new features.

Research

PIH’s strong implementation research background and Zipline’s strong marketing capabilities will help us better understand, improve, and disseminate the impact of our solution. This data can be used to inform deepening or broadening different components of our solution.

Partners In Health - Inshuti Mu Buzima (PIH/IMB)

Oncology Manager (40% FTE)

Senior Pharmacy Program Manager (30% FTE)

Oncology Director (10% FTE)

Zipline

Fulfillment Operator Kayonza Distribution Center (15% FTE)

Fulfillment Operator Muhanga Distribution Center (15% FTE)

Head of Health System Integration (10% FTE)

Rwanda Country Manager (5% FTE)

PIH/IMB has supported the Ministry of Health in Rwanda to strengthen the primary and chronic care services within the public health system for 15 years, specifically delivering high-quality cancer care to rural Rwandans for 8 years. Zipline has been working alongside the Ministry of Health to conduct drone deliveries of essential medications and blood for 4 years.

PIH-IMB has collaborated with the Ministry of Health and the Rwanda Biomedical Center for over 15 years. Zipline has partnered with the Ministry of Health in Rwanda for 4 years.PIH/IMB and Zipline have worked together since the beginning of the COVID-19 pandemic in Rwanda.

PIH/IMB is a non-profit NGO. Zipline is a private US logistic company that sells drone delivery services to public and private entities to improve efficiency in health care supply chains.

Medications 

PIH/IMB, through the sustained support of donors, is able to procure cancer medications at little to no cost to the patient. Through advocacy, we hope that the prices of these drugs will reduce over time. 

PIH/IMB Oncology Team 

PIH/IMB oncology staff set the treatment regiment and dosage for our cancer patients. They also provide ongoing mentorship to health-care providers who administer oral cancer medications outside of PIH/IMB’s current catchment area. Their salaries are raised through fundraising 

MOH Healthcare providers 

Health-care providers administering oral cancer medications and seeing patients are Ministry of Health employees. 

Zipline Delivery 

With all its customers in Rwanda and beyond, Zipline operates under a contract framework involving a form of payment for the service rendered. Zipline has a current agreement with the Rwandan Ministry of Health to deliver blood and essential medicines to all health facilities outside of Kigali. 

The MIT Solve community includes MIT faculty and health economists- we hope to leverage this network during the nine months of personalized support to design a costing study that will allow us to do evidence-based advocacy at the national and global level for universal access to quality cancer care.

We hope that by becoming a MIT Solver, our team will generate and disseminate findings that can be used to improve, deepen and broaden the impact of our solution

We would like to create a value-based healthcare assessment that could be used by other countries around the world who may consider implementing this solution. The assessment would collect data from patients, providers and supply chain experts to determine whether the Zipline solution would work for their context by bringing value to the patient (reduction in travel time) while being affordable for Ministries of Health/governments to take on (cost of drones, cost of medications, etc.)

We would like to partner with MIT faculty or initiatives who could support (a) implementation research on value-based health care delivery and (b) development of an app that remote health providers can fill when giving patients their oral cancer drug refills that will allow the oncology team to monitor patients.

Example 1: With support of MIT faculty, we would conduct a cost comparison or economic evaluation to determine the most valuable option for patients that is still cost-effective for the public health system to own/absorb (fuel and transport to bring rural, low-income patients to 2 facilities for medications and care? Drone delivery of medications with remote care options?)

Example 2: With the support of MIT faculty, we could develop an application that can take patient data from tablets at remote health facilities and feed it back to BCCOE Oncology team. This app would also help remote health providers encourage patients to go to Butaro Cancer Center of Excellence (BCCOE) if they are late for a visit, or if their vital signs are abnormal. 

Our delegate, Jean Bosco, meets all the qualifications for this prize.

If awarded, our team will use The Elevate Prize to ensure continued supply of oral cancer drugs to Rwandan cancer patients across the country, while exploring ways of making the current solution more patient-friendly (point-of-care information systems, home delivery, adding features such as lab tests, etc) and add new features to reduce loss to follow-up.

According to the UN SDGs, the probability of dying from any of the four main non-communicable diseases – cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – between the ages of 30 and 70 was 18 per cent in 2016. The risk remains markedly higher for men globally, at 21.6 per cent, compared with 15 per cent for women. Improving access to cancer treatment for rural cancer patients is a critical part of improving the health and well-being of the world's people.

If awarded, our team will use The People's Prize to ensure continued supply of oral cancer drugs to Rwandan cancer patients across the country, while exploring ways of making the current solution more patient-friendly (point-of-care information systems, home delivery, adding features such as lab tests, etc) and add new features to reduce loss to follow-up.