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Satellite Workshops in District Hospitals for Sustainable
Prostheses Foundation of H.R.H The Princess Mother
Thailand

The Problem

1. What was the situation before the initiative? (The problem)
Of the 65 million populations of the Kingdom of Thailand. About 80% of its inhabitants work in agricultural sector due to majority of the country natural areas are paddy rice fields and semi-arid farm lands. The total number of disables in this country is 1.9 million or 2.9 percent of the total populations. There are 474,967 disables that need the prostheses and orthoses for their daily living. The large segment of this group lives in remote rural area. Lack of financial means and of basic health education. The only center that can provides the prostheses is the provincial hospital in center of the city, far-away from home. The disables have to take time away from families and work to travel long distance over difficult and often dangerous terrain. Even when they eventually arrive at the provincial hospital, it often take long queue and months to receive the prosthetic fitting , due to shortage of prosthetic technician. There are 296 prostheses and orthoses technicians serving the whole country, at this moment . Even through the disables get the prostheses, they need periodic checks once they are in use, and occasionally require repair or replacement. By the mobile clinic of Prostheses Foundation to the rural areas around the country hundreds of trips, still can not accomplish to the quality and sustainability of prostheses services to the poors.

Solution and Key Benefits

 What is the initiative about? (the solution)
2. What is the initiative about? (The solution)
The objectives of the initiative are to increase the accessibility of amputees to the prostheses in terms of fast, easily and good quality prostheses that can be obtained within one or two days, free of charge regardless of ethnicity or religion. And also regularly services by the skillful technicians under the supervision of medical doctors in local district hospital. We believe that after amputees receiving the prosthetic legs, they can again walk, works, take care of themselves, look after their families, and return to being a more functional member of the society.

The achievement of setting up the satellite workshops in 35 district hospitals around the country. It proved to be the sustainable community service to poor amputees. The Prostheses Foundation provide the 4 months training course for those amputees who willing to work with the district hospital as the prosthetic technician. And set up the prosthetic workshop without charge and also provides free upgrades to the machines and equipment periodically. With the new technic of PF modified CIR sand casting, it is not only preserves the environment by employing reusable materials, but also by using less equipment, obtain greater accuracy, easier fabrication, and faster delivery.
After the implementation, the amputees in the remote rural area are the most affected by the initiatives. The average service time for below the knee (BK) prostheses reduced from month to only 1 day. Above the knee (AK) prosthesis reduced form 2-3 months and more than 4-5 visits to only 2 days in only one visit, and return home with the appropriated prosthetic leg. The amputees satisfaction in Burirum Province which has 4 satellite workshops in the year 2010, in the category of confidence in prosthetic leg using is 82.80 percent and technician service is 80.80 percent.
During five years(2007-2011) period of the initiatives, there are 29 satellite workshops distribute in the district hospitals around the country and three outside the country ; Ache in Indonesia , Burundi and Senegal in the Africa Continent . They provided service to 5,926 legs, which are BK prosthesis 3,054 legs, AK prosthesis 875 legs, TK prosthesis 200 legs, Symes’ prosthesis 94 legs and 1600 legs of repairing. All the materials and prosthetic parts are made from local quality materials which meet the ISO standard but ten fold cheaper than the import one. It saves the large amount of the government expenditure.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
3. Who proposed the solution, who implemented it and who were the stakeholders?
The Prostheses Foundation has provided mobile clinics to serve the poor amputees in remote rural areas five trips a year for twenty years, but it is not enough to solve the problems. With the cooperation of the Thai National Health Security Office (NHSO) and the commitment of the director of district hospitals to work together with the Prostheses Foundation to improve the quality prosthetic service to the poor amputees by human resources development, knowledge transfer and prosthetic workshop set up in district hospitals. With the concepts of high quality, accuracy, easily fabrication and faster delivery prosthetic legs, but low cost, environmental conservation and sustainable service.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
4. Describe how and when the initiative was implemented by answering these questions.
a) What were the strategies used to implement the initiative?
With the awareness and full support from the Thai National Health Security Office (NHSO) and director of the district hospitals to comply with the requirements of poor amputees in remote rural areas, it was the national policy that all amputees should be able to access to the prostheses regardless of their ethnicity, social or financial status. The Prostheses Foundation of H.R.H. The Princess Mother provides knowledge transfer, training prosthetic technicians and the full equipped prosthetic workshop for the district hospitals.
The satellite prosthetic workshop initiatives were established with the following objectives:
1. To improve the accessibility to lower limb prosthetic leg for the underprivileged amputees in remote rural areas.
2. To raise the standard of lower limb prosthetic fabrication and delivery time.
3. To increase district hospital’s competency to take care of the poor amputees to the level of best practice.
The strategies used to achieve the above objectives are as follows:
1. Empower staffs of the district hospital especially the director, physicians and physical therapists in streamlining the prosthetic services.
2. Training of 2-3 disabled amputees to be the skillful lower limb prosthetic technician to work with the district hospital.
3. Provide free machines, tools, equipment and materials to install the prosthetic workshop in the selected district hospital.
4. Each technician will join the mobile clinic two or three times a year for continuous, knowledge and practical skills updating.



How they were established and by whom?
The Prostheses Foundation of H.R.H. The Princess Mother is the main organization to work through the above strategies with the cooperation of director of district hospital.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
b) What were the key developmentation steps and the chronology?
In order to achieve to the key successes of setting up a sustainable prosthetic service workshop in district hospital. The secretary general of the Prostheses Foundation has to get the commitment from the hospital director. Physicians and hospital personnel need to understand the suffering of amputees in their community and willing to improve the service. The hospital has to provide a sheltered space of about 5x10 meters for workshop installation. Two to three community persons who have themselves suffered leg amputation and are willing to become technicians, selected by the district hospital director. All undergo a four months training program at the Prostheses Foundation, using PF modified CIR sand casting technic. The syllabus consists of theory, demonstration and the acquisition of practical skills, with the rigorous evaluation. They will return to work with the district hospital under supervision of the trained physician and physical therapists. During the technician training period, the prosthetic workshops were installed in the district hospital by the Prostheses Foundation without charge. A yearly report is supplied by each district hospital detailing service progression, workshop quality, types and numbers of prostheses provided, problems encountered and any support that may needed. Site visit by executives from the Prostheses Foundation to assist problem solving, ensure quality of service and the satisfaction of the disabled without interfering with internal management of the hospital.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
c) What were the main obstacles encountered? How were they overcome?
There are three major obstacles exist.
1. Shortage of medical personal especially physician and physical therapist to be trained to supervise the prosthetic technician. Instead of that, the practical nurse or occupational therapist was trained in some of the district hospital.
2. Difficulty in selection of the appropriate amputees who willing to accept training and return to work. Encouraging and promote a more positive image of people with disabilities. Especially if they can gain their independence, get the opportunity to work and get the salary from the district hospital. Even it is the priority objective to train the disabled amputees, but some hospital the Prostheses Foundation accepts the healthy person that already employed as the hospital personnel instead.
3. Limited salary for those trained technicians. This can be overcome by supporting from the National Health Security Office (NHSO) to pay back basic revenues to the district hospital according to the number of prostheses done. Means that the hospital can generate more income and can step up the technician’s salary.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
d) What resources were used for the initiative and what were its key benefits?
Resources used to improve the quality and sustainable lower limb prosthetic service include:
1. Human resources, teams work together both from Prostheses Foundation of H.R.H. The Princess Mother and medical team from the district hospital, including hospital director, physicians, physical therapist, nurses etc. To provide them the opportunity to bring their expertise and ideas into improving the high standard of health care service, especially in quality prosthetic service.
2. Budget for prosthetic workshop installation was devided into two categories. The district hospital provides a sheltered space of about 5x10 meters, with sufficient ventilation and public utilities. The second past was the workshop installation given by the Prostheses Foundation. Machines, tools, equipment and materials mostly were made by the Prostheses Foundation under the Foundation’s patents and using locally available, inexpensive and durable materials. The budget come from donation of the private sectors.
3. The key benefits are:
1) The underprivileged disabled amputees in the remote rural areas can easily access to the prosthetic services with the cost -effectiveness and great satisfaction.
2) Empower district hospitals to provide prosthetic services with quality comparable to those provided by the Prostheses Foundation.
3) Green technology, cost-effectiveness and without interference the government budget.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
5) Is the initiative sustainable and transferable?
The Prostheses Foundation’s policy is to maintain the high quality prosthetic services to serve the underprivileged amputees through out the country with customers satisfaction. Annual academic meeting to allow technicians to increase their knowledge and to share experiences. A short refresher course including both theory and practical skills is given during return to work with the Prostheses Foundation’s mobile clinic two or three times each year. This is to ensure the quality of service provided by the technicians.
A yearly report is supplied by each district hospital detailing service progression, workshop quality, types and numbers of prostheses provided, problems encountered and any support that may needed .
Site visit by executives from the Prostheses Foundation to assist the district hospital in solving problems. Improving the quality of workshop service and upgrading machines and equipment without any budget interference to the district hospital.
Currently thirty five satellite workshops have been established in Thailand, and five to six new workshops will be established each year, until the objective of at least one workshop in each of our seventy seven provinces is attained. The details of establishment of satellite workshops are as follow:

Year Number of workshop
2007 7
2008 4
2009 5
2010 6
2011 7
2012 6



The locations of satellite workshop are shown on the map below:

















Two international workshops have been established, one on Burundi and one in Senegal, Both of these African workshop function very well, And they are the role model of the Africa Continent.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
6) What are the impact of your initiative and the lessons learned?
After implementing the initiative, satellite workshops have expanded to cover many areas of the country, district hospitals potential to provide the appropriate lower limb prostheses with the green environmental technology, cost -effectiveness, high quality, easier fabrication and fast delivery. These successful initiative has also produced not only the disable amputees satisfaction but medical personnel, especially those amputee-technicians’ satisfaction and pride in their work as well.
The Prostheses Foundation has dedicated to the underprivileged disabled amputees both national and international communities. It has won the organization many awards such as:
• First Prize Winner of Tararom Quality Award in “Inventing Artificial Limbs from Waste Plastic Bottles, Thailand”, 1993
• Third Prize Winner of Innovation Awards, “Prosthetic Legs using Waste Plastic Bottles.” From National Research Council of Thailand,1994
• The Best Innovation Work in “The Fast and Adequate Prosthetic Legs Services” from National Research Council of Thailand,2000
• The most prosthetics donated by a Single Organization was 664 artificial legs, donated and fitted by The Prostheses Foundation (Thailand) Sanamluang, Bangkok, Thailand between 16-26 July 2006 by Guinness World Records LTD. , 2006
• First Prize in Innovation Award for Medical and Public Health Inventions. From National Research Council of Thailand,2007
• The most prosthetic donation by a single organization was 864 artificial legs, donated and fitted by The Prostheses Foundation of H.R.H. The Princess Mother (Thailand) in Wat Phra Pathom Chedi, Nakorn Pathom, Thailand between 12-25 February 2012, by Guinness World Records, 2012

The Prostheses Foundation of H.R.H. The Princess Mother is also accredited in quality management standard of ISO 2001:2008. In design and manufacture of polycentric knee joint, above the knee prosthetic skeleton, below the knee prostheses skeleton and dynamic SACH foot by SGS (Societe Generale de Surveillance), Switzerland and UKAS (United Kingdom Accreditation Service.), 2012





Lessons Learned
1. Satellite workshop in district hospitals can provide the ease accessibility to the lower limb prosthetic services for the underprivileged disables amputees in the remote rural areas.
2. Satellite workshop in district hospitals can provide the same standard and quality of lower limb prostheses services.
3. Successful workshops have also produced not only the amputees’ satisfaction but the trained amputee-technicians great satisfaction as wall.
4. The trained amputee-technicians are pride in their work and as role model of the other disabled amputees.
5. Satellite workshops is a state-of-the-art prosthetic service, which is most economical of high quality, sustainable and appropriately affordable in low income countries. It is not only replicated in several regions of Thailand but also international communities.

Contact Information

Institution Name:   Prostheses Foundation of H.R.H The Princess Mother
Institution Type:   Non-Governmental Organization  
Contact Person:   Dr.Therdchai Jivacate
Title:   Secretary-General  
Telephone/ Fax:   66 53 112271-3
Institution's / Project's Website:   www.prosthesesfoundation.or.th
E-mail:   therdchai.jivacate.md@gmail.com  
Address:   199 Moo.4 Donkaew,Maerim District
Postal Code:   50180
City:   Maerim
State/Province:   Chaing Mai
Country:   Thailand

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