| 4. In which ways is the initiative creative and innovative?
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The key strategies of WCM project involved the active participation of TFHWs, utilization of accessible and affordable communications equipment and technology, and existing infrastructure: malaria clinics and the internet. The chronology in developing WCM was started in 2009, when a team of key persons, that included TFHWs of Mae Sarieng Malaria clinic, and the expert microscopist from the reference laboratory in Chiang Mai, conducted a needs assestment for a better diagnostic tool. Past experince indicated that viewing different spots on the same blood film could lead TFHW in the field and the expert microscopist at the reference laboratory to interpret and diagnose a blood film differently. The team therefore explored a way for people in different locations to precisely review and discuss a blood film together in the same way. This led the team to review and compare costs and performances of existing digital microscopic cameras as well as a method to transmit a blood film to a different location for simultanous viewing and discussion with minimum cost and effort. Then, the expert microscospist surveyed, reviewed, acquired and tested various commercial webcams available domestically and internationally. Findings from the survey and testing served as a quality benchmark for the webcam-based diagnostic tool that the team set out to develop.
In 2009 to 2010, based on the aforementioned survey of existing webcams, the expert microscopist and other colleagues at the reference laboratory designed and assembled an experimental WCM from locally available parts. Afterward the team from the reference laboratory conducted 2 field tests of the experimental WCM involving 5 malaria clinincs in Mae Hong Son province.
During 2010 - 2011, the participating TFHWs pilot tested and evaluated the experimental WCM. The results of the pilot test were used by the development team at the reference laboratory to modify the first WCM. Field tests were then repeated to ensure that the reliability of the WCM was equal to direct examination of blood films under the microscope, and potential users were satisfied with the tool and method. The field TFHWs and the deveopment team discussed and agreed upon a new procedure for using WCM as well as a new monitoring and evaluation method.
Between 2011 to 2012, the modified WCM was used in a malaria clinic in Mae Sarieng district. The TFHWs and the development team in Chiang Mai monitored and evaluated WCM by bimonthly teleconference calls and adhoc teleconference for difficult cases. At the end of each day, 10% of negative blood slides were randomly selected together with 100% of the positive blood slides, recorded as a video and sent to the reference lab. The next day, an expert microscopist rechecked all the recorded files and sent the results back to the TFHW in the malaria clinic in Mae Sarieng. If there was any disagreement, the blood films were put online for discussion to reach a consensus decision. The patients with erroneous results were followed up for an appropriated treatment. From September 2013, the team developed a scaled up plan to increase WCM use to 10 new sites in the province. The development team also developed a monitoring and evaluation plan for a blood slide bank using an online data base that can be monitored daily by the expert microscopist.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The stakeholders involved in the implementation are the TFHW who participated in the WCM design and in learning how to use the WCM and computer. The medical scientist at the reference laboratory created the WCM and set up the new system of quality control. Staff of the Center of Excellence for Biomedical and Public Heath Informatice – BIOPHICS), a non-governmental organization affiliated with Mahidol University, were responsible for developing computer software for WCM, instructions for WCM programme and online diagnosis. The Strategic Planning Committee and Executive Board Funding Committee of ODPC 10 allocated a part of the budget for implementation of initial WCM project. Last but not least, the Executive Board Committee of Department of Diseases Control (DDC), Ministry of Public health allocated the grand budget for implementation of WCM in all remote malaria clinics, 10 sites.
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| 6. How was the strategy implemented and what resources were mobilized?
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The resources for this initiative were composed of startup costs for one site approximately 90,000 Baht (2,790 USD). These were composed of microscopes 60,000 Baht (1,860 USD), Computers 20,000 Baht (620 USD), WCM 4,000 Baht (124 USD) and miscellaneous 6,000 Baht (186 USD) e.g. blood film preparation set, stationery and waste disposal setup.
In addition, the operating expenses are approximately composed of expenses for implementation, monitoring and evaluation of the initiative, THB. 60,000 (1,855 USD), partial salaries of 2 TFHWs involved in the initiative, 4,320 Baht per month (134 USD), partial salary of the expert microscopist = 3,000 Baht per month (93 USD), malaria clinic and office maintenance = 1,800 Baht per month (56 USD) and blood slide preparation = 5 Baht per patient (0.15 USD).
The initial WCM project had one site at the malaria clinic in Mae Sarieng. The TFHW was trained in the use of the WCM and programme on-site during a visit of the team from the reference laboratory, for a cost of around 20,000 Baht (620 USD). The implementation of 10 sites is needed to save time and traveling budget. The expense for training was approximately 5,000 Baht per persons (155 USD), which was supported by DDC.
Moreover, there are in-kind contributions from BIOPHICS (salaries for IT persons, internet access, computer programme development, and field monitoring and evaluation)
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The most successful of this project is the WCM which provides an affordable and reliable diagnosis tool and a modern system of quality control using internet technology. The image quality of the WCM is high with a resolution of 1600 x1200 pixels. In the video mode, the frame rate is 30 fps. The resolution of a still image is 2 megapixels and can be enhanced up to 8 megapixels. WCM is equipped with a built-in microphone. WCM is an affordable (4,000 Baht or 124 USD) and user-friendly tool that provides high quality and simple software with a symbolic tool-set. Therefore, TFHWs were satisfied and actively participate in the programme. The accuracy of malaria microscope diagnosis has increased from 98.6% in 2011 to 99.1% in 2012, to 99.5% in 2013. The time to confirm microscope malaria diagnosis was reduce from an average of 21 days to 24 hours, and for dilemma situations within 30 minutes. The other TFHWs in remote malaria clinics also wanted to join the project to support their work. At present, WCM has been implemented in all remote malaria clinics (10 sites with 70 TFHWs) in Mae Hong Son province. The TFHWs who use this tool have more confidence in reporting the result of malaria diagnosis by microscope. They also use WCM to exchange their experience and knowledge of malaria diagnosis via the social network (Facebook) with colleges. During 2011 to 2012 there were 24 dilemma situation consultations which resulted in all patients receiving the appropriate treatment following the consultation. The chances of the malaria parasite spreading to the community were reduced. Moreover, it is more economical for the patient due to improved accuracy in diagnosis and treatment, and the elimination of the expense of a lengthy follow up.
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| 8. What were the most successful outputs and why was the initiative effective?
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Steps and systems for monitoring output and progress of the initiative began with field tests and structured questionnaires to evaluate performance of the WCM and the users’ satisfaction. The results of the questionnaires were compiled and analyzed by the development team at the reference laboratory. Then, modifications of the WCM and the operating computer programme were made according to the analysis of the field tests and questionnaires. Weekly scheduled teleconference calls between TFHWs and microscopist were set up for monitoring and supervision purposes. All blood films which had been in a consultation or teleconference on the weekly schedule were directly re-examined under microscopes to test the reliability of WCM. Annual field monitoring and supervision were included in the project at least once a year. Patient’s evaluation forms were recorded daily and analysed for treatment outcomes and service satisfaction. All patients’ data were kept confidential.
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| 9. What were the main obstacles encountered and how were they overcome?
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The first obstacle of this project is internet system which sometimes fails due to bad weather. The solution is recording blood films in digital format and video files for later review and uploads when the internet signal returns.
Secondly, the warm and humid climate can cause the lens of the WCM to become moldy. The instruction for microscope and WCM maintenance comes with ways to prevent this problem. In brief, when microscope and webcam is not in use, it should be kept in a box with desiccants or in a microscope cabinet that contains desiccants and electric lamps, and a daily record of temperature and humidity in the cabinet should be kept.
Thirdly, in the areas with no electricity, installment of solar panel for power to run computer, internet modem, and WCM are necessary. ODPC 10 is exploring alternatives to mitigate this problem.
Fourth, the attitude of TFHWs who had no direct experience with WCM was doubtful and unsure about diagnostic accuracy of the new method compared with the traditional method that they were trained and familiar with. More exposure to and experience with the new method (WCM) can solve this problem.
Lastly, WCM is designed with future modification in mind. When computer technology and the quality of webcams improve, WCM can be modified accordingly. The instruction for WCM comes with the anticipation for future modification.
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