| 4. In which ways is the initiative creative and innovative?
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The key strategies of WCM project involved: 1) WCM development appropriate for use in the field; 2) active participation and training of FHWs, and 3) 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 FHWs of Mae Sarieng Malaria clinic, and the expert microscopist from the reference laboratory in Chiang Mai, conducted a needs assessment for a better diagnostic tool. Past experince indicated that viewing different spots on the same blood film could lead FHW in the field and the expert microscopist at the reference laboratory to interpret and diagnose a blood film differently. The team explored a way for people in different locations to precisely view and discuss a blood film together simultaneously. 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 microscospist surveyed, reviewed, acquired and pilot tested several commercial webcams. 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 experimentalWCM from locally available parts. Afterward the team from the reference laboratory conducted 2 field tests of the experimental WCM at 5 malaria clinincs in Mae Hong Son province for 8 months
During 2010 - 2011, the participating FHWs pilot tested and evaluated the experimental WCM. Results of the pilot indicated that FHWs were satified with the image of blood film WCM just some slightly modify of an adapter to fix with eyepice of microscope and the extension cord. 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 FHWs and the deveopment teamdiscussed and agreed upon a new procedure for using WCM as well as a new monitoring and evaluation method.
From September 2011 until present, the modified WCMwas used in a malaria clinic in Mae Sarieng district. The FHWs 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 avideo and sent to thereference lab. The next day, an expert microscopistrechecked all the recorded files and sent the results back to the FHW 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 developnent team also developeda 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 FHWs 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 (70 FHWs).
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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 FHWs 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 programmeon-site during a visit of the team from the reference laboratory, for a cost of around 20,000 Baht (620 USD). This cost compose of per diem and accommodation for 3 staffs, gasoline and materials include WCM and document printing. The implementation of 10 sites is needed to save time and traveling budget. The expense for training was approximately 9,000 Baht per persons (278 USD), which was supported by DDC. This cost included per diem, accommodation local transportation, gasoline and materials include WCM and document printing.
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 aspect of this project is FHWs were satisfied with WCM and actively participated in the program. The WCM 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 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.
In addition, 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 has reduced from an average of 21 days to 24 hours, and for dilemma situations within 30 minutes. During 2011 and 2012 there were 24 dilemma situation consultations, which resulted in all patients receiving the appropriate treatment following the consultation. These results in reduction the chances of the malaria parasite spreading to the community.
Furthermore, the FHWs who use this tool have more confidence in reporting the results 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. The other FHWs 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 (ten sites with 70 FHWs join the program) in Mae Hong Son province.
Lastly, WCM is now distributed for using in many microscope diagnosis laboratories; these included Chiangmai University, the Training Center at Prabudabaht Saraburi, the office of diseases prevention and control region 7, the vector borne diseases center and private laboratory sector. The feedback satisfaction form the users were 95% which is above the standard (85%).
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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 program were made according to the analysis of the field tests and questionnaires.
Work manual and data collecting forms for new system of quality control via WCM also developed by the team which compose of microscopists and FHWs to ensure it is understood able for the users (microscopist and FHWs). The data forms include the general information of patient, the result of diagnosis, the problems of using WCM and the satisfaction of patient relevant to WCM and the service.
Additionally, to monitoring the implementation of the strategy weekly scheduled teleconference calls between FHWs and microscopist were set up and recorded. 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. The annual field monitoring and supervision were included in the project at least once a year. The work manual for monitoring and supervision were developed and use as a tool for data collecting.
All data is monthly collected and analyzed and used for planning and improving the system to expand the project for the other malaria clinics in remote areas which have a high malaria incidence.
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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 causethe 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 FHWs 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. The compartments of WCM are general materials, cheap and easy to find.
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