| 4. In which ways is the initiative creative and innovative?
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The first strategy of ‘leveraging partnership through policy driving’ involves: 1) initiating three networks, 2) expanding to six networks 3) establishing Tha Song Yang committee for malaria management, 4) meeting, monitoring and evaluation. In 2010, ODPC 9, in coordination with VBDU 9.3.5, identified relevant stakeholder presently providing health care (SHPC, DHO and Tha Song Yang community hospital) and NGOs and invited them to join the initiative. Ad-hoc and regular meetings, such as district health board monthly meetings, were held to identify and discuss present roles played by each involved member and their available resources.
After deliberation of all issues, challenges were identified through SWOT and gap analysis of health care services at each stage and contact points within health care delivery chain. It was found that malaria in childhood was also a significant emerging including the scarcity of the resource which these needed more assistance. Therefore, the BPPU, local or Tambon administrative Organizations and community were involved for collaboration to manage the challenges in 2011. With a purpose to reducing malaria case and increasing quality of life in an affected area as a commitment, sub-district Tha Son Yang committee for malaria management was developed and ensured all objectives and strategies were represented.
Additionally, communication channels were set up to ensure those involved were constantly updated on the developments of the project such as telephone contact list, email address and radio wave for remote area. Furthermore, formal and informal meeting, monthly monitoring and fiscal evaluation were key activities which has influenced to decision-making process amongst six stakeholders. This serves as the mechanism for maintaining participation and involvement throughout the implementation of the ICD/CIM initiative.
The second stage set into action of service on site and prevention activities which were agreed upon by the team discussed above in 2011. Main activities were active malaria care in the village by integrating team, campaigning and surveillance .For more efficient work, an instruction manual was developed, proposing the organization’s role and responsibility, job descriptions such as the screening, blood testing, prescribing, and follow-up of patients. For example, it provided case identification by the community health volunteers, blood examination, diagnoses, giving medication by VBDU officers and education for malaria prevention by outreach team. Moreover, the BPPU has played a significant role to tracking and promoting student case for treatment and disease surveillance.
Concurrently, the selection for health volunteers in community and training could be done for achieving community health advocates and building capacity of health volunteers of the third strategy. During 2010-2012, one day course training has been arranged for village health volunteers and community leaders for malaria prevention and education which this trains 100 persons per year. There was intensive program for healthcare providers such as hospital staff, VBDU officers and health center officers for laboratory technique, diagnosis and treatment in 2011. Furthermore, VBDU 9.3.5 has applied the workshop training or focus group training for one day which this course has selected the key community influencers such as shamans, village chiefs and teachers to be health representatives and advocates since 2012.
All trainees will be listed in the record and provided jobs in cluster of community for coordinating team when visits, identifying case, tracking and educating. Moreover, they are a member of the committee which can be developing the policy. These activities can be served the achievement and sustainability of this initiative due to increasing community networks, trusts and acceptance, public involvement and health education in the fourth strategy. Therefore, to maintain networks, it needs to develop key health advocates, health education, meeting, and having participation with community in traditional culture.
(see annex 4)
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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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Stakeholders and their responsibilities in the ICD/CIM initiative were as follows:
1) VBDU 9.3.5 and VBDC 9.3 served as the coordination and communication organizations, assisting all partnering organizations’ implementation activities, along with acted as secretary of the committee. At the same time, they also delivered the primary service of malaria care (eg. detecting, treatment under supervision, follow up, education).
2) Public Health Agency and Health Care Providers in the area included the Sub-district Health Promotion Center (SHPC), the District Health Office (DHO), and Tha Song Yang community hospital. These provides health volunteers, administered health care services (diagnosis, treatment, transfer, follow up), educated and communicated with community leaders, as well as shared data on epidemiology and shared materials, medication and vehicles.
3) Local Administrative Organization in Tha Song Yang provided on-site identification of key community leaders, solicited their assistance with the initiative, and also supported budget, materials, vehicles and gasoline
4) The Border Patrol Police Units (BPPU) acted in accordance with the Royal Program initiated by HRH Princess Sirindhorn in the eradication of childhood malaria in the region. The BPP teachers educated parents and children serving as mentors in malaria prevention. Furthermore, The BPP teacher assisted healthcare providers to follow up student who affected malaria and recorded data for the report and surveillance.
5) Non-government Organization (NGO) such as International Organization for Migration (IOM) and Project Local Empowerment (PLE) coordinated and educated migrants and refugees for malaria prevention.
6) Community by key community leaders such as village chief, community head, teacher and ex malaria person. They were volunteers assisted in preparing community when team visited and identifying risky people, disseminating malaria information, monitoring medicine administration, tracking treatment, and keeping records’ affected patients. Their fluency in various local dialects bridged the communication gap, obtaining the vital voices of patients and community members.
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| 6. How was the strategy implemented and what resources were mobilized?
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The initiative was intended to minimize resource use, as well as to leverage and combine all available resources amongst the stakeholders.
The budget of this initiative has been funded approximately 90,000 Baht (2,790 USD) each year by the Department of Disease Control, allocated through ODPC9. The funding was primarily intended for materials, supplies and fuel to control and treat the disease. External funding support came from the Global Fund project approximately 500,000 Baht (15,500 USD) in 2012, but this funding was not integrated with the projects of the original allocations. Conversely, the other budgets, including that from the Vector-borne Disease Control Center, Tha Song Yang District and Tak Province, serve primarily to implement the action plan of the network members including the Border Patrol. For all units involved, the total budget includes resources would be allocated for network activity in specific periods, target areas, and participants in order to implement aggressive antimalarial practices. It was less probably to share the budget amongst stakeholders, but human resources, technology resources, materials, vehicles and technical supports could be sharing.
In terms of human resources and technical supports, main staff were taken from relevant agencies, that is, 4 persons from the VBDU 9.3.5, 6 persons from Tha Song Yang community hospital, Sub-district health promotion center and health center office, 1-2 persons from TAO, 2 persons from BPPU, 4 persons from NGOs and 4 persons from community. The staffs were responsible for managing the meeting, administering their resource, practicing the pro-active service on site following a guidance and action plan. Four staff from the VBDC 9.3 and ODPC9 had a role of supervision and evaluation. Furthermore, about four hundred community health leaders and advocates volunteered for malaria prevention and participation. Within ethnic minority, Tha Song Yang team assigned 7 – 9 such volunteers in the fiscal year 2010 – 2012 and NGO team communicated through the translators also provided access to information on disease prevention, control and monitoring the patients’ drug usage.
Other resources such as non-pharmaceutical supplies, equipment, mosquito nets, vehicles and gasoline presented inadequate. It could be transfer materials and any supplies between organizations. In cases where extra vehicles were required, they were provided by the hospital, or in the case of routes that are difficult to traverse, military vehicles were provided.
Each collaborating member must commit to reduce the number of people affected by malaria and ensure the continued efforts to provide comprehensive public service. Therefore, resources management: all resources were blended to create an approach to reach the initiative’s goals. The principal approaches involved: 1) encourage participation from allied public agencies at every level from districts to province, 2) incorporate data, information technologies, and knowledge management to provide a database for malaria management in high transmission areas, 3) introduce the ICD/CI Model to conduct the initiative, and 4) take full responsibilities by relevant public officers and volunteers.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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First, to networks, the initiative has changed organizational administration and transformation amongst six organizations so that organizational culture changed and administrative reforms occurred. Six parties developed the same purpose and a commitment, policy feedback, the collaborative efforts to deserve the malaria management and resource management. The sub-district administration facilitated all activities in the area and pushed health policy into the committee at district and provincial level. Moreover, the participation of volunteers enhanced connection and communication between the organizations and their communities. In addition, the network’s outputs were creative malaria activities and a guidance of work instruction for network collaboration on-site service.
Second, to malaria service, VBDU 9.3.5 has changed an approach of malaria care from passive service at malaria clinic to pro-active service in the village by collaborating team (annex 5). More than the malaria treatment, new approach could detect asymptomatic cases, outreach the high risk area, high risk groups such as children, pregnant and immigrants, as well as trace the patients and educate people. Furthermore, it reduced time and cost of travelling to health facilities and also built the community trusts. People satisfaction increased from 80% to 95% after the pro-active service approached and an average time consuming of service including travelling time dramatically decreased from 10 hours to 15 minutes per person (Mass screening is about 50-60 person per visit).
Third, to individuals and providers, the achievements included the reduction of malaria morbidity and mortality rate, the prevention of disease transmission by early case detection and treatment, an increased disease prevention reaction rate and the use of vector control, and an increase the outcomes despite a reduced budget. Number of infected malaria in Tha Song Yang was reduced from 6,096 cases in 2010 to 5,453 and 3,208 cases in 2011 and 2012. From the data in Tha Song Yang community hospital, the severity of malaria cases also reduced as demonstrated by the decreasing of average admission period to two day during 2010-2012. The budget for anti-Malarial drugs was decreased from 462,654 baths (14,457 USD) in 2010 to 260,735 baths (8,148 USD) in 2012, and blood transfusion was reduced from 217 to 194 to 160 packs in 2010, 2011, and 2012 respectively. Forth, to human capability and community, there have been the different courses for training the health volunteers and community leaders since 2010 which were about 400 volunteers in community.
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| 8. What were the most successful outputs and why was the initiative effective?
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The program of integrated service provision to control malaria in high-risk areas was operated from 2010 to 2012. It was monitored monthly by the operational plan and by comparing the data with the standard of the MoPH for Malaria control. The information included service data and disease control data. Service data included information on the number of visitors, including risk group patients, screening, type of infection, treatment, outcome, follow up and number of deaths. Disease control data included information on the number of households receiving the mosquito nets and vector control by chemical spray. In the past, the data were compiled according to the epidemiological report system of the MoPH.
The information system was established using a geographic information system, located in Bangkok. Both the Bureau of Vector Borne Disease Control and the Department of Disease Control collaborated to conduct the system with faculty of Tropical Medicine, Mahidol University. This management information system collected real time data of malaria activity. The National Malaria Program and health facilities were able to enter, retrieve and analyze the data in their area directly.
Additionally, there were network meetings in the area to discuss, problems and obstacles of the implementation in order to develop solutions that incorporated all involved parties and practices. The process consisted of performance monitoring and evaluation based upon the guidelines and usage of the resources such as personnel, budget, vehicle, disease control materials, and customer satisfaction.
The monitoring program focused on the number of services received, population screenings, patient treatments, numbers of treated patients who needed a follow up, numbers of families receiving the insecticide- mosquito nets and the activity of chemical substances controlling the disease carrying mosquitoes. The reports for the ODPC 9 included performance reports of each health unit and summarized reports with data analysis. Additionally, higher unit supervision and monitoring (VBDC9.3 and ODPC9) served as technical support for both standard and high quality services. During the monthly operation higher-level inspectors Vector Borne Disease Center 9.3, the Office of Disease Prevention and Control 9, Phitsanulok Province inspected the accuracy of the implementation.
Ultimately, the formal assemblies included monthly meetings of health units, district health committee meetings, monthly village meetings and yearly refresher courses for health volunteer and community leaders. Moreover, the informal cooperation and participation by all networks and stakeholders from government, local administration and citizen sectors were seen through meetings and discussions.
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| 9. What were the main obstacles encountered and how were they overcome?
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Three main obstacles were encountered during the implementation of the initiative. First, people with deeply-rooted belief in spiritual and supernatural refused and dissatisfied with medicine procedures and treatment, so they were habitual talking and persuading the others to deny. All respective providers were implemented to solicit their trust and cooperation with ‘Openness, Understanding, Communicating, Educating and Trust other’. Healthcare providers initially participated with people any traditional activities and cultures, often consulted for amenable practices to patients and relatives and encourage other community members, educated and communicated on the causes and effects of malaria, on malaria immunity and the ways in which modern medicine might save their lives. This was applied continuous, gradual pressure in order to modify the behavior of community members to one of vigilance, subsequently allowing them to embrace the modern medicine without compromising their ancestral beliefs. Also this initiative invited and trained shamans could be enhanced through the success of the combination of spiritual and medical treatments.
Second, population movement and diversity as well as the language difference were complexity. Community volunteers and NGOs could help for interpreters and educate the refugee and immigrant patients. Furthermore, the IEC materials, including VCDs, posters and leaflets, were available in Thai, Karen and Burmese and other language.
Third, the staff, healthcare officers, integrating teams and volunteers were changed their jobs, positions, retired or dead. This led to discontinuing of practice when visited and serviced. A guidance and work instruction for integrating team on-site service was developed and applied for all. Within this, it clarified each organization’s role and responsibility, flowchart of work process and job description. Additionally, on the job training, lay knowledge, exchange knowledge forum and regular meeting can transfer knowledge and help each other. The AAR was used to facilitate learning and improvement.
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