| 4. In which ways is the initiative creative and innovative?
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This project was first conducted in 2005 at Sankampang hospital, Chiangmai. This hospital is an District hospital that has 30 beds. They created a database for TB patients to resolve the problem of patients’ data loss and the manual report keeping.
We (DPC10) have supported our health networks in terms of TB surveillance and preventions. We have extended the capacity of the original Sankampang database to the TB information system that can help for disease detection, prevention, control and treatment. We have developed our TB database every year by expanding our connection with hospitals. During the development process, we listen to our connections’ needs and feedback while trying to improve our system according to their needs. This process is repeated until we and our connections are agreeable. We call this process as Plan – Do – Check – Act.
The TB information system contains four components including 1) common TB patients, 2) MDR-TB patients, 3) Household contacts, and 4) TB laboratory. Our system has been easy to use and even if untrained officers who has a little computer background can use it. We have continually developed our TB information system for helping a local officer about TB report. Each setting which can access to this database can use this data for tracing and referring TB patients. In addition, the information in the database can be used for statistics analysis and reports in terms of remission rate, mortality rate, treatment discontinuation rate (default rate), treatment quality, the newly diagnosed patient rate, and screening for high risk patient.
The second strategy: cooperative connection development
Because of smart database ,health networks can use analyzed the data to explore their own problem and realise to cope the problem .We arranged a number of meetings with our connections for brainstorming creation of the treatment plan, referral plan, and follow-up plan for TB patients in local level.
We monitored our health networks, gave them suggestions, and set meetings with them in order to improve our new guideline for taking care of TB patients. We have a guideline for screening TB in HIV patients, a guideline for taking care of prisoners with TB, a guideline for screening household contact, and a guideline for surveillance MDR TB patients.
The third strategy: human resource development
We did gap analysis and need assessment, and found that our officers and health networks needed more knowledge and skills in TB disease. Then, we developed a training program for healthcare providers, screws, and volunteers in a community. The training programs that we developed are for both new providers and experienced providers. The examples of program are the curriculum for administrating a TB clinic ,the program for TB care for new providers, the Directly Observed Treatment (DOT) watcher program, the program for TB screening in the community for volunteers.
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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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Model development “Integrating Network and Community Participation for Effective TB Control in Phayao province” was an example of Community base Participation that encourage the change in TB policy from community level and also continuation for sustained the TB problem solving of the community.
In this community program, we have various stakeholders that hold different responsibilities as follows:
• Public hospitals, private hospitals, and detention centers are responsible for TB diagnosis and treatment. These settings are required to transfer patients’ information to patients’ local clinics.
• Sub-district health promoting centers are helping community connections and village volunteers in terms of TB screening, and referral process. In addition these centers are responsible for tracking patients’medication, observing drug allergy symptoms, and visiting patients at thier homes.
• Phayao provincical public health center is reponsible for supporting district public health centers
• DPC10 is responsible for providing knowledge about TB, follow up, and evaluating the process. In addition, DPC 10 compiles and reports the data, received from the community, to the policy maker, and trains officers who involve with TB clinic.
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| 6. How was the strategy implemented and what resources were mobilized?
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Significant resources in supporting the operations in order to achieve the goal in controlling Tuberculosis (TB) had very important components which were personnel, budget, equipment, and medical supplies.
For human resources, the most important were the health officers of the Office of Disease Prevention and control, region 10th (DPC10) consisting of doctors, nurses, pharmacists, laboratory technicians, public health officers. For Health officers in Phayao Province level, it consisted of provincial TB coordinator (at least 1 district TB coordinator per one district) and District Hospital personnel that consists of doctors, nurses, pharmacists, laboratory technicians, and hospital TB coordinator. For prison section, it consisted of prison commanders, prisoner TB leaders ,doctors, and nurses from the nursing service inside the penitentiary. For local administrative section, it consisted of administrators, officers from the public health of the local administration. For public sectors, it consisted of mainstay in village health volunteers that 1 person took care of 10-15 households and communities’ leaders.
For the budget, the DPC10 had allocated the budget to support the development of operation format, to train new staff, to provide curriculum for development of the operation on the integration of TB and other related diseases, to monitor the implementation of the program, to make a standard assessment on the tuberculosis clinic operation, and set the meetings to present the activities, outputs and outcomes of the program in the regional area (the 8 provinces in the upper North of Thailand) including the supporting on the allocation budget and improving the TB database until it could be standardized. Some budget came from local administration for TB screening and public relation about TB knowledge and awareness in the community.
For materials, equipment and medical supplies, there were supports for recording program, operation manuals, guidelines for operation of tuberculosis control, anti-tuberculosis drugs for hospitals where providing their service to patients who have no or lack of treatment access, and medical equipments such as gloves, safety mask, sputum cartridge, agar. There was also a support for tuberculosis diagnosis confirmation and drug susceptible testing through TB laboratory by using special techniques.
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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 output in developing TB Information technology System was the database which covered the 4 areas of information. They are (1) general TB patient, including TB-HIV co-infected patients, (2) the household TB contact, (3) Multi-drug resistant TB (MDR-TB) patients and (4) TB laboratory diagnosis. Local health officers could analyzed the data and then make their suitable local TB management plan between village health volunteers and Sub-district health promoting hospital. The system also has an alert function as it can inform the health care provider about the patients who were lost to continuously receiving treatments, or migration. The system also has information that shares and connects among the hospitals where patients could be referred for treatment. The information is also used for the evaluation and plan for timely management of the TB problems.
For the network output, there were the joining networks from 18 areas consisting of Provincial Public Health offices, District Health Offices, Provincial Hospitals, District Hospitals, Prisons and leaders of civil society. The results showed the development on the integration mechanism and consequently made the appropriate action plan for the local contexts. Therefore, there was the occurrence of the working process that initiated from the problem-based learning, and resulted in the development of their local operational guidelines that suit with the local contexts. For example, the management guideline for TB and HIV co-infection, the guideline for management of TB in the prison, the guideline for diagnosis and treatment for the household contacts under 18 years old, and the guideline for MDR-TB surveillance via cooperation with health networks.
For the output in personnel development and services in the TB clinics, there were people who passed the various capacity building training courses such as TB diagnosis and treatment for Internists, TB microscopic diagnosis, comprehensive TB control program for new TB clinic officers, treatment and care for the TB household contacts, MDR-TB case finding and diagnosis, and the utility of the records in the database that accounted for 257 trainees. The program focused on developing local health personnel for increasing their performance in TB prevention and control. The trainees were consisted of doctors, nurses, pharmacists, and laboratory technician. After training, they could be able to practice in accordance with Thai National Tuberculosis Program in terms of case finding, diagnosis, treatment, and transferring knowledge and experience to village's health volunteers for screening people with suspicious symptoms, home visiting, and directly observed treatment.
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| 8. What were the most successful outputs and why was the initiative effective?
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This TB control model development which has cooperatively run among health networks and communities and it started the operation since 2009-2011. This system was initiated with the problem-based learning, solving the problems, and development the model until it was the good practice. The model was shared to the public and it was consciously developed with the match for the local contexts. It has been evaluated and developed continuously since 2012 onwards.
TB information technology system emphasized on monitoring the quality of the records and the data flow in order to assess the validity from Phayao Provincial Public Health office and the DPC10. The system has been used to check the accuracy and completeness of the recorded data, for providing the high quality information. We (DPC10) have requested the area to submit the information to us. The evaluation process was divided into three phases. The first phase, the timeliness of data submission was evaluated in every 30 days. The second phase, the validity of the patients’ registration record was assessed in every 90 days, and the Third phase, the quality and validity of the data were annually examined.
The evaluation of TB control program in each local area used the key indicator which was the success rate of treatment in new registered TB patients should be exceed 85 percent at the baseline and annually increase at least 2 percent in success rate according to the World Health Organization (WHO) target. To achieve this goal, the death rate and default of treatment rate must be minimized. The quality evaluation of TB service in each hospital was composed of two steps. The first step was the hospital self-assessments via the standard evaluation form. The second step, the DPC10 officers randomly selected the hospitals for quality assessment with careful consideration. The DPC10 officers examined the treatment outcomes of TB patients, case findings and cooperation with health care networks. In 2013, all TB clinics in Phayao province were passed the criteria of the standard evaluation.
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| 9. What were the main obstacles encountered and how were they overcome?
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1. The technology problem: Originally, there was a variety of TB information systems in terms of Hardware and Software. Therefore, the system was needed to be updated frequently, and the local users felt unhappy with this situation. DPC10 personnel have tried to help the users for updating the program in the local area at least once a year. DPC10 also have offered channels for consultation, for example, Facebook® and mobile phone which was able to directly contact with the programmers and the model development team in anytime.
2. The personnel problems: There was a high turnover rate of TB coordinating persons resulted in discontinuous TB work in the local area. To fill this gap, DPC10 surveyed for the new TB staffs and created the training for them. There were some refresher courses for experienced officers. DPC10 also offered knowledge and technical support to health networks via clarification of the guideline on TB control program, supervision, monitoring and consultation.
3. The problem related to implementation of the network in the area: The civilian societies in the local area thought that TB was not a public health concern. They did not understand the TB natural history and the importance that the societies should support TB patients to completely and regularly take anti-TB drugs for prevention of the MDR-TB. Therefore, the local communities were not interested in TB prevention and control. However, the problem was solved by providing knowledge of TB natural history and the mode of TB transmission. In addition, the smart database which has been available in every local area would make the communities paying their attention and preferable cooperation the implementation because they knew their local TB situation; they would explore the potential causes of TB problems and find the reasonable way to solve the problems.
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