“Webscope” enabling In-Time Accurate Delivery of Critical Diagnosis Prevent Unnecessary Malaria Deat
The Office of Disease Prevention and Control 10

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Witnessing tragic deaths from curable disease like malaria is truly disheartening for healthcare workers and demoralizing to public health organizations. In 2010 alone, 80 unnecessary malaria deaths were witnessed in Thailand. All cause of death could be traced back to the lack of timely and accurate disease diagnosis which hindered or delayed the proper administering of time-sensitive treatments. The situation was devastating for all healthcare providers for they knew malaria treatment was not complicate and well-practiced. If properly administered, the treatments would expect a recovery rate close to 100%, as evidenced by the recovery of more than 31,000 other malaria patients reported in Thailand in 2010. Further inquiry indicated that 90% of the unfortunate deaths occurred in remote and hard-to-access areas along the Thai border. Consequently, the ability in upholding of the overarching mission of the Ministry of Public Health in providing equity healthcare for all citizens was questioned, as capability in delivering universal healthcare quality for all races and ethnicities were challenged. These humanitarian issues demanded an effective approach to eliminate unnecessary death caused by the curable malaria as to rebuild and restore public confidence in the country’s healthcare system. The most reliable malaria diagnosis, and has direct impact treatment given to patient is examination of blood smear using microscopy. Its technique is simple and cost effective, and has versatile applications to diagnosis diseases such as tuberculosis, protozoan and helminthes infections. These reasons made microscopy the preferred diagnosis standard for malaria units and clinics established around remote areas through Thailand’s Malaria Control Program. Based on the outcomes of the diagnosis, appropriate medical treatments, or non-treatment, could then be administered effectively. Thus accuracy of the diagnosis had profound impact in determining the fate of patients contracted malaria – to live or to die. Despite all the advantages, microscopy had its shortcomings. Analyzing and determining malaria strands from blood smears required experience and expertise from medical workers. For monitoring and quality assurance purposes, all malaria unit analyzed blood slides were submitted to the Regional Labs for reevaluation every 10 days. Procedure was 100% of positive-tested slides would be reaffirmed while 10% sampling of negative-tested slides were examined for possible errors. Any irregularity would be reported back to its origin. However, average turnaround time is 24 days before the originating malaria unit would be alarmed to initiate counter measures. Often time the where about of the affected patient was unknown, or the patient’s health already deteriorated acutely due to no treatment, or in the worst case, the patient died. Totally disheartening as in the case of a mother died from curable malaria only a month after giving birth. Inappropriate and delayed treatment of malaria had dire consequences in the global level. It provided a nurturing condition conducive to and heightened the chance of malaria parasite to develop resistance to available antimalarial drugs. A new antimalarial drug might take 10 plus years to develop – too late to contain the increasingly fast spreading of a new incurable strand of malaria on earth.

B. Strategic Approach

 2. What was the solution?
The Office of Disease Prevention and Control 10 Chiang Mai (ODPC), Department of Disease Control, Ministry of Public Health is responsible for conducting research and creating innovative methods for prevention and controlling diseases efficiently in 8 provinces in Northern Thailand. Unnecessary deaths by malaria in remote areas had increased urgent need of an accuracy, reliabilitye, timeless, simple, timely, and inexpensive. Previous experience using a web camera taking an image from the microscope during study in UK, Dr. Aungkana Saejeng introduced an “webcam connected microscope (webscope)” as a tool to the team. Webcams are generally inexpensive compared to other cameras. They can be used to take video clips and still pictures. Various software tools in wide use can be employed for use with Windows, Mac and Unix systems. Webcams have been used for a number of purposes, such as video security, video calling and videoconferencing, video monitoring general activity and health care. The target groups of this initiative were classified into three groups. The first target group is health-workers who used webscope for malaria diagnose. The second target group is all Thai and Non-Thai people who received health services from health-workers. And the third target group is school children in remote areas. The goal of the project was saving lives in remote areas of those who unnecessary died due to malaria. To achieve this, four strategies were used. The first strategy was accomplishing an acceptation from health-workers in using the tool and the newer quality assurance system using Information Communications Technology (QA-ICT-system). Creating ownership made the health-workers more actively participate in the project. Secondly, technology transferring was implemented by setting up a training course. The third strategy used was team building, camaraderie related between checkers and health-workers. It improves working harmony, work environment and is sustainable. The fourth strategy was regularly monitoring and supervising, to ensure the tool and the system were accuracy, precisely and function perfectly. Two modes of system were developed. The first mode system was imitated from the routine quality control by saving a 4 image and one 5 -6 minute video files of blood sample examine using WebScope. The files are uploaded onto a simple-social network system at the end of each day. A malaria-checker daily re-examines the videos of blood films in accordance with established malaria QA protocol (10% negative and 100% positive). The system mode reduced the time of confirming blood film from an average of 21 days before implementation to less than 24 hours after implementation. Patients were followed up and received appropriate treatment within a day of reporting. The rapid response eliminates the “follow up loss” problem. The second mode of system was emergency situation by setting up real-time microscopic consultation of difficult or equivocal diagnostic cases. Webscope is installed on one eyepiece of a microscope and connected to a computer. The health-workers can examine a blood film on the computer screen and the image of the blood film can be recorded as a still photo or a video file. When a health-worker was uncertain about a diagnosis, a webscope is activated and connected to the internet for online consultation with malaria-checkers at the reference laboratory. During the consultation, the blood film is viewed live online by connecting images from the microscope to a computer using the Team Viewer program or Remote desktop connection. Due to the instantaneous nature of the consultation, treatment plans can be initiated at point of care minimizing loss of follow up.

 3. How did the initiative solve the problem and improve people’s lives?
This is the first affordable step of using inexpensive and simple tool, familiar system via common used social network to reduce the time of confirming and eliminating unnecessary deaths by malaria in remote areas. Most importantly, reduce the time lag, between diagnosis and treatment leading to decrease “follow up loss”, drug resistant malaria, and further spread of malaria among the population. Besides optimizing malaria diagnosis and treatment, real-time interactive discussions between the health-workers and the malaria-checkers at the reference lab promote harmony in communication by increasing positive learning experiences as well as, boosting confidence among health-workers. Health-workers in remote areas and malaria-checkers can now view the image on a microscope at the same time. Online training was also established without agenda due to the low cost of the system. In addition all malaria patients also can view their own blood smear from monitor screen which increase an understanding and awareness of malaria parasite infection.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Based on the situation analysis using SWOT analysis (see attached files), the key strategies of project involved: an acceptable webscope development appropriate for use in the field; there were two main issues related, firstly the specification of webcam used, and secondly how to make it fix to the microscope perfectly. During 2009 – 2010, the processes of “Plan Do Check Act” were repeated several times. Based on the aforementioned survey of existing webcams many webcams, difference models, difference companies were tested for the quality of image and with a number of variations of all malaria parasite species. Then a high quality image webcam were modified and tested in the field and brought back to the reference laboratory to improve. In late 2010, an webscope was complete and tested in 5 malaria clinics compare with commercial camera microscope. The satisfaction survey of the webscope was done after 8 months of trial. The feedback from all users was satisfactory overall. Health-workers were satified with the image of blood films taken by webscope. There is a suggestion of the modifying of an adapter to fix the eyepice of microscope and the extension cord. Field tests were then repeated to ensure that the reliability of webscope was equal to direct examination of blood films under the microscope (standard), and potential users were satisfied with the tool and method. The field health-workers and the deveopment team discussed and agreed upon a new procedure for using webscope as well as a new monitoring and evaluation methods. From September 2011 until the present, the webscope was used in a malaria clinic in Mae Sarieng district. The health-workers and the development team in Chiang Mai monitored and evaluated webscope 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. Within the day or later next day, an expert microscopistre checked all the recorded files and sent the results back to the health-worker 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 appropriate treatment. In December 2013, the Department of Disease Control allocated budget to implement the initiative to cover all remote areas in Mae Hong Son province. The training course was setting up for 2 days to transfer technlogy and the ICT-system which comes from the agreement of health-workers and reference laboratory staff to achive the goal of the project. During the training course all problems occured in remote areas. Two modes of ICT-system were implemented immediately after the training. In June 2014, the initiative was implemented in another 25 malaria clinics in other remote parts of Thailand, including in 3 red zone provinces. The initiative is also included in the work plan of the Department of Disease Control for improving diagnosis parasitetic infection in remote areas. Monitoring and evaluating the results of implementing the initiative in other parts of Thialand are in process.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The stakeholders involved in the implementation are the health-workers and malaria-checkers who participated in the tool design and in learning how to use the tools and computers. The medical scientists at the reference laboratory created the tools and set up the two modes of ICT-system of quality control. The expert information technology staff of the Center of Excellence for Biomedical and Public Health Information – BIOPHICS), a non-governmental organization affiliated with Mahidol University, cooperated in the software used in our project and produced instructions of software used. In addition, they also contributed time for consulting and solving problems of internet system errors and software errors online during the work. The Strategic Planning Committee and Executive Board Funding Committee of ODPC 10 allocated a part of the budget for implementation of initial 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 AWCM in all remote malaria clinics, 14 sites (70 health-workers). Patients were able to view the analysis taking place and ask them for the reaction. They contributed the time to answer questionnaires by a satisfaction survey. Last but not least, the private sector and people in the city who have more opportunity (privilege group) to contribute budget for solar cells and computers to the remote areas. This is an importance issue which makes the project expand from remote areas in Mae Hong Son.
 6. How was the strategy implemented and what resources were mobilized?
In the development of the webscope prototype, webcams for testing were donated from a range of sources who responded to a request for help in bringing the original concept to reality: family relatives, neighbours, colleges, health workers and medical scientists. ODPC 10 implemented the initiative with 100% funding by the Thai Government. Besides staff time and input, this was composed of: microscopes, webscopes, computers, miscellaneous other essentials as materials and stationery, blood film preparation sets and waste disposal arrangements. The investment for instrument one site are approximately 80,0000 baht (2,790 USD). These are composed of: microscopes – 50,000 baht (1,860 USD), computers and accessories – 20,000 baht (620 USD), webscope – 4,000 baht (124 USD), and lab supplies and stationery – 6,000 baht (186 USD) e.g. blood sample preparation set, stationery and waste disposal set up. The addition to previous routine costs resulting from the initiative was the webscope – 4,000 baht (124 USD). All equipment, microscopes, computers and webscopes can be used for a minimum of 10 years with good maintenance. The cost for malaria diagnosis is approximately 5 baht. These costs are covered by OPDC 10 yearly budget. The project was piloted on one site, the malaria clinic in Mae Sarieng District which has the highest incidence of malaria in Mae Hong Son. The health worker was trained during on-site visits in using the webscope and program. The cost was around 20,000 baht (620 USD), composed of: per diem and accommodation for 3 staff, gasoline and materials, icluding WCM and document printing. Implementation on 10 sites was then needed to save time and travel budget. The expense for training was approximately 9,000 baht per person (278 USD) and was supported by DDC. This included per diem, accommodation, local transportation, gasoline and materials including webscope and document printing. The salary of health workers and clinic maintenance is supported by the Thai Government and is approximately 5,000-20,000 baht per person. Since health workers work and live in their local area there is no need for transportation or house renting. In-kind contributions were given by BIOPHICS: time/salaries of IT experts, internet access, computer programme development, and field monitoring and evaluation. Once the initiative was seen in operation, additional resources were received from the private sector, such as emergency power supplies and solar cells for remote area clinics.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Approximately 220,000 people in Mae Hong Son are at risk of malaria infection. 2,971 people were enroll with 1,111 were positive all saved from death due to malaria. The most successful aspect of this project is the development of AWCM and the ICT-system to strengthen health care delivery in malaria clinics in remote areas. It is evidently shown the reduction time for accurate diagnosis of malaria from 21 days to 10 minutes. The mortality rate has fallen to zero in remote areas since the initiative was implemented. It is also noticeable in the reduction of people being hospitalized. The poorer malaria patients can save money and return to work, the children with malaria can return to school quicker than before. Thus this initiative strongly suggested unlocking the people in the malaria poverty trap. Moreover, the webscope is reliable compared with directly examining the microscope 100% compatible results. The initiavtive were very simple the health-workers in remote areas can learn and do it immediately after returning to their malaria clinic. In addition they also teach and coach their colleges how to use the webscope and the ICT-system which makes more health-workers become involved in the project. It clearly shows the enthusiastic acceptance by health-workers in the fields of the new equipment and the systems. Furthermore, the webscope is now distributed for use in many microscope diagnosis laboratories; these included Chiang Mai University, the Training Center at Prabudabaht Saraburi, the Office of Diseases Prevention and control region 7, the vector borne diseases center and the private laboratory sector. The feedback satisfaction form the users was 99% which is above the standard (85%). This initiative can be easily replicated in any other part of Thailand and other countries. In addition, it can also be a model for others microscope diagnosis diseases e.g. intestinal parasites and tuberculosis.

 8. What were the most successful outputs and why was the initiative effective?
Monitoring is the routine tracking of key elements of the initiative project through record keeping, regular reporting, surveillance systems and periodic surveys. The programed managers determined which malaria clinics require greater effort to improve health service based on the data weekly summary report from reference laboratory staff. Weekly scheduled teleconference calls between health-workers in remote areas and malaria-checkers were set up to solve problems and improve individual performance. Indicators were used for monitoring is the accuracy of malaria diagnosis, the quality of blood slide preparation, the response time back to the malaria clinic in remote areas, and the satisfaction of health-workers and the patients who were involve in project. According to the initiative project involved in a AWCM, the reliability and accuracy of the tool must be checked daily compared with the standard method (directly examine blood slide on microscope; one positive one negative). Site visiting malaria clinics in remote areas by the program manager and team was conducted twice a year to solve problems which cannot be seen in reports and online systems. It also allows the team to provide on the job training and motivate health-workers. Steps and systems for monitoring output and progress of the initiative began with field tests and structured questionnaires to evaluate performance of the health-worker 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 webscope and the operating computer programs were made according to the analysis of the field tests and questionnaires. The impact indicators are annual incidence per 1000 mid-year population among Thai and non-Thai and refugees in camps, the mortality rate and cost effective. All data is collected monthly and analyzed and used for planning and improving the system and expanding the project for other malaria clinics in remote areas which have a high incidence of malaria.

 9. What were the main obstacles encountered and how were they overcome?
The basic problem was the remoteness of the clinics from the reference laboratory and the poverty of the regions. This produced major communication problems: lack of electricity and long delays in processing patients' blood samples. This was solved by the creation of the webscope which allowed recording of these in digital format and video, upload and transfer to the laboratory for rapid checking. Equipment, webscopes, computers and solar cells for energy were installed to allow the new system to function. Miscommunication had been common, the sense of being checked and of “us and them” was almost intrinsic to relationships and initial collaboration was at times fraught. Team building, a sense of shared mission, mutual recognition and respect had to be instilled. The project management team had to be very sensitive to this and seek to engage an enthusiastic workforce. Health workers were understandably diffident about the new tool and accompanying system. They were familiar with the traditional method in which they were trained. They had to be incorporated into the development of the webscope and its introduction and have a sense of ownership. Involvement and familiarisation, as well as a clear improvement in their working systems, knowledge and results brought reassurance. Closer, quicker collaboration with now more obviously supportive colleagues greatly added to this. From the beginning the potential of this proposed new approach was easy to explain to colleagues. It offered a vital improvement; lives could be saved. This helped greatly to overcome reticence and win commitment.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Benefits are about people. It's not whether you have the forms filled in or whether the checks are written. It's whether the people are cared for when they're sick, and helped when they're in trouble. The key benefits resulting from this initiative contributes to lives being saved in remote areas. During 2013 – 2014, there were 24,314 people that were involved and 1,133 were malaria positive and received appropriate treatment within 1 hour. 100% of these patients completed drug compliance, and returned for drug monitoring. 92.6% of the return patients were malaria negative. 7.4% of the return patients were malaria positive, of these 77.9% were classified as new infections and 22.1% were suspected of antimalarial drug resistance. The length of time involved in the quality control system was drastically reduced from an average of 21 days (range 16 to 66 days) to 10 minutes, and no loss of patients for appropriate treatment. It is also noticeable in the reduction of people that were hospitalized. The number of severe malaria patient at hospitals was decreased from 47 to 1 compared to before and after initiative implementation. The number of malaria deaths fell to zero. The numbers of students with malaria infection in Mae Hong Son province were reducing from 769 to 243 cases. Moreover, the advantage of using AWCM is the image of parasite is larger and clearer for the health-workers and malaria-checkers to examine. During first trial, a health-worker who made an incorrect blood examination told us “If I can see the parasite clearly as I see on the monitor screen, I would not have made any mistakes.” This makes us even more certain that the AWCM is suitable to implement in remote areas. It reduces eye strain of examine blood samples on microscope. In addition they can communicate on the exact same picture and same parasite. The knowledge sharing occurs daily among health-workers. Health-workers gain more experience and confidence in diagnosis and are better at retaining the patients in treatment. Better diagnosis and treatment and online discussion motivate health-workers to improve their performance and boost their morale and teamwork. No treatment failures, in turn, create a sense of fulfillment for those who are involved and inspire them to strive for better outcomes. Overtime, the relationships among health-workers and between health-workers and malaria-checkers were strengthened improving collaborative teamwork and trust. 100% of people were satisfied with the services at malaria clinics and were confident with the results. Many patients who came to the malaria clinic told our team survey that they are confident with the results of malaria diagnosis and treatment at the malaria clinic. “Last month I went to hospital and I wasn’t sure about the result so I came to the malaria clinic to confirm. Because I saw my friend who has malaria was unconscious and had blood coming out from his nose due to not getting antimalaria drugs, a man told us during survey. In addition, the patients who come to the malaria clinic not only received diagnosis and treatment from health-workers but also can receive directly from expert microscopist at the references laboratory in Chiang Mai. It is no doubt that the initiative project has increased the equity of access to health services by professional health workers of people in remote areas. The poorer malaria patients can save money and return to work, the children with malaria can return to school quicker than before. The financial burden for malaria patients has been reduced due to quicker diagnosis and appropriate treatment. The physical and psychological well-being and health of the patients and their families are also improved. Economic losses due to misdiagnosis incurred by the patients and their families are substantially reduced. In the case of a misdiagnosis in a patient with severe symptoms, he/she must be admitted to a hospital. The cost of medical care at a hospital is approximately 6,500 Baht (202 USD). Therefore, people in remote areas received the appropriate treatment from the malaria clinic no extra cost than medical care at a standard hospital. The deliberate process that involves the health-workers in the decision making process empowers them increasing their confidence in in provision of health care. The initiative also increases patients’ involvement in their malaria diagnoses and treatment plans. The AWCM allows individual patients to see images of parasites on blood slides, providing the opportunity for patient education and treatment instructions. As a result, patients’ adherence to treatment improves which in turn leads to a better health care outcome and prevents drug resistant malaria and the further spread of malarial infection. The likelihood of malaria drug resistance cannot be verified at this time. The initiative project has improved the effectiveness in monitoring and evaluation of the treatment of malaria patients in remote areas, which is important in detecting any drug resistance that might occur.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The Department for Disease Control of the Ministry of Public Health has integrated the initiative into the policy for malaria and parasite control in remote areas of Thailand and allocated supporting budget for implementing it there, especially in the three Southern provinces (red zone) where access is frequently difficult. As a result the continuing operation of this system will be assured by national, regional and local offices throughout Thailand. This scaling up to national level is readily achievable given the minimum cost of equipment and ease of training. The continuous improvement of technology with parallel reductions of its cost makes maintenance and replacement of the essential equipment very simple. The webscope system can also be used to diagnose and treat other micro-organisms such as bacteria, parasites and worms in similar remote areas. In fact, the webscope has already evolved from a simple diagnostic tool for malaria to a multi-purpose diagnostic and teaching tool. Its high resolution imagery, affordability, portability and user friendliness means that it is currently being used in various training courses, domestically and internationally, for instance in an international malaria training workshop conducted by the Department of Biochemistry of Chiang Mai University. The Department of Disease Control and OPDC 10 used it in an international training course on malaria prevention for control officers and medical doctors from South East Asia and Africa supported by the Japan International Cooperation Agency. And again in the training of post-graduate students from the University of Utah and University of New England. In addition, the webscope was used to record images of parasite growth at different incubation periods in a study of anti-malarial drug resistance at OPDC 10 in Chiang Mai. It was also used for diagnosis training and research on drug resistant malaria at the Malaria Training Center, Bureau of Vector Borne Diseases, DDC, MoPH and in the Faculty of Medicine, Chiang Mai University. And at OPDC 7, Ubonratchathani province,it was used to examine insecticide droplets. Recently there is an epidemic of Ebola in Africa where there is a high incidence of malaria. Patients infected with Ebola or Malaria have very similar symptoms. The webscope system would allow early, accurate diagnosis of malaria ruling out ebola and many lives could be saved. WHO estimated that there were 627,000 deaths from malaria worldwide in 2012 (uncertainty interval 473,000-789,000). If this initiative could be more widely implemented across the world it would greatly reduce the number of unnecessary deaths.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
This has been an extraordinary, most valuable experience for those involved, refreshing and re-energising. It probably brought us all back to our common purpose and focus: the health of our patients. Something easily forgotten at times in the requirements of our daily routines and administrative responsibilities. The lessons learned may well appear simply an understanding of the obvious, nonetheless they were real. The management team quickly realised the success of the project pivoted on the positive reaction of the health workers, our colleagues in the field. We needed their “buy-in” and preferably enthusiasm. They were being asked to accept major change (seldom an appealing prospect), give time for additional training, and to follow radically new operating, reporting and maintenance procedures. We needed a team all working for and with one another for the benefit of our patients. Checkers in the reference lab were similarly being asked to confront and embrace change with a fresh mind-set. No longer were they remote from the health workers, the next faraway step in a sequence. They would be working closely in real time with one another. The quality of their communication was crucial to the success of their efforts, the quality of treatment for the patients. Empathy, positive feedback and encouragement would win the good will of health workers, motivate them and support effective mentoring. Professional and interpersonal skills were constantly improved all round, alongside knowledge and self esteem. More and more participants in the project came to recognise and appreciate the mutual and over all benefit from a personal as well as professional perspective.. Another key lesson learned has been the need to keep an open mind, to look at what's happening in other areas of medical, health activity and seek good maybe even best practice. A simple reflection, after all, on equipment used elsewhere kick started this initiative. Perhaps we can learn from other areas, their methods and approaches. We don't know – yet. This has made us more ready to share our experiences and insights in case they could be helpful to others. Similarly we should have an open mind on new technology, embrace rather than fear it. And look at it from our viewpoint: what can it perhaps do for us when carrying out our duties. This has been a salutary learning experience.

Contact Information

Institution Name:   The Office of Disease Prevention and Control 10
Institution Type:   Government Agency  
Contact Person:   Dr.Wittaya Liewsaree
Title:   Director Office of Diseases Prevention Control  
Telephone/ Fax:   66 53 140 767
Institution's / Project's Website:  
E-mail:   aungkana@hotmail.co.uk  
Address:   447 Chiangmai-Lumphum Rd., T. Watkate, A.Muang
Postal Code:   50000
City:   Chiang Mai
State/Province:   Chiang Mai

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