| 4. In which ways is the initiative creative and innovative?
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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.
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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 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.
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| 6. How was the strategy implemented and what resources were mobilized?
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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.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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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.
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| 8. What were the most successful outputs and why was the initiative effective?
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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.
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| 9. What were the main obstacles encountered and how were they overcome?
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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.
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