| 4. In which ways is the initiative creative and innovative?
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Handmade Webscope is creative and innovative in that, to the best of our knowledge, it is the first affordable, real-time, internet-based malaria microscopic diagnosis equipment in remote areas. Webscope, a quality assembled camera equipment mounted onto an existing microscope, offers a high quality video and still images of blood slides that is user-friendly, low cost, simple and easy to use. With minimal training, malaria field workers can use it correctly and effectively. Most importantly it eliminates time lag between diagnosis and treatment as all from different places can view the same picture or image at the same time. It clearly reduces the risk of losing malaria patient and further spread of malaria parasites into a community. Besides appropriate treatment, real-time interactive discussion between malaria field workers and expert microscopist is a powerful inspiring and low cost learning tool. Quick diagnosis and treatment also boosts confidence of malaria field workers and patients. Compare to commercial microscopic equipment designed for microscope with the same quality of image, Webscope is 75 times cheaper and can be built with locally available parts. Globally the Webscope can be replicated with minimal cost in other resource-poor areas that can access to internet.
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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 Office of Disease Prevention and Control (ODPC) 1 Chiang Mai, is responsible for conducting research and creating innovative methods for effective prevention and control of diseases in eight provinces in Northern Thailand. Mae Hong Son is one of the eight provinces with the highest malaria incidence. Ninety percent of the province is mountainous forest lining from the north to the south of the province with a 483-kilometer long border to Myanmar with high movement of people across the border through out the year. People in this area are from different ethnics and origins including Thai natives, Tai people (Tai Yai), Chinese, Burmese, and 63 percent of the residents are hill tribes such as Mhong, Lisu, Lahu, Lua and Pagakayor. In 2012, there were 243,251 of them that were at risk to malaria. The annual malaria incidence rate was 6.12 per 1,000 population, ranked third of the country and was higher than 32 times of the country’s rate.
According to the existing infrastructure, Vector Borne Disease Units (VBDU) are located in malarial endemic areas. Each VBDU has 5- 6 malaria workers. One of them provides care at malaria clinic (passive case detection) while the rest travel to remote villages with light microscopes and antimalarial drugs (active case detection). They prepare and examine blood slides in the village and treat infected patients immediately. Under this project, in situation when the diagnosis was equivocal for malaria infection, malaria worker return to the clinic to consult experts online and returned to the village to provide treatment if the slide was determined positive. Access to efficient and qualified diagnosis to be used as a basis to provide prompt antimalarial treatment will be a significant factor to prevent death of malaria patients and to control the spreading of disease in the community.
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| 6. How was the strategy implemented and what resources were mobilized?
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The methodology was based on the “learning-by-doing” theoretical and practical principle. The basic of the process was technology transfer while increasing enthusiasm and the sense of ownership on the initiative and leadership in malaria elimination.
The existing malaria control field infrastructure is composed of one VBDC in a provincial city and 10 VBDU in districts and sub-districts with 91 permanent staff. The main local partners are school, border patrol police and local administrative organization. In 2009, internet malaria online was starting in Mae Hong Son. At the same time, deep sorrow of one malaria death has urged ODPC 1 team an idea of using internet to reduce time of confirming blood slide, using ideal real time consultation 24 hours via internet. The initiative tool must be affordable to allow realistic deployment and use in the field units with easy replacement. The available commercial microscope camera is too expensive and too complicated for using in remote areas. Cheap and common use Webcam was selected and many models from different companies were tested for the quality of image with all malaria parasite species. A webcam with specifications offering a high quality image was identified, modified, then trialed and brought back to the reference lab for improvement.
By late 2010, both malaria field workers and microscope experts were involved at the starting point of the initiative, selected and designed the tool including the system setting up, of which malaria field worker can easily learn and adopt. The webcam connected microscope (Webscope) was completed and then tested in 5 malaria clinics in comparison with a commercial camera microscope. The user survey was carried out after 8 months of trials, producing very high levels of satisfaction. The local malaria field worker strongly suggested using of the innovative “Webscope” as a tool for further work. However, there were some suggestions for modification of a connecting adaptor and of the extension cord that were accepted. Field trials were then repeated to ensure that reliability of the Webscope was equivalent to direct examination of blood films under the microscope. End users were very satisfied with the Webscope and the method. The malaria field workers and development team discussed and agreed new procedures for using the Webscope and new monitoring and evaluation method.
From September 2011 till now the Webscope has been in use in all 10 Vector Borne Units in Mae Hong Son. The malaria workers and development team monitor it through bi-monthly teleconference calls and ad hoc teleconference for difficult cases. A the end of each day 10% of the negative blood slides and 100% of the positive slides are randomly selected, recorded as a video and sent to the reference lab. The next day an expert microscopist examines all of them and sends back the results to the health workers. In case of any disagreement, the relevant blood slide is put on screen online for discussion towards reaching a consensus. A patient with erroneous results is immediately followed up for appropriate treatment.
In 2014 - 2016 the initiative was extended to another 84 malaria clinics in other remote parts of Thailand including 3 red zone provinces. The initiative had also been incorporated into the work plan of the Department of Disease Control for replication to use as diagnosis of intestinal parasitic infection for the most at risk population and students in schools in rural remote areas. Along with expansion of the initiative, Webscope was remodeled due to a variety of existing microscope model used in different areas. Monitoring and evaluation of implementation of the initiative in other parts of Thailand is ongoing.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Webscope was developed by a technical team of the regional ODPC 1 laboratory, then tested for reliability, validation and refinement of all elements by malaria field workers with a technical support of Biomedical and Public Health Informatics (BIOPHICs), Mahidol University. Later, the Department of Diseases Control, Thailand MOPH funded the project for scaling up to cover all districts in Mae Hong Son province. Internet expenses were supported by Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Malaria field workers mandated malaria case management in hard-to-reach areas.
Local administrative organizations were a critical success component of this initiative with continuous support in budget and equipment such as solar cell, microscope. They also provided vehicles and gasoline for transportation and organization of Malaria Champaign, and played a major role in promoting community participation,
At the opening of school semester, students including Thai and non-Thai, returned from their home mostly from high risk areas were tested for malaria using Webscope by malaria field workers and Border Patrol Police (BPP). The BPP acted in accordance with the Royal Program initiated by HRP Princess Sirindhorn in elimination of childhood malaria in the region. The BPP teacher educated children via Webscope and assisted health care providers to follow up students who were affected by malaria.
Non-government Organizations (NGOs) coordinated and educated migrants and refugees for malaria prevention and collected and sent blood slides for malaria detection in suspected cases.
Community leaders were volunteers in preparing community for active case detection identified risk person and filled cultural and communication gaps to ensure that people in the communities receive early diagnosis and actively participate in malaria elimination.
Importantly, family cares were needed for treatment success due to completion of treatment and follow up.
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| 8. What were the most successful outputs and why was the initiative effective?
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1) The main successful output of the initiative was the development of Webscope which was reliable, user-friendly, cost effective, and applicable in any endemic malaria and hard-to-reach areas. The malaria field workers were inhabitants in remote areas who had no opportunity to use technology before the initiative began. This initiative had created a novel mechanism with direct benefits to quality malaria management delivered to target population by increasing motivation and developing enthusiasm of malaria field workers, who played an important role in hard-to-reach areas.
2) The next successful output was development and engagement of stakeholders and partners at all levels so the existing resources were utilized effectively to support all activities reflecting accomplishments of the initiative implementation. Advantages of engagement also benefited a unique of insight specific malaria issues, built trust in informal and formal communications in target areas, and increased harmony environment of team work.
3) Community participation was an output from promotion and empowerment of community in order to help the initiative access to hard-to-reach population especially most at risk people such as the under 5 children, pregnant women, migrants, internally displaced people, daily cross-border workers, and the elderly. With this initiative, high quality of malaria diagnosis were delivered to these groups to promote equality in access to care and human rights.
4) This initiative was designed for health system strengthening especially competency of human resources through planned trainings and trainings without agenda. The objectives were accomplished perfectly during the project timeline. Knowledge management of lesson learned was reported to the national level to be used as evidence to policy decision making. Currently there are 94 Webscopes, scaling up from 10 at the beginning in Mae Hong Son since 2012, to other endemic provinces in Thailand. The National Malaria Elimination Plan in Thailand also has set up a work plan to implement Webscope in all health service units, including health care centers and hospitals in remote areas. The plan also incorporates application of its use for microscopic diagnosis of other diseases
The Webscope innovation and engagement system targeted most at risk people who were central to the design and delivery of the services. All outputs of our initiative intensively responded to the United Nations Sustainable Development Goals (SDGs) in providing quality malaria management towards malaria elimination goal.
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| 9. What were the main obstacles encountered and how were they overcome?
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Malaria field workers were initially not familiar with the new tool and accompanying system but the traditional method in which they were trained. Thus, they had to be incorporated into the development of the Webscope and its introduction to create a sense of ownership. Involvement, familiarization, knowledge, as well as a clear improvement in working system, had brought up their confidence. Closer and quicker collaboration with more supportive colleagues had greatly added value to the project.
From the beginning, the potential of this proposed new approach was easy to be explained to colleagues. It offered a vital improvement that lives could be saved. This helped greatly to overcome reticence and win commitment.
In some ethnic groups, culture ghost causing sickness is the most solid part of health education communication. Using Webscope as a tool to view their own blood has increase patient trust, confidence and acceptance in malaria field workers.
The first model of Webscope, used in Mae Hong Son province, showed a high satisfaction of user. However, when it widely distributed to other regions of Thailand. a problem of fixing focus and diameter of eyepiece was found. Therefore, Webscope model 2 was developed based on the problem of variety in microscope model. The 2nd model of Webscope with focus adjustment using water pipe and rubble foam as a screw and diameter change to fix with the eyepiece of microscope. The new design of Webscope also helped protect the eyepiece of microscope from scratching. It also can be used with stereo-microscope for mosquito dissection and chemical droplet counting in the Dengue Control program in Thailand.
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