Questions/Answers

Thailand is striving for malaria elimination while drug-resistant malaria is a worldwide serious health problem. Malaria is claimed as a neglected disease, mainly found in the remote highlands along the country border where 78.13% of all patients were poor people in minority groups. Malaria is the cause of death if they received improper or delayed treatment. The objective of this initiative is to provide the underprivileged population in remote areas to access the precise, accurate, safe and complete treatment with sustainability by using an innovative device/package, which is a simple, inexpensive and convenient method for both service providers and recipients. The innovative device/package consists of the following: (1) A thick and thin film preparation box is a simple innovation for smearing blood films. The device helps local health care providers and health volunteers to prepare standard blood smears for malaria diagnosis; (2) Fluorescent Spot Test which is simplified in use by local health care providers to screen G6PD deficiency at a local level to prevent complication from taking primaquine. Primaquine is a specific drug for radically curing malaria. Providing primaquine to the patient with G6PD deficiency leads to red blood cell hemolysis resulting in renal failure and death; and (3) “Drug package” labeled with a flow chart diagram of tablet portraits showing how to take medicines correctly day by day. The package helps patients and relatives who are caregivers to understand easily even they are unable to read and write (e.g. a child with malaria having a mother who is a caregiver to give medicines correctly). These packages are developed into different local languages. This innovative device/package is able to eliminate malaria effectively and sustainably due to an increase in the surveillance coverage on drug resistance by participating people and health volunteers in the curative measure.

This initiative aligns with the category 1 to deliver inclusive and equitable services as malaria is a neglected disease. Most of the patients are ethnic groups with destitute backgrounds and living in remote areas along the country border. With innovational services provided in the package, the local health care providers in outreach areas are able to render effective services to the deprived people, including expanding service channels to deliver the accurate and precise screening test prior to treatment prescription. Patients must be safe during taking anti-malarial drugs for treatment and adhere to the treatment completely without any cost.

The implementation of providing the precision medicine in the outreach areas mutually correlates with the Sustainable Development Goals SDGs) 3: Good Health and Wellbeing under assurance to live healthy and good socially for everyone and every age as the initiative reduced malaria incidence rate to 1.07 person per 1000 population. According to the KPI 3.3, the initiative contributes to ensure the healthy living and well-being of malaria cases and eliminate malaria transmission by the end of 2030 to achieve the scheme of health for all. Everyone, even staying in the tough areas, can simply access to malaria services effectively and safely.

The device/package is practically applied from local and economical materials and developed for mass production as in-house tools. As these instruments can lower the costs, shorten the time of services, and increase channels to access quality services, all patients can obtain convenient, prompt and safe services as well as a reduction in travel expenses. These also include access to the same quality of care and services as urban patients. Moreover, they have an opportunity to receive medical consultation via telephone calls, online applications, and telemedicine system to sustain the management of public services.

Mae Hong Son province is the eighth largest province in Thailand, sharing a common border, measuring 483 kilometers in length, with Myanmar. The province covers with mountainous terrain and is surrounded by tropical forest and creeks which are considered as appropriate sites for mosquitos to live and breed. Various ethnic groups in Mae Hong Son, such as mobile migrants and stateless groups, frequently cross to the neighboring country to find new jobs due to impoverishment in their areas while the transportation is difficult and limited to access to health care services, especially in the rainy season. It was also found that the language barrier and cultural differences are the great challenges which made them not receive primary healthcare services. Therefore, public health officers and healthcare volunteers require to provide such services on behalf of physicians, nurses, pharmacists, and medical technologists. The invention of the innovation does not only allow these practitioners to enhance their capability to work effectively, but also reduce the unnecessary cost that might occur. The patients can look after themselves by applying an appropriate approach and the health volunteers can track patient’s symptoms and provide measures to prevent malaria transmission in the area.

This initiative provides precision malaria diagnosis and treatment in remote and inaccessible areas. The government concentrates on the management of the coverage for all in equity services without any cost. Due to the basic human rights and welfare, all people living in remote communities, including persons living in the neighboring country, shall equally receive effective malaria care such as diagnosis, and treatment, and monitoring regardless of genders, nationality, ethnicity, and religions.

The target group is all malaria cases. This initiative is beneficial to all clients to receive 100% accurate malaria diagnosis and have a precision of G6PD deficiency test prior to taking for the proper treatment. All malaria cases with normal G6PD enzyme were prescribed with the radical treatment plan. Treatment adherence increased from 26.8% in 2009 to 87.0 % in 2019, resulting in parasite clearance on the appointed follow-up date and the recovery rate was as high as 99.8%. N evidence of drug resistance found in Mae Hong Son province. The effectiveness of the implementation toward malaria cases dropped significantly from 1,180 cases in 2015 to 275 cases in 2019 (76.69% reduction rate). In Mae Hong Son province, the malaria morbidity rate decreased to 78% per 1000 population. Moreover, 4.59% of those malaria cases were detected with the G6PD deficiency according to the test. Those cases were referred to receive such treatment under the supervision of physicians to avoid renal failure and hemodialysis which burdens the patients with high expenditure at 3,500 baht/time; the treatment must be conducted twice a week for the lifetime.

This innovation is established for the local healthcare providers and clients to utilize this innovation to enhance efficacy of providing accurate, precision and safe treatment toward malaria patients. In 2010, first device was initiated to highlight efficacy of diagnosis by developing an online quality control system by using webcam connected microscope (Webscope). It was aimed to shorten waiting time of the diagnosis results. Together with development of “Drug package” aims to assist patients to obtain the medical treatment and act appropriately according to the instructions received. The result clearly showed the average time of diagnosis reduced from 21 days to 24 hours. Additionally, the webcam can visually display the malaria parasites via VDO conference simultaneously. From 2011 to present, the Webscopes were applied in other areas. The results from the online assessment toward the quality control system for malaria diagnosis and treatment revealed that preparation of standardized blood film is significant for diagnosis. Owing to the challenges on malaria drug-resistance in several areas of the country, an integrated system for treatment follow-up is necessary to have participation from all public health facilities and health volunteers to prepare blood films. Therefore, the innovation to prepare blood films and G6PD deficiency screening test implemented by health care providers was developed for treatment safety. To ensure drug adherence, the “drug package” was enhanced from an envelope to a durable ziplock plastic pack with labels. Each bag is filled with tablets. Due to language barrier, the labels on packs are illustrated with a diagram showing drug tablet flow from day 1 to the end. Four different languages (Thai, Thai Yai, Burmese, and Karen) are also printed on the pack. According to the 2019 assessment report, it was found that 95–100 % of the users were satisfied with this innovation, overall.

The challenges of this innovation are acceptability of the users and sustainable use of the innovation package without feelings of burden. The problems were resolved by providing training, user manual, and demonstration video to which the users can access at all times. The online tracking and field supervision were applied so that the users can see how valuable their tasks were. The innovation is progressively improved by the user's recommendations and observations.

Drug resistance in malaria is a major health problem worldwide, particularly the underprivileged populations in outreach areas. This device/package is the world’s first innovation for the people in remote areas. According to the complexity of accuracy malaria microscope diagnosis, G6PD deficiency screening test and complication of antimalarial prescription, the device/package was launched to precise malaria services and treatment. In addition the device/package was also served network health sectors as a tool for specify the date for a follow up visit. This innovation has been widely accepted from both health providers and clients that benefit to people in remote areas.

Based on the research and development and the periodical feedback from the clients and the healthcare providers, the morbidity and fatality rates of malaria reduce to zero in Mae Hong Son province. The past operations performed of each device and package was combined so that the people in remote areas would receive prompt, precise, and safe medical operations. More importantly, integrated drug efficacy surveillance system was successfully established in Mae Hong Son initiative.

The initiative invention was presented at the ASTMH 67th Annual Meeting in 2018, New Orleans, Louisiana, USA. In 2018, this innovation was widely implemented in 43 provinces in Thailand where malaria transmission occurred. There were different geographical conditions, people, and social which were complicated. Even though it was a beginning phase and involved many health care providers and health sectors, it was highly accepted that some devices such as the “blood film preparation block”, which assisted the preparation of standardized thick and thin blood films in a single slide in a faster and easier manner. The “Webscopes” were also used in many areas to capture photos in the microscope either malaria or parasite worms, which were required diagnoses by a microscope. It was useful in training programs for malaria diagnosis, parasitology study, and efficacy measurement of insecticide sprayers in vector control. Moreover, the G6PD deficiency screening test was applied to the newly born in hospitals, and the test resulted in better efficiency when compared to other methods.

G6PD deficiency screening test is not only used for malaria patients, but it can also be applied in the ordinary people. Rather than Primaquine which is applied to treat malaria, the drugs have an effect to patients with G6PD deficiency (e.g. antibiotics agent groups: chloramphenicol, co-trimoxazole, furazolidone, furmethonol, nalidixic acid, neoarsphenamine, nitrofurantoin, nitrofurazone, para-amino salicylic acid (PAS), sulfa group: co-trimoxazole, sulfacetamide, sulfamethoxypyrimidine, dapsoneand chemical, other medicines: (naphthalene), alpha-methyldopa, methylene blue, and pyridium). However, this initiative kit has limited use according to budget and manufacturing issues. The development plan is set for knowledge transfer, quality control system for reagent preparation in production and uses. The “labeled plastic drug packs”, only needs illustration of malaria tablets that can help patients to understand and to remind themselves and their relatives to comply with the prescribed medicines. These initiatives still require support to develop mass production.

This innovation is funded by the Global Fund for malaria disease. The funds cover expenditures on materials, trainings, handouts and other mass publications. Budget assistance is also from the Department of Disease Control, health sectors, and other local administrative organizations to spend for human resources, infrastructures, utility expenses, and wages. Moreover, the innovation receives support of electronic software, social media channels/facilities to be used by local health care providers. The significant dedication is the user’s support for their time to learn and use this innovation and answer the evaluation forms.

To achieve the declaration which 6 GMS countries jointly endorsed the agreement in moving forward to eliminate malaria at the 9th ASEAN Summit Meeting in 2014, Thailand endorsed the policy to eliminate malaria by 2024. Form Communicable Diseases Act B.E. 2558, requires the integration of all government sectors to join the mission. The health volunteers enter refreshment literacy training annually to raise incremental awareness of malaria drug resistance impacts, including requirement of the monitoring efficacy of treatment which is subject to run as routine and mandatory work for all public health facilities. This model is demonstrated cost effectiveness innovation obviously.

Yes

The national monitoring and evaluation committee for the midterm strategic plan of malaria elimination program, which consisted of malaria expertise from various sectors, monitored and evaluated this initiative. Also, an ad hoc evaluated team from the Innovation and Research Division, Department of Disease Control, in classification of Business Process Management Innovation, conceded an excellent level award. Moreover, Office of the Public Sector Development Commission conducted the evaluation and officially granted an award for this innovation for “Thailand Service Award 2018” category. Several monitoring and assessment by the experts from WHO headquarters and WHO Thailand were also made.

The indicators of this initiative are 100% malaria patients received precise services, accuracy diagnosis, safety treatment, completed prescription of malaria drug courses. 100% of primary diagnosis was accurate. All malaria cases are tested for G6PD deficiency before providing a prescription. 70% of malaria cases were follow up their appointment schedule. 80% of the cases had punctual drug adherence completely and accurately. According to questionnaires and online interviews, it was revealed that patients provided overall service satisfaction rate up to 95-100%. Based on the follow-up reports, there were no side effects from drugs, and all malaria cases were cured.

The outcome of this initiative was approved as a guidance policy for the national surveillance malaria drug resistance. Public health facility in Mae Hong Son province gained knowledge and understood awareness as well as importance of treatment and follow-up procedures by using the innovation package as a device, which produces credible data and information to modify the national drug policy. Especially, this innovation helps ensure the completion and accuracy of treatment in distant areas without a chance to return for follow-up visit. Additionally, the local implementations facilitate integration at the local level to share human resources, budget, and materials. Another challenge is an expansion of the innovation to other areas where different contexts of social, culture, life style, living conditions, including the risk in conflict areas, are identified For the acceptance, utilization, monitoring and evaluation, the collaboration from all sectors and stakeholders is required. Moreover, quality control system of the innovation is necessary to provide confidence of services to all users and patients.

The Office of Prevention and Disease Control 1, Chiang Mai province, plays the major role in research, development of literacy for surveillance, disease prevention and control, and health threats in 8 provinces in the northern region. The Office supports several operations such as prescribing medicines and non-medicine commodities and providing malaria health training to the public health officers at the health promotion hospitals, community hospitals and provincial hospitals in order to facilitate the integration of service system. Division of Vector-Borne Disease monitors and evaluates the operations. Then the results will be publicized and can be raised as a policy at the national level. Local government organizations and provincial health offices provide the budget and human resources to support utilization of the innovation effectively. Faculty of Associated Medical Sciences, Chiang Mai University, provides technical supports and knowledge on G6PD deficiency test. Health volunteers and population in the target areas are able to take care of themselves to completely adhere to the treatment and to remind the check-up schedule of the patient. Otherwise, the patient may passively wait at home for the service or the relatives are accountable for reminding the patients to perform according to the instructions.

The key objectives of the network collaboration for comprehensive implementation between public health sectors and other local sectors who have a mutual goal, are to improve quality of life among the outreach population; and to provide same standard of services. New malaria cases will be reported immediately within 24 hours while case investigation will be completed within 3 days, and control disease transmission shall be implemented within 7 days. In addition, there is a patient referral system from both local unit to a hospital and after discharge from the hospital. Hospital shares information to local health care providers to follow up the case who resides remotely and cannot return for the future check-up appointment at the hospital. Faculty of Associated Medical Sciences, Chiang Mai University coordinates the monitoring and evaluation of the use of innovation for G6PD deficiency test.

It is understood that medical services that are provided to raise the quality of life of the locals by government sectors are necessary to understand different contexts of the rural people so that they can receive quality service like the services in urban areas. The officers shall comprehend and accept those differences. Not only does the success of the initiative come from recommendations and suggestions from the involving groups, but it also derives from the mutual understanding between service providers and the local people. Utilizing the innovation correctly will be beneficial for the officers to disseminate knowledge to prevent malaria transmission to ordinary people and officers from different functions in case the disease occurs in their areas.