Questions/Answers

Since 2000, Thailand has made significant progress in reducing its malaria burden. Thailand’s traditional paper-based reporting system was complex and time-consuming, which caused delays in data analysis, information sharing between health agencies and related sectors, and deployment of response measures. The main objective of the online malaria information system (MIS), introduced in 2009, is to reduce the time taken to collect reports from all service delivery points, to perform data analysis of related factors, and to utilize data for prompt response to the outbreaks. The system captures individualized electronic records of suspected and confirmed malaria cases, synthesizing multiple sources of data including epidemiological data from health facilities, and entomological surveillance and vector control data from public health field offices. Visual graphic displays of results are easy to interpret and use for decision-making, even for health workers at subnational levels. The second objective of the malaria online system is to facilitate real-time reporting and monitoring of targeted responses to disrupt malaria transmission. The MIS has served as a major surveillance tool for the National Malaria Program since the launch of Thailand’s National Malaria Elimination Strategy in 2017, aiming to stop local malaria transmission by the year 2024. The malaria online system is now being used by the Division of Vector Borne Diseases (DVBD) to monitor real-time malaria trends, to identify locations and villages where transmission occurs, to measure coverage of interventions including patient follow-up, active case detection, to track performance of ‘1-3-7’ benchmarks (case reported within 1 day, case confirmed and investigated within 3 days, and appropriate response implemented within 7 days), and to predict possible outbreaks and/or unusual caseload. At the administrative level, the malaria online system generates information for decision-making on program planning, human resources, and budget allocation.

Thailand’s malaria online initiative is linked to Category 4: “Promoting digital transformation in the public sector by harnessing the power of digitized data for strategic decision-making.” By tracking data in real time utilizing digital technology, tailored actions are taken at village and district levels to address last-mile challenges to achieve malaria elimination. These include making services available and appropriate for hard-to-reach, mobile, and migrant populations in forested areas; preventing potential malaria outbreaks; and ensuring continued coverage of services in unstable settings. Shrinking the malaria map, province by province, simultaneously contributes to closing Thailand’s development gaps among varying geographies and communities.

The malaria online system supports Thailand in its quest for malaria elimination by 2024, a goal aligned with SDG Target 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.” As advised by the WHO Global Technical Strategy for Malaria (2016-2030), surveillance systems must be strengthened and increasingly utilized for programmatic decision-making as a country moves along the malaria transmission continuum. As malaria incidence declines, the disease becomes more focal/clustered and requires more detailed and frequent reporting. Thailand’s online MIS facilitates timely reporting and analysis of accurate and complete data for improved targeting of limited resources. Additionally, with the concentration of remaining malaria cases in specific geographies or communities, data must be within reach of subnational officers who are well situated to implement appropriate response actions. The malaria online is a powerful tool for Thailand to identify, track, and treat the last-mile cases of malaria, a critical component to ensure the end of the national epidemic, and to support malaria elimination in the Greater Mekong Subregion (GMS).

Malaria online aligns with the objectives of Thailand’s national Digital Economy and Society Development Plan to transform the public sector into a digital government (Thailand 4.0), build an equitable and inclusive society, and build citizens’ trust and confidence in digital technology. The government is investing in digital infrastructure improvements which will further enhance the performance and reach of malaria online. User-focused features of malaria online promote sustainability as data are utilized for precision planning including procurement and distribution of commodities (e.g., rapid diagnostic tests, anti-malarial medicines). These efforts improve efficient use of resources and minimize environmental contamination from waste products.

Government health infrastructure is more accessible to Thai and documented migrants closer to urban areas, and malaria service coverage for at-risk populations has been recognized as a shortfall. The malaria foci map feature of the MIS is used to guide selection of locations for village and border malaria posts. Unlike government-operated hospitals with fixed locations, malaria posts are operated by local community members with flexible locations based on malaria epidemiology, allowing for greater access to malaria services in target areas and communities, including hard-to-reach and highly mobile populations (e.g., migrants, daily border crossers, illegal workers, and undocumented populations). The GMS is known as the global epicenter for drug-resistant malaria. Therefore, supervised treatment and follow-up is an essential part of routine case management to ensure successful outcomes for all patients regardless of nationality or legal status. Malaria online captures individual case-based data from both government facilities and malaria posts for monitoring of treatment efficacy and service quality. Automatic analysis features and data visualization displays are developed with user input to maximize the use of strategic information by health staff at the local levels to facilitate communication and teamwork with local administrative bodies and partners in malaria elimination efforts.

The open access web-based online malaria surveillance system which displays malaria statistics and aggregated data is available to the public across the country. Individual case information is accessible by authorized health workers. Malaria can impact all populations in transmission areas regardless of their gender, age, or ethnicity. Thus, all people who are at-risk of or are affected by malaria will receive appropriate and equitable malaria prevention and treatment services. Women are encouraged to work in the field of information technology. Among data entry staff, 71% of them are women.

Target users of the malaria online system include public health workers at field level and higher-level health authorities at regional and national levels. At field level, the initiative has reduced the time required for data gathering, reporting, and analysis. Workers are now able to conduct real-time situation analysis and take rapid actions as needed. Previously, paper-based reporting of data was aggregated and transmitted on a monthly basis. The time required for reports to transmit from point-of-care service providers to the national level took 5-6 weeks. With the web-based malaria online system, malaria case data are available immediately after data are entered. At provincial and national levels, malaria online provides the same set of information for decision support, resource allocation, and prioritization of elimination activities. As a result, management of malaria cases among vulnerable populations has improved, driving down the malaria epidemic in Thailand. Moreover, geo-referenced information has been used successfully to leverage financial support from local governments at the sub-district level with malaria transmission, known as Local Administrative Organizations, to invest funds toward malaria elimination in their jurisdictions.

1) To achieve the shift from a paper-based to an electronic-based surveillance system, the Division of Vector Borne Disease (DVBD) began by reviewing its surveillance workflow. DVBD then worked with software developers at the Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS) to develop a system for digitization of malaria case investigation forms that was capable of analytics and data visualization. Draft versions of malaria online were pilot tested with select Vector Borne Disease Units (VBDU). Malaria online was first introduced in three provinces on the Thailand-Cambodia border in 2008-2009, then scaled up step-wise to ensure system stability: it was expanded to seven additional provinces in 2010-2011, and then countrywide in 2012. Additional modules were added to the database based on user feedback, including: entomological surveillance, weekly epidemic detection and malaria case response activities. 2) Capacity building of malaria online stakeholders is key to the success of the system. Key user groups include: 1) IT/developers at the DVBD who maintain database integrity and work with technical officers to develop new features or improvements to the system; 2) local IT staff at VBDUs who interface daily with malaria online for data entry, data query, and report generation; and 3) public health officers at all levels who access malaria online for planning and implementation. Annual trainings are conducted by the DVBD for different user groups depending on their specific roles and responsibilities. Technical support is provided through specific manuals, job-aids, and a hotline. 3) A key development included the integration of the national infectious disease notification system to malaria online. Previously, two parallel systems for malaria data existed: the hospital-based infectious disease notification and surveillance system and the malaria surveillance. In 2015, quality control and validation measures were instituted to remove duplication data in the combined database in malaria online.

Main challenges included limitations in technical resources and funding. With external and internal funding, a team of multidisciplinary specialists developed malaria online. When the first version was launched, many areas lacked stable Internet connectivity, prompting the introduction of an offline feature. With infrastructure improvements and simplification of data entry requirements, users in hard-to-reach areas, including NGOs, can input data into malaria online (e.g., cases from refugee camps and migrant worksites). Initial resistance by staff was overcome through advocacy, training, and user-driven feedback and improvements. Automated data visualization and displays improved usability of surveillance information by local staff.

The MIS is the first disease-specific surveillance database in Thailand incorporating data from hospitals (general health services) and the vertical program (vector-borne disease control). Vector control information is combined with malaria case reports and investigations to generate village malaria foci maps with household information and intervention coverage. Malaria online is used for malaria-free district verification, generating the evidence needed for Thailand to earn eventual WHO malaria-free certification. A mobile application is currently being piloted in three provinces to expand its reach. The MIS is a model for surveillance of other diseases in Thailand and malaria surveillance in the GMS.

Thailand is the first country in the GMS to adopt digital technology for malaria surveillance. The initial inspiration was drawn from the weekly reporting of infectious disease surveillance by the Department of Disease Control and the efforts to make malaria surveillance more effective. Subsequent improvements were made based on feedback from hotlines, user interviews, and surveys, and recommendations from an assessment by BIOPHICS in 2013-2014. Data visualization features have been added to improve ease for users.

Yes, the learning and experience from the web-based malaria surveillance system has been adapted to other disease surveillance systems in the country. Having developed the novel electronic malaria surveillance system for DVBD, BIOPHICS, the system developer, subsequently used it as the model for development of a similar tuberculosis surveillance system for Thailand.

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The surveillance system was started by DVBD as a solution to address delays of paper-based reporting, reduce workload, and minimize human errors. With this goal in mind, DVBD staff worked closely with BIOPHICS to provide insight on current reporting processes and challenges. BIOPHICS provided technical support in health informatics development. Initial financial support for software development and equipment was from the Bill and Melinda Gates Foundation and later from the Global Funds to Fight AIDS, Tuberculosis and Malaria, while government budget supports health officers’ salaries, infrastructure development, and daily operational costs, such as electricity, internet, and equipment maintenance.

Digitization of health information is aligned with government policy in Thailand 4.0. In particular, the Ministry of Public Health (MoPH) is in the process of transforming the national health information system through digital technology to achieve convergence of information technology and health services with increasing budgetary support. Since 2017, both hardware and software including servers supporting the system are hosted and maintained by the Information Center under Department of Disease Control. In terms of institutional sustainability, the malaria online system has been improved for interoperability and data compatibility with the broader hospital-based general health services systems of the MoPH.

Yes

An evaluation of the MIS was conducted by a team of health information specialists from Mahidol University, including BIOPHICS staff, from December 2013 to January 2014, the results of which were published in May 2016 in JMIR Public Health and Surveillance. A mixed-methods technique was used with a framework based on system effectiveness attributes. Three data collection methods were utilized: data records review, survey of system users, and in-depth interviews with key stakeholders. Sites selected were from Tak and Trat, two border provinces with high malaria transmission.

The objective of the evaluation was to assess the effectiveness of the malaria online system by examining key attributes of the electronic surveillance system, according to the United States Centers for Disease Control and Prevention’s Guidelines for evaluating public health surveillance systems. These key attributes included: simplicity, flexibility, data quality, acceptability, timeliness, stability, and usefulness. Data record review and semi-structured interviews were used to assess data quality. Data review was used to assess timeliness. Structured questionnaires were used to assess simplicity and acceptability. Structured questionnaires and semi-structured interviews were used to assess flexibility, stability, and usefulness.

One of the main findings of the evaluation was that the online malaria information system is well accepted by the system users at both management and operational levels. The data quality has enabled malaria personnel to perform more effective prevention and control activities. The evaluation of quantitative and qualitative data confirmed that the online surveillance system has high levels of simplicity, acceptability, stability, and flexibility. The results of the evaluation suggested that the electronic MIS helps improve the quality of Thailand’s malaria surveillance system. The initiative’s functionalities have provided the malaria staff with close-to-real-time, high-quality case management data. The evaluation found that the implemented system has, for the most part, achieved its objectives. However, there was evidence of some inconsistencies and logical errors in data reported due to user-error. Responding to this finding, the DVBD has conducted more training for staff and health officials who perform data entry so that they are familiar with useful features of the malaria online system. To ensure data quality, the Data Quality Assurance (DQA) process is conducted on monthly basis by malaria supervisors at provincial and regional levels while IT staff at national level review overall data correctness.

The DVBD, as the manager of the National Malaria Program under the Department of Disease Control, is responsible for tracking malaria cases and elimination activities in the online malaria information system as part of the National Malaria Elimination Strategy and Operational Plan. Malaria online has been developed and embedded at the DVBD to serve the needs of the National Malaria Program. These needs include situation analysis, monitoring intervention coverage, and evaluation of program performance. BIOPHICS, the system developer based in Bangkok, provides ongoing technical support in health information and digital technology, including troubleshooting complex hardware and software issues. The VBDU, as field implementer, is responsible for malaria case-based data collection and serves as the entry point for data digitization. Efficient workflow at the VBDU has a direct effect on real-time surveillance and response to prevent and eliminate malaria. As active malaria online users, VBDU staff provide valuable feedback on data entry problems and potential improvements. The Offices of Prevention and Control (ODPC), the Provincial Health Office (PHO) and the Vector Borne Disease Center (VBDC), as regional and provincial supervisors, utilize malaria online for planning and implementation.

From its inception, the development, implementation, and adoption of the malaria online system were conducted through collaboration, engagement, coordination, and partnerships with donors, international advisors and agencies, researchers and experts, and local health officers. Malaria online was developed to serve the routine surveillance needs of the vertical malaria program. However, stepwise inclusion of all aspects of malaria program activities and integration with the national disease notification system have resulted in a comprehensive malaria information system. Alignment with global and regional agendas for sustainable development and national goals for a digital society and malaria elimination has facilitated the development and adoption of malaria online in Thailand. User engagement has improved the design and acceptability of malaria online. At each step of system development, stakeholder consultations and field interviews were conducted to achieve user-driven product. At the same time, a clear development plan, including an outline of resources needed, was used to advocate support from government, donors, and technical partners. Technical partners are invited to continue to evaluate and propose ideas to improve malaria online functions and performance. Data visualization tools have been introduced to meet user demands and are open to everyone, further enhancing the inclusiveness of this initiative.

The DVBD remains vigilant in monitoring the malaria online system’s performance and data quality. Through preliminary evaluation, it is evident that further training for users is needed. The DVBD is currently testing a mobile malaria online application in three provinces to enable data entry on-location as activities are implemented. This should help improve real-time data collection at the community level and field monitoring of service delivery. As the malaria program is increasingly integrated with the general health services system, greater ownership and capability among users within relevant health agencies is needed for future success.