Questions/Answers

Critical congenital heart diseases (CCHD) are prevailing problem worldwide. In Thailand, approximate 1,000 babies are born annually with CCHD, one important cause of Thai’s neonatal mortality (8.3/ 1000 live births, World Bank Report 2012). Though, newborn babies undergo routine physical examinations within 24- 48 hours after delivery, CCHD may not be identified particularly those do not exhibit symptoms. Pulse oximetry (PO) screening, an additional test to detect CCHD in newborn, is painless, non-invasive and inexpensive using low-cost pulse oximeter apparatus, available in all hospitals. Any trained medical and nursing staff can perform the screening. PO screening is globally accepted and recommended but not mandatory in Thailand. To address the problem of neonatal mortality, Queen Sirikit National Institute of Child Health (QSNICH), the major healthcare provider for Thai children, initiates the innovative public service “CCHD Screening to Reduce Neonatal Mortality in Thailand”. This involves the introduction of the PO screening to all healthcare providers, training them and developing of the innovative interpretative tools to ensure effective detection of newborns with CCHD. Early detection of heart defects leads to the required proper monitoring and following up with pediatric cardiologists and establishing early treatment will also help decrease morbidity and mortality among these newborns. The initiative is established in 2013 then continuously expanded its network across the country. Recently the initiative has gained attention and been integrated into the national newborn service plan as the mandatory public service for newborns. The initiative also reaches out to the population by raising awareness, creating public demand to support health and well-being of these vulnerable newborns. Since the inception of the initiative and its implementation, Neonatal mortality is reduced to 7.3/1,000 live births in 2016. This is directly in line with SDG 3. Moreover, the initiative ensures equal access to service nationwide, thus matching SDG 10.

The overall objectives of the initiative are to 1) Reduce the neonatal mortality. Thai’s rate is higher than the neighboring Singapore and Malaysia; 2) End preventable deaths of vulnerable newborns from undetected CCHD ensuring healthily growth, give them the chance to grow up and live their lives for the good of their family, society, country and the world at large; 3) Provide training of PO screening technique and QSNICH's innovative result interpreting technique to empower health providers; 4) Raise the national healthcare standards of practicing routine physical examination of newborns throughout Thailand by standardization and qualifying the mandatory PO screening 5) Create public awareness thus generating greater public demand for this lifesaving neonatal CCHD screening; 6) Reduce the newborn’s length of hospitalization for CCHD treatment by early detection and treatment of newborn with CCHD before development of severe cyanosis, resulting in shorter hospital day which realize the problem of shortage of needed Newborn Intensive Care Units (NICU) and saving of national health resources thus ensuring the reduction of national health budget as a whole; 7) integrate the screening service into national newborn service plan throughout 13 health zones of Thai healthcare system thus ensuring equal access to the service nationwide.

The initiative is completely new innovative public service in Thailand that saves vulnerable newborns with CCHD, most from financially poor families. It ensures newborns’ survival supporting their right to live (Article 7, UN Convention on Rights of Child), having healthy lives and wellbeing and end preventable deaths of them aligned with UN SDG 3. Thorough research and development to create appropriate criteria and interpretation protocol of PO screening, provision of training the relevant workforce to acquire screening skills and understand patients’ needs, the initiative ensures affordable and quality public service. Creation of service network across country, QSNICH needs to mobilize financial resources to all partners. Merging the initiative into national newborn service plan has made the service mandatory for equal public access and reducing of inequality supporting SDG10. Public communication has been continuously promoted e.g. via television (https://youtu.be/PWs28H0i0TQ) by National Health Security Office (NSHO) since 2013, public newspapers, Journals and other venues, to ensure easily public obtain information about this service and public rights; resulting in a mechanism to ensure families providing feedback, filing complaints, and requesting compensation equitably. Consequently, the network can further develop and are accountably response of this service to the public demand to save vulnerable newborns.

The initiative improves the delivery of public PO screening services to save the most vulnerable newborn lives, end preventable deaths of them from CCHD and also promote their good health and well-being (SDG3, target3.2 and 3.4). It ensures that the most vulnerable newborns receive universal health coverage. All families can access to the CCHD screening service which is safe, effective, quality, and affordable, thus are protected from financial risk of high expense for treatment of their babies seriously ill from CCHD (SDG3, target3.8) The initiative has empowered the relevant health workforce by training, and has managed to reduce the health risk of CCHD in newborns (SDG3, targets3.c and 3.d). Disseminating the initiative to network hospitals across the country ensures equal opportunity and reduce inequality of access to the CCHD screening service for newborns, all of whom are in need(SDG10, target10.3). As is known, illness and disability lead to poverty. Thus preventing the death and disability of newborns with CCHD that could result from missing or delayed diagnosis and treatment of CCHD in newborn indirectly helps to guard against extreme poverty for families which in turn may create many social issues (SDG1, target 1.1).

The initiative has addressed a significant issue of children under 5 years of age, focusing on the group of most vulnerable newborns, to end preventable death of newborns resulting from delayed diagnosis and treatment of CCHD. QSNICH did studies and technology assessment to address the problem, and adopted the PO screening for newborns which is a simple, painless, noninvasive, and inexpensive technic that all trained health personnel can do effectively. Undergoing the PO screening test within 24-48 hours after delivery, newborns with hidden CCHD can be detected earlier and transferred to pediatric cardiologists in the regional hospital to save their lives. Therefore, systematically launching the initiative named “CCHD Screening to Reduce Neonatal Mortality in Thailand” as the public service has proven to be worthwhile. It has involved transferring innovative technology of electronic data collection and interpretation, and disseminating this model to the hospitals nationwide to reduce national neonatal mortality and promote healthy growth and well-being of newborns. QSNICH has worked intensively to empower health personnel, ensure their ability to provide PO screening and interpret its results effectively, and prevent human errors. Eventually the initiative was integrated into national newborn service plan to enhance its rapidly transfer and sustainability.

The initiative has positively impacted Thailand by aiding the vulnerable newborns. CCHD is considered a significant cause of neonatal mortality in Thailand, 8.3/1000 live births (World Bank 2012). Congenital heart defect (CHD) is a global prevailing problem, the incidence being approximately 6-8/1000 live births those are about 6000 to 7000 each year in Thailand. Among this group 1-1.5/1000 or approximately 1,000 newborns develop CCHD. They may not survive, since the abnormalities of their heart lead to severe danger of oxygen shortage, quickly turning them into critical blue or cyanotic babies who need long-term intensive care to save their lives which lead to many other problems such as shortage of NICU, high cost healthcare, lower family income or even psychological problems of parents. Concern by this, QSNICH has worked committedly to reduce preventable neonatal deaths due to CCHD. Thus the initiative “CCHD Screening to Reduce Neonatal Mortality in Thailand” has been launched using PO screening to detect newborns with CCHD and refer them for appropriated treatment in the referral hospitals which have potential to provide comprehensive healthcare for newborns with CCHD. The initiative has been administrated systematically to ensure the quality, equity, equal public accessibility, and effectiveness of the service.

Thailand’s healthcare for newborns with CCHD used to be reactive, not proactive. Therefore, the introduction of pulse oximeter screening under the "CCHD Screening to Reduce Neonatal Mortality Rate” initiative by QSNICH to all healthcare providers nationwide is a true innovation. The screening is now part of the routine physical examination for newborns. QSNICH also created the BLUE BABY WHEEL (BB wheel) an innovative, low-tech, inexpensive tool used to collect and properly interpret results ensuring accurate, quality and efficient screening. Furthermore, QSNICH cooperated with King Mongkut's University of Technology North Bangkok (Prachinburi Campus), using current information and communication technology (ICT), to develop the “CCHD screening” smartphone application (compatible to both iOS and Android operating systems) to offer another version of BB wheels that is more attractive and lifestyle-appropriate for those familiar with ICT. Last, but not least, the real-time monitoring and evaluation web-based program for the CCHD screening was created through cooperation of Lampang regional hospital and QSNICH. Moreover the integration of the initiative into national newborn service plan has introduced the innovative idea, policy, and management system, which is new and unique in Thailand, to ensure all the quality, rapidly growth and expansion of this public service to vulnerable newborn.

This initiative has been implemented to realize SDGs and targets (Item2.1). The majority of program activities are original innovations (Item4.1). Since 2002, studies of PO screening have shown a variety of criteria and effectiveness of this screening that has been accepted and recommended worldwide, but only few countries have adopted it as a mandatory public service for newborn. The Center of Excellence in Pediatric Cardiology of QSNICH, the major public healthcare provider for newborns and children, receives the greatest number of critical blue babies with CCHD referred from other hospitals across Thailand. To address the problem, QSNICH is committed to ending these preventable newborn deaths and serving the Ministry of Public Health (MOPH) policy of reducing Neonatal Mortality. The research and development of PO screening was conducted to determine the most appropriate criteria and effectiveness of its implementation across the country by QSNICH and partners. The PO screening for CCHD has since been adopted and included as public service, added to the routine physical examination for newborns. In this initiative, which comprise of many activities and innovations, the BB wheel interpretative tools and CCHD screening application, which empower health personnel and enhance transferability, are the most important innovations.

The initiative has received resources from government agencies and partners, enabling sustainable public service provision. The resources include: 1) FINANCIAL: NHSO funded the researches and Technology Assessments. When the initiative was launched policy advocacy and integrated into the national service plan for newborn through the healthcare system, the MOPH’s Department of Medical Services (DMS), with which QSNICH affiliated, mobilized the budget to all hospitals, including those joining the program as the screening provider or also as affiliated training center for CCHD knowledge sharing to further promote dissemination of the initiative to the district and community hospitals within the same geographic area, as many regional and provincial hospitals have done. 2) INFORMATION AND COMMUNICATION TECHNOLOGY (ICT): The innovative smartphone application was sponsored by King Mongkut's University of Technology North Bangkok (Prachinburi Campus )’s postgraduate program. ICT has been used in reporting and evaluating the initiative, through the innovative, reliable, secure, and real-time web-based program. Lampang regional Hospital has contributed to the initiative’s web-based program development and maintenance. 3) HUMAN: The postpartum units’ staff at the partner hospitals support QSNICH’s initiative by performing the screening and QSNICH organizes visits, exchanges and academic meetings to further disseminate information and enhance screening skills.

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The initiative was piloted in zone 13 (Bangkok region) and once the results confirmed the screening technique’s precision and credibility, the innovation was disseminated nationwide. Currently, there are 208 hospitals in 59 provinces, 13 health zones of Thailand, implementing the screening. The initiative was created focusing on transfer-ability of all activities, including 1) the innovative interpreted tools: the BB wheels and the CCHD screening smartphone application which facilitate the operators and make the task more enjoyable; 2) provision of pulse oxymeter apparatus to demonstrate the administration’s support and concern; 3) personnel training for regional and provincial hospitals in 13 health zones to empower their staff to manage the screening accountably and systematically, and create the next trainers; 4) support for regional and provincial hospitals for further dissemination of the initiative to district and community hospitals in the same area; 5) integration of the PO screening service into national newborn service plan; 6) development of the web-based data collection and system evaluation program for the hospitals implementing CCHD screening to report easily; 7) knowledge sharing of the initiative to neighboring countries e.g. Lao People’s Democratic Republic (PDR) and Malaysia.

The initiative is able to be sustained because it covers the three sustainability pillars: social, economic and environmental. 1. Social aspect: the initiative truly reduces neonatal mortality meaning babies are saved from death and can grow up to contribute to society. Fewer families lose their newborns to disease and are happier thanks to the joy that a newborn and seeing a child grow bring. Parent’s possible enormous grief, psychological trauma and disorders from a child’s death plus the possible consequences of social impairment or the breaking up of a family are avoided. Additionally, creation of public demand by public knowledge sharing ensures social support for the initiative’s sustainability; 2. Economic aspect: The possibility of families being less able to make a living as they deal with the loss of a baby is lowered. Newborns whose lives are saved thanks to the CCHD screening go on to become adults who can contribute to the economy. For the nation as a whole, the government budget for public healthcare provision has been reduced significantly since the initiative makes early detection of CCHD in newborns possible as opposed to delayed diagnosis which leads to acute death or critical health status that requires long term intensive care with death or disability a real possibility, which further burdens families and society. Moreover, the screening initiative is a preventive step that leads to costs lower than complicated treatment for late diagnosis; 3. Environmental aspect: The initiative has resulted in the development a paperless mobile application (CCHD screening application for smartphone) and a supporting web-based program for data collection and evaluation that requires minimum environmental resources consumption.

The initiative has been structured systematically to enhance sustainability over time by implementing the following strategies: 1) Research and development including innovation were involved to obtain appropriate protocol and technic within context of Thailand, which has been accredited by Thailand’s Royal College of Pediatricians as a prudential procedure that should be added to routine newborn physical examination; 2) Addressing the national and international problem: It is a public service really serving the most vulnerable group of newborns who are their parents’ and families’ future. The future of the society, country, and the world at large rests on these newcomers to the world. This is especially true for countries facing an ageing population. Therefore this screening initiative’s importance will not diminish over time. The initiative also lessens social and economic problems at the individual, family, society and country levels that result due to bereavement from loss of beloved babies; 3) Elevating this initiative’s status to a policy and integrating it into the national newborn health service plan ensures its continuity as well as material and budget resources provision from MOPH; 4) Partnering with regional and provincial hospitals results in support in manpower, empowers the hospitals through training of their personnel to accurately conduct screening and become trainers themselves for future staff at their and other hospitals, ensures equal service access in the area of their responsibility, and creates a CCHD screening network serving the vulnerable newborns all over Thailand for the good of our next generation; 5) Highlighting the need for the initiative through public relations and publishing its success have created public concern and demand for the newborn CCHD screening service as a basic social need; 6) Developing a web-based evaluating and report system that is paperless means no paperwork burden, making staff even more willing to do the screening.

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The initiative has been evaluated formally and systematically by QSNICH represent MOPH in three categories as followings 1) the operational output; 2) the stakeholders relationship focus on satisfaction and cooperation; 3) the national neonatal mortality. Portal of evaluation, the initiative has used the innovative online evaluating program to monitor the operational output. The program has been developed using information and communication technology (ICT) for the operators to report of their work conveniently and has provided real time evaluation without burden of paperwork. Meanwhile the data has been reported to DMS, MOPH every 3 months. The stakeholder satisfaction and cooperation have been measured annually using the satisfaction of the service providers regarding the innovative interpreting tools (the BB wheel and the CCHD screening application for smartphone), via an online free survey program each year. For the year 2017 the link to the survey is https://www.surveycan.com/survey184857 or QR code. The increasing amount of the operational results entered in the supporting system also represents the stakeholders’ or partners’ cooperation. The national neonatal mortality which is the ultimate goal of the initiative has been measured and published by the third party organizations national and international, as MOPH and World Bank.

The initiative has significantly impacted the lives of the most vulnerable newborns, especially those with CCHD as shown by the evaluating system: 1. The number of hospitals implementing CCHD screening increased from 4 to 208 within 5 years of the initiative, meaning the service provision has spread to many areas of Thailand and that there is a good trend for partner cooperation. 2. The number of hospitals has grown rapidly after launch of the innovative CCHD screening smartphone application. 3. Newborns receiving screening have risen in number from thousand to hundreds of thousands annually meaning more children’s lives have been saved before it’s too late and that equality in access to the public service is promoted. 4. The number of newborns with positive screening results confirms the ability of health personnel to detect at-risk newborns and give them timely comprehensive lifesaving treatment. 5. the most important impact is the gradual drop in neonatal mortality thanks to the national healthcare service plan for newborns which includes the screening. According to a World Bank report, the rate has decreased from 8.3/1,000 live births in 2012 to 7.3/1000 live births in 2016.

The evaluation indicators are 1) the number of hospitals implementing CCHD screening; 2) the number of newborns undergoing PO screening within 24-48 hours after birth; 3) the number of newborns with positive PO screening; 4) satisfaction of the BB wheel evaluating tool, in 2015 then change to 5) satisfaction of the CCHD screening application for smartphone, in 2016-2017; 6) National neonatal mortality, reduction of which is the ultimate goal of the initiative and national service plan for newborns, that has been monitored by MOPH and World Bank annually; 7) The ratio of NICU to newborn which is one indicator of the newborn service plan which is also monitored by QSNICH, the main organization in charge of the service plan, to show the readiness of the facilities and manpower across Thailand in treatment of critically ill newborns. The ratio of NICU to newborn, which decreased from 1: 731 in 2015 to 1:690 and 1:583 in 2016 and 2017 respectively, is measured as an indicator of newborn service plan alongside the initiative and shows that NICUs are developed to serve critical newborns and also intend to reduce neonatal mortality.

The initiative has been executed mainly by QSNICH and partners within the MOPH and others including 1) The hospitals involved in research and development of the PO screening and pilot study were the first group of hospitals committed to finding the appropriate PO screening protocol and technic, meeting regularly and providing PO screening to newborns including collecting data and interpretation; 2) The Royal Academy of Pediatricians of Thailand arranged meetings to discuss the PO screening benefits and certified it as a recommended procedure to be added to the routine physical examination for newborns ; 3) The public and private partner hospitals implement the screening and their staff play the most important role of providing the screening to all newborns nationwide. They participate in annual national meetings, scheduled site visits and training courses, all of which QSNICH arranges to empower them. The community of healthcare personnel who practice the PO screening in the 13 health zones actively uses social media channels, e.g. LINE groups, set up by QSNICH. Via these channels, those in the same health zone exchange knowledge consult and create relationships; 4) Because of QSNICH’s and NSHO’s regular public relations, public awareness of the importance and benefits of the PO screening has grown. More parents of newborns are demanding the screening service; 5) MOPH’s DMS provided budget for the initiative and NHSO granted budget for operation of the screening in health zone 13; 6) King Mongkut’s University’s students worked on developing the mobile application for the initiative. QSNICH’s relationship with the university has thus been a win-win situation with QSNICH receiving the application and the students learning being enriched; 7) Lampang hospital was the partner in developing the web-based evaluating program with the same purpose of doing the best for the good of newborns in Thailand.

The lessons to be taken away from the initiative are: 1) any initiative needs to be developed on the basis of a clear vision and with focus on the most vulnerable, in this initiative newborns, to ultimately address greater national and global problems and realize sustainable development. This type of initiative will motivate and encourage all stakeholders; 2) ICT permeates all areas of operations, evaluation, and communications, accelerates the initiative’s growth significantly because it can bridge social gaps and lifestyle of the new generation workforce and makes connection to remote areas easier. ICT also plays a major role in facilitating transfer of the model, exchanging information and lessons learned among workers, enhancing partner relationships which is key to the initiative’s success, and boosting public awareness and equality in accessing the service; 3) Management needs to be kept aware of the program and its impact to ensure budgets and supporting materials are granted regularly to continuously improve the program. Future improvement entails: 1) Having all hospitals with newborn delivery services implement CCHD screening 2) Having both MOPH and NSHO provide budgets to all 13 health zones in Thailand.