Queen Sirikit National Institute of Child Health Year of nomination 2018 Supporting document Document 1 of CCHD Screening to Reduce Neonatal Mortality in Thailand Content Page Executive Summary 1 Background, Situation and Problem 5 Evaluation of the Initiative 7 Innovations of the Initiative 14 Implementation of the Initiative 19 Stakeholders 24 Resources 26 Monitoring and Evaluation System 28 Results 30 Obstacles and Solutions 33 Benefits and Mutual Benefit 35 Sustainability and Transferability of the Initiative 39 Success Story 42 Lesson Learned 53 Future Challenges 54 Acknowledgement 55 TITLE: CCHD Screening to Reduce Neonatal Mortality in Thailand 1. Executive Summary 1.1 Problem: According to a 2012 World Bank report, the neonatal mortality rate in Thailand was 8.3 per 1,000 live births. This is much higher compared to Malaysia’s 4 per 1,000 live births and Singapore’s 1 per 1,000 live births. One of the Sustainable Development Goals’ (SDGs) targets is to end preventable deaths of newborns and less than 5 years old age which the success confirms by the index mortality rate of children fewer than 5 and neonatal mortality. Because neonatal mortality is approximate 50% of the mortality of children under 5, so that the newborn babies are vulnerable and need to be given special attention. Thailand has also been working to reducing the neonatal mortality rate as the ultimate goal of Thai National Health Service Plan for newborn. 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. Though, newborn babies undergo routine physical examinations within 24 - 48 hours after delivery, CCHD may not be identified particularly those do not exhibit symptoms. However, after returning home, a neonate with congenital heart disease will develop severe symptoms and die before the family can bring him to the hospital or may arrive at the hospital in the critical condition. CCHD can be severe and the risk of death can become very high, also any number of crippling complications those will leads to other social and economic problems at the individual, family, society and country levels that result due to bereavement from loss of beloved babies or the family need to take care of disable babies. If an infant with congenital heart disease already exhibit severe symptoms, he needs to be taken care of - 1 - at tertiary hospital with the necessary facilities and expertise. A newborn patient with congenital heart disease may also need to remain in the hospital for a longer period of time to receive the needed treatment. As a result, the medical expenses for the family can be extremely high. Another problem is that the longer a congenital heart disease patient has to stay in the hospital, the lower the turnover rate for beds for critically ill patients. Consequently, the overall operation and image of the hospital can be negatively impacted. It can be concluded that overall treatment for newborns with critical congenital heart disease in Thailand was reactive. Thus affect Thailand’s goal of reducing the neonatal mortality rate in Thailand. 1.2 Development of the Initiative The Center of Excellence (COE) in Pediatric Cardiology is one center of excellence of Queen Sirikit National Institute of Child Health (QSNICH), the major public healthcare provider and policy maker for the improvement of healthcare service for newborns and children in Thailand, realizes the problem and commit to end preventable deaths of newborns due to CCHD and serving the Ministry of Public Health (MOPH) policy of reducing Neonatal Mortality. Currently QSNICH provides services to more than 1,300 to 1,400 child patients with congenital heart defects each year or approximately one out of every four such patients across the country because of their ability in doing the complete accurate diagnostic and give them comprehensive treatment. After studying the treatment chain for newborn with CCHD and found that the delayed of diagnosis and treatment is the most important factor that compromised this chain, QSNICH searched for the proactive prevented tool which is the pulse oximetry (PO) screening in newborns that will - 2 - detect those newborns with CCHD before they develop the severe symptoms and be critically ill. The PO screening is a simple, painless, noninvasive, no risk and inexpensive technic, using simple device available in all hospitals, and gives reliable results. All trained health personnel can do the screening. 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. 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 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. Thus QSNICH initiates the innovative public service “CCHD Screening to Reduce Neonatal Mortality in Thailand” in 2013. The initiative aims to end preventable death of newborn with CCHD in Thailand by implement of the PO screening service in all hospitals providing the newborn delivery across the country. This involves the introduction of the PO screening to all relevant healthcare providers, training them and developing of the innovative interpreting tools to ensure effective detection of newborns with CCHD: the BB wheel interpretative tools, CCHD screening application, and the web- based data collection and system evaluation program for the hospitals implementing CCHD screening to report easily, and convince them that the screening is the procedure that worth to do since it can really save those newborns with CCHD. The PO screening for CCHD has since been adopted and included as public service, added to the routine physical examination for newborns. Furthermore it has been integrated into national newborn service plan to ensure the greatest and fastest of its transferability and sustainability. - 3 - 1.3 Impact of the Initiative 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. It 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 in 56 provinces 13 healthcare regions of Thailand within 5 years of the initiative, meaning the service provision has expanded 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 smart phone 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 7.3/1,000 live births in 2016. - 4 - 1.4 Challenges of the Future The challenges of the initiative at the end of the Twelfth National Healthcare Development plan are to 1. Expand the PO screening service in newborns to 100% of hospitals providing newborns delivery in Thailand. 2. Have the formal MOU with NSHO to support the operational budget to all hospitals providing the PO screening service in all 13 Thailand’s s as in 13th. 3. Have at least 60% of newborns in Thailand each year receive the PO screening within 24-48 hours before discharging from the hospitals. These will confirm the true success of this innovative public service “CCHD Screening to Reduce Neonatal Mortality in Thailand” and the realization of Thai government, Ministry of Public Health to the Agenda 2030 Sustainable Development Goals and Targets as; SDG3, target3.2, 3.4, 3.8, 3.c and 3.d; SDG1, target 1.1; and SDG10, target10.3. 2. Background, Situation and Problems According to a 2012 World Bank report, the neonatal mortality rate in Thailand was 8.3 per 1,000 live births. This is much higher compared to Malaysia’s 4 per 1,000 live births and Singapore’s 1 per 1,000 live births. One of the sustainable development goals’ (SDGs) targets is to end preventable deaths of newborns and less than 5 years old age which the success confirms by the index mortality rate of children fewer than 5 and neonatal mortality. Because neonatal mortality is approximate 50% of the mortality of children under 5, so that the newborn babies are vulnerable and need to be given special attention. - 5 - Thailand has also been working to reducing the neonatal mortality rate as the ultimate goal of Thai National Health Service Plan for newborn. Congenital Heart Defect (CHD) is a global prevailing problem, the incidence approximately 6-8/1,000 live births from over 730,000 newborns those are about 6,000 to 7,000 each year in Thailand. Among this group 1-1.5/1,000 or approximately 1,000 newborns develop CCHD, a leading cause of neonatal deaths.