Use of smartphone technology for elimination of malaria in Bhutan
Bhutan has made significant strides in reducing the burden of malaria since 2001 through sustained political and financial support by the Government. The National Malaria Control Programme has achieved the Millennium Development Goal 6 of reducing morbidity and mortality of malaria through implementation of intensified malaria interventions. At present, malaria remains endemic in 16 districts, out of which 7 border India where perennial transmission takes place. Further, numerous developmental activities, in particular hydrodam projects are going on in Bhutan requiring many labourers from neighboring malaria-endemic districts of India to migrate for short periods; this is a threat for maintaining success in controlling malaria in the country.
At present, Bhutan has reached the pre-elimination phase of its malaria campaign. To maintain success so far, and move ahead with elimination the malaria programme now needs to be present in each health-facility catchment area, and to have information on the location of households with type of intervention adopted, temporary settlements, rice fields, dams, ponds, forests, cases, deaths, vectors, breeding places, health facilities etc. in all the malaria-endemic districts. Further, information about malaria-positive cases, deaths and weekly fever reports (suspected malaria) needs to be submitted at district level and at national level without delay.
To accomplish this, the programme requested WHO’s Regional Office for South-East Asia to help and support them in reorienting the malaria staff according to the new requirements of the programme. Although, there are already many tools available for collecting the required information such as global positioning system (GPS) devices, and personal digital assistants (PDAs) none can be used to transmit the information instantly to concerned authorities. To overcome this problem, WHO chose a smartphone, which although a household device can also be used for improving malaria surveillance. Using a smartphone one can easily collect the geo-code of any entity and transmit the information instantly. Also, the cost of the phones is approximately equivalent to GPS devices.
It was decided to initially pilot the concept in all the health facilities of one district, and then if the pilot proves successful to expand this to all endemic districts. The data collection tools required were developed using Open Data Kit (ODK) and staff concerned were trained in their use. As Internet services were not available in all the health facilities, it was decided that data would be extracted manually from the phone every week in the National Malaria Control Programme office and a pooled database would be created using KOBO processing tool to integrate all the instances. In addition, the staffs concerned were trained in transferring the information in to a GIS tool, and analysis and interpretation of the data.
So far, Bhutan has been able to pilot the project successfully in all the health facilities in the catchment area of Sarpang district and was able to map the location of all the households, breeding sites, malaria cases, project areas and temporary settlements. The malaria programme is using this information to: determine populations at high risk of malaria using buffer zone analysis; identify houses eligible for indoor residual spraying around the confirmed cases; and identify settlements that are at risk and need outreach services etc.
The country plans to replicate this experience in the other six districts with perennial transmission of malaria with the added facility of recording all the malaria cases and deaths investigation information using a smartphone or tablet computer. The cost of a tablet may be a little more than a smartphone, but will help establish a malaria elimination database at central level as well as at district level.