DOTS 2010 Program

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Draft 2010 2015 Philippine Plan to Control TB (Phil_PaCT)Dr. Mariquita J. Mantala Member, Task Force on TB Control Strategic Plan Development NTP Midyear Consultative Workshop August 11, 2009

Presentation flow

Rationale for Updating Align with sector-wide approach of F1 and PIPH plans as well as with global developments Define long term plan to address programmatic constraints identified during monitoring and evaluation Utilize 2007 NTPS results for better epidemiological estimates, targeting and budget-setting Harmonize substantial resources from government and partners to ensure efficiency and effectiveness Define how to maximize newly-developed technologies appropriate to country situation

Planning processNTP mobilized support (WHO, USAID (TB LINC and HPDP) and Global Fund) in Feb. 09 Steering Com and Task Force organized in March 09 Situational analysis done in April and May 09 Draft prelim. plan presented to stakeholders on July 8 9, 2009 Complete draft plan presented to stakeholders on Aug. 5 -6, 2009FINAL PLAN : SEPTEMBER, 2009

Major challenges based on situational analysisDecreasing TB prevalence and mortality but with threat from MDR-TB, HIV/AIDS

National targets in CDR and TSR achieved but with variation in local program performance

Quality assured TB services not universally accessible

*Big proportion of HCPs not adopting DOTS protocol incl. hospital and PPs * Weaknesses in ensuring quality diagnostic tests and drugs

*Poor TB care-seeking behaviour of clients *Needs of special population not fully addressed: MDR-TB HIV/TB co-infection, vulnerable groups

Varying support to TB control by the LGUs Inadequate and uncoordinated TB care financing

The Plan s Vision, Goal and ObjectivesTB free Philippines To reduce the TB burden in the Philippines in line with the MDG, Stop TB Partnership Strategy and Philippine health sector reform

Objective 1Reduce local variation in TB control program performance (Governance)

Objective 2Scale-up and sustain coverage of DOTS implementation

Objective 3Ensure quality DOTS services

Objective 4Reduce out-of-pocket expenses for TB care

(Service delivery)



Objectives and StrategiesObjectives1. Reduce local variation in TB control program performance 2. Scale-up and sustain coverage of DOTS 3. Ensure quality of TB services 4. Reduce out-ofpocket expenses 1. 2.

StrategiesLocalize implementation of TB control Monitor health system performance

3. Engage both public & private TB care providers 4. Promote and strengthen positive behavior on TB care 5. Address the needs of MDR-TB/HIV & other vulnerable populations 6. Regulate and make available quality of TB diagnostic tests & anti-drugs 7. Certify and accredit TB care providers 8. Secure adequate financing for TB control program and improve fund utilization

Targets in 2015Impact:Reduce TB mortality and prevalence by half in 2015 compared to 1990 data

Outcome:At least 85% of incident TB cases are detected and at least 90% have successful treatment

Planning FrameworkImpact : TB Prev, , Mortality Outcome: CDR, TSR, MDR-TB

Reduced local variation Strat 1 & 2 9 perf. targets

Scaled-up and sustained DOTS Strat 3 ,4&5 12 perf. targets

Quality dx tests and drugs are available Strat 6 & 7 7 perf. targets

Reduced out-ofpocket expenses Strat 8 3 perf. targets

Strategy 1. Localize TB control program implementationRationale:The LGUs at the provincial, city and municipal levels manage the TB control program within the decentralized health system set-up.

Challenges: Varying program performance among provinces and cities NTP is perceived as a national program connotes lack of ownership by some LGUs Inadequate LGU support With uncoordinated stakeholders

Performance targets1. 1 70% of provinces include clear TB control plan within the Provincewide Investment Plan for Health (PIPH/AIPH) and AOP

Major activities NationalFormulate guidelines in developing TB control strategic and operational plan for PIPH/AIPH/AOP Review and consolidate PIPHs/AOPs

LocalConduct situational asssesment Craft locally specific interventions and incorporate in PIPH/AOP

1.2 70% % of provinces / cities are DOTS compliant

Develop standards / system for determining compliance to DOTS management Assess compliance to DOTS standards by provinces and cities

Identify and address gaps and needs

Performance targets1.3 90% of priority provinces /HUCs have achieved program targets using performance grant

Major activities National LocalPrioritize provinces for TA and financial support based on TB burden, performance and absorptive capacity Develop guidelines and implement performancebased grants Develop guidelines and capacitate region to provide TA to provinces/cities Strengthen / establish PP collaborating mechanisms at national and regional Implement local TB plan with support through performance grant

1.4 CHD and partners with capacity to provide TA to provinces and cities 1.5 Public-private collaborating mechanisms strengthened to include CUP

Identify TA needs and request for support

Establish PP collaborating mechanism at provincial / city level

Proposed classification of Provinces / CitiesLevel 1 - DOTS complying or adhering: complies to 8 standards of effective TB control program implementation Level 2 - DOTS performing: Level 1 plus achievement of program targets (CDR and TSR) and EQA standards; with initiatives for MDR-TB and vulnerable population Level 3 - DOTS sustaining: Level 1 and performing for at least 3 years

Proposed Standards for a DOTS-compliant Province / City1. With a province/city-wide multi-year TB control plan that responds to local situation (PIPH/AIPH) 2. A local governance structure that manages implementation of the province-wide TB control program and that coordinates publicprivate participation in TB control 3. A network of provincial and municipal TB laboratories that maintains quality-assured DSSM, both by public and private laboratories and with access to TB Diagnostic Committee for management of smear negative TB cases 4. With capacity to ensure uninterrupted supply of anti-TB drugs in all the DOTS facilities within its catchment

Proposed Standards for a DOTS-compliant Province / City5. A DOTS service network for TB care and diagnosis, involving both public and private health care providers and other levels of health care With program of activities being implemented, to increase demand for TB services With system that regularly analyzes program performance (e.g. regular monitoring and evaluation, at least an annual PIR and quarterly reporting to CHD)



8. Secured funding for TB control program implementation

Strategy 2. Monitor health system performanceRationale:Information is needed to come up with evidence-based decisions that would lead to improved program performance

Challenges: Varying, unintegrated TB information systems Poor quality of TB mortality data Delayed report at all reporting levels Available information not maximized for decision-making

target2.1 Trend of TB burden tracked

NationalConduct 4th NPS, second DRS and TB mortality survey Integrated TB into NDHS and APIS


2.2 TB information generated on time, analyzed and used 2.3 TB information system integrated with national M&E and FHSIS

Expand web-based electronic TB Strengthen monitoring information system and supervision Adopt ETR Enhance NEC capacity to manage TB information system Analyze LGU score card

2.4 NTP capacity to Capacity-building support and monitor Additional human resources health system strengthened

Strategy 3. Engage all health care providers to adopt DOTSRationale:Standardized quality TB care ensures early TB case detection and treatment; hence, prevents poor treatment outcome that may lead to MDR-TB and reduces financial burden to patients.

Challenges: Hospital staff, private practitioners and staff of other government clinics are not adopting the DOTS protocol. Limited implementation of Public-Private Mix DOTS (PPMD) Training problems

Performance targets3.1 70 % of component cities and key municipalities are with functional public-private collaboration mechanism (for service delivery level)

Major Activities NationalAdvocate for adoption of ISTC through national professional societies

LocalEstablish DOTS referral network among RHUs/HCs and other non-NTP TB care providers. Sustain the public-private sector participation including use of PhilHealth reimbursements Expand Public-to-Public Mix DOTS (P2P) Capacity-building

3.2 90% of public Update policies and hospitals and 60% of guidelines on hospital DOTS private hospitals are participating in Strengthen incentives DOTS, either as /enablers provider or referring unit

Performance targets

Major Activities National Local

3.3 70% of 9,000 Adopt ISTC Train members of targeted PPs are referring Coordinate with professional socities patients to DOTS facilities professional societies and other groups 3.4 Health workers are equipped to deliver DOTS services Integrate some DOTS training with training courses of other infectious diseases Integrate some DOTS training courses and outsource some courses Establish HR management information system Conduct capabilitybuilding activities

Strategy 4. Pursue positive TB behavior of communitiesRationale:Clients health-seeking behavior affects TB detection and treatment

Challenges: 68% of TB symptomatics are not doing anything or are self-medicating High poor treatment outcome, such as the d