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Page 1: DOTS 2010 Program

Draft 2010 – 2015 Philippine Plan to Control TB (Phil_PaCT)

Dr. Mariquita J. MantalaDr. Mariquita J. MantalaMember, Task Force on Member, Task Force on

TB Control Strategic Plan DevelopmentTB Control Strategic Plan DevelopmentNTP Midyear Consultative WorkshopNTP Midyear Consultative Workshop

August 11, 2009August 11, 2009

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Presentation flow

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Rationale for UpdatingRationale 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

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Planning process

FINAL PLAN : SEPTEMBER, 2009

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Major challenges based on situational analysisMajor challenges based on situational analysis

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TB – 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 1 Objective 2 Objective 3 Objective 4

Reduce local Scale-up and Ensure quality Reduce variation in sustain coverage DOTS services out-of-pocketTB control of DOTS expenses forprogram implementation TB careperformance

(Governance) (Service delivery) (Regulation) (Financing)

The Plan’s Vision, Goal and Objectives

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Objectives and StrategiesObjectives Strategies

1. Reduce local variation in TB control programperformance

1. Localize implementation of TB control2. Monitor health system performance

2. Scale-up and sustain coverage of DOTS

3. Engage both public & private TB care providers4. Promote and strengthen positive behavior on TB care5. Address the needs of MDR-TB/HIV & other vulnerable populations

3. Ensure quality of TB services

6. Regulate and make available quality of TB diagnostic tests & anti-drugs

7. Certify and accredit TB care providers

4. Reduce out-of- pocket expenses

8. Secure adequate financing for TB control program and improve fund utilization

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Targets in 2015

Impact: 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

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Planning Framework

Impact : TB Prev, , Mortality

Outcome: CDR, TSR, MDR-TB

Reduced local variation

Scaled-up and sustained DOTS

Quality dx tests and drugs are available

Reduced out-of-pocket expenses

9 perf. targets

12 perf. targets

7 perf. targets

3 perf. targets

Strat 1 & 2 Strat 3 ,4&5 Strat 6 & 7 Strat 8

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Strategy 1. Localize TB control program implementation

Rationale:The LGUs at the provincial, city and municipal levels manage the TB control program within the decentralized health systemdecentralized 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

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Performance targets Major activities

National Local1. 1 70% of provinces include clear TB control plan within the Province-wide Investment Plan for Health (PIPH/AIPH) and AOP

Formulate guidelines in developing TB control strategic and operational plan for PIPH/AIPH/AOP

Review and consolidate PIPHs/AOPs

Conduct 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

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Performance targets Major activitiesNational Local

1.3 90% of priority provinces /HUCs have achieved program targets using performance grant

Prioritize provinces for TA and financial support based on TB burden, performance and absorptive capacityDevelop guidelines and implement performance-based grants

Implement local TB plan with support through performance grant

1.4 CHD and partners with capacity to provide TA to provinces and cities

Develop guidelines and capacitate region to provide TA to provinces/cities

Identify TA needs and request for support

1.5 Public-private collaborating mechanisms strengthened to include CUP

Strengthen / establish PP collaborating mechanisms at national and regional

Establish PP collaborating mechanism at provincial / city level

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Proposed classification of Proposed classification of Provinces / CitiesProvinces / Cities

Level 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

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Proposed Standards for a DOTS-compliant Province / City

1. 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 public-private 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

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Proposed Standards for a DOTS-compliant Province / City

5. A DOTS service network for TB care and diagnosis, involving both public and private health care providers and other levels of health care

6. With program of activities being implemented, to increase

demand for TB services

7. 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

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Strategy 2. Monitor health system performance

Rationale: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

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Performance target

Major ActivitiesNational Local

2.1 Trend of TB burden tracked

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

Capability-building

2.2 TB information generated on time, analyzed and used

Expand web-based electronic TB information system

Strengthen monitoring and supervision

Adopt ETR

2.3 TB information system integrated with national M&E and FHSIS

Enhance NEC capacity to manage TB information system

Analyze LGU score card

2.4 NTP capacity to support and monitor health system strengthened

Capacity-buildingAdditional human resources

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Strategy 3. Engage all health care providers to adopt DOTS

Rationale: 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

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Performance targets

Major ActivitiesNational Local

3.1 70 % of component cities and key municipalities are with functional public-private collaboration mechanism (for service delivery level)

Advocate for adoption of ISTC through national professional societies

Establish DOTS referral network among RHUs/HCs and other non-NTP TB care providers.

Sustain the public-private sector participation including use of PhilHealth reimbursements

3.2 90% of public hospitals and 60% of private hospitals are participating in DOTS, either as provider or referring unit

Update policies and guidelines on hospital DOTS

Strengthen incentives /enablers

Expand Public-to-Public Mix DOTS (P2P) Capacity-building

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Performance targets Major ActivitiesNational Local

3.3 70% of 9,000 targeted PPs are referring patients to DOTS facilities

Adopt ISTCCoordinate with professional societies and other groups

Train members of professional socities

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 capability-building activities

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Strategy 4. Pursue positive TB behavior of communities

Rationale: 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 defaulters,in some areas

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Performance targets

Major activities

National Local

4.1 Reduced by 30% the number of those self-medicating and not consulting HCPs

Develop SD packages within ACSM plan,based on findings of barrier analysis

Develop quality control for material development with built-in evaluation

Implement BCC for communities

Involve pharmacists and drug store outlets

4.2 High defaulter rate in identified provinces and cities reduced by 40%

Provide TA and training on IPC of target audienceConduct OR’s on defaulters and treatment partners

Implement BCC for clients & DOTproviders

4.3 No. of communities participating in TB control increased by 50%

Develop national guidelines and tools

Mobilize community support for TB control through CBOs, FBOs

Link communities with local health unit or aDOTS unit

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Strategy 5. Address MDR-TB,TB/HIV and needs of vulnerable popn

Rationale:• Global initiatives are endorsed to halt the worsening effect of MDR-

TB,TB-HIV/AIDS co-infection that threatens the gains of TB control programs.

• Effectively reaching the vulnerable populations require a target-specific approach.

Challenges:• Only 20 % of estimated incident MDR-TB cases are detected and put

into programmatic management

• NTP response to needs of vulnerable population is still limited

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Performance targets Major activitiesNational Local

5.1 A total of 14,440 MDR-TB cases have been detected and provided quality-assured second line anti-TB drugs

Designate and capacitate a DOH unit as manager on PMDT

Adopt new tool for diagnosis such as the line probe assay

Establish key infrastrucutres: 35 new Treatment Centers 39 new Culture Centers 5 new DST sites

Establish more treatment Sites

Establish referral system

5.2 TB / HIV collaborative activities established in identified HIV high-risk areas

Conduct surveillance of TB-HIV co-infection

Strengthen the programmatic collaboration of TB/HIV activities

Expand TB/HIV collaboration through exisiting structures (e.g local AIDS council)

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Performance targets

Major activitiesNational Local

5.3 and 5.4 Program for childhood TB and TB in prison implemented nationwide

Policy review and update

Collaborate with other agencies

Phased implementation of TB program for children and prisoners (to include training,drug management,monitoring and evaluation)

5.5 Policies, plans and models for other vulnerable populations are locally developed/ adapted, in coordination with CUP members

Conduct population-specific studies to analyze the vulnerabilitiesDevelop policies and guidelines for DOTS services among the vulnerable groups Pilot test the models for local application

Localize modelled initiatives and replicate accordingly

Integrate other health concerns of vulnerable groups with localized TB initiatives and models

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Strategy 6. Regulate quality of TB diagnostic tests and drugsRationale: Availability of quality-assured smear microscopy (diagnosis) and

uninterrupted supply of anti-TB drugs (treatment) are two of the five key elements of the DOTS strategy

Challenges :• Only 75% of TB laboratories are covered by EQA

• Only 67 TB Diagnostic Committees have been established

• Unpredicted episodes of on-and-off shortages of anti-TB drugs

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Performance Targets Major activitiesNational Local

6.1 The TB laboratory network managed by NTRL ensures that 90% of microscopy centers are providing sputum microscopy within the standards

Capacitate National TB Reference Laboratory, regional TB labs and provincial QA centers

Establish certification of microscopy centers

Expand implementation of EQA to cover private laboratories

6.2 TB microscopy services expanded in cities and in underserved areas

Provide logistical support for expansion and upgrade of TB microscopy centers

Establish more MCs in big cities to attain one TB lab/< 100,000 popn by establishing new labs or utilizing hospital-based or private labs

Adopt innovative approaches to expand microscopy services in hard-to-reach areas

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Performance Targets Major activities

National Local6.3 All provinces and HUCs have access to TB Diagnostic Committee (TBDC)

Develop QA standards or a mechanism for monitoring/evaluating proficiency of TBDC

Establish TBDC in priority areas and sustain them through provision of local support

6.4 Quality anti-TB drugs are always available in all DOTS facilities

DOH to provide all first line anti-TB drugs (FDCs) and LGUs to help in the buffer stock and in the SDFs

Improve drug management system

Training on drug management

Use modern communication to manage drugs

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Strategy 7. Certify and accredit TB care providers

Rationale: There is a need to harmonize DOTS implementation among health

care providers to ensure quality of TB services.

Challenges:• Less than 25% of DOTS facilities are DOTS-certified

and accredited

• Less than 20% of private practitioners are adopting DOTS

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Performance targets Major activitiesNational Local

7.1 70% of DOTS facilities are certified and accredited

Streamline certification and accreditation process

Organize more teams of certifiers and T.A. providers

Improve social marketing on the TB-OPB package

7.2 Standards for hospital participation in TB control included in DOH licensing and PhilHealth accreditation requirements

Work with HFDB and PhilHealth to incorporate DOTS standards

Advocate adoption of standards and capacitate hospital staff

7.3 Infection control measures are in place in all DOTS facilities

Develop and disseminate national policies on infection control

Implement local control measures based on national guidelines

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Strategy 8. Secure adequate financing of TB control program and improve fund utilization

Rationale:Adequate financing is required to sustain the implementationof DOTS in the country, since it takes decades to achieve the TB control goals and to create public health impact.

Challenges: • Estimated gaps in financing TB control• Varying local investment for TB control• PhilHealth TB Outpatient Benefit Package is not optimized• Weak coordination among different sources of funds

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Performance targets

Major activitiesNational Local

8.1 Reduced redundancies and gaps in TB financing through multi-year and multi-sector financial planning

Develop a national TB accounts and financial planning tool a. Update yearly the 5-year national

rolling TB financial plans

Develop a province-wide TB investment planning framework andcosting module

Develop and lodge FAPS in thecoordinating mechanism installed in PIPH/AIPH

Incorporate a TB module for the DOH-LGU resources tracking system

Update yearly PIPH / AIPH /AOP to incorporate TBsubplans

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Performance targets Major activitiesNational Local

8.2 National and local government, FAPs and other donor commitments are secured through national government counterpart funding, LGU TB budgets and performance-based grants

Develop TB performance monitoring tool

Develop a TB-specific performance-based grant mechanism

Establish the FAPs development pipeline and enhance the coordinating mechanism

Sign MOAs between CHDs and LGUs for the implementation of performance-based grants

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Performance targets Major activities

National Local

8.3 Role of social health insurance as financing tool is expanded through greater availability of accredited providers and increased utilization of PHIC TB-DOTS benefits

guidelines for the allocation / utilization of the TB-DOTS case payment package

Improve social marketing of PHIC TB DOTS benefits

Install mechanism to ensure that HCPs receive appropriate reimbursements, especially for the public sector

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Levels of Program ImplementationLevels of Program Implementation

Levels of program implementation

National

Regional

Provincial / City

Interlocal

Municipal

Barangay

Family

Service Delivery Points

Regional hospitals

Provincial hospitals

District hospitals

RHUs / HCs / PPMDs / Clinics

BHS

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For finalization

• Implementing arrangement• Cost

• Monitoring and evaluation plan

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THANK YOUTHANK YOU