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LALAINE L. MORTERA, MD, FPCP, FPCCP
Program Manager PTSI
REVISITING PRIVATE
SECTOR IN TB CONTROL
TB: Myths and MisconceptionsTB is not a problem in the Philippines anymore.
Nobody dies from TB.
TB is uncontrolled due to high cost of medicines.
In reality, the Philippines ranks #9 in the world and #4 in Western Pacific Region
TB is the 6th cause of death in the country.
Anti-TB medicines are available for free in many government centers, including some private health facilities.
Medicines given for free by DOH are of poor quality.
Medicines from DOH have undergone quality control testing in the same way as commercial preparations.
TB: Myths and Misconceptions
No TB diagnosis can be made by chest x-ray alone. International standards will recommend the use of direct sputum smear microscopy (DSSM)
I can diagnose TB by chest x-ray alone.
TB is one of the infectious diseases that needs to be reported.
It is mandatory to report infectious diseases to government, but tuberculosis is an exception.
TB: Myths and Misconceptions
TB is a major public health problem and therefore diagnosis and management must be standardized according to the national TB program.
I can individualize the diagnosis and management of my TB cases.
TB: Myths and Misconceptions
The National TB Program is only applicable for government-run facilities like the health center. The private sector follows international guidelines and standards.
I can lose my patients if I refer them to the health center or PPMD unit.
Why refer to the DOTS unit, I do not receive my PHIC reimbursements anyway..
How do we stop TB from spreading…
STOP IT AT ITS SOURCE!
TOP
Priority
How is TB spread prevented?
Exposure
Infection
Active Disease
Inactive Disease
STOP TB AT ITS SOURCE!
Active Disease
WHO/IUATLD recommends
DOTS Strategy
(Directly Observed Therapy Short course)
How is TB treated?
DOTS…. the way to go!
WHO 1998" DOTS is the only TB
control strategy to consistently produce 85 percent cure rates.
“DOTS is also one of the
most cost-effective health interventions, compared to those available for other diseases ."
DOTS requires more….
• Political commitment• Sputum microscopy (DSSM)• Supervised treatment• Uninterrupted drug supply• Recording and reporting
2006
November 2009
The New Global Strategy to Stop TB
PTSI TECHNICAL PROPOSALRFA NO: 09-00001.00
“TECHNICAL ASSISTANCE TO ENHANCE PRIVATE SECTOR PARTICIPATION IN TB CONTROL”
February 17, 2010 to June 30, 2011
PTSI Vision and Mission VISION:
PTSI is the premier non-government organization working for TB control in the Philippines. It is nationally known as the TB resource center involved in TB research, training, clinical management and innovative community based approaches.
MISSION:We strive to complement the government's National TB Control
Program: to instill professionalism and integrity in our organization; and to ensure our client's and donor's
satisfaction through an efficient and effective delivery of services.
PHILIPPINE TUBERCULOSIS SOCIETY, INC.(ORGANIZATIONAL SUPPORT FRAMEWORK)
BOARD OF DIRECTORS
* EXECUTIVE DIRECTOR
* DEPUTY EXECUTIVE DIRECTOR
* TB ADVISORY COUNCIL(TBAC)
* QUEZON INSTITUTE(QI)
* CENTRAL LABORATORY
HOSPITAL SERVICES
* FIELD OPERATIONS DIVISION (FOD)
* BRANCH CLINICS ELEVEN
(11)
* RESEARCH DIVISION
* TRAINING DIVISION
FINANCE FUND RAISINGHUMAN RESOURCE &
ADMINISTRATION
LEGEND:* Divisions and Offices supporting the project.
PMT
EXECUTIVE DIRECTOR
DEPUTY EXECUTIVE DIRECTORTBAC
PROGRAM MANAGER
STANDARDS & PRIVATE PROVIDERSSPECIALIST
OPERATIONS MANAGER
M&E PLANNING SPECIALIST
PUBLIC INFORMATION
ADVOCACY COMMUNITY
MOBILIZATION
GOVERNANCE AND POLICY
SPECIALIST
FINANCE AND ADMINISTRATIVE OFFICER
AREA MANAGERS (12)
PHARMA MARKET
SPECIALIST
Project Scope of Work • Assist GOP achieve overall health goal to reduce TB
prevalence and mortality by 50% (MDG) • Reach 70% CDR and 85% cure rates by
strengthening/increasing private sector/private providers’ participation in TB control in project areas
• Work with private and public sectors both at the national and local levels in these areas
• Will complement TB LINC activities and other TB partners
Overall Objective
• Increase private sector contribution in the provision of quality DOTS services.
Specific Objectives1. To increase acceptance and practice of DOTS
among private sector providers.2. To improve the policy, financing and
regulatory environment for private sector participation in DOTS.
3. To expand and improve the delivery of quality DOTS services in the private sector.
4. To strengthen policy and institutional governance for private sector involvement.
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Project Components
Subcomponents1.1: Policy development
and advocacy1.2: LGU-Private Sector
Partnership Development
Component 1:Policy, Financing and Regulatory Environment for DOTS Implementation in the Private Sector Improved
Subcomponents2.1: Private sector DOTS
expansion2.2: Systems support for
private DOTS practice
Component 2:Systems Capacity forQuality DOTS Implementation in the Private Sector Improved
Component 3:Utilization of DOTS Facilities and Services Improved
Subcomponents3.1: Development and
implementation of a BCC strategy
3.2: PPM advocacy
Strategic Objective: Desired family health sustainably achievedImproved Case Detection by Private Sector
PTSI Implementation Sites
Zamboanga CityAklan
Pangasinan
AlbayBulacan
Quezon City
BoholCompostela Valley
Marawi City
Negros Occidental
Negros Oriental
Sarangani
PhilCAT: fighting TB through unified action
• The Philippines has a large private sector (both profit and non-profit )
• Private sector is a valuable resource available and widely utilized even by the lower income groups
• …. But like any intervention that impacts on practice, it needs time… possibly innovation
THE PRIVATE SECTOR
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1910 - PTS organized1978 - Nationwide implementation of NTP1987 - SCC in Blister-packs introduced1992 - Local Government Code implemented1996 - D.O.T.S. strategy pilot-tested2002 - D.O.T.S. nationwide (98% coverage) 2003 - Pilot Testing of CDC PPM Models PhilTIPS, GFATM grant – PPM Initiatives 2006 - PBSP/TBLINC 2010 - PBSP/TBLINC/PTSI
Initiatives in TB Control
Problem Statement• Local variations in extent and quality of TB-DOTS
coverage• Symptomatics’ exposure to non-DOTS TB treatment• Consumer-patient behavior detrimental to desired
TB-DOTS treatment outcomes• LGU non-ownership of local TB control objective• Remaining population outside TB-DOTS treatment
DOH Program Implementation ReviewJanuary 2008
Points of Patient Contact
At point of care
At point of sale
At point of service
At Point of Care
Patient
Referring MD
MicroscopyAny
Private Diagnostic
Center
Follow-up
Patient Flow upon Consult
X-ray
PharmacyVariable practicesReporting of Infectious cases?Compliance of patients?
PRIVATE MEDICAL
PROVIDERSHOSPITAL
WORK-BASED CLINICS
HMO
Factories, large
companies
Multi-specialty eg. HMO, Hospital
Independent /hospital-based
Single, multi-practice,
hospital-based
TB Clients
At Point of Care
PhilCAT: fighting TB through unified action
THE PRIVATE PRACTITIONER(Pre PPM and Training Period)
• Estimated: 20,000-35,000 smear (+) cases
• Average new TB patients seen/month: 16• Use of CXR as primary diagnostic tool:
45%• Use of sputum microscopy as primary
tool: 12%• Treatment adherence to NTP: 25%• Recording/reporting: Variable
-Kraft AD, et al. : UP Economics Foundation: Private Provider Study Team, March 2005 (unpublished)-Philippine Health Statistics 2002
DOTS Trained MD
Patient
Referring MD
Microscopy
TBDC Referral
DOT
PPMDUnit
Monthly Follow-up
Recording Reporting
Flow ofReferral forDOTS Referring Doctors
DOTS Practices?
PhilCAT: fighting TB through unified action
PRIVATE PRACTITIONERS(Post PPM and Training Period)
• 75% aware of DOTS but only 35% adopt it in their practice
• Pulmos: 99% awareness; 59% practice
• IDS: 97% awareness; 45% practice
• Age: 42.1 (29-75)• Years in practice: 9.3 (1-
49)• TB patients in a month:
53.6 (9-275)• % sputum positive: 17.7 (0-
50)• % sputum (+) referred to DOTS centers: 43.3
- Garcia & Benedicto (for publication) 2006- Garcia & Benedicto (for publication) 2006
Kraft AD, et al. : UP Economics Foundation: Private Provider Study Team, March 2005 (unpublished)
PhilCAT: fighting TB through unified action
Reasons for NOT Referring to DOTS Centers
Center relatedInaccessible, Doubt capabilitiesUnaware, Center not certified
44.4%
Medication relatedErratic drug supply, Quality
48.9%
Overall set-upBad experience, Unfamiliar with set-up
26.7%
Patient relatedNot willing, Confidentiality, Patient may
be offended
82.2%
Practicing DOTS in clinic 24.4%
At Point of Sale
Patient
Referring MD
MicroscopyAny
Private Diagnostic
Center
Flow for a TB Symptomatic
X-ray
PharmacyDelay in diagnosisDelay in treatment
43%
PhilCAT: fighting TB through unified action
TB case load in the private sector, 2000
Country Retail Sales Cost / Course Estimated (USD Million) (USD) Cases
India 85.3 100 853000
Indonesia 12.3 100 123000
Pakistan 11.7 100 117000
Philippines 16.6 200 83000
Bangladesh 2.3 100 23000
Adapted from: The economics of TB drug development, 2001
PDI ResultsAfter 12 months of Operation: July 2004 to June 2005
• 170 participating pharmacies reported serving a total of 7,432 customers buying TB drugs or inquiring about TB.
Out of this customer pool, 29% were trying to obtain TB drugs without prescription.
…carefully screened for referral to a DOTS clinic for proper diagnosis and treatment.
Outcomes of TB Screening of Customers Without Prescription in PDI Pharmacies 2004-2005
• 1,139 Referred• 363 (32%) accessed DOTS clinics• 320 (88%) confirmed TB symptomatics• 298 (93%) completed sputum exams.• 101 (34%) confirmed TB cases• 60 (59%) Smear positive.
95% of all declared TB cases were enrolled and treated in the DOTS clinics.
• Pharmacy workers are able to pre-screen customers; thereby preventing a significant proportion from taking TB drugs unnecessarily;
• True TB symptomatics, particularly those self-medicating, are identified and referred for appropriate diagnosis and treatment in the DOTS clinics.
At Point of Service
Patient
Referring MD
MicroscopyAny
Private Diagnostic
Center
Flow for a TB Symptomatic
X-ray
• AFB Results of private labs not recognized by DOH
• Quality of x-ray services?
?
FACTS1. 43% TB symptomatics SELF-MEDICATE 2. 40% TB symptomatics consult PRIVATE SECTOR3. Private providers on DOTS:
– lack of knowledge, poor adherence– lack of or absence of system support
– no network of treatment support groups– Limited access to quality microscopy services
– NO recording/reporting system
4. Lack of community awareness regarding DOTS and the National TB Program
?GAPS AND ISSUES IN YOUR
FACILITY
Gaps and IssuesEXISTING DOTS CLINIC: Satisfied with present referral system? 2-way referral system with feedback mechanism in
place? Need to expand network of referring sites? Need for re-training for referring doctors? Need to train new provider staff? Do you have problems with PHIC reimbursements?
Gaps and IssuesHOSPITAL Owners: Established referral system to a DOTS facility? Willing to install a DOTS facility in the hospital? Existing hospital policy on TB management and
reporting of cases? Training of in-house lab personnel for DSSM? Hospital pharmacy policy on TB drugs? Training of in-house staff as referring MDs? Willing to make hospital ISTC-compliant?
Gaps and Issues
LABORATORY Owners: Established referral system to a DOTS facility? Willing to provide quality DSSM services? Willing to be trained? Willing to join the DOTS network? Willing to be linked to DOTS referring MDs? Existing laboratory policy for reporting AFB
results? External QA system?
Gaps and Issues
PHARMACY Owners: Willing to join the DOTS Network? Established referral system to a DOTS facility? Willing to be trained? Any pharmacy policy on TB drugs?
The PTSI Approach
Proposed Strategies and Interventions
Entry Points for Intervention
At point of care
At point of sale
At point of serviceRe-training?System supportPolicies
No Rx No DrugDOTS ReferringPharmacy
Expand DOTS Laboratory network
Levels of Intervention
Existing PPMD: Enhance referral system Re-training Accreditation/Renewal Link to DOTS network
Non-DOTS Hospital TA to establish PPM DOTS Unit Link to DOTS network
Levels of Intervention
Pharmacy: DOTS Referring Pharmacy Link to a DOTS Network
Laboratory: DOTS Referring Laboratory Link to a DOTS Network
Strategies and InterventionA. Referral system improvement
Enhance referral system with feedback mechanism Expand PPM DOTS Network
DOTS Referring Pharmacies DOTS Referring MDs DOTS Referring laboratories
Capability of PHO/MHO
B. CUP local implementation for multi- sectoral partnership development
Strategies and InterventionC. Capacity Building
Enhanced modules Target: MDs, labs, pharmacies DOTS Providers Training ISTC Orientation to hospitals
D.Integration in the CurriculumE.Behavior change for Private providers
and their clientsF. Develop mechanisms to simplify DOTS
The Private Sector As a DOTS Referring MD
As a PPM DOTS Provider
As a TBDC Member
As a DOTS Referring Lab
As a DOTS Referring Pharmacy
As a DOTS Advocate
Operating System per Catchment Area:
DOTSFacilities:PPMDHC
Pharmacy
Pharmacy
Hospital
Pharmacy
RCC / LGUHealth System
DSAPPPhA
DOH
CHD
BFAD
PHILCAT/Local Coalitions
LOCAL TB CHAMPIONS
CLIENT
CLIENT
CLIENT
CLIENT
A Macroperspective of PPM Interplay
Workplace
M.D.
M.D. HMO
Workplace
HMO-PPMD
Hospital
TBDC
TBDC
MicroscopyPRIVATE
MicroscopyPRIVATE
MicroscopyPUBLIC
Workplace
Challenge to PCCP TB Council
• Work plan to disseminate the ISTC– Annual conventions, RTDs, CMEs– ISTC orientation in your hospitals
• Be active as local TB champions and serve as ISTC experts in the 12 sites
• PCCP project: Target the HMOs• Quezon City Practice: Stand Alone Practice
DOTS Model
Challenge to PCCP TB Council
• Be active as members of TBDC• Multi-sectoral consultation on PHIC TB OPB• Be active members of PMA in local chapters
to promote CUP – need for sector policy?• Mechanisms to monitor PCCP compliance to
ISTC?