IPHO-Maguindanao

October 2005 – September 2009

GOAL Reduce TB Morbidity and Mortality in Maguindanao

STRATEGICOBJECTIVES

Increase detection rate of smear positive TB cases from 69% to 75 % by September 2009

Increase cure rate of smear positive TB cases from 72% to 85% by September 2009

Target Population: 475,056 individuals aged 15 and above living in Maguindanao province.

Major Strategies:

•Quality Assurance

•Capacity Building

•Behavior Change Communication

•Advocacy and Social Mobilization

TB situation in Maguindanao

Five Elements of D.O.T.S Gaps/Challenges

Political Commitment Shortage of staff (medical technologists) & funding for TB program from LGUs.

Case detection through

Quality assured bacteriology

5 functioning laboratories; 7 medtechs; 19 microscopes; insufficient training; no systematic quality control activities.

Standardized treatment, with supervision and patient support (DOT)

Geographic distance of patients to health centers deterrent in supervised treatment; many patients complete tx. w/o lab confirmation.

An effective drug supply and management system

Existing supplies insufficient to treat all cases.

Monitoring & Evaluation System Data not readily available; delays in data entry & submission of reports; no cohort analyses.

Department of HealthAutonomous Region in Muslim Mindanao

Integrated Provincial Health Office: Program Coordinators

District level: 4 Hospitals, serve as Lab ValidationCenters *quality control*

Municipal level: 28 RHUsHuman Resources: 13 MTs, Doctors, Nurses

TB Activities:Med Tech receives smearing, reads & sends report to BHS

Nurse supervises RHUs.Midwives smear & stain samples, send them to MTs with

MotoristReceive results, sends them to BHS, DOTS.

Barangay Health Stations: Midwives provide primary health care, Including TB activities: receive sputum samples from patients, and give

results to patients, DOTS

Health and Nutrition Posts: Barangay Health WorkersTB Activities: receive sputum samples from patients, give results to patients,

DOTS

Irregular supervision of RHUs & BHSs

Motorist transportsmeared samplesand results from

RHUs t Lab. Validation

Center

Some patientsasked to come back to BHS or

HNP for samplingor results

1 Med tech/ 4 municipalities not

available all days/week

Midwives lack smearing skills

BHWs lack smearing

skills

Innovation one:Improving access with BHWs role expansion

• Training in DOTS, and sputum collection & smearing– DOTS: 2-day– Sputum Collection & smearing: 5-day training (didactic 2 days;

practicum 3 days)

• 116 BHWs with 2 major roles:1. Collecting sputum & smearing– Transport slides (no MOW)– Recording

2. As treatment partner

Innovation two:Microscopists on Wheels

• Private transport group (mostly single motorcycle) plying at remotest area volunteered to provide services for TB control & prevention.– Free or discounted fare for TB patients & symptomatics– Free transport of slides or specimen– Promote TB awareness & free services of RHU

• Membership: voluntary• Loose support group or formally organized• Process used:

– RHU recommended transport group from their area

– Gen. orientation & core group formation @ provincial level

– Follow-up meeting @ RHU level.

Innovation threeTB Club

• Serves as a peer-support group to ensure patient’s treatment compliance& reduce stigma.• Activities:

– sharing and encouragement among members to motivate adherence to treatment regimen

– cured patients giving testimonies and serving as peer-educators– contact tracing– case referral

• Membership: voluntary• Structure: flexible, formally organized or loose-group.

Table 1. Percentage Contribution of Support Groups to Case Finding in 10 Municipalities,

Maguindanao,PhilippinesSupport Groups

No. of symptomatics referred

No. referred who turned positive

Total No. of Smear Positives

% Contribution

MOW 65 27 96 28.125

TB Clubs 39 6 96 6.25

Table 2. Percent Contribution of BHWS to Case Finding in __ Municipalities,Maguindanao Philippines, July-September 2007

Support

Group

No. of Slides Smeared

No. turned positive

Total no. of smear positive cases (RHUs)

% contribution of BHWs

BHWs

LESSONS LEARNED: INNOVATIONS

• Spirit of volunteerism abounds even in the poorest of communities; people just need to be given the right opportunities.

• Explore promising practices from other projects that can be replicated, adapted or enhanced.

• Develop a common framework or mechanism to implement MOWs or TBClubs across the municipalities but allow some flexibility for operationalization.

• Mechanisms for sustaining the enthusiasm of volunteer health workers should be part of the overall plan.

• Actively engage the support of the local government to provide incentives to the volunteer health workers.

• A good documentation of the contribution of the support groups is a must to demonstrate their effectiveness.

Operations Research on Gender Inequalities

Objective: To determine the nature of disparities in the no. of cases detected for men and women; particularly , whether these disparities are related to

inequalities in access to TB care services for women in Maguindanao.

Methodology:

Sampling: 5 randomly chosen high performing RHUs

Data Collection: Clinical Observations, exit interviews, FGD and records review

Operations Research on Gender Inequalities

Objective: To determine the nature of disparities in the no. of cases detected for men and women; particularly , whether these disparities are related to inequalities in access to TB care services for women in Maguindanao.

Methodology: Sampling: 5 randomly chosen high performing RHUs Data Collection: Clinical Observations, exit

interviews, FGD and records review

FINDINGS and Opportunities for increasing the standard of quality of care

• No difference between sexes regardingsatisfaction with quality of care, but more female clients reported to have received complete information on TB treatment regimen• Patient’s treatment card does not include sex disaggregated data to

trace contacts.• More women registered as symptomatics but less were asked to

provide sputum samples.• More female clients were asked to bring their contacts.• Female clients were poorer than male clients.• More female clients perceived lack of privacy during consultation.• More female clients preferred face-to-face communication.• More female clients came from same barangay where the RHU is

located, a concern of where women seek care if they don’t live near the RHU.

• Few gave suggestions on how to improve the services of RHU but women recommended giving the medicines for a week supply to save time and fare while men recommended improving information.

• Include sex disaggregated data on the contacts in the treatment card• Increase active case finding among male patients for female contacts• The first TB screening for both sexes’ clients should be done in

private ward.• Ensure complete examination and request of sputum samples to

symptomatic male and female.• Increase awareness among general population for the gratuity of the

TB drugs and where they can seek TB services.• Ensure all female and male clients receive their first dose of

treatment.• Increase awareness among all TB clients & BHWs, esp. service be

negotiated with MOW for female clients living in underserve area.• Increase face-to-face activities for both clients to increase access.• Increase awareness among both clients about the role of the BHWs

as treatment partners.• Use the TB Clubs as a forum where female clients provide feedback

about the TB services and recommendations to improve it.

Proposed Interventions

for gender-sensitive TB control