1

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.

21

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

24

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?