DOTS 2010 Program
Transcript of 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
Presentation flow
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
Planning process
FINAL PLAN : SEPTEMBER, 2009
Major challenges based on situational analysisMajor challenges based on situational analysis
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
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
For finalization
• Implementing arrangement• Cost
• Monitoring and evaluation plan
THANK YOUTHANK YOU