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Dr. Mariquita J. Mantala Member, Task Force on TB Control Strategic Plan Development NTP Midyear Consultative Workshop August 11, 2009
Rationale 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
2009 . 5 -6. USAID (TB LINC and HPDP) and Global Fund) in Feb. plan presented to stakeholders on July 8 9. 09 Steering Com and Task Force organized in March 09 Situational analysis done in April and May 09 Draft prelim. 2009 Complete draft plan presented to stakeholders on Aug.Planning process NTP mobilized support (WHO. 2009 FINAL PLAN : SEPTEMBER.
HIV/AIDS National targets in CDR and TSR achieved but with variation in local program performance Quality assured TB services not universally accessible *Big proportion of HCPs not adopting DOTS protocol incl. vulnerable groups Varying support to TB control by the LGUs Inadequate and uncoordinated TB care financing . hospital and PPs * Weaknesses in ensuring quality diagnostic tests and drugs *Poor TB care-seeking behaviour of clients *Needs of special population not fully addressed: MDR-TB HIV/TB co-infection.Major challenges based on situational analysis Decreasing TB prevalence and mortality but with threat from MDR-TB.
Goal and Objectives TB free Philippines To reduce the TB burden in the Philippines in line with the MDG.The Plan s Vision. Stop TB Partnership Strategy and Philippine health sector reform Objective 1 Reduce local variation in TB control program performance (Governance) Objective 2 Scale-up and sustain coverage of DOTS implementation Objective 3 Ensure quality DOTS services Objective 4 Reduce out-of-pocket expenses for TB care (Service delivery) (Regulation) (Financing) .
Engage both public & private TB care providers 4. Strategies Localize implementation of TB control Monitor health system performance 3. Scale-up and sustain coverage of DOTS 3. Ensure quality of TB services 4. Promote and strengthen positive behavior on TB care 5. Address the needs of MDR-TB/HIV & other vulnerable populations 6. Certify and accredit TB care providers 8. Reduce local variation in TB control program performance 2. 2. Reduce out-ofpocket expenses 1.Objectives and Strategies Objectives 1. Regulate and make available quality of TB diagnostic tests & anti-drugs 7. 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 .
TSR. MDR-TB Reduced local variation Strat 1 & 2 9 perf. Mortality Outcome: CDR. targets Quality dx tests and drugs are available Strat 6 & 7 7 perf.Planning Framework Impact : TB Prev. targets .4&5 12 perf. targets Reduced out-ofpocket expenses Strat 8 3 perf. targets Scaled-up and sustained DOTS Strat 3 . .
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 .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 system set-up.
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 1. 1 70% of provinces include clear TB control plan within the Provincewide Investment Plan for Health (PIPH/AIPH) and AOP Major activities National Formulate guidelines in developing TB control strategic and operational plan for PIPH/AIPH/AOP Review and consolidate PIPHs/AOPs Local Conduct situational asssesment Craft locally specific interventions and incorporate in PIPH/AOP 1.
5 Public-private collaborating mechanisms strengthened to include CUP Identify TA needs and request for support Establish PP collaborating mechanism at provincial / city level .3 90% of priority provinces /HUCs have achieved program targets using performance grant Major activities National Local Prioritize provinces for TA and financial support based on TB burden.Performance targets 1.4 CHD and partners with capacity to provide TA to provinces and cities 1. performance and absorptive capacity Develop guidelines and implement performancebased grants Develop guidelines and capacitate region to provide TA to provinces/cities Strengthen / establish PP collaborating mechanisms at national and regional Implement local TB plan with support through performance grant 1.
DOTS complying or adhering: complies to 8 standards of effective TB control program implementation Level 2 .Proposed classification of Provinces / Cities Level 1 .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 .
With capacity to ensure uninterrupted supply of anti-TB drugs in all the DOTS facilities within its catchment . both by public and private laboratories and with access to TB Diagnostic Committee for management of smear negative TB cases 4. A local governance structure that manages implementation of the province-wide TB control program and that coordinates publicprivate participation in TB control 3.Proposed Standards for a DOTS-compliant Province / City 1. A network of provincial and municipal TB laboratories that maintains quality-assured DSSM. With a province/city-wide multi-year TB control plan that responds to local situation (PIPH/AIPH) 2.
regular monitoring and evaluation. at least an annual PIR and quarterly reporting to CHD) 6.g. Secured funding for TB control program implementation . A DOTS service network for TB care and diagnosis. 8.Proposed Standards for a DOTS-compliant Province / City 5. involving both public and private health care providers and other levels of health care With program of activities being implemented. to increase demand for TB services With system that regularly analyzes program performance (e. 7.
Monitor health system performance Rationale: Information is needed to come up with evidence-based decisions that would lead to improved program performance Challenges: Varying.Strategy 2. unintegrated TB information systems Poor quality of TB mortality data Delayed report at all reporting levels Available information not maximized for decision-making .
target 2.3 TB information system integrated with national M&E and FHSIS Expand web-based electronic TB Strengthen monitoring information system and supervision Adopt ETR Enhance NEC capacity to manage TB information system Analyze LGU score card 2.1 Trend of TB burden tracked National Conduct 4th NPS. analyzed and used 2.4 NTP capacity to Capacity-building support and monitor Additional human resources health system strengthened . second DRS and TB mortality survey Integrated TB into NDHS and APIS Local Capability-building 2.2 TB information generated on time.
Challenges: Hospital staff. hence. Limited implementation of Public-Private Mix DOTS (PPMD) Training problems . Engage all health care providers to adopt DOTS Rationale: Standardized quality TB care ensures early TB case detection and treatment. prevents poor treatment outcome that may lead to MDR-TB and reduces financial burden to patients.Strategy 3. private practitioners and staff of other government clinics are not adopting the DOTS protocol.
Performance targets 3.1 70 % of component cities and key municipalities are with functional public-private collaboration mechanism (for service delivery level) Major Activities National Advocate for adoption of ISTC through national professional societies Local 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 Expand Public-to-Public Mix DOTS (P2P) Capacity-building 3.2 90% of public Update policies and hospitals and 60% of guidelines on hospital DOTS private hospitals are participating in Strengthen incentives DOTS. either as /enablers provider or referring unit .
3 70% of 9.000 Adopt ISTC Train members of targeted PPs are referring Coordinate with professional socities patients to DOTS facilities professional societies and other groups 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 capabilitybuilding activities .Performance targets Major Activities National Local 3.
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.Strategy 4. in some areas .
of communities Develop national guidelines participating in TB and tools control increased by 50% .2 High defaulter rate in identified provinces and cities reduced by 40% Provide TA and training on IPC Implement BCC for of target audience clients & DOTproviders Conduct OR s on defaulters and treatment partners Mobilize community support for TB control through CBOs.Performance targets Major activities National Local Implement BCC for communities Involve pharmacists and drug store outlets 4. FBOs Link communities with local health unit or a DOTS unit 4.1 Reduced by 30% Develop SD packages within the number of those ACSM plan.based on findings self-medicating and not of barrier analysis consulting HCPs Develop quality control for material development with built-in evaluation 4.3 No.
TB-HIV/AIDS co-infection that threatens the gains of TB control programs. Effectively reaching the vulnerable populations require a targetspecific approach.Strategy 5.TB/HIV and needs of vulnerable popn Rationale: Global initiatives are endorsed to halt the worsening effect of MDRTB. Address MDR-TB. 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 .
1 A total of 14.Performance targets 5.440 MDR-TB cases have been detected and provided quality-assured second line anti-TB drugs Major activities National 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 Local Establish more treatment Sites Establish referral system 5.g local AIDS council) .2 TB / HIV collaborative activities established in identified HIV high-risk areas Conduct surveillance of TB-HIV coinfection Strengthen the programmatic collaboration of TB/HIV activities Expand TB/HIV collaboration through exisiting structures (e.
drug management.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 vulnerabilities Develop policies and guidelines for DOTS services among the vulnerable groups Pilot test the models for local application .monitoring and evaluation) Localize modelled initiatives and replicate accordingly Integrate other health concerns of vulnerable groups with localized TB initiatives and models Policy review and update 5.Performance targets Major activities National Local Phased implementation of TB program for children and prisoners (to include training.4 Program for childhood TB and TB Collaborate with other in prison implemented agencies nationwide 5.3 and 5.
Strategy 6. Regulate quality of TB diagnostic tests and drugs Rationale: 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 6. regional TB labs and provincial QA centers Establish certification of microscopy centers 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 Local Expand implementation of EQA to cover private laboratories .2 TB microscopy services expanded in cities and in underserved areas Major activities National Capacitate National TB Reference Laboratory.1 The TB laboratory network managed by NTRL ensures that 90% of microscopy centers are providing sputum microscopy within the standards 6.
4 Quality anti-TB drugs are always available in all DOTS facilities Major activities National Develop QA standards or a mechanism for monitoring/evaluating proficiency of TBDC 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 Local Establish TBDC in priority areas and sustain them through provision of local support Training on drug management Use modern communication to manage drugs .3 All provinces and HUCs have access to TB Diagnostic Committee (TBDC) 6.Performance Targets 6.
Strategy 7. Challenges: Less than 25% of DOTS facilities are DOTS-certified and accredited Less than 20% of private practitioners are adopting DOTS . 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.
2 Standards for hospital Work with HFDB and participation in TB control PhilHealth to incorporate included in DOH licensing DOTS standards and PhilHealth accreditation requirements 7.1 70% of DOTS facilities Streamline certification and are certified and accredited accreditation process 7.Performance targets Major activities National Local Organize more teams of certifiers and T.A.3 Infection control measures are in place in all DOTS facilities Advocate adoption of standards and capacitate hospital staff Develop and disseminate Implement local national policies on infection control measures control based on national guidelines . providers Improve social marketing on the TBOPB package 7.
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 .Strategy 8. Secure adequate financing of TB control program and improve fund utilization Rationale: Adequate financing is required to sustain the implementation of DOTS in the country. since it takes decades to achieve the TB control goals and to create public health impact.
1 Reduced redundancies and gaps in TB financing through multi-year and multi-sector financial planning Major activities National Develop a national TB accounts and financial planning tool a.Performance targets 8. Update yearly the 5-year national rolling TB financial plans Develop a province-wide TB investment planning framework and costing module Develop and lodge FAPS in the coordinating mechanism installed in PIPH/AIPH Incorporate a TB module for the DOH-LGU resources tracking system Local Update yearly PIPH / AIPH / AOP to incorporate TB subplans .
2 National and local government. FAPs and other donor commitments are secured through national government counterpart funding. LGU TB budgets and performance-based grants Major activities National Develop TB performance monitoring tool Develop a TB-specific performance-based grant mechanism Establish the FAPs development pipeline and enhance the coordinating mechanism Local Sign MOAs between CHDs and LGUs for the implementation of performancebased grants .Performance targets 8.
Performance targets Major activities National Local Improve social marketing of PHIC TB DOTS benefits Install mechanism to ensure that HCPs receive appropriate reimbursements.3 Role of social health guidelines for the insurance as financing tool allocation / utilization of is expanded through the TB-DOTS case payment greater availability of package accredited providers and increased utilization of PHIC TB-DOTS benefits . especially for the public sector 8.
Levels of Program Implementation Levels of program implementation National Regional Provincial / City Interlocal Municipal Barangay Family Regional hospitals Provincial hospitals District hospitals RHUs / HCs / PPMDs / Clinics BHS Service Delivery Points .
For finalization Implementing arrangement Cost Monitoring and evaluation plan .
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