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A Different Kind Of Smear Campaign: Controlling TB In Zamboanga

City Using RSS


For years, tuberculosis has remained one of the top diseases in Zamboanga City. With more than
800,000 people, the city ranks sixth in the nation in terms of population. At 1,483.3849 square
kilometers, it is the countrys third largest urban center that covers a variable terrainthe main urban
center, coastal areas, islands, and rugged mountains.
This vastness and geographic range means that not every Zambuangeo can come to health centers.
In the same vein, it is hard for government health workers to make the long trip to these far-flung
areas. Going to the poblacion or downtown is an ordeal on the part of a TB suspect transportation
and food costs, loss of working hours, and the toll that this journey itself would take on an already
frail body.
In 2003, the city government launched the Unidad na Pelea Contra TB, a call for unity to find more
and treat more TB cases as a swift response to the early implementation of the TB DOTS strategy.
In the earlier years of this government program, there was a low number of TB cases that were
identified due to the limited number of microscopy centers where Direct Sputum Smear Microscopy or
DSSM could be done. But most of these centers are located within a seven-kilometer radius of the
city. This means that people in remote areas were underserved.
Recognizing the problem, and in collaboration with CHD 9, the TB LINC Program came to the aid of
the city health authorities. With the formalization of agreements, plans and programs, work began in
earnest to wage a campaign designed to bring TB control services closer to the people. This support
came in various forms. Notable were the TB in the Workplace in identified factories, offices and
industrial plants, and the TB-in-Prison programs that aim to control the incidence of TB among their
employees and prison inmates, respectively.
Hand in hand with these structural set up were activities designed to enhance the referral, recording,
and reporting systems of existing barangay health units and community hospitals; another work
center of great relevance was Remote Smearing Stations or RSS staffed by volunteers and health
workers trained as smearers, who are tasked to collect sputum samples, conduct smear preparation,
and send the specimens to the microscopy centers for examination by licensed/trained microscopists.
Especially critical in the fight against TB in Zamboanga City is the establishment of these Remote
Smearing Stations. Before TB can be ascertained and diagnosed, three specimens of sputum samples
are required from the patient. To reach those in far-flung areas, twelve RSS were put up in 2008 in
geographically isolated areas like the citys island and mountainous villages.
Initially, ten informal health workers, usually drawn from the ranks of the Barangay Health Workers,
were trained in sputum smearing and assigned to eight hard-to-reach barangays. These smearers
collected the sputum specimens in their areas and brought these to the main health centers for
diagnosis. Worthy of note is the fact that while monetary assistance could lift an initiative off the
ground, it is the good heart of the people that yields success. In the citys case, many of the
smearers were volunteers who were driven simply by the desire to help their townfolk. Their
unstinted commitment to render service to the affected population has led to the successful
diagnosis, treatment, and cure of hundreds of TB cases in the city.
The RSS initiative has significantly helped to bridge the gap between the citys health services and
the people. Early detection is already at arms reach for TB patients, especially the poor and those
who live far from the centers. The numbers speak for themselves. One, the number of TB suspects
found rose from 7,690 in 2007 to 11,965 in 2011. The smearers have helped decrease the workload
of the microscopists and because the smearers do the preparatory work in their stead, the
microscopists can accommodate more slides to examine . Diagnosis and releasing of results have
become faster, and consequently, enrolling patients in TB DOTS is done at a much faster pace.
While the citys Case Detection Rate has improved, the RSS initiative has also played a major role in
improving the Cure Rate. With an institutionalized sputum follow up system, it has reduced the
number of people who default on their treatment through constant health watch, education and
counseling from the smearers. Patients can submit follow-up specimens directly to the smearers, who
shoulder the responsibility of passing these on to the microscopy center.
Tuberculosis as a cause of illness and death in Zamboanga City has now dropped to 14th place.
Arguably, this, more than anything else, underlines the strides made by the city government and TB
LINC in the campaign to eradicate the disease. The contribution of smearers to the number of
sysmptomatics referred increased from 7% in 2008 to 11% in 2012, while the contribution of
smearers to the identification of New Smear Positive or NSP cases rose from 3% in 2008 to 8% in
2012.
Zamboanga City is not resting on its gains. In 2011, nine additional volunteer members from the TB
task force and 16 BHWs were trained as new smear service providers. The smearers cover 40 or 41%
of 98 barangays, mostly rural and island. It is not hard to imagine that in just a few years, the citys
entire expanse will be served by these dedicated men and women, and that every Zambuangeo will
have painless access to TB treatment.
Bringing TB Services to GIDA Communities in Zamboanga Sibugay
The province of Zamboanga Sibugay in western Mindanao is divided into three Inter-local Health
Zones. Two of them, Ipil and Alicia, are located on the mainland. The third health district, dubbed
OlTaMa is an island that encompasses the municipalities of Olutanga, Talusan, and Mabuhay which
in turn are considered as Geographically Isolated and Economically Depressed Areas.
The island can be reached only after traversing two and a half hours of alternating rough and paved
roads on the mainland and a long boat ride on a pump boat, followed by circuitous motorcycle rides
to the islands interior. Travelling to and from the island can impoverish the sick or well alike. As for
persons on the island afflicted with TB, the constant clinical visits and the diagnostic expenses
required for the cure may be so prohibitive that this recourse is often foregone.
Prior to USAID support, the much needed laboratory services were found only at the Olutanga
Municipal Hospital. The islands three RHUs did not provide such services.
While the hospital can be found in the center of the island, bad road conditions and steep travel fare
of Php300 which is way above average daily income render it virtually inaccessible for poor patients.
Compounding the problem is a lack of medical technologists or trained microscopists. Health workers
were also untrained in the basics and protocol of TB DOTS (Directly Observed Treatment Short
Course). These deficiencies manifested themselves in hard numbers that were way below the
provincial targets.
TB LINC helped the LGU reach out to the people in the GIDA. It encouraged the support of local
leaders in the training of health personnel and the upgrading of facilities. The Integrated Provincial
Health Office and municipal health offices of the island lobbied for the hiring of a medical technologist
for Mabuhay. Meanwhile, Olutanga ang Talusan trained their rural health midwives in sputum
microscopy. Three additional microscopy laboratories were installed.
The program won legislative support as well when the LGUs issued ordinances with corresponding
budget support for TB control. Good examples are ordinances in Mabuhay and Talusan that allocated
funds worth Php35,000 and Php20,000 respectively. The former included an annual budget increase
of 3% while the latter allowed the money surplus for the year to be carried over to the succeeding
year.
Training for microscopists and smearers was pursued. In addition to the new midwives-turned-
microscopists, 15 BHWs from the GIDA barangays were designated as informal laboratory workers
tasked to collect sputum samples from patients afar and to prepare these for viewing. Two of the
workers had lost family members to TB and this impelled them to render service to the program.
Basic TB DOTS training was also provided to 45 RHU personnel and 100 BHWs.
The local government also set up Remote Smearing Stations or RSSs. Barangay health stations in the
island were refitted to serve this purpose. Smearers were assigned to these stations to provide
specimen collection services to be stained and later read at the main health centre for staining and
reading. Local leaders recognized workers for such outstanding contributions to the TB program.
Talusan rewarded a midwife who ably performed her role as a microscopist with a permanent
position in the municipal health office. A year-end bonus of Php1,500 also awaited BHWs and
smearers.
With TB LINC assistance, CHDZamboanga Peninsula enhanced their capability on External Quality
Assurance System and gave out microscopes while the Integrated Provincial Health Office chipped in
the staining materials, medicines, and quality assurance checks. The Ipil Catholic Prelature
Community-Based Health Program ferried TB health education to the island.
All these activities bridged the gap between Zamboanga Sibugays underserved people and the health
services they sorely needed. The campaign to educate the people has resulted in the heightened
public awareness of TB as a health problem. They now freely and fearlessly submit to treatment. The
presence of the remote smearing stations and smearers nearby means that townsfolk no longer have
to endure arduous and expensive travel just to avail themselves of medical services. Half of the
islands barangays totalling 26 in all now have remote smearing sites. The case notification rate has
dramatically improved. For example, in Talusan, the rate leaped from 41 per 100,000 in 2007 to 74
per 100,000 in 2011. The number of TB suspects increased from 245 in 2007 to 424 in 2011. Three
sputum collection rates have increased for Talusan and Mabuhay, from 75% and 78% in 2007,
respectively, to 99% and 97%.
With an institutionalized sputum follow-up checks, OlTaMas cure rate as a whole jumped from 42%
in 2006 to 93% in 2010. With the islands contribution, the province achieved the cure rate target of
86% in 2010, way higher than the 60% in 2006. The addition of the three microscopy laboratories
has reduced the erstwhile 1:90,000 facility-to-population ratio to an impressive 1:22,500,
unquestionably within the WHO standard. All four laboratories attained more than 95% correct
microscopy results. Even better, a 100% accuracy was noted during the recent EQA period.
In sum, much ground has been made in the fight against TB in Zamboanga Sibugay even as it faces
the heavier challenge of keeping up the good work especially among GIDA areas.
TB DOTS in Ramiro Community Hospital, Bohol
Bohol is a province of involved communities, with the private sector playing a significant role in the
anti-tuberculosis crusade. With the nationwide implementation of the DOH-prescribed Directly
Observed Treatment Short Course or TB DOTS in public and private facilities, synergies here yielded
positive results in managing TB cases. The Ramiro Community Hospital in the capital of Tagbilaran
typifies the convergence of government and private sector initiatives.
The hospital is a 100-bed facility whose catchment is widespread, catering to more than a 100,000
people according to 2010 census. Since its early days, hospital owners have partnered with public
health offices and, in 2010, adopted the TB DOTS framework. In time, a referral network was put in
place to deal with patients diagnosed with TB through USAID assistance. In 2011, the hospital
headed, by Dr. Audrey Ramiro, was cited by the Department of Health as a private sector partner in
the implementation of the National Tuberculosis Program in the province.
Dr. Ramiro and her staff created the hospitals own TB Team, with a TB Referral Flow to guide its
operations. The setting up of a TB DOTS Center that was seconded to its Ancillary Services defined
the roles of its medical staff in the coordination and management of cases. According to the survey
studied by hospital staff, only about a third of TB outpatients were being referred to the TB DOTS
Center when the initiative began. Thus, the hospital mobilized personnel down the line to address the
gap and increase detection. Aside from follow up referrals, the hospital also adopted a coupon
system for each of the patients that documented their visits to the DOTS room and ensured they
complied with the all rules of treatment.
The hospital handles TB care in many creative ways. It devised a Treatment Monitoring Report that
feeds back information on the progress of patients referred by the private physician to the Hospital
TB DOTS center. Besides this, it developed its own Treatment Outcome Report that feeds back
information to the private physician as well on the positive or negative results of anti-TB treatment. It
provides services with a personal touchby sending birthday greetings to TB patients via SMS text
messaging. It gives priority to persons with disability, and conducts a continuing satisfaction survey
among patients using a questionnaire coached in the local language.
Added to this is the launching of project called Blue Balloon, an activity where mass Tuberculin Skin
Testings (TSTs) for child TB suspects were conducted in two elementary schools and four day care
centers which led to the identification of nine positive TB cases out of the 206 children examined.
Because of this a line item in its budget for the free testing of children under five years of age was
provided.

Aside from coordinating regularly with the Provincial Health Office of Bohol and managing its own
referral mechanism, the hospital invited peer hospitals to TB DOTS orientation activities for private
doctors, nurses, and hospital administrators. As
hospital administrator, Dr. Ramiro spearheads these initiatives, true to her hospitals motto of Doctors
Treat, God Heals.
To supplement across-the-board training, the hospital enhanced information dissemination and
communication through the production of pamphlets and a quarterly newsletter called Tisis. Top
management support enabled the continuous creation of local information materials tailored to the
needs of stakeholders in the TB loop, be these patients or practitioners. The hospital went even
further to host monthly enabling activitiesthe distribution of free goodies to patients especially the
poor thus attracting them to complete their medications. Media exposure has likewise been promoted
to the extent that the Bohol Sunday Post lauded the hospitals initiatives in TB prevention and cure.
Aside from contributing funds from its own sources, the hospital has tapped philanthropic individuals
and groups to support its TB control program. Rotary International rose to the call by providing funds
for an Adopt and Support a TB Patient program.
In-house and other visiting consultants and private clinics have begun implementing TB DOTS for
their patients. From the start of the Hospital TB DOTS Center, the number of public and private
physicians referring their TB patients to the Center increased by four-fold17 physicians in the
second quarter to 73 physicians in third quarter of 2012. Altogether, there was an increase in
referrals of TB suspects from 630 in 2011 to 971 in just three quarters of 2012.
Partners view this accomplishment as a fruit of the strengthened relations not just among private
hospitals but among institutions in the industry like pharmacies that now are engaged in TB DOTS
referrals as well. Dr. Ramiro has been influential in enticing not only hospital administrators but also
private clinics, laboratories and pharmacies in TB DOTS, says Mrs. Policenia Rances, Provincial NTP
nurse coordinator. Regular dialogues she held attracted many health professionals. Hospital
personnel take pride in their contributions to TB Control. The systems, open communications, and
close rapport have brought them all together to form a micro-community with a strong punch against
TB but a soft heart for the poor. It is what we could give of ourselves that matters, says Jirby Baja,
Nursing and In-service Education Coordinator. She adds, The high morale of the TB Team is
inspiring in itself.
For itself, aside from helping sustain the roles of its partnersthe Bohol Provincial NTP team, the
CHD 7, the Tagbilaran CHO and development partners like USAID through TB LINC-PTSI, the hospital
will seek better ways to create a supportive environment that will nurture the public-private mix of
clinicians that jointly move to reduce TB to the level of insignificance in Bohol.
Integration of DSSM in the Medical Technology
Curriculum of UNO-R
Bacolod City, the provincial capital of Negros Occidental, had a population of 532, 943 in 2010. It has
three TB microscopy centers with a ratio of 1:177, 647 population which does not meet the ideal
ratio of 1:100,000 population. The areas served by the microscopy centers were only those near the
centers while barangay residents remote areas and far from the microscopy services had the difficulty
accessing laboratory services.
Other cities and municipalities in the province also lacked microscopy services such as the
Municipality of Murcia, a mountainous area without a medical technologist. Most often, people had to
go to other towns for the laboratory examination.
In 2010, pulmonary tuberculosis still ranked as the 9th leading cause of illness and the 7th primary
cause of death in the province. To improve these health statistics, there was a need to expand the
implementation of DOTS to other stakeholders especially in the private sector, including the
University of Negros Occidental-Recoletos, an old and respected educational institution.
The inadequacy in the DSSM-trained microscopists in the province provided a fertile ground for the
private sector to be tapped. One promising possibility was to integrate training in the UNO-R Medical
Laboratory Science curriculum. After undergoing the DSSM training, trainees could be deployed in
areas where there were no medical technologists.
With this dream in mind, the National Tuberculosis Control Program offices in the province
approached the University for schemes on how to make TB Microscopy services available in remote
areas. The University readily accepted the challenge. In succeeding meetings among partners (UNO-
R, Center of Health Development Region 6, the Bacolod City Health Office, the Provincial Health
Office, Gawad Kalinga Kalusugan (a faith-based volunteer organization) and TB LINC, the dream to
integrate DSSM in the curriculum of medical technology students was fulfilled. Hence, a covenant was
signed in May 2010 where the partners pledged to pool their expertise, human, and logistical
resources to maximize the outcome of DSSM integration in the curriculum.
The signed covenant detailed the roles and responsibilities of the stakeholders. To prepare the school
to integrate the DSSM in the curriculum, two faculty members of the Medical Technology department
were sent to the National TB Reference Laboratory for DSSM training. This was the first step toward
preparing the university as one of the future DSSM training provider, thus reducing dependence on
the CHD and NTRL, and making training available anytime. Later, eight medical technology graduates
were deployed as volunteers for a month in areas without a microscopist (Murcia) or in microscopy
centers with high volume load such as Bacolod City. All trained medtechs had to perform at least 300
sputum smears before they were issued a training certificate.
The deployment of trained medtechs (as volunteers) in Bacolod City and Murcia provided the needed
temporary microscopy services. In Murcia alone, of 91 TB symptomatics, 23 (19%) were found
positive for tuberculosis. These sputum positives detected by the volunteers represented more than
50% of the total 40 sputum positive cases in the municipality in 2010. Six of the eight DSSM-trained
graduates were able to do volunteer work in various laboratories in Bacolod City and other nearby
municipalities. Four of them were able to examine a total of 844 sputum smears, 99 or 12% of which
were found to be sputum positive for TB bacilli.
The integration of DSSM in the medical technology curriculum produced the first batch of DSSM
trained microscopists who contributed to the improvement of access of TB symptomatics and TB
patients to TB microscopy services in both urban and rural settings. This resulted in an increased
case detection in areas which previously reported very low or no pulmonary TB cases at all. The
experience inspired the volunteers and gave them an edge in the professional marketan advantage
that only graduates of UNO-R could boast of. UNO-R, being the first to integrate DSMM in the
medical technology curriculum, can serve
as a model for other colleges. The model likewise ensures a continuous supply of DSSM-trained
microscopists.
The experience of UNO-R shows that integrating DSSM in the medical technology curriculum is an
effective strategy to address the shortage of DSSM-trained microscopists in underserved areas.
Empowering Aetas in TB Control
The Barangay Camias, Porac Experience
Porac, Pampanga is home to the largest concentration of the Aeta Indigenous Peoples in Region III
according to estimates of the provincial government. Its hilly terrain hosts five Aeta barangays
Camias, Diaz, Inararo, Sapang Uwak, and Villa Maria that lie at the foot of three major peaks of
Mount Abo, volcanic Mount Pinatubo, and Mount Lingay. Aetas claim these parts as their ancestral
domain.
In collaboration with the Provincial Health Office, Porac was identified as one of the ten priority areas
to receive technical assistance from USAID through TB LINC. The capability building on
communication and TB counseling among health workers and BHWs ,and the training in community-
based TB management among the barangay council gave rise to a TB Control Operational Plan that
boosted the capabilities of health workers to stop TB in the mountain barangays like Camias, with the
full support of the Municipal Health Officer, Dr. Lilia Panlilio, and the Local Chief Executive, Mayor
Condralito B. de la Cruz.
Cognizant of the need to expand availability of community volunteers for TB, the Mayor encouraged
convergence of the six Community Health Teams (CHTs) and the newly trained Aeta IP BHWs on TB
counseling. He makes it a point to join one of the teams on their weekly drive uphill to see for
himself how the information campaign is winning hearts and minds. In league with local legislators,
he worked out an item in the local budget to provide the program with counterpart funding to shore
up resources from partners like the provincial government, business leaders and civic organizations
for information drives, table clinics, medicines and diagnostics that combine to improve TB case
detection and cure. The deployment of a motorcycle for the purpose by Governor Lilia Pineda
complemented their efforts.
Dr. Panlilio added, Many Aetas feel isolated because the flow of assistance to the mountains is often
hindered. We could not follow up TB treatments done at the RHU with home visits because Aeta
families are constantly on the move in response to planting opportunities. During monsoon season,
mountain passes erode and become impassable. Barangay captains or their health workers are forced
to board returning government vehicles that rationed water and food relief in order to fetch badly
needed medicines. Further, many Aetas are more inclined to stick to their traditional ways of healing.
Our LGU has adopted a policy of attraction, Dr. Panlilio informed. Aeta families who come to the
RHUs for TB treatment are given boxes of milk. Further, every treatment partner who refers a
sputumpositive TB case receives an incentive pay of Php200 and an additional Php100 if the patient
is cured.
RHU Physician Dr. Neil San Andres concurs: Doctor-patient relations here are unique because health
workers have to be extremely patient. We attend to the dual tasks of examining and educating
individual patients at the same time. To my thinking, even a lifetime is not enough to change popular
beliefs deeply rooted in culture, hence, we welcome the personal touch of TB LINC. The training of
Aeta health volunteers on interpersonal communication and TB counseling skills was an added boost
because they are our umbilical cords that give the time we could not give to explaining the
importance of the TB treatment protocol.
The health seeking behavior of the whole Porac population is still improving, say six on a scale of
ten, continued Dr. Neil. We, the health workers, have formed a united front to impart basic
knowledge because there were cases in the past when the Aetas threw away the medicines they
were given upon reaching home. All RHU medicines, including those for all TB categories, are given
free under DOHs universal healthcare promotion program. By educating the Aetas, we prevent such
wastage.
No one understand these dynamics better than 47-year-old Barangay Camias Chairperson Edwin
Abuque, whose bloodline reaches far back to the colonial times when Aetas ruled the mountain crests
of Luzon. He is proud of the feats of his crew of six trained Aeta BHWs because they have the
compassion and zeal to serve the broad Camias community and the areas beyond. In fact, they were
the first among the trainees in town to implement their action plan. The BHWs form three teams with
five members each drawn from the tribal families. Each team has an assigned area of coverage. They
work closely with the DSWDs community health teams and partner with parent-leaders who help in
the conduct of health lectures that resulted in the subsequent establishment of the Barangay TB
Management Council that crafted a Barangay TB Control Operational Plan, serving now as roadmap.
As a result, TB cases detected in Camias for the year have remained stable at six, four of which has
been cured, one under treatment, and the lone fatality a resident of another barangay. Chairperson
Abuque says: My barangay council keeps a conscious watch against the resurgence of TB cases in
Camias. To cap it all, our six BHWsDaisy and Roland Capuno, the Popatco women Jocelyn, Nora
and Josephine, and my wife Violeta see to it that the single case undergoing treatment is closely
attended to.
Chairperson Abuque hopes to complete a barangay health station that the LGU has identified as
priority project in 2013, a transport system to ferry the ill, and the paving of access roads. With
these, he hopes to have a TB-free barangay.
RHU Doctor Creates Culturally-Sensitive TB Control IECs
in the Local Language
Dr. Felipe Boyong Cuyugan, Medical Health Officer of Floridablanca, Pampangas Rural Health Unit
1 exudes a passion for healing that goes beyond the box of professional practice. This 52-year-old
medical practitioner felt the first stirrings to become a Peoples Doctor way back in his student days
at the Angeles University that sent him on social immersions to the hills. He got the break when he
was formally hired by the Department of Health, first as an RHU physician in 1990 then as a Doctor
to the Barrios under the Aeta Assistance Program of the United States Agency for International
Development (USAID). He chose Floridablanca as his workplace where he now lives with his wife, a
nurse in the same RHU who shares his apostolate of public service.
Through the years, he saw a profound need and vowed to fill iteffective communication between
health professionals and patients. This need was embedded in the unique culture mix of lowland
Pampangueos called the unat and upland Pampangueos called the kulot. In the cross currents, he
found that public information, education and communication can be compromised by this ethnicity.
It is difficult to convince people to participate more closely in their own health care, to stress that
medicines can only be effective if taken on doctors orders, and to perceive treatment as a two-way
process between physician and patient, he explains. His key finding in public practice was that
locales can understand basic concepts better and clearer in their own local language than in either
the Filipino or English.
His answer to the communication impasse: culturally sensitive information materials translated in
Kapampangan. His first IEC objective: TB Control. He rewrote complex IEC materials into friendly
versions that patientslowlander and IP alikecould relate to and more quickly internalize.
He got another break when the TB LINC Project organized an Interpersonal Communication and
Counselling (IPCC) Trainers Training in Floridablanca. During the monitoring meetings that followed,
Dr. Boyong himself was coaching the Rural Health Midwife on the IPCC modules and dry-running the
sequence of the slide presentation in the vernacular for roll out the following day.
The RHU doctor reasoned that he was simply moved by the human factor. To his thinking,
educational messages on print are useless unless understood by the vast majority of the un-schooled
and unless they are slanted toward the cultural values of IPs with whom he was deeply bonded.
Dr. Boyongs original Powerpoint presentations consisting of 36 slides capture actual scenarios that
unfold in the different TB-DOTS sites. They are art and photo-intensive as well as text-lean because
Aetas are more captivated by color contrasts and animation than by any word on print. Medical terms
and cases were levelled down using the local idiom. Targeted audiences are vulnerable communities
in Nabunturan, Mabalacat, Dau and surrounding IP domains.
The 14 trained Aeta BHWs are counted upon by Dr. Boyong to be the IEC bearers who will boost the
lectures of rural midwives and nurses. TB comes first in the line of public health materials I plan to
launch because Aetas strongly discriminate against any person in the clan diagnosed with the
disease, he observes. Secondly, 80 patients in the two municipal RHUs are under treatment for
Categories 1 to 3 adult TB; with improved communication, we may be able to influence the health-
seeking behaviour of the 107,000 municipal population. Thirdly, Aeta cure rates and compliance with
treatment modalities are
influenced by their transience. Fourthly, Aeta literacy levels are low. We are lucky that there are no
recorded cases of multi drug resistant TB in the area yet.
Floridablanca has earned the distinction of being the Most Innovative LGU in TB Control in
recognition of Dr. Boyongs initiative in translating basic facts on tuberculosis control in
Kapampangan. He received the award during the Provincial TB Program Implementation Review on
September 14, 2012 given by DOH Center for Health Development for Central Luzon and PBSP.
He is ready to broaden his IEC coverage and hopes funds needed will be available for print and disc
production. Up close, his goal is to catch the interest of people in the IP areas, schools, and assembly
sites of Floridablancas 33 barangayswith the sole purpose of preventing them from catching TB.
Lubao, Pampanga Musters Barangay Council Support Against TB
Health ranks high on the agenda of the Local Chief Executive and barangay leaders of Lubao,
Pampanga. At the top of the political ladder, the lady mayor is a staunchsupporter of the fight against
TB. Across the three cities and 19 municipalities of the province, Lubao records the most improved in
TB case detection and cure rate according to the Local Government Performance Management
System from 2010 to 2011. A first class municipality, Lubao has a population of 150,843 in 23,446
households.
Enthused by this performance, the LGU opened its doors for more interventions to curb TB. In
collaboration with the Provincial Health Office, TB LINC facilitated a consultation meeting among
barangay officials led by Sangguniang Bayan health committee member Carlos Carlos in June 2012.
Carlos conferred with 64 barangay captains and officials from the 36 out of the 45 barangays in the
municipality on the possibility of replicating promising practices in TB as seen in other provinces such
as forming a Barangay TB Management Council. This Council will drum up multi-sector support for
the reduction of TB.
Cognizant of the enthusiasm of the barangay leadership, Barangays San Francisco and San Roque
has been identified as priority barangays to join the other municipalities to formally organize their
Barangay TB Management Council. A successful pilot area on BTBMC is easier to replicate for wider
coverage, SB Carlos says.
With help from TB LINC, the team started to form the TB Councils of San Francisco and four other
selected barangays by holding a two-day workshop. In the workshop, the six members of the San
Francisco BTBMC were handpicked. The Committee is headed by Glenda Flores as chair. It was to
evolve as a grassroots management group that would lead, coordinate and oversee the
implementation of the barangay-based TB campaign.
After the two-day organizational orientation workshop, the San Francisco Council headed by Flores
eagerly started implementing their re-entry plan by first conducting an orientation-seminar for Nurses
ni Nanay, a group of qualified registered nurses hired by the provincial government for a period of
two to four months in community service, and secondly by organizing three batches of community
assemblies on TB. The Council likewise solicited funding from overseas Filipino workers for the
purchase of supplies and materials for the RHUs. The Council tapped the trained BHWs to orient a
mothers group organized among women fetching their children from school. In order to educate
more people, the Council posted the TB DOTS flipchart provided in the barangay nutrition stations
and in other high visibility areas.
To further institutionalize its gains, the San Francisco BTBMC worked for the passage of a Barangay
Resolution creating a TB Task Force composed of local community members such as tricycle
operators and drivers associations, senior citizens, and other groups. The TB Task Force was
successfully launched and to date, it has conducted three community assemblies and referred 11 TB
suspects to the Lubao RHU 2, all were sputum positive for TB and now undergoing treatment with
the BTBMCs as their treatment partners. Underscoring her commitment, Council Chair Flores said that
her goal is to contribute to increase the rates of case detection and cure and to shield Lubao children
from the unwanted TB complex.
San Rafaels Barangay Captain convinced of San Franciscos experience despite short period of time
from capacitation, shared his vision of a TB-free barangay in the near future. He says: I want my
constituents to be healthy, and I want to be of service to all who come to the barangay hall for
health and medical-related concerns. I am most willing to refer them to the RHUs, the centers, or
hospitals if needed. Previously, there were TB cases that were not properly attended to which led to
deteriorated conditions and even death. Now I am convinced that TB is curable if detected early.
Fighting TB can be a collaborative effort. Awareness and proper orientation on the disease combine
to eradicate TB. With the proper implementation of the TB program, a Zero Case and Zero Casualty
scenario is possible in my barangay.
By mustering the support of barangay leaders, Lubaos BTBMC will continue to deliver the needed
health services with the participation of the community and other support groups. With self-led
people, Zero Case barangays are a sure thing in the future.

Faith Works Wonders for Zamboanga Sibugay Communities


Access to health services is not easy for many people in the province of Zamboanga Sibugay, a
province occupying 3,228 square kilometers in the Zamboanga Peninsula. Nine of its 16 municipalities
are classified as either fourth or fifth class with the provincial capital of Ipil as the sole first class. The
province has three Inter Local Health Zones, two of which are in the mainland and one on the island
district of Olutanga-Talusan-Mabuhay or OlTaMa.
Persons close to the Rural Health Units or Barangay Health Stations can easily avail of diagnostic and
clinical services but these are quite prohibitive to those who live in far places. Generally, residents
seek out herbalists called the manghihilot or albularyo. Hospitals or health centers become the option
only after illness has progressed. Trips to these facilities can take as little as two to 24 hours on foot
or five hours on a habal-habal or single motorcycle ride over bumpy dirt roads. The habal-habal is the
only local taxi around and the hiring can be quite expensive.
In 2008, the TB profile of Zamboanga Sibugay showed a Provincial Case Notification Rate (CNR) of
close to 100 and a Cure Rate of 67%. The only municipality that reflected a high CNRhigh CR
picture in the province was Ipil. The TB situational analysis conducted by the Integrated Provincial
Health Office (IPHO) revealed that treatment partners in the RHUs were scant, communities were not
participatory, and case holding activities were poor. This became the focus of a consultative process
that followed.
Talks between Bishop Julius Tonnel, DD of the Prelature of Ipil, the diocesan Community-Based
Health Program (CBHP), and TB LINC, a USAID supported Project implemented by Philippine
Business for Social Progress (PBSP) were held. In 2009, the group agreed to conduct advocacy and
social mobilization work in the community. A Memorandum of Agreement identifying the
responsibilities of key players was signed. Under the MOA, health workers were to provide medical
and diagnostic services and to monitor and supervise volunteers. The IPHO and RHUs were to
conduct the training with TB LINC providing technical assistance. The offshoot was the creation of a
special network of church workers made up of volunteer nurses, teachers, housewives, and some
members of the clergy from different parishes. They rendered free services in all the municipalities
and almost 85% of barangays in Zamboanga Sibugay following directives issued by the Diocese.
What is so distinct about this network is that information on TB control and management was built
into the weekly ecclesiastical lectures. As an outstanding innovation, the council organized
households as implementing structures wherein one household has eight to twelve cell groups (selda)
with roughly 15 families in each. CBHP coordinators monitored and supervised the household-run
seldas. A provincial spiritual director was appointed to assist the seldas. Aside from their usual health
education classes in the community, the CBHP health workers also conducted health education
classes in schools, jail wards, and womens groups in order to reach out to more people, and enable
the public to identify TB suspects, and refer to the nearest TB DOTS facility.
To gain further ground, CBHP did more than just intervene. A pastoral letter from Bishop Tonnel that
counseled the congregation on the need to address TB was read during regular Sunday masses.
CBHP members took the initiative of translating the TB counseling modules in the local language.
Large tarpaulins on the subject were likewise designed and displayed in strategic public places. A
priest who came down with TB and was healed volunteered himself as a resource person during
advocacy dialogues.
Overall, the CBHP became the LGUs performing partner in health. CBHP Coordinators sit in the Local
Health Boards of nine municipalities and the province as NGO representatives. The CBHP also
functions as the secretariat of the Provincial Multi-sectoral TB Alliance. Now considered part of the
extended workforce of the RHU, they regularly attend BHWs meetings. Having recognized the
contribution of CBHP to the province-wide TB program, DOH Region IXCHD allocated funds for
capability building of 25 new CBHP coordinators in TB-DOTS. The CBHP continues to strengthen itself
by involving more facilitators and trainers from the communities and constantly reviewing operations
during biannual spiritual retreats.
CBHP volunteer workers equally help in case finding and referrals and serve as treatment partners of
identified TB patients. To prepare CBHP workers adequately for these roles, the IPHO and RHUs train
them on Basic TB-DOTS, with emphasis on their crucial role of ensuring that TB patients assigned to
them take their doses as directed and submit themselves for regular sputum examinations.
The extensive network of CBHP has reached out to near and distant communities. Citizens of
Zamboanga Sibugay are now growing increasingly aware of the nature of TB, its signs and
symptoms, and its prevention and cure. TB patients no longer inhibit themselves from seeking
information or getting help. They could merely ask volunteers to bring them to the health centers or
go on their own.
Case detection rate and cure rate in the whole province have improved from 2010 to 2011. Referrals
of more TB suspects were found, from 208 in 2010 to 250 in 2011. More new smear positive cases
were recorded from 35 in 2010 to 59 in 2011 as a result of CBHP community work. Provincial cure
rate improved in succession from 71% in 2009, 82% in 2010 to 86% in 2011.
As observed by one volunteer, Faith has widened access to health services since it created a link
between the community and the health network that fostered an environment of trust and relief.
The bishops spiritual and personal commitment to the program and the players broad perspective
and acquired knowledge of TB enabled them to meet the demands of the constituency. As the
workers gained acceptance, they became more confident in their work to help people regardless of
religious affiliation or ethnicity. Since the cost of transportation inhibits persons from seeking
treatment, the CBHP now searches for means to bring sputum specimens from homes to the health
centers. Budgets have been allocated for the transportation allowance of CBHP workers who fan the
spirit of volunteerism while influencing others to do the same. Some habal-habal drivers even bring
TB patients to the health centers at reduced fares or none at all.
The CBHP network feels that the initiative can be sustained through the creation of programs for
volunteers so they could persevere in their advocacy. The consultative process has drawn many
players from various disciplines and has proven that spiritual formation and social development, faith
and progress, can go hand in hand to work wonders and create impact. Relational harmony among
health workers, capacity building programs, and the cooperation of institutions and individuals are all
vital to the continued success of the partnership.
Lake Sebus RHU on Wheels, Sanda and other IP Customs
Push TB Programs Forward
There is something about Lake Sebu, South Cotabato that makes it an eden of sorts. For one, its
accessibility via a deathdefying ride on the habal-habal motorcycles proves that it is a place that is far
and beyond the reaches of development. This landlocked municipality that is rich in indigenous
heritage and is home to the Tiruray, Ubo, Tboli, and Manobo Indigenous Peoples.
However, being on the margins of Mindanao, Lake Sebu faces enormous challenges. Seventeen out
of its 19 barangays are in the hinterlands and difficulty of access has posed a hindrance to the
delivery of basic health services. Though priority programs have been acted upon by the local
governments, health issues more often take a back seat and the people do not receive proper
medical attention. Communities that subsist on farming and fishing consequently miss out on health
awareness and resort to doctors only at the last minute.
TB awareness and treatment is evidently low in these parts. Reports from the RHUs indicate that
Lake Sebu has posted both low TB case detection and cure rates. To comprehensively respond to the
challenge, local health initiatives were started, ranging from the reorganization of health zones for
proper management and supervision to the involvement of local barangay whose leaderships were
viewed as the conduits of communication.
A culture that is as peculiar as Lake Sebus needed peculiar strategies. In dealing with TB, the LGU
has effectively descended to the grassroots to solve the problem in a local mannerhitting more
targets beyond the planned.
The strategy of facilitative supervision restructured the barangays into six clusters, each handled by
a cluster coordinator and information officer. The re-clustering which began in 2010 tapped local
cooperation to support TB prevention and testing. The midwives and other health workers who were
trained in TB DOTS were supported logistically and financially by the barangays LGUs which became
direct stakeholders of the initiative.
The strategy has strengthened the interface between the local health unit and the communities. We
hail from Lake Sebu but this is the first time for us to reach remote barangays and sitios, reports
one nurse on an assignment. We are happy to have helped, we have breached barriers, speak the
language and understand cultural practices. We have found the skills to explain health issues to the
natives in their own tongues as a consequence of which they now understand the program and their
part in it.
By increasing household coverage and immediately assisting TB suspects, case detection rate began
to increase. The synergy between health workers and the barangays also facilitated not only tests
and treatments but also educational campaigns for the people. Barangay health worker are assigned
a certain number of families or households to cover, says Gina, a health worker. We visit the sitios
to inform the people of the imperative to help neighbors they observe to be showing symptoms of
chronic cough and fever and to know their unmet needs. We draw up a Target Client List. We
provide one-on-one health information and refer prospective patients to the Rural Health Midwife
who could dispense the needed service. This strategy has clearly translated service targets into
concrete grassroot indicators. The open communication between the workers and the local
community, as well as the close coordination among supervisors has created an effective feedback
and monitoring mechanism, assuring adequate health care for the communities.
Funding challenges were also dealt with through partnerships with non-governmental organizations.
What began as consultations led to a fully set up public-private mix that not only identified pressing
health issues in the municipality but also mapped out areas of responsibility of each organization.
With the prodding of the Department of Health, the municipal health office unified the direction for
health care, in effect harnessing resources and harmonizing programs and activities. The LGU
constantly dialogues with its partner institutions to implement TB information drives. The
interbarangay clustering has brought health care to the doorsteps of isolated households and has
evolved into a blue print of collaboration.
The TB preventive campaigns have greatly benefitted from the collaborative exercise. Active partners
Mahintana Foundation, Santa Cruz Mission, ACDFI, and International Care Ministries held trainings on
TB DOTS. Medical equipment had also been made available through these partnerships, making free
diagnostics readily accessible to the people, and patients closely monitored and supported.
Distance and inaccessibility have been bridged by these organizations in the attempt to bring down
TB incidence in Lake Sebu. This scenario enhanced what had already been initiated by the LGU.
Another innovation supportive of the TB campaign and other programs is the Rural Health Unit on
Wheels. In a municipality classified as geographically isolated and depressed, the mobile Municipal
Health Office (MHO), whose teams are deployed hree to five days every quarter, deliver basic health
services to the places dominated by the omnipresent habal-habal. These MHO extensions enable the
main health office to find TB suspects with the support of the inter-barangay cluster. Together with
the sputum collection and examinations, a wide variety of basic services not otherwise available are
delivered to the areasblood smearing for malaria, minor surgery, dental treatments, maternal-child
health services, immunization, and environmental sanitation. The RHU of Lake Sebu evaluates these
programs on a quarterly basis. The mobile delivery became another platform for ensuring early
diagnosis and treatment of TB in a given locality.
While services are now being brought to places where they are needed most, treatment, according to
health workers, continued to be challenging. An answer was found in tapping a cultural practice: the
sanda. In the sanda, an individual honors a commitment by pawning valuable personal itemsa
Tboli belt, malong or blouse, watch, credentials of carabaos or other properties, and certificates of
birth or marriage.
Before a patient is treated, the sanda is undertaken and the collateral given to the RHU for
safekeeping. Only when the patient is declared free of TB will the goods be returned. In a span of
two to three years, workers report that the strategy yielded very positive outcomes: cure rate
increased from 40% in 2008 to 90% in 2010. The mechanism, they say, prevents coercion and
reverences local values upheld by the IPs and the community at large.

The Rise of the NCR Regional Coordinating Council


Toward Bureaucratic Efficiency
In 2003, the Department of Health adopted the Public Private Mix Directly Observed Treatment
Strategy (PPMDOTS or PPMD), a World Health Organization model for TB detection and
management. It draws together health care entities from the private and public sectors into the NTP
and expansion activities.
With national and local governments and private companies involved in a single program, one can
get tangled in the maze of structures. Issues like the program overlaps, duplication of activities,
underserved areas, and unmet targets were encountered. These were attributed to the lack of a
single coordinating body to oversee PPMD implementation.
A fix to the poor performance across the country came with the establishment of the Regional
Coordinating Committee for Private Public Mix DOTS (RCC-PPMD). In the National Capital Region
(NCR), a grant from the Global Fund to fight AIDS, TB, and Malaria coursed through the Philippine
Coalition Against Tuberculosis assisted the creation of the RCC-PPMD, providing a body tasked to
oversee the operation of a public-private partnership for the NTP implementation. Its objective was
to increase case detection aided by private sector contribution and improve the cure rate of TB
patients.
Chaired by the Regional Director and co-chaired by a member of the private sector, the president of
the regional coalition against TB, its basic members are representatives from the Philippine Health
Insurance Corporation or PhilHealth, the Medical NTP Regional Coordinator and identified technical
experts from partner agencies.
The NCR-RCC evolved as a venue where ideas, platforms and issues are discussed and dissected to
further TB control goals. Under the CHD Regional Director, TB LINC technical assistance groomed the
NCR as the first region to have a regional coordinating committee with robust functions within the
context of the Philippines Plan of Action to Control TB (PhilPACT)
The creation of RCC through a Department Circular was easy, but the Councils constitution took
time. Council members were selected based on knowledge, skill, influence and commitment to the
NTP program. According to Dr. Irma Asuncion, OICDirector IV, NCR, the composition of the
membership of the NCR-RCC may be small, but these organizations were deliberately and carefully
chosen not only because of their commitment to the NTP but also because of their ability to influence
people and implement programs.
Clamor for wider regional participation gave birth to an expanded group. The original group is
composed of organizations like the Department of Labor and Employment, Bureau of Corrections,
Department of Interior and Local Government, Philippine National Police, and the Coalition Against
Tuberculosis in Metro Manila composed of private hospitals, clinics and pharmacies implementing
PPMD. Representatives from the Department of Education, Bureau of Jail Management and Penology,
Department of Social Welfare and Development, Department of Interior and Local Government,
PhilHealth, Metro Manila Development Authority, Philippine Association of Fellows in Pulmonology,
technical advisers from the World Health Organization, Department of Health, and Philippine
Tuberculosis Society, Inc., constituted the expansion.
Now fully staffed, the Council took to the first task of developing policy documents defining the
mandate of the Council. It started with the holding of orientations on PhilPACT and securing the
commitment of participating agencies. Outputs were operational plans of participating agencies which
were consolidated and harmonized by CHD into the RCC strategic plan, a guide to all current NTP-
related activities. Thereon, the Council held successive committee meetings and follow-through
activities.
The road onward was rocky. Sailing through rough climates, the RCC could hardly maneuver as the
CHD staff involved were doing multiple tasks. The lack of funds also stalled RCC expansion. Changes
in leadership in some private companies snagged the Council; fortunately, this did not prevent the
sectors participation. Three factors have contributed to the success of the NCR RCC: tough
leadership and commitment, camaraderie and a strong sense of partnership, favourably for the
Council. Also, the Council and the presence of technical experts and grant funds.
Under the revitalized NCR-RCC, there are 15 local chief executives who have signed the document
pledging their support to the TB DOTS program, says Dr. Amy Medina, NTP Regional Coordinator.
More pharmacists, referring physicians and companies are presently implementing TB DOTS. St.
Lukes Medical Center, Capitol Medical Center, SM Group of Companies and Smart
Telecommunications were significant additions to the partnership. Likewise, the Association of City
Health Officers in Metro Manila, the Philippine College of Chest Physicians, Compassion International,
other private organizations and local chief executives have openly embraced the program.
Dr. Medina adds: case detection and cure rates did not significantly increase but the attitude and
behavior of health providers both in public and private have tremendously improved. Case reporting
and monitoring progressed as volunteer health workers and health professionals became familiar with
TB DOTS. The case detection rate (CDR) of the National Capital Region in 2009 posted at 69%
versus 74% in 2010, while the case notification rate (CNR) registered at 97%. With the increased
commitment of LCEs, higher CDRs and CNRs in the future are projected. To provide further incentive
and bring TB Control performance to global benchmarks, NCR-RCC introduced an awards and
recognition system for best performing sectors in various categories.
It is better to start small thereon build strong foundation in order for the Council to be sustainable,
Dr. Irma Asuncion confided. The public-private partnership can change the statistics of TB incidences
in the country especially when its members are passionate and committed to the vision of a healthy,
vibrant society.

Healthy Lungs for Her People: Story of the Lapuyan Lady Mayor
To reach the municipality of Lapuyan, a poor coastal town in Zamboanga del Sur, one has to
navigate through approximately 15 kilometers of rough road from a highway crossroad. Travel alone
is enough to discourage anyone from visiting the place, and this situation does little to help the fight
against the dreaded tuberculosis disease which has affected many of the indigenous residents: the
Subanen.
This is a scenario that Lapuyan Mayor Daylinda Sulong and her constituency of Subanens know only
too well. As a general rule, the Subanen community is cautiously receptive and at times, wary of
modern medicine. But these challenges Mayor Sulong has bravely surmounted.
To date, her office has allotted the biggest budget to health services ever appropriated yet in the
amount of Php200,000 specifically intended for the local TB Program. This fund is earmarked for
programmed activities, medicines, medical supplies, other logistics and information dissemination.
Though TB LINC assistance is acknowledged, it is to Mayor Sulongs credit that Lapuyans TB
program has been institutionalized. Mayor Sulong put the USAID assistance to good use by signing
into effect Municipal Ordinance No. 25 I 2008 which earmarked funding for the training of health
personnel and the procurement of anti-TB drugs to supplement stocks already received from the
Department of Health.
It is no secret that Mayor Sulongs own husband, a Subanen himself and a former Mayor, is a former
TB patient who has now fully recovered thanks to the Lady Mayors firm belief in the efficacy of the
sustained TB regimen.
Mayor Sulong has been open in publicly citing her husbands case, using this as a testimonial in her
dialogues with Subanen leaders. This has significantly helped in removing the social stigma on TB.
The Subanen have likewise began to put their trust in the Mayor and the governments TB Program.
Mayor Sulong set the tone for the community when she brought her husband to the health center in
lieu of a private hospital outside the municipality. She professes trust in the accuracy of Direct
Sputum Microscopy and the efficacy of free anti-TB drugs. In her visits to the Subanen leaders, she
continues to advocate for the wider acceptance of the free services and medicines provided by the
RHU, in the process winning greater community trust and confidence.
Mayor Sulongs efforts also include converting an unused warehouse into a TB DOTS facility which
now serves TB patients not only from the municipalitys 24 villages but also from nearby areas as
well, benefitting over 200,000 residents. This novel facility also has a new sputum collection area that
awards TB patients with their coveted privacy. She has also hired a full-time medical technologist to
provide microscopy services and assigned a nurse to take charge of clinical services.
The municipalitys TB program not only improved sputum microscopy but also resulted in more
accurate case recording and reporting. There was a visible increase in the number of patients
diagnosed with TB who were immediately placed on treatment. The number of TB suspects who
submitted themselves to an examination likewise increased from 73 to 179 from 2008 to 2011.
Previously, the Subanen would think twice before heading to the centres to consult medical
practitioners but now, majority of them actively seek out the doctors and nurses from the facilities or
from the community health groups. The Subanen are given the opportunity to attend TB education
classes. From January to June of 2012, at least 100 TB suspects were registered by the municipal
RHU.
Mayor Sulong widened the spread of her TB campaign by forming the Barangay TB task force
composed mostly of Subanen in order to fan out toward far-flung barangays and to improve
Lapuyans present cure rate of 32%. She is also recruiting more barangay TB volunteers to assist the
BHWs in case holding activities. The Mayors future plan is to form a TB Patrol Team comprised of
BHWs whose duties would be to conduct house-to-house TB education and case finding.
Seeing people in my town becoming healthier inspires me, says Mayor Daylinda Sulong. Indeed, the
adage health is wealth has been reiterated with clarity by the very system she designed. All that
this strong-willed Lady Mayor from Lapuyan wants is healthy lungs for her people.
Hermosa TB Council, Zamboanga City
Crucible of Good Practices in TB Control
Most of Hermosa, Zamboanga Citys 774,407 people reside in remote environs, far from the basic
amenities of the urban landscape. Zamboanga City has registered tuberculosis as the leading cause
of morbidity and mortality from 2003 to 2008. Many of the identified TB suspects and patients within
that time frame were unable to avail of basic TB control services or were even undiagnosed because
of the distance from their homes to the nearest health centres. Ranked 9th in 2007 in TB morbidity
and 5th in TB mortality in 2008 in the country, the challenge lay in identifying and lowering the
number of cases. To do this, the city government led by Mayor Celso L. Lobregat found it imperative
to bring TB control services closer to the people.
The quest for TB eradication began in 2003 when the TB DOTS strategy was being tested in the
Zamboanga Local Government Units ( LGUs). The city governments swift response was to fully
support through calling for unity in the fight against TB or the theme Unidad na Pelea Contra TB.
By 2007, with funds pouring into the TB control program, and with technical support from USAID, the
birth of the Hermosa TB Council (HTC), by virtue of Executive Order CL 130-2007 that fell in line with
the National Government Executive Order 187 of 2003 and DILG Memorandum Circular 98-155,
became a natural recourse. The Council was seen as the mechanism by which the LGU could curb the
disturbing rate of TB incidence in the city, it being composed of both public and private sectors with
potential to contribute resources for the effective mobilization of a unified strategy.
Mayor Lobregat and City Health Officer Dr. Rodelin Agbulos were designated Council chair and co-
chair respectively with representatives from various sectors as members. These included the
Committee on Health of the Sangguniang Panlungsod, Centre for Health and Development-
Zamboanga Peninsula, Local Health Boards, the Zamboanga City Medical Center, PhilHealth, Rotary
Club of Zamboanga, representatives from the USAID, the Global Fund to Fight Aids, TB and Malaria,
PBSP, World Vision Development Foundation, the Philippine Coalition Against Tuberculosis,
Community/Village-based Anti-TB Task Force volunteer groups organized by World Vision, the TB
patient group, and the academic and business sectors among others.
In time, the Hermosa TB Council became the focal network that oversees, centralizes and unifies all
activities of the TB Control Program of the city. The sectoral composition of the Council is credited
with minimizing the duplication of efforts and the stiff competition for resources.
To discourage patients from self-medicating and to prevent the rise of multi-drug resistant
tuberculosis or MDR TB, the City Council enacted the No prescription, No dispensing of anti-TB drugs
Ordinance and being implemented in 2011 in collaboration with the local Pharmacy and drugstores
association.
The crest of private sector participation was reached in August 2010 when 19 private companies
formally declared support for the TB in the Workplace Program. A joint Memorandum of
Understanding was signed by representatives of the Center for Health and Development (CHD),
Region 9, city and barangay LGUs, the City Mayor as HTC head, and key representatives of
Department of Labor and Employment (DOLE).
Three companies set up a system for managing TB among their employees. Suspected employees
were referred to the appropriate medical facility and given attention for proper diagnosis and
treatment. The companies partnered with the Ayala District Rural Health Unit (RHU) in the
management of the TB cases. The Hermosa HTC was clearly a success on account of its program
focus, annual budget allocation, institutionalized Council meetings, and defined roles and
contributions of sector representativesthe elements that propelled the council toward its goals.
With a start-up budget of Php200,000.00 upon creation, it seeks to reach a 70% case detection rate
and an 85% treatment rate for the city. The HTC plan and programs were farmed out to the
members who generously contributed expertise and resources.
Local funds not being enough, the HTC today looks up to public-private and grant organizations to
keep ongoing projects moving. There are entities that provide unconditional support such as the
Rotary Club of Zamboanga that supports the Annual Lung Month celebration and the Stop TB: Bike,
Run and Walk triathlon which has attracted the participation of up to 15,000 people from different
parts of the city.
The Zamboanga Hermosa TB Council and the prolific team of public health doctors and multisectors
have made possible the building of additional TB DOTS centers and the establishment of eight
Remote Smearing Stations. The smearers trained organized TB task forces in 98 barangays and
operationalized an effective referral and tracking system, and lending muscle to the TB in the
Workplace Program and Pharmacy DOTS Initiative. The conduct of information campaigns with
members of multi-media drummed up major HTC events and the production of IEC materials. A pool
of experts and trained volunteers contributes both talent and resources.
So far, the Council efforts was able to raise the case detection rate from 63% in 2003 to 117% in
2011. Cure rate registered at 75% in 2003 improved to 94% in 2010. Rating performance now falls
within the national and global benchmarks. The positive outcome is that TB is no longer among the
top ten leading causes of illness and death in the city in 2011a scenario unimaginable in the past
but which the HTC and Zamboangueos can truly be proud of.
Active Volunteerism Bridges Gaps in Health Among the Subanen
The municipalities of Lakewood and Kumalarang in Zamboanga del Sur suffer from a scarcity of
health facilities. But the Subanen indigenous peoples who populate the mountainous rural areas
would rather resort to traditional healing methods than take the grueling ride on the habal-habal
motorcycle to the nearest health facility. This is one of the reasons why diseases like tuberculosis
fester.
The Subanen perceive TB as an illness to be feared and to be ashamed of. They see it as some kind
of an obnoxious lump that grows in the lungs that secrete bad phlegm. Once they feel bad, they rush
to healers called balyan, bringing eggs or live chicken in exchange of cure. Oil is applied to the chest
area aided by a whispered chant. Without the intervention of a medical specialist, the condition
would worsen. Only would the family seek help from the Barangay Health Worker (BHW).
When the TB LINC Project broke ground in the district, the Subanen Womens Organization
(Pikhumpongan Dlibon Subanen, Inc. or PDSI), recognized as a champion of Subanen culture, was
tapped as a technical assistance partner (TAP). Their role was to facilitate increased awareness and
easy access to TB DOTS services among the Subanen, in Zamboanga del Sur.
Belonging to the same culture and speaking the same language, the PDSI organized the Subanen
health volunteers for TB control assisted by the USAID funding. Volunteer Subanens agree that
communicating and propagating the message of TB control in the local tongue has helped make
dialogues more understandable to the members of the community. They eventually developed a plan
to implement the program.
To prepare the health volunteers for the task at hand, Rural Health Units of Kulamarang & Lakewood
provided training on basic TB DOTS and advising their fellow Subanen. They were given guidelines to
enable them to become good health educators and treatment partners. Subsequently, they played
vital roles in case finding and motivating TB suspects to seek consultation. They bring IEC materials
to the purok (small housing cluster) health education meetings and assist TB suspects reach the main
health center where they are primed for tests and treatments. Some common catchwords in their
advocacy are: TB is contagious but curable because TB medicines are given for free.
Barangay captains were also oriented in TB management and control, paving the way for the
organization of the Barangay TB Management Council (BTBMC). This Council is responsible for
implementing and monitoring activities under the program and has made huge strides among the
Subanen because its members include the people themselves. The Council oversees coordination
between the Subanen TB task forces, referred patients, and the attending facilities such as the RHUs.
The Council likewise assists in the transport of the sputum specimens collected during onsite visits to
the RHU for examination. Since there were occasions when the sputum specimens were not readily
processed due to geographical distance and the lack of medical technologists, a trained microscopist
was hired for the community.
What eased the implementation of the TB Control undertaking was the deployment of community
organizers in Subanen barangays. The PDSI hired and deployed six community organizers, three each
for Lakewood and Kumalarang. The organizers took charge of community mobilizing, encouraging the
natives and their families to actively participate in the program activities and events. They also
monitored the progress of the implementation of the BTBMC plan.
The TB Control Program was further strengthened when the mayor signed a municipal ordinance to
support it, and when all the barangay councils in both Lakewood and Kumalarang authored and
passed Barangay Resolutions allocating funds for the purchase of anti-TB drugs, monitoring and
supervision, and the training of health workers. As a result of these interventions, more people in the
municipalities of Lakewood and Kumalarang are now aware of the signs and symptoms of TB and
promptly seek consultation at the Barangay Health Station or Rural Health Units. Significantly, the
group reports that during the third and fourth quarters of 2010 and the first quarter of 2011,
community TB volunteers and educators have reached about 26,704 people during their health
education campaigns.
Case detection rate also has increased. In Focus Group Discussions (FGD) held in the second quarter
of 2011 the RHU NTP coordinator mentioned the high rate of consultation by the Subanen. This rose
from 20% to a high of 60%. Further, records also showed an increase in the number of consultations
by the Visayan speaking populace. This could be attributed to the intensified health education
campaigns done by community volunteers at the barangay level where the crowds also include
Visayans as captive audiences.
The IPs of Zamboanga del Sur, its Visayan-speaking population, and the general population are now
beginning to see and appreciate a new kind of spring. A clear indication is that the people, whether
Subanen or not, now freely go to and even frequent the health stations and socialize with one
another in the town centers. All the bloodlines here consider themselves part of the larger social
mainstream, conscious of the need to eradicate the menace of TB that stands in the way of their
prosperity.
Elevating TB Scores in Nabunturan, Compostela Valley
Compostela Valley in Eastern Mindanao is an emerging local economy. Indices show that in about 20
years, it will be one of the most prosperous provinces of the country for its human and natural
resources. As a young province established in 1998, ComVal is exceeding expectations as a melting
pot of indigenous cultures like that of the Manobos, Dibabawons, and Manguangans, and as a rising
agricultural and industrial producer.
ComVal too, has tried to take small steps to join the worldwide campaign to curb tuberculosis. In the
provincial capital of Nabunturana first class municipality of some 17,000 householdsbarangay
initiatives have been tapped to create programs that respond to grassroot issues. Whereas public
health was allocated funds averaging Php7 million, TB control was not given sufficient attention for
many years. Data show that in 2006, TB was 4th in morbidity and 5th in mortality causes in
Nabunturan alone. To strengthen financial and human resources for health, the municipal
government persuaded barangays to formulate action plans to respond to the TB crises in their
localities.
The Municipal Health of Officer of Nabunturan batted for the inclusion of the TB control in barangay
development plan or BDP. To motivate local leaders, the government launched an award system in
2006 recognizing the Most BDP Adhering Barangays, a scheme that rewards fully-implemented
barangay plans and which did not realign or re-program budget allocations. Close coordination and
dialogue with the barangays helped the Health office place TB treatment and information
dissemination among the barangay priorities; while barangay allocations for health care varies, the
initiatives that were built from earlier technical assistance given to the municipal health services has
multiplied financial resources to augment existing campaigns and treatment programs. Rural health
midwives worked on the improvement of supply and equipment acquisition, as well as the
refurbishment of barangay health stations.
In the same year, the MHO also received technical support from the Lead for Health Project, a
USAID supported project being implemented by the Management Sciences for Health to institute a
cost recovery scheme for medicines. The system benefited the municipal Rural Health Unit (RHU) by
allowing it to generate income to supplement local funds. With local dialogue and legislation, the
scheme and a supportive ordinance provide 75% and 25% profit sharing for the RHUs and the
municipal government, respectively. Funds are now available for indigent patients referred to the
municipal social welfare office.
The barangay allocation and financial sourcing was a boon to the TB management program. The RHU
was able to maximize human resources whose capabilities were strengthened to identify and
promptly treat TB patients at their level. TB suspects are entitled to free sputum tests and based on
the results, are given the necessary treatment. Treatment begins with the filling up of the kasabutan
or agreement form which the patient is asked to sign to ascertain completion of the treatment
regimen. Treatment programs are closely monitored by the RHU together with the community
partners. In some cases, barangay officials were sought in case supervision.
The TB situation in our barangay is special, says Maxima Perez, a BHW. Before, patients used to
report to the health units only when seriously ill. Today, we could track down TB suspects in our
areas during regular quarterly programs like Operation Timbang and immunization drives. House
visits too, according to Perez, have been helpful in early diagnosis that nips TB at the grassroots.
Identified TB suspects on these house visits are given sputum cups for collection. There are only a
few TB cases now. In 2010, I supervised the treatment of three TB patients but one of them expired.
In 2011 I only had one patient. This year, I have
none so far.
Coordination was the key to the success of TB initiatives in Nabunturan. Aside from weekly staff
meetings where TB monitoring is discussed, we feed regular information to the Rural Health
midwives regarding patients who fail to return on sputum collection dates, reports Alice Flores, a
medical technologist at the RHU. If the patient is saddled by transport costs, the midwives make the
rounds for sputum extraction and facilitate the delivery of specimens to the diagnostic team.
Feedback mechanism established through barangay networking has not only maximized the
workforce; it has also opened communication lines between health providers and the public; thus,
the stigma that previously hounded TB patients has vanished.
Private organizations played a pivotal role in the TB program of Nabunturan and the province. Global
Fund, with the support of the DOH-Center for Health Development for Davao Region, facilitated the
establishment of a Public-Private Mix DOTS, centralizing the system to respond more efficiently to the
TB programs of five other ComVal municipalities, namely New Bataan, Compostela, Monkayo,
Montevista, and Mawab. The new inter-local health zoning launched in Nabunturan improved case
detection through referrals from private physicians.
In 2009, the TB LINC Project engaged the Philippine Tuberculosis Society to involve local pharmacies
in TB DOTS implementation, completing the campaign for improving the participation of private
sector. Aside from significantly improving case referrals, the pharmacy DOTS initiative also prompted
government officials to file and approve a municipal ordinance on the No prescription-No anti-TB
drug dispensing, thus minimizing self-medication. This is shown by the increasing number of patients
now seeking consultation. More people are consulting now even for a cough of only two days,
claimed by the MHO. The government continued to intervene by ordaining the use of PhilHealth
reimbursements for TB confinements, and by providing commensurate municipal health budget.
TB in the Workplace of Northern Cement Corporation, Pangasinan
Sison, Pangasinan, is a third class municipality with 28 barangays and a population of 46,147 as of
2012. It is endowed with rich natural resources like limestone and shale reserves mostly found in
Barangay Labayug. Northern Cement Corporation, the largest employer of skills in the vicinity,
quarries and develops these resources for the Philippine construction and building industry.
The Municipal Health Office of Sison is the prime health structure on which the company and its large
workforce rely upon for their medical needs. It has 27 Barangay Health Stations. Since 2007, the
Health Office observed the rising number of TB cases among employees. In that year alone, of the
43 new smear positive TB cases in Sison, four (9.30%) were workers of the Corporation. Some of the
problems encountered among the employees were lack of understanding of the disease and refusal
to submit sputum specimens during follow-up. There were those who withdrew from treatment for
fear of side effects; to compound this, there was a slack of resources and time on the part of both
health providers and patients.
Thus, after a series of dialogues with the Health Office, NCC embarked on a policy of promoting a
more healthy working environment for its workers. A Memorandum of Understanding for the
implementation of a TB DOTS in the Workplace Program was signed on March 23, 2010 between
NCC and its partners: the Sison MHO, Urdaneta Hospital, the Provincial Health Office, DOLE Regional
Office, and representatives from TB LINC. A boost to this was NCCs own membership in the
Pangasinan Koalisyon Alis-TB (Pangkat) program of the provincial government of Pangasinan.
Heads and personnel from the different departments of NCC were chosen by the workers themselves
to compose a Health Committee that became the voice that brought health concerns to the
awareness of management. The NCC human resource department and health clinic, in coordination
with the occupational health and safety department, the RHU and TB LINC conducted workshops on
TB prevention and control.
IEC materials on TB signs and symptoms, prevention and control were displayed in work areas and
the clinic. Peer educators and counselors were also trained per area to remind co-workers to seek
consultation upon manifesting warning signs and symptoms.
TB preventive protocols were launched in the NCC workplace. TB case finding is now done in January
when all employees undergo annual physical examinations. Workers whose x-ray results indicate TB
are referred to the RHU TB DOTS Center for direct sputum smear microscopy or DSSM. Workers who
manifest signs and symptoms of TB are referred to the company physician. If the DSSM result is
positive, the RHU feeds this back to the NCC clinic for treatment and sputum follow-up. If the DSSM
result is negative but radiologic findings are suggestive of TB, the RHU coordinates with the company
nurse. The RHU refers the patient to the TB diagnostic committee in the locality. The company nurse
ensures that all requirements and documentation including a complete medical history of the referred
patient are provided to the RHU.
For case holding, the company physician and nurse closely coordinate with the RHU concerning the
treatment status and progress of referred and diagnosed TB patients especially during the intensive
phase of treatment. The NCC TB Coordinator acts as treatment partner in the workplace upon return
to work of the TB patient to oversee the maintenance of treatment. All employees and qualified
dependents diagnosed with TB are covered by the case management services until results of the RHU
warrant a fit to work order. The final decision to issue this order is made by the NCC physician. In
events where extension of leave is necessary, the RHU does the case holding until the NCC medical
team deems the patient fit to return to work.
The company also ensures uninterrupted drug supply and nutritional supplements. Medicine
inventories are done by the NCC clinic staff and are responsible for the storage of drugs and supplies.
During rest days, drugs are endorsed to the designated treatment partner at home. All employees
found to be sputum positive for TB are advised to bring their dependents who are TB suspects for
DSSM.
Workers with TB are not discriminated against and are instead supported with adequate diagnosis
and treatment and are entitled to work as long as they are certified by the company physician to be
physically fit. They return to work as soon as their illness is controlled. To support their recuperation,
employees who have resumed working are given free accommodations, allowed flexible leave
arrangements, are shifted from night to day work or from a heavy to a light work. Employees with TB
curable within six months are given assistance in the form of PTB leaves. Patients not cured within
the same period are recommended for work transfer, an extension of leave, or disability retirement.
These good practices resulted in increased case detection, compliance rate and cure rate among the
TB patient employees of NCC. Case detection rate among the TB suspects increased from 9% in 2009
to 15% in 2010. Compliance rate and cure rate among employees found to be positive with TB were
100% in 2009. Days lost due to absenteeism among the workers were also reduced. The referral
system between the NCC and the RHU has also become more systematic. Social stigma has been
reduced and some cured patients even volunteer as peer counselors and educators.
The TB in the Workplace Program of NCC has become a venue for more open communication
between the management and workers. This paved the way for a more comprehensive family health
promotion program starting with TB DOTS. Due to its favorable outcomes, the program has been
allotted a company budget to sustain expenses incurred in implementation.
Overall, the NCC Sison experience has proven that the workplace can indeed be one of the best
venues for TB prevention and control. The corporate will of the top management and its departments
has welded the company to a closely knit partnership among various aid agencies, the DOH, the
municipal and barangay governments, and TB LINC. With the continuation of this initiative, it may
not be long before NCC reports a zero-TB incidence among its workforce, intensifying productivity
and securing the good life for all, plant-wide.

Negros Grace Pharmacy: A TB DOTS Referring Pharmacy in Negros


Occidental
The Negros Grace Pharmacy is a family-owned corporation with a chain of more than 36 drugstores
in the capital cities of Bacolod and Iloilo. The company is committed to support public and private
efforts to reduce the incidence of tuberculosis. Because of this commitment, the pharmacy
participated in the implementation of the Directly Observed Treatment Short Course or TB DOTS as a
Referral Network for this initiative in Bacolod City. Eight branches of the pharmacy in Bacolod City are
involved.
The local DOTS Referral Network mechanism aims to stimulate, increase and sustain the contribution
of the private sector in addressing TB issues. It complies with and promulgates the provisions,
implementation framework, and strategies of the National TB Program, the International Standards
for Tuberculosis Care (ISTC) and the Comprehensive and Unified Policy for Tuberculosis Control
(CUP).
The engagement of Negros Grace Pharmacy was a result of the positive response of the owner-
manager, Mrs. Bella Yao, after the advocacy training on TB prevention and control for laboratories
and pharmacies conducted by the Bacolod City Health Office and TB LINC-PTSI. This started a series
of meetings between the pharmacy owner and Philippine Tuberculosis Society, Inc. (PTSI). These
meetings eventually led to adoption of the pharmacy-based TB referral system.
The Grace Pharmacy experience proved that sales would not suffer by being part of the DOTS
referral system. Using sales data, Mrs. Yao showed that there was a minor decline in the sale of anti-
TB drugs at the start of the initiative. However, the decline was temporary and sales picked up
months after the pharmacy staff continued educating the customers. It turned out that customers
were impressed by the extra time, effort and attention to TB education that were given before sales.
The Provincial Health Office and the Bacolod health office, encouraged by the commitment of the
Pharmacy owner have provided technical assistance in the establishment of the DOTS Pharmacy
Initiative (PDI). Pharmacists and pharmacy aides were trained on the right approaches and how to
convince TB suspects to visit health facilities for their check-up, diagnosis and complete treatment
rather than to simply self-medicate.
A number of positive outcomes were realized after the installation of the PDI. There was a spike in
the number of referrals from the drugstore as attested by the staff of receiving health facilities.
Negros Grace Pharmacy realized an increase in profit despite the adoption of the referral system.
Sales from anti-TB drugs rose despite the change in the drugstores sales policy as claimed by Mrs.
Yao herself: Initially my instruction to the pharmacy staff was go ahead and sell but educate. After
our pharmacist and pharmacy assistants underwent the capability training assisted by TB LINC, the
policy became do not sell, educate first. For us, information and education was an added service.
When the patients returned, they had prescriptions.
The knowledge and skills gained by trainee pharmacists were cascaded down to other staff. The
pharmacy serves patients who come for their anti- TB medications on a daily basis. Many of them
initially came without prescriptions but this was a welcome opportunity for the pharmacy personnel to
initiate education activities. They examine patients for signs of cough that lasts for two weeks and to
rule out other co-morbid conditions. If the TB suspect is willing to enroll in DOTS, they were referred
to health centers closest to their residence and given referral forms. Internal changes took place as
well within the company. Reluctance vanished when sales gradually picked up. The involvement of
the pharmacy owner was critical in enabling the pharmacy-DOTS initiative to reach its goals.
Pharmacists and pharmacy aides of the chain now enjoy their new-found roles of educating and
counseling customers and identifying possible TB suspects. They find greater joy and fulfillment
particularly when they meet poor and disadvantaged customers who come for their medicines. TB
suspects who regularly patronize the pharmacy are given the option whether to avail or not of free
medications through the DOTS program of the DOH after proper TB diagnosis.