1. REVISITING PRIVATE SECTOR IN TB CONTROL
LALAINE L. MORTERA, MD, FPCP, FPCCP
Program Manager PTSI

2. TB: Myths and Misconceptions
TB is not a problem in the Philippines anymore.
In reality, the Philippines ranks #9 in the world and #4 in Western Pacific Region
Nobody dies from TB.
TB is the 6th cause of death in the country.
TB is uncontrolled due to high cost of medicines.
Anti-TB medicines are available for free in many government centers, including some private health facilities.

3. TB: Myths and Misconceptions
Medicines given for free by DOH are of poor quality.
Medicines from DOH have undergone quality control testing in the same way as commercial preparations.
I can diagnose TB by chest x-ray alone.
No TB diagnosis can be made by chest x-ray alone. International standards will recommend the use of direct sputum smear microscopy (DSSM)

4. TB: Myths and Misconceptions
It is mandatory to report infectious diseases to government, but tuberculosis is an exception.
TB is one of the infectious diseases that needs to be reported.
I can individualize the diagnosis and management of my TB cases.
TB is a major public health problem and therefore diagnosis and management must be standardized according to the national TB program.

5. TB: Myths and Misconceptions
The National TB Program is only applicable for government-run facilities like the health center. The private sector follows international guidelines and standards.
I can lose my patients if I refer them to the health center or PPMD unit.
Why refer to the DOTS unit, I do not receive my PHIC reimbursements anyway..

6. How do we stop TB from spreading…
STOP IT AT ITS SOURCE!

7. How is TB spread prevented?
Exposure 
Infection
Active Disease
 
Inactive Disease
TOP Priority
Active Disease
STOP TB AT ITS SOURCE!

8. WHO/IUATLD recommends DOTS Strategy
How is TB treated?
WHO/IUATLD recommends DOTS Strategy
(Directly Observed Therapy Short course)

9. DOTS…. the way to go!
WHO 1998
" DOTS is the only TB control strategy to consistently produce 85 percent cure rates.
“DOTS is also one of the most cost-effective health interventions, compared to those available for other diseases ."

10. DOTS requires more…. Political commitment Sputum microscopy (DSSM)
Supervised treatment
Uninterrupted drug supply
Recording and reporting

11. 2006

12. November 2009

13. The New Global Strategy to Stop TB

14. PTSI TECHNICAL PROPOSAL RFA NO: 09-00001
PTSI TECHNICAL PROPOSAL RFA NO: “TECHNICAL ASSISTANCE TO ENHANCE PRIVATE SECTOR PARTICIPATION IN TB CONTROL” February 17, 2010 to June 30, 2011

15. PTSI Vision and Mission
PTSI is the premier non-government organization working for TB control in the Philippines. It is nationally known as the TB resource center involved in TB research, training, clinical management and innovative community based approaches.
MISSION:
We strive to complement the government's National TB Control Program: to instill professionalism and integrity in our organization; and to ensure our client's and donor's satisfaction through an efficient and effective delivery of services.  

17. DEPUTY EXECUTIVE DIRECTOR
TBAC
DEPUTY EXECUTIVE DIRECTOR
PROGRAM MANAGER
OPERATIONS MANAGER
STANDARDS & PRIVATE PROVIDERS
SPECIALIST
PHARMA MARKET SPECIALIST
GOVERNANCE AND POLICY SPECIALIST
PUBLIC INFORMATION ADVOCACY COMMUNITY MOBILIZATION
M&E PLANNING SPECIALIST
FINANCE AND ADMINISTRATIVE OFFICER
AREA MANAGERS (12)

18. Project Scope of Work
Assist GOP achieve overall health goal to reduce TB prevalence and mortality by 50% (MDG)  
Reach 70% CDR and 85% cure rates by strengthening/increasing private sector/private providers’ participation in TB control in project areas
Work with private and public sectors both at the national and local levels in these areas 
Will complement TB LINC activities and other TB partners

19. Overall Objective
Increase private sector contribution in the provision of quality DOTS services.

20. Specific Objectives
To increase acceptance and practice of DOTS among private sector providers.
To improve the policy, financing and regulatory environment for private sector participation in DOTS.
To expand and improve the delivery of quality DOTS services in the private sector.
To strengthen policy and institutional governance for private sector involvement.

21. Project Components
Strategic Objective: Desired family health sustainably achieved
Improved Case Detection by Private Sector
Component 1:
Policy, Financing and Regulatory
Environment for DOTS Implementation in the Private Sector Improved
Component 2:
Systems Capacity for
Quality DOTS
Implementation in the Private Sector Improved
Component 3:
Utilization of DOTS
Facilities and Services Improved
Subcomponents
1.1: Policy development and advocacy
1.2: LGU-Private Sector Partnership Development
Subcomponents
2.1: Private sector DOTS expansion
2.2: Systems support for private DOTS practice
Subcomponents
3.1: Development and implementation of a BCC strategy
3.2: PPM advocacy

22. PTSI Implementation Sites
Pangasinan
Quezon City
Bulacan
Albay
Negros Occidental
Zamboanga City
Aklan
Negros Oriental
Bohol
Compostela Valley
Marawi City
Sarangani

23. THE PRIVATE SECTOR
The Philippines has a large private sector (both profit and non-profit )
Private sector is a valuable resource available and widely utilized even by the lower income groups
…. But like any intervention that impacts on practice, it needs time… possibly innovation
SLIDE 6. THE PRIVATE SECTOR
We know for a fact that the private sector is a significant provider of health services not only in our country but elsewhere in the world.
In the Philippines, many patients, even those in the lower income groups, prefer to consult private clinics or hospitals.
This is despite the fact that many basic services are provided by the public health facilties for free.
PhilCAT: fighting TB through unified action

24. Initiatives in TB Control
PTS organized
Nationwide implementation of NTP
SCC in Blister-packs introduced
Local Government Code implemented
D.O.T.S. strategy pilot-tested
D.O.T.S. nationwide (98% coverage)
- Pilot Testing of CDC PPM Models
PhilTIPS, GFATM grant – PPM Initiatives
PBSP/TBLINC
PBSP/TBLINC/PTSI

25. Problem Statement
Local variations in extent and quality of TB-DOTS coverage
Symptomatics’ exposure to non-DOTS TB treatment
Consumer-patient behavior detrimental to desired TB-DOTS treatment outcomes
LGU non-ownership of local TB control objective
Remaining population outside TB-DOTS treatment
DOH Program Implementation Review
January 2008

26. Points of Patient Contact
At point of sale
At point of care
At point of service

27. At Point of Care Patient Flow upon Consult Microscopy Patient
Any
Private
Diagnostic
Center
Patient
Microscopy
Patient Flow upon Consult
Referring MD
X-ray
Follow-up
Variable practices
Reporting of Infectious cases?
Compliance of patients?
Pharmacy

28. PRIVATE MEDICAL PROVIDERS
At Point of Care
WORK-BASED CLINICS
PRIVATE MEDICAL PROVIDERS
HOSPITAL
HMO
Factories, large companies
Single, multi-practice, hospital-based
Independent /hospital-based
Multi-specialty eg. HMO, Hospital
TB Clients

29. THE PRIVATE PRACTITIONER (Pre PPM and Training Period)
Estimated: 20,000-35,000 smear (+) cases
Average new TB patients seen/month: 16
Use of CXR as primary diagnostic tool: 45%
Use of sputum microscopy as primary tool: 12%
Treatment adherence to NTP: 25%
Recording/reporting: Variable
-Kraft AD, et al. : UP Economics Foundation: Private Provider Study Team, March 2005 (unpublished)
Philippine Health Statistics 2002
PhilCAT: fighting TB through unified action

30. DOTS Practices? Flow of Referral for DOTS Referring Doctors
DOTS Trained MD
PPMD
Unit
Patient
Microscopy
DOTS
Practices?
Referring MD
Flow of
Referral for
DOTS Referring Doctors
TBDC Referral
Monthly
Follow-up
Recording
Reporting
DOT

31. PRIVATE PRACTITIONERS (Post PPM and Training Period)
75% aware of DOTS but only 35% adopt it in their practice
Pulmos: 99% awareness; 59% practice
IDS: 97% awareness; 45% practice
Age: 42.1 (29-75)
Years in practice: (1-49)
TB patients in a month: 53.6 (9-275)
% sputum positive: 17.7 (0-50)
% sputum (+) referred
to DOTS centers:
Kraft AD, et al. : UP Economics Foundation: Private Provider Study Team, March 2005 (unpublished)
- Garcia & Benedicto (for publication) 2006
PhilCAT: fighting TB through unified action

32. Reasons for NOT Referring to DOTS Centers
Center related
Inaccessible, Doubt capabilities
Unaware, Center not certified
44.4%
Medication related
Erratic drug supply, Quality
48.9%
Overall set-up
Bad experience, Unfamiliar with set-up
26.7%
Patient related
Not willing, Confidentiality, Patient may be offended
82.2%
Practicing DOTS in clinic
24.4%
PhilCAT: fighting TB through unified action

33. 43% At Point of Sale Flow for a TB Symptomatic Microscopy Patient
Any
Private
Diagnostic
Center
Patient
Microscopy
Referring MD
X-ray
43%
Flow for a TB Symptomatic
Delay in diagnosis
Delay in treatment
Pharmacy

34. TB case load in the private sector, 2000
Country Retail Sales Cost / Course Estimated
(USD Million) (USD) Cases
India
Indonesia
Pakistan
Philippines
Bangladesh
SLIDE 8. ESTIMATES OF TB CASE LOAD IN THE PRIVATE SECTOR
There are no good data on the number of TB cases seen in the private sector.
But we can have an idea based on sales of anti-TB drugs since drug sales in the country will be accounted for mainly by private patients. The estimate based on 2000 data is 83,000 cases. The actual number of cases may even be double this estimate if we assume a lower cost of treatment.
Adapted from: The economics of TB drug development, 2001
PhilCAT: fighting TB through unified action

35. PDI Results After 12 months of Operation: July 2004 to June 2005
170 participating pharmacies reported serving a total of 7,432 customers buying TB drugs or inquiring about TB.
Out of this customer pool, 29% were trying to obtain TB drugs without prescription.
…carefully screened for referral to a DOTS clinic for proper diagnosis and treatment.

36. 363 (32%) accessed DOTS clinics 320 (88%) confirmed TB symptomatics
Outcomes of TB Screening of Customers Without Prescription in PDI Pharmacies
1,139 Referred
363 (32%) accessed DOTS clinics
320 (88%) confirmed TB symptomatics
298 (93%) completed sputum exams.
101 (34%) confirmed TB cases
60 (59%) Smear positive.
95% of all declared TB cases were enrolled and treated in the DOTS clinics.

37. Pharmacy workers are able to pre-screen customers; thereby preventing a significant proportion from taking TB drugs unnecessarily;
True TB symptomatics, particularly those self-medicating, are identified and referred for appropriate diagnosis and treatment in the DOTS clinics.

38. ? At Point of Service Flow for a TB Symptomatic Microscopy Patient
Any
Private
Diagnostic
Center
Patient
Microscopy ?
Referring MD
X-ray
AFB Results of private labs
not recognized by DOH
Quality of x-ray services?
Flow for a TB Symptomatic

39. FACTS 43% TB symptomatics SELF-MEDICATE
40% TB symptomatics consult PRIVATE SECTOR
Private providers on DOTS:
lack of knowledge, poor adherence
lack of or absence of system support
no network of treatment support groups
Limited access to quality microscopy services
NO recording/reporting system
Lack of community awareness regarding DOTS and the National TB Program

40. GAPS AND ISSUES IN YOUR FACILITY?
GAPS AND ISSUES IN YOUR FACILITY

41. Gaps and Issues EXISTING DOTS CLINIC:
Satisfied with present referral system?
2-way referral system with feedback mechanism in place?
Need to expand network of referring sites?
Need for re-training for referring doctors?
Need to train new provider staff?
Do you have problems with PHIC reimbursements?

42. Gaps and Issues HOSPITAL Owners:
Established referral system to a DOTS facility?
Willing to install a DOTS facility in the hospital?
Existing hospital policy on TB management and reporting of cases?
Training of in-house lab personnel for DSSM?
Hospital pharmacy policy on TB drugs?
Training of in-house staff as referring MDs?
Willing to make hospital ISTC-compliant?

43. Gaps and Issues LABORATORY Owners:
Established referral system to a DOTS facility?
Willing to provide quality DSSM services?
Willing to be trained?
Willing to join the DOTS network?
Willing to be linked to DOTS referring MDs?
Existing laboratory policy for reporting AFB results? External QA system?

44. Gaps and Issues PHARMACY Owners: Willing to join the DOTS Network?
Established referral system to a DOTS facility?
Willing to be trained?
Any pharmacy policy on TB drugs?

45. Proposed Strategies and Interventions
The PTSI Approach
Proposed Strategies and Interventions

46. Entry Points for Intervention
At point of sale
No Rx No Drug
DOTS Referring
Pharmacy
At point of care
Re-training?
System support
Policies
At point of service
Expand DOTS Laboratory network

47. Levels of Intervention
Existing PPMD:
Enhance referral system
Re-training
Accreditation/Renewal
Link to DOTS network
Non-DOTS Hospital
TA to establish PPM DOTS Unit

48. Levels of Intervention
Pharmacy:
DOTS Referring Pharmacy
Link to a DOTS Network
Laboratory:
DOTS Referring Laboratory

49. Strategies and Intervention
A. Referral system improvement
Enhance referral system with feedback mechanism
Expand PPM DOTS Network
DOTS Referring Pharmacies
DOTS Referring MDs
DOTS Referring laboratories
Capability of PHO/MHO
B. CUP local implementation for multi- sectoral partnership development

50. Strategies and Intervention
C. Capacity Building
Enhanced modules
Target: MDs, labs, pharmacies
DOTS Providers Training
ISTC Orientation to hospitals
Integration in the Curriculum
Behavior change for Private providers and their clients
F. Develop mechanisms to simplify DOTS

51. The Private Sector As a DOTS Referring MD As a PPM DOTS Provider
As a TBDC Member
As a DOTS Referring Lab
As a DOTS Referring Pharmacy
As a DOTS Advocate

52. Operating System per Catchment Area:
A Macroperspective of PPM Interplay
Workplace
DOH
RCC / LGU
Health System
Workplace
TBDC
CLIENT
PHILCAT/Local Coalitions
HMO-
PPMD
Pharmacy
M.D.
Microscopy
PRIVATE
LOCAL TB CHAMPIONS
Hospital
Microscopy
PUBLIC
DOTS
Facilities:
PPMD HC
HMO
M.D.
CLIENT
DSAP
Client – pharma
Client – DOTS
Background – Players (DOH, Local Champions, etc)
CLIENT
PPhA
Microscopy
PRIVATE
Hospital
Pharmacy
Pharmacy
TBDC
CHD
CLIENT
Workplace
BFAD

53. Challenge to PCCP TB Council
Work plan to disseminate the ISTC
Annual conventions, RTDs, CMEs
ISTC orientation in your hospitals
Be active as local TB champions and serve as ISTC experts in the 12 sites
PCCP project: Target the HMOs
Quezon City Practice: Stand Alone Practice DOTS Model

54. Challenge to PCCP TB Council
Be active as members of TBDC
Multi-sectoral consultation on PHIC TB OPB
Be active members of PMA in local chapters to promote CUP – need for sector policy?
Mechanisms to monitor PCCP compliance to ISTC?