1. SUSTAINING DOTS AND MOVING FORWARD WITH THE STOP TB STRATEGY César Bonilla MD.

2. MORBIDITY AND INCIDENCE RATE OF TUBERCULOSIS PERU 1990-2003 Source: National Health Strategy for TB Prevention and Control (ESN-PCT) DOTSDOTS Expansion and Sustainability Start of reform and loss of leadership

3. PERIOD OF ADMINISTRATION (IN MONTHS) AT THE NATIONAL TB CONTROL PROGRAM 1991-2004 133 8 13 12 2 0 20 40 60 80 100 120 140 DR. PG SUAREZ DR. R. ACCINELLI DR. E TICONA DR. R CANALES DR. D. ZAVALA Months

4. 2 BK per SR are performed 530,000 SR were not tested 1,060,000 BK were not performed SR Tested BK + 2,4 % per every 42 SR 1 case BK + 12,500 cases of SP-PTB went undiagnosed DIAGNOSIS GAP OF SMEAR POSITIVE PULMONARY TB (SP PTB) BKs DX Años

5. MAGNITUDE OF THE MDR-TB PROBLEM IN PERU The presence of MDR-TB is the result of numerous failures by the healthcare system over time: 1.Use of ineffective treatment regimes for MDR-TB during the 80s and 90s which amplified the resistance. 2.Persistent MDR-TB cases in the community without timely access to adequate treatments which increased sources of infection with MDR bacilli among contacts. 3.Poorly defined therapeutic policies in relation to new MDR- TB cases among contacts of documented MDR-TB cases. 4.Underestimation of the magnitude of MDR-TB which prevented adequate diagnosis and treatment interventions. CHILDREN < 18 YEARS OLD WITH MDR-TB WITH ACCESS TO STAND. AND INDIV. RETREATM, AND THREE-YEAR TREND LINE PERU 1996-2004 1 5 26 32 56 92 124 173 213 y = 26,8x - 53,778 R 2 = 0,9352 0 50 100 150 200 250 300 969798990001020304 Nº of children with MDR-TB < 18 years Linear (< 18 y)

6. NEW PARADIGMS 1.Human dignity, bioethics, human rights within a health citizen context, for the control of TB and MDR-TB. 2.Comprehensive and integrated healthcare to enhance TB and MDR-TB control actions. 3.Intersectoriality, interinstitutionality and development of strategic partnerships for TB and MDR-TB control, for the advocacy and design of public policies. 4.Multidisciplinary teams made up by the healthcare team, civil society representatives and associations of people living with TB, for organizing and providing care to people with TB and MDR-TB. 5.Strategic communication.

7. Coordination, Conducting, Communication, Cooperation. Shared management, leadership and accountability. National Health Strategy for TB Prevention and Control Comité Técnico Permanente Group of Experts Strategies and Programs Technical Criteria EsSALUD Dep. of Health Scientific Associations Universities NGOs Civil Society Criteria, Strategies, Plans and Commitments Technical Specialization Criteria Strategic Management Public Health and Epidemiology MINSA Representatives Departments TECHNICAL STANDING COMMITTEE ADVISORY COMMITTEE STOP TB Committee Peru TB/HIV Co- Infection Committee National Multisectorial Health Coordinator

8. Sector Management Decentralization Modernization Health Prevention and Promotion HR Comprehensive Care Funding Democratization DOTS DOTS PLUS MINSA Multidisciplinary, Multifunctional, Intersectorial and Interinstitutional Team AMSCTraining Research Biosafety HIV/TB PAL Others Evaluation Supervision Monitoring Strategic Partnerships PPM Advocacy Social Mobilization Continuos Quality Improvement AND NATIONAL HEALTH STRATEGY FOR TB PREVENTION AND CONTROL Technical Efficiency Comprehensive Insurance Local Governments HRTAs Technologic. Developm. Institutional Culture Accreditation Service Supply and Rational Use of Drugs POLICY GUIDELINES OF THE HEALTH SECTOR HRTA: High Risk of Transmission Areas

9. MINSA Citizen Watch Institutional and Intersectorial Articulation Comprehensive Care National Health Strategy for TB Prevention and Control Public Stakeholders (Citizenship) Institutional Stakeholders AND Intersectorial Stakeholders

10. STRATEGIC PLAN 2004-2010 Ministry Decision 721-2005 Vision To consolidate and maintain by 2010 higher levels of efficiency and effectiveness by ensuring the progressive and sustained decrease of tuberculosis incidence in Peru. Mission To ensure early detection and diagnosis, as well as timely, supervised and free-of-cost treatment of people affected by TB, MDR-TB and the TB/HIV co-infection in all healthcare services in Peru, in order to reduce the TB morbidity and mortality rate as well as its social and economic implications.

11. STRATEGIC PLAN 2004-2010 RM 721-2005 General Objective To progressively and sustainably decrease TB incidence through timely, supervised and free-of-cost detection, diagnosis and treatment of people with TB in all healthcare services in the country by providing comprehensive quality care in order to reduce the morbidity and mortality rate and its social and economic implications. Impact Goal To decrease the incidence rate of smear positive pulmonary TB from 66.39/100,000 inhabitants (Annual Report ESN-PCT 2004) to 53/100,000 inhabitants by the end of 2010.

12. TS MDR-TB Building Strategic Partnerships Biosafety Training Module TS – TUBERCULOSIS Evaluation Report ESN-PCT 2004 TECHNICAL HEALTH STANDARDS (TS) AND PUBLICATIONS Tuberculosis Training Module

13. PERU STOP TB PARTNERSHIP CEREMONY FOR SETTING-UP THE COMMITTEE

14. IDENTIFICATION OF SYMPTOMATIC RESPIRATORY PATIENTS PERU 1990-2005 16 % Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

15. % CASE DETECTION, ESTIMATED RATE AND REPORTED RATE OF SP-PTB PERU 2000-2005 Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA and Global Tuberculosis Control WHO Report 2006 WHO GOAL CASE DETECTION: 70 % 96 % % Case Detection Rate of SP PTB x 100,000 inhabitants 0 20 40 60 80 100 120 200020012002200320042005 0 10 20 30 40 50 60 70 80 90 100 % DetectionReported SP PTB Estimated SP PTB

16. MORBIDITY AND INCIDENCE RATE OF TB IN PERU 1990-2005 Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA DOTS Expansión y Sostenibilidad DOTS Pico Epidemiológico Inicio de Reforma y Perdida de Liderazgo Gestión y Recuperación de liderazgo Pico Epidemiológico DOTS DOTS Expansion and Sustainability Epidemiological Peak Start of Reform and Loss of Leadership Management and Recovery of Leadership Epidemiological Peak

17. COHORT STUDIES OF NEW SP-PTB CASES 2001-2005* * First Semester **Compendium of indicators for monitoring and evaluating national tuberculosis programs WHO/HTM/TB/2004.344 Outcomes2001 % 2002 % 2003 % 2004 % 2005* % 2001-2005* % Cured9291,589,389,689,590,385 22,2333,32,73 2,2 2,42,22,12,25 Defaults33,24,34,24,33,84 0,80,91,91,10,81,13 2001 % 2002 % 2003 % 2004 % 2005* % 2001-2005* % WHO GOALS ** % 9291,589,389,689,590,385 Failures22,2333,32,73 Deaths2,2 2,42,22,12,25 33,24,34,24,33,84 Referrals 0,80,91,91,10,81,13 Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

18. Nº of MDR-TB cases enrolled in Retreatment % MDR-TB Deaths 2,641 68 14.7 % 3 % Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA CASES ENROLLED IN MDR-TB TREATMENT AND % OF DEATHS PERU 1997 – 2005

19. % Negative Culture in MDR-TB Retreatment Cases Months of Re-Treatment Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA BACTERIOLOGICAL CONVERSION AT SIXTH MONTH OF MDR-TB RETREATMENT PERU 1997 – 2006 Implementation of MDR-TB Technical Standard, New Standardized Regime and Strengthening of MDRTB-Technical Unit Implementation of Former Standardized Regime (To access this treatment patients had to go through various first-line drug treatments) Changes in Inclusion Criteria for Former Standardized Regime (Recommended for failures to primary and secondary regime)

20. Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA BUDGET OF NATIONAL HEALTH STRATEGY FOR TB PREVENTION AND CONTROL PERU 1991-2006 Average Annual Budget 1991- 2005: $ 3 000,000 USD DOTS STRATEGY: POLITICAL COMMITMENT Millions $ USD 9 780,000 $ USD

21. THE FUTURE OF THE COUNTRY IS SHAPED HAVING THEIR NEEDS IN MIND Tuberculosis can be cured Discrimination too Let us show our support and understanding towards this cause

22. Health Sector Reform: Decentralization, and the new concepts of quality care, equity, participation of civil society and information transparency, represent the most relevant aspects of the reform and an opportunity for National TB Control Programs. Without technical and regulatory support and commitment to national goals, decentralization is the main enemy of any National TB Control Program, since it dismantled all processes aimed at achieving success. Reform should be applied gradually. LESSONS LEARNED

23. Management in the National Health Strategy for TB Prevention and Control : DOTS is not only measured by its ability to provide diagnosis and treatment but also for promoting values, managerial capacity and commitment. Healthcare services must articulate supply and demand so they can be adapted to the actual health needs. An opportunity must be identified in the multifunctionality and turnover of staff. LESSONS LEARNED

24. Strategic Partnerships: TB control must incorporate new stakeholders since we have shifted from a biomedical approach to a community and participatory approach. TB is a public health issue that concerns us all. The concept of citizen rights and responsibilities must be included in the new management of the ESN-PCT. The integration of the State with the civil society allows an increase in collective health awareness. LESSONS LEARNED

25. Strategic Partnerships: The updating of the Technical Standard legitimized by the participation of civil society and organizations of people living with TB strengthens the governing role of MINSA. The participation of community health promoters enhances the DOTS strategy. The participation of organizations of people living with TB gives a human face to the social mobilization efforts aimed at controlling the disease. LESSONS LEARNED

26. Within the framework of the Millennium Development Goals and the prioritized public health objectives of the Americas, policies must be established to subsidize those affected by TB, starting with the mother and child component. Strategic multidisciplinary partnerships must be set up to monitor the extent and impact of the intervention in the poverty, exclusion and tuberculosis component. Respect for human dignity, bioethics and human rights must be promoted at all management levels in order to eradicate stigmatization and discrimination against people living with TB. NEXT STEPS

27. As part of the TB Control Strengthening in Peru, the following actions must be taken : Maintain current indicators and propose others to be used at a management level such as:  Social participation in citizen watch actions,  Incorporation of tuberculosis as a socioeconomic development indicator.  Subsidy coverage in health and nutrition (access to diagnosis, treatment and rehabilitation of complications and aftereffects). NEXT STEPS

28. As part of the TB Control Strengthening in Peru, the following actions must be taken: Improve the managerial capacity of the intermediate multidisciplinary working teams. Consider High Vulnerability Areas with High Risk of Transmission (urban-marginal areas, borderline communities, indigenous populations, people deprived of their liberty and others). Promote decentralization of care to people co-infected with TB/HIV. Continue to improve comprehensive household care (personalized care) of people co-infected with MDR-TB/HIV in accordance with the particular needs of each patient. Address the problem of incurable MDR-TB. NEXT STEPS

29. THANK YOU