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

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Presentation on theme: "1 LALAINE L. MORTERA, MD, FPCP, FPCCP Program Manager PTSI REVISITING PRIVATE SECTOR IN TB CONTROL."— Presentation transcript:

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

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

3 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. TB: Myths and Misconceptions No TB diagnosis can be made by chest x-ray alone. International standards will recommend the use of direct sputum smear microscopy (DSSM) I can diagnose TB by chest x-ray alone.

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

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

8 WHO/IUATLD recommends DOTS Strategy ( D irectly O bserved T herapy S hort course) How is TB treated?

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: “TECHNICAL ASSISTANCE TO ENHANCE PRIVATE SECTOR PARTICIPATION IN TB CONTROL” February 17, 2010 to June 30, 2011

15 PTSI Vision and Mission VISION: 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.

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

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 1.To increase acceptance and practice of DOTS among private sector providers. 2.To improve the policy, financing and regulatory environment for private sector participation in DOTS. 3.To expand and improve the delivery of quality DOTS services in the private sector. 4.To strengthen policy and institutional governance for private sector involvement.

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

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

23 PhilCAT: fighting TB through unified action 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 THE PRIVATE SECTOR

24 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 Initiatives in TB Control

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 care At point of sale At point of service

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

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

29 PhilCAT: fighting TB through unified action 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

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

31 PhilCAT: fighting TB through unified action 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: 9.3 (1-49) TB patients in a month:53.6 (9-275) % sputum positive:17.7 (0-50) % sputum (+) referred to DOTS centers: Garcia & Benedicto (for publication) 2006 Kraft AD, et al. : UP Economics Foundation: Private Provider Study Team, March 2005 (unpublished)

32 PhilCAT: fighting TB through unified action 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%

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

34 PhilCAT: fighting TB through unified action TB case load in the private sector, 2000 Country Retail Sales Cost / Course Estimated (USD Million) (USD) Cases India Indonesia Pakistan Philippines Bangladesh Adapted from: The economics of TB drug development, 2001

35 PDI Results After 12 months of Operation: July 2004 to June 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 Outcomes of TB Screening of Customers Without Prescription in PDI Pharmacies ,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 Patient Referring MD Microscopy Any Private Diagnostic Center Flow for a TB Symptomatic X-ray AFB Results of private labs not recognized by DOH Quality of x-ray services? ?

39 FACTS 1.43% TB symptomatics SELF-MEDICATE 2.40% TB symptomatics consult PRIVATE SECTOR 3.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 4.Lack of community awareness regarding DOTS and the National TB Program

40 ? 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 The PTSI Approach Proposed Strategies and Interventions

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

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

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 D.Integration in the Curriculum E.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: DOTS Facilities: PPMD HC Pharmacy Hospital Pharmacy RCC / LGU Health System DSAP PPhA DOH CHD BFAD PHILCAT/Local Coalitions LOCAL TB CHAMPIONS CLIENT A Macroperspective of PPM Interplay Workplace M.D. HMO Workplace HMO- PPMD Hospital TBDC Microscopy PRIVATE Microscopy PRIVATE Microscopy PUBLIC Workplace

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?


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