Presentation on theme: "REVISITING PRIVATE SECTOR IN TB CONTROL"— Presentation transcript:
1 REVISITING PRIVATE SECTOR IN TB CONTROL LALAINE L. MORTERA, MD, FPCP, FPCCPProgram 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 RegionNobody 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? ExposureInfectionActive Disease Inactive DiseaseTOP PriorityActive DiseaseSTOP 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 treatmentUninterrupted drug supplyRecording and reporting
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 TBACDEPUTY EXECUTIVE DIRECTORPROGRAM MANAGEROPERATIONS MANAGERSTANDARDS & PRIVATE PROVIDERSSPECIALISTPHARMA MARKET SPECIALISTGOVERNANCE AND POLICY SPECIALISTPUBLIC INFORMATION ADVOCACY COMMUNITY MOBILIZATIONM&E PLANNING SPECIALISTFINANCE AND ADMINISTRATIVE OFFICERAREA MANAGERS (12)
18 Project Scope of WorkAssist 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 areasWork 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 ObjectiveIncrease private sector contribution in the provision of quality DOTS services.
20 Specific ObjectivesTo 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 ComponentsStrategic Objective: Desired family health sustainably achievedImproved Case Detection by Private SectorComponent 1:Policy, Financing and RegulatoryEnvironment for DOTS Implementation in the Private Sector ImprovedComponent 2:Systems Capacity forQuality DOTSImplementation in the Private Sector ImprovedComponent 3:Utilization of DOTSFacilities and Services ImprovedSubcomponents1.1: Policy development and advocacy1.2: LGU-Private Sector Partnership DevelopmentSubcomponents2.1: Private sector DOTS expansion2.2: Systems support for private DOTS practiceSubcomponents3.1: Development and implementation of a BCC strategy3.2: PPM advocacy
23 THE PRIVATE SECTORThe 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 innovationSLIDE 6. THE PRIVATE SECTORWe 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 organizedNationwide implementation of NTPSCC in Blister-packs introducedLocal Government Code implementedD.O.T.S. strategy pilot-testedD.O.T.S. nationwide (98% coverage)- Pilot Testing of CDC PPM ModelsPhilTIPS, GFATM grant – PPM InitiativesPBSP/TBLINCPBSP/TBLINC/PTSI
25 Problem StatementLocal variations in extent and quality of TB-DOTS coverageSymptomatics’ exposure to non-DOTS TB treatmentConsumer-patient behavior detrimental to desired TB-DOTS treatment outcomesLGU non-ownership of local TB control objectiveRemaining population outside TB-DOTS treatmentDOH Program Implementation ReviewJanuary 2008
26 Points of Patient Contact At point of saleAt point of careAt point of service
27 At Point of Care Patient Flow upon Consult Microscopy Patient AnyPrivateDiagnosticCenterPatientMicroscopyPatient Flow upon ConsultReferring MDX-rayFollow-upVariable practicesReporting of Infectious cases?Compliance of patients?Pharmacy
28 PRIVATE MEDICAL PROVIDERS At Point of CareWORK-BASED CLINICSPRIVATE MEDICAL PROVIDERSHOSPITALHMOFactories, large companiesSingle, multi-practice, hospital-basedIndependent /hospital-basedMulti-specialty eg. HMO, HospitalTB Clients
29 THE PRIVATE PRACTITIONER (Pre PPM and Training Period) Estimated: 20,000-35,000 smear (+) casesAverage new TB patients seen/month: 16Use 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 2002PhilCAT: fighting TB through unified action
30 DOTS Practices? Flow of Referral for DOTS Referring Doctors DOTS Trained MDPPMDUnitPatientMicroscopyDOTSPractices?Referring MDFlow ofReferral forDOTS Referring DoctorsTBDC ReferralMonthlyFollow-upRecordingReportingDOT
31 PRIVATE PRACTITIONERS (Post PPM and Training Period) 75% aware of DOTS but only 35% adopt it in their practicePulmos: 99% awareness; 59% practiceIDS: 97% awareness; 45% practiceAge: 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 (+) referredto DOTS centers:Kraft AD, et al. : UP Economics Foundation: Private Provider Study Team, March 2005 (unpublished)- Garcia & Benedicto (for publication) 2006PhilCAT: fighting TB through unified action
32 Reasons for NOT Referring to DOTS Centers Center relatedInaccessible, Doubt capabilitiesUnaware, Center not certified44.4%Medication relatedErratic drug supply, Quality48.9%Overall set-upBad experience, Unfamiliar with set-up26.7%Patient relatedNot willing, Confidentiality, Patient may be offended82.2%Practicing DOTS in clinic24.4%PhilCAT: fighting TB through unified action
33 43% At Point of Sale Flow for a TB Symptomatic Microscopy Patient AnyPrivateDiagnosticCenterPatientMicroscopyReferring MDX-ray43%Flow for a TB SymptomaticDelay in diagnosisDelay in treatmentPharmacy
34 TB case load in the private sector, 2000 Country Retail Sales Cost / Course Estimated(USD Million) (USD) CasesIndiaIndonesiaPakistanPhilippinesBangladeshSLIDE 8. ESTIMATES OF TB CASE LOAD IN THE PRIVATE SECTORThere 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, 2001PhilCAT: 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 Pharmacies1,139 Referred363 (32%) accessed DOTS clinics320 (88%) confirmed TB symptomatics298 (93%) completed sputum exams.101 (34%) confirmed TB cases60 (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 AnyPrivateDiagnosticCenterPatientMicroscopy?Referring MDX-rayAFB Results of private labsnot recognized by DOHQuality of x-ray services?Flow for a TB Symptomatic
39 FACTS 43% TB symptomatics SELF-MEDICATE 40% TB symptomatics consult PRIVATE SECTORPrivate providers on DOTS:lack of knowledge, poor adherencelack of or absence of system supportno network of treatment support groupsLimited access to quality microscopy servicesNO recording/reporting systemLack 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 ApproachProposed Strategies and Interventions
46 Entry Points for Intervention At point of saleNo Rx No DrugDOTS ReferringPharmacyAt point of careRe-training?System supportPoliciesAt point of serviceExpand DOTS Laboratory network
47 Levels of Intervention Existing PPMD:Enhance referral systemRe-trainingAccreditation/RenewalLink to DOTS networkNon-DOTS HospitalTA to establish PPM DOTS Unit
48 Levels of Intervention Pharmacy:DOTS Referring PharmacyLink to a DOTS NetworkLaboratory:DOTS Referring Laboratory
49 Strategies and Intervention A. Referral system improvementEnhance referral system with feedback mechanismExpand PPM DOTS NetworkDOTS Referring PharmaciesDOTS Referring MDsDOTS Referring laboratoriesCapability of PHO/MHOB. CUP local implementation for multi- sectoral partnership development
50 Strategies and Intervention C. Capacity BuildingEnhanced modulesTarget: MDs, labs, pharmaciesDOTS Providers TrainingISTC Orientation to hospitalsIntegration in the CurriculumBehavior change for Private providers and their clientsF. Develop mechanisms to simplify DOTS
51 The Private Sector As a DOTS Referring MD As a PPM DOTS Provider As a TBDC MemberAs a DOTS Referring LabAs a DOTS Referring PharmacyAs a DOTS Advocate
52 Operating System per Catchment Area: A Macroperspective of PPM InterplayWorkplaceDOHRCC / LGUHealth SystemWorkplaceTBDCCLIENTPHILCAT/Local CoalitionsHMO-PPMDPharmacyM.D.MicroscopyPRIVATELOCAL TB CHAMPIONSHospitalMicroscopyPUBLICDOTSFacilities:PPMDHCHMOM.D.CLIENTDSAPClient – pharmaClient – DOTSBackground – Players (DOH, Local Champions, etc)CLIENTPPhAMicroscopyPRIVATEHospitalPharmacyPharmacyTBDCCHDCLIENTWorkplaceBFAD
53 Challenge to PCCP TB Council Work plan to disseminate the ISTCAnnual conventions, RTDs, CMEsISTC orientation in your hospitalsBe active as local TB champions and serve as ISTC experts in the 12 sitesPCCP project: Target the HMOsQuezon City Practice: Stand Alone Practice DOTS Model
54 Challenge to PCCP TB Council Be active as members of TBDCMulti-sectoral consultation on PHIC TB OPBBe active members of PMA in local chapters to promote CUP – need for sector policy?Mechanisms to monitor PCCP compliance to ISTC?