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

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.

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)

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.

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..

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

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

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

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 ."

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

2006

November 2009

The New Global Strategy to Stop TB

PTSI TECHNICAL PROPOSAL RFA NO: 09-00001 PTSI TECHNICAL PROPOSAL RFA NO: 09-00001.00 “TECHNICAL ASSISTANCE TO ENHANCE PRIVATE SECTOR PARTICIPATION IN TB CONTROL” February 17, 2010 to June 30, 2011

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.  

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)

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  

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

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.

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

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

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

Initiatives in TB Control 1910 - PTS organized 1978 - Nationwide implementation of NTP 1987 - SCC in Blister-packs introduced 1992 - Local Government Code implemented 1996 - D.O.T.S. strategy pilot-tested 2002 - D.O.T.S. nationwide (98% coverage) - Pilot Testing of CDC PPM Models PhilTIPS, GFATM grant – PPM Initiatives 2006 - PBSP/TBLINC 2010 - PBSP/TBLINC/PTSI

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

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

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

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

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

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

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: 43.3 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

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

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

TB case load in the private sector, 2000 Country Retail Sales Cost / Course Estimated (USD Million) (USD) Cases India 85.3 100 853000 Indonesia 12.3 100 123000 Pakistan 11.7 100 117000 Philippines 16.6 200 83000 Bangladesh 2.3 100 23000 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

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.

363 (32%) accessed DOTS clinics 320 (88%) confirmed TB symptomatics Outcomes of TB Screening of Customers Without Prescription in PDI Pharmacies 2004-2005 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.

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.

? 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

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

GAPS AND ISSUES IN YOUR FACILITY ? GAPS AND ISSUES IN YOUR FACILITY

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?

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?

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?

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?

Proposed Strategies and Interventions The PTSI Approach Proposed Strategies and Interventions

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

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

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

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

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

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

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

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

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?