Monograph No. 11HSRA Monograph No. 11 5 TABLE OF CONTENTS FOREWORD 7 PREFACE 8 ACKNOWLEDGMENTS 9 ACRONYMS 10 EXECUTIVE SUMMARY 13 TB BURDEN AND CONTROL EFFORTS IN THE PHILIPPINES 18

HSRA Monograph No. 11 1

Monograph No. 11

2010—2016 PHILIPPINE PLAN OF ACTION TO CONTROL TUBERCULOSIS (PhilPACT)2


2010-2016PHILIPPINE PLAN OF ACTIONTO CONTROL TUBERCULOSIS

(PhilPACT)

HSRA Monograph No. 11

DEPARTMENT OF HEALTHRepublic of the Philippines


2010-2016 Philippine Plan of Action to Control Tuberculosis (PhilPACT)Health Sector Reform Agenda Monograph No. 11August 19, 2010

ISBN No. 978-971-92539-2-1

Published by the Department of Health-Health Policy Development and Planning Bureau (HPDPB)in partnership with the National Center for Disease Prevention and Control.San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, 1003 Philippines.TELEPHONE +632-781-4362 EMAIL [email protected]

An electronic copy of this publication can be downloaded at: http://www.rchsd.doh.gov.ph

The mention (if any) of specific companies or of certain manufacturer’s products does not imply thatthey are endorsed or recommended by the DOH in preference over others of a similar nature. Articlesmay be reproduced in full or in part for non-profit purposes without prior permission, provided creditis given to the DOH and/or the individual authors for original pieces. A copy of the reprinted or adaptedversion will be appreciated.

Health Sector Reform Agenda Mario C. Villaverde, MD, MPH, MPMMonograph Series Editorial Board Ma. Virginia G. Ala, MD, MPH

Lilibeth C. David, MD, MPH, MPMKenneth G. Ronquillo, MD, MPHOrville C. Solon, PhD

Health Sector Reform Agenda Leizel P. Lagrada, MD, MPH, PhDMonograph Series Rosa G. GonzalesPublications Management Team Clarissa B. Reyes

Regina C. Sobrepeña, MDDorie Lynn O. Balanoba, MDAlbert Francis E. Domingo, MDVida Zorah S. Gabe, MA

Technical Editor Emelina S. Almario

Copyeditor Arvin A. Mangohig, MA

Cover Design and Layout Ariel G. Manuel

Suggested Citation:

2010-2016 Philippine Plan of Action to Control Tuberculosis . Health Sector Reform Agenda – Monographs.Manila, Republic of the Philippines - Department of Health, 2010. (DOH HSRA Monograph No. 11).

We acknowledge the contribution of the following partners towards the facilitation and developmentof this publication’s content and preparation: The Global Fund to Fight AIDS, Tuberculosis and Malaria;The World Health Organization; and Linking Initiatives and Networking to Control TB. The UPecon-HealthPolicy Development Program, U.S. Agency for International Development Cooperating Agency, providededitorial support in the preparation of this document.


TABLE OF CONTENTSFOREWORD 7PREFACE 8ACKNOWLEDGMENTS 9ACRONYMS 10EXECUTIVE SUMMARY 13

TB BURDEN AND CONTROL EFFORTS IN THE PHILIPPINES 18Background 18

Brief Profile of the Philippines 18Basic Facts about Tuberculosis 18

Magnitude of TB Problem 18TB Prevalence, Incidence, and Mortality 18MDR-TB 20TB/HIV Coinfection 20

Socioeconomic Burden of TB 21Performance of the National TB Control Program (NTP) 21

Overall TB Control Performance in the Philippines 21Assessment of TB Service Delivery 23Assessment of the Regulatory Environment of TB Control 29Assessment of Governance in TB Control 31Financing of TB Control 33

ASSESSMENT OF THE 2006–2010 NATIONAL STRATEGIC PLAN TO CONTROL TB 35

THE 2010–2016 PHILIPPINE PLAN OF ACTION TO CONTROL TB (PhilPACT) 38Philippine Health Sector Reform and Stop TB Partnership 38Strategic Thrusts for 2010–2016 41Strategies, Performance Targets, and Activities 41STRATEGY 1: Localize implementation of TB control 41STRATEGY 2: Monitor health system performance 44STRATEGY 3: Engage both public and private health care providers 45STRATEGY 4: Promote and strengthen positive behavior of communities 47STRATEGY 5: Address MDR-TB, TB/HIV, and needs of the vulnerable populations 49STRATEGY 6: Regulate and make available quality TB diagnostic tests and drugs 52STRATEGY 7: Certify and accredit TB care providers 54STRATEGY 8: Secure adequate funding and improve allocation and

efficiency of fund utilization 56

Financing Requirements 81Monitoring and Evaluation 85

MOVING PhilPACT FORWARD 88Alignment with Other Planning Frameworks 88Contribution to Global Efforts for TB Control 88Jumpstarting PhilPACT I mplementation 91

ANNEXES 93ANNEX 1: Composition and Tasks of the Steering Committee and

Task Force for the TB Control Plan 93ANNEX 2: List of Participants in the July 8–9, 2009, and

August 6–7, 2009, Consultative Workshops 95 Held at the Grand Opera Hotel, Manila

ANNEX 3: Proposed DOTS Service Packages 97ANNEX 4: Monitoring and Evaluation Matrix 100

REFERENCES 111


LIST OF TABLES AND FIGURES

TABLE 1. TB Burden for Global, Western Pacific Region, and Philippines, 2007 19

TABLE 2. TB Magnitude in 1982, 1997, and 2007, Philippines 20

TABLE 3. Health Care Providers Consulted by TB Suspects (%), 1997 and 2007 27

TABLE 4. Strategies, Performance Targets, Activities, and Time Frame 58

TABLE 5. PhilPACT Financing Requirements by Strategy and Year in Philippine Pesos 82

FIGURE 1. Trends of CDR, Cure Rate, and Treatment Success Rate, 2003–2008, Philippines 22

FIGURE 2. Case Detection Rate (%) by Region, 2008 22

FIGURE 3. Treatment Outcome (%) of 2007 Cohort of New Smear Positive TB cases 22

FIGURE 4. Cure and Completion Rates by Region, 2007 Cohort 22

FIGURE 5. Estimated Annual Financing Requirements of PhilPACT from 2010–2016in Philippine Pesos 83

FIGURE 6. Distribution of Estimated PhilPACT Cost by Major Strategy 83

FIGURE 7. Share of PhilPACT F inancing by Stakeholder/Source 83

FIGURE 8. Estimated Funding Gap, 2010–2016 84


FOREWORDIn January 2009, the National Center for Disease Prevention and Control (NCDPC) of the Department of

Health (DOH) started the task of reviewing and updating the 2006–2010 National Strategic Plan to control TB.The task was spurred by its desire for the Philippines to achieve the millennium development goals (MDGs)for TB control in 2015.

In bringing the Plan forward to 2016, the DOH saw the need to:

align the TB control strategic direction with the sectorwide approach of the Health Sector ReformAgenda and incorporate the TB control plan within the Provincewide/ARMM/Citywide InvestmentPlans for Health;

define the long-term actions to address key issues and constraints identified by various programevaluation and monitoring teams;

utilize the results of 2007 National TB Prevalence Survey (NPS) to generate better estimates ofthe TB epidemiological situation and set realistic programmatic targets;

strategize how substantial resources from the government, FAPs, and other sources could beeffectively and efficiently utilized; and

identify how to maximize recently developed technologies and global guidelines to achieve theMDGs for TB control.

With the concurrence of the Technical Assistance Coordination Team (TACT) of DOH, NCDPC mobilized technicaland logistical support from the Global Fund Against AIDS, TB, and Malaria; the World Health Organization; and theUnited States Agency for International Agency (USAID) through the Linking Initiatives and Networking to ControlTB (TB LINC) and the Health Policy Development Program (HPDP). DOH organized two groups to work on the planwith the issuance of Department Personnel Order (DPO) No. 2009-2125. The Steering Committee, chaired by theDirector of the NCDPC and cochaired by the Director of the Infectious Disease Office (IDO), provided policy andstrategic oversight while the Task Force (TF), headed by the NTP manager and assisted by the short term consultantof WHO, conducted the situational assessment, drafted the strategic plan, and convened consultations withstakeholders. (Annex 1 presents the composition and functions of the two groups.) TACT reviewed and approvedthe TF outputs endorsed by the Steering Committee.

To carry out its functions, the TF relied on guidelines provided by the health sector/logical framework andthe four implementation pillars of health sector reform. It systematically assessed the TB burden and TBcontrol efforts in the Philippines through the review of published and unpublished literature and interviewsof key informants. The resulting comprehensive situational assessment (SA) report became the basis for the2010–2016 Philippine Plan to Control TB (PhilPACT).

The PhilPACT was then presented for a critical review by stakeholders through two consultative workshops.NCDPC pursued this multisectoral and broad based participation not only to solicit inputs to the plan but also tostrengthen its linkages with partners and ensure support from the different stakeholders. The first consultation,held on July 8–9, 2009, at the Grand Opera Hotel in Manila, focused on the goals, strategies, performance targets,and activities. The second consultation, held on August 5–6, 2009, at the same venue, reviewed the results of thefirst and discussed the needed financial plan including resource requirements, implementing arrangements,and monitoring and evaluation plan. Eighty participants attended the first consultation while 70 participantscame to the second. (Annex 2 presents the list of participants for the two workshops.)

The PhilPACT is intended to serve as a road map to reduce TB to a level where it is no longer a public healththreat in the country. Expected users are policy makers, managers of TB control program at all levels,implementers, local and international partners, and everyone who dreams of and is committed to workingtowards a TB-free Philippines.

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PREFACE

Tuberculosis (TB) remains a major public health problem, ranking 6th among the 10 leading causes ofmortality in the country, making the Philippines 9th globally among 22 high TB-burdened countries accordingto the World Health Organization (WHO).

Significant progress has been achieved since the Philippines adopted the Directly-Observed Treatment,Short Course (DOTS) Strategy at the end of 1996 and has had 100% DOTS population coverage by the publicsector since the end of 2002. Because of government efforts to rectify and improve health care delivery, therehas been impressive and dramatic increase in the detection and cure rates for TB. While a strong groundworkhas been placed, acceleration of efforts is entailed to expand and sustain successful TB control. All stakeholdersare called upon to achieve the TB targets linked to the Millennium Development Goals (MDGs), set to bereached by 2015. Much remains to be done.

The 2010–2016 Philippine Plan of Action to Control TB (PhilPACT), defined by multisectoral, broad basedcollective and technical inputs from various national and local agencies and partners, underlines the keystrategic approaches towards achieving these targets at the national level. The Plan is in line with the fourpillars of the Health Sector Reform Agenda which emphasize governance, particularly in localizedimplementation and universal access to DOTS. This also includes a responding plan to the needs of multi-drugresistant TB (MDR-TB), HIV/TB Coinfection, and the vulnerable populations, such as TB in Children, TB in Jail/Prisons, and the Indigenous People.

Once again, the National Tuberculosis Control Program (NTP) enjoys a high political commitment especiallyin the context of the DOH plan. The NTP is spearheading once again a more comprehensive strategic plan thatwould incorporate the TB control plans to the Provincewide/ARMM Investment Plan for Health (PIPH/AIPH).

A sound strategy and a strong partnership between local government units, civil society, technical andfinancial partners are the keys to the success of the plan. Together, we can reduce by half the TB prevalenceand mortality until it is no longer a public health threat, bringing us closer to our vision of a TB-Free Philippines.

Enrique T. Ona, MD, FPCS, FACS Secretary of Health

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ACKNOWLEDGMENTS

CONTRIBUTORS AND RESOURCE PERSONS

Special thanks are due to all the people whose collaborative efforts went to this final documentation ofthe 2010–2016 Philippine Plan of Action to Control TB.

Both functioned in providing invaluable technical and administrative assistance.

MEMBERS OF THE STEERING COMMITTEE

Chairperson Dr. Yolanda E. Oliveros, Director IV, NCDPC, DOH

Alternate Chairperson Dr. Jaime Y. Lagahid, Director III, IDO, DOH

Vice Chaiperson Dr. Rosalind G. Vianzon, NTP Manager, IDO DOH

Members Dr. Virginia Ala, Director IV, BIHC, DOHMs. Maylene Beltran, Director IV, BIHC, DOHDr. Lilibeth David, Director IV, BLHD, DOHDr. Jocelyn Gomez, PHO–BulacanDr. Albert P. Herrera, CHO–MarikinaDr. Leda Hernandez, M.O. VII, IDO, DOHDr. Woojin Lew, Medical Officer, WHO Country OfficeMs. Arlene Ruiz, Chief, HNFP Division, NEDAMs. Amelia Sarmiento, Executive Director, PhilCATDr. Padma Shetty, Chief, Office of Health, USAIDDr. Madeleine Valera, SVP, Health F inance, PHIC

Secretariat Dr. Ernesto Bontuyan Jr., M.O. IV, NTP–IDOMr. Lorenzo Reyes, M&E Coordinator, GFATM

MEMBERS OF THE TASK FORCE (TECHNICAL WRITING GROUP)

Chairperson Dr. Rosalind G. Vianzon, NTP Manager, IDO DOH

Vice Chairperson Dr. Mariquita J. Mantala, Short-term Consultant, WHO

Members Dr. Ma. Cecilia Ama, NTRL–RITMDr. Mar Wynn Bello, BIHCDr. Liezel Lagrada, HPDPBDr. Carlo Panelo, HPDPDr. Carlos Antonio Tan, HPDPDr. Ann Remonte, PhilHealthDr. Dennis Batangan, TB LINCDr. Arthur Lagos, TB LINC

Secretariat Dr. Winlove Mojica, HPDPMs. Yasmine Hashimoto, TB LINC


ABBREVIATIONS AND ACRONYMS

ACSM Advocacy, Communication, and Social Mobilization

AIDS Acquired immunodeficiency syndrome

AO Administrative order

ARMM Autonomous Region in Muslim Mindanao

BHFS Bureau of Health Facility Services

BHS Barangay health station

BHW Barangay health worker

BIHC Bureau of International Health Cooperation

BJMP Bureau of Jail Management and Penology

BLHD Bureau of Local Health Development

BuCor Bureau of Corrections

CBO Community-based organization

CDR Case detection rate

CHD Center for Health Development

CHO City health office/officer

CIPH City Investment Plan for Health

CNR Case notification rate

CR Cure rate

CUP Comprehensive Unified Policy

DALY Daily adjusted life year

DepEd Department of Education

DILG Department of the Interior and Local Government

DOH Department of Health

DOJ Department of Justice

DOLE Department of Labor and Employment

DOT Directly observed treatment

DOTS Directly observed treatment, short-course

DRS Drug resistance survey

DSSM Direct sputum smear microscopy

DST Drug susceptibility test

DSWD Department of Social Welfare Development

EO Executive order

EQA External quality assurance

ETR Electronic TB registry

F1 FOURmula One for Health (Health Sector Reform in the Philippines)


FAP Foreign-assisted project

FDC Fixed dose combination

FHSIS Field Health Service Information System

GAA General Appropriations Act

GDF Global Drug Facility

GIDA Geographically isolated and depressed area

GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria

HC Health center

HCP Health care provider

HIV Human immunodeficiency virus

HPDP Health Policy Development Program

HPDPB Health Policy Development and Planning Bureau

HUC Highly urbanized city

IDO Infectious Disease Office

IEC Information, education, and communication

ILHZ Interlocal Health Zone

ISTC International Standards on TB Care

JAC Joint Appraisal Committee

JATA/RIT Japan Anti-TB Association/Research Institute of TB

KAP Knowledge, attitudes, practices

LCE Local chief executive

LCP Lung Center of the Philippines

LGU Local government unit

LHB Local health board

M&E Monitoring and evaluation

MC Microscopy center

MDG Millennium development goal

MDR-TB Multidrug resistant tuberculosis

ME3 Monitoring and evaluation for effectiveness and equity

MHO Municipal health office/officer

MOP Manual of procedures

NCC National Coordinating Committee

NCDPC National Center for Disease Prevention and Control

NCHFD National Center for Health Facility Development

NCHP National Center for Health Promotion

NCIP National Commission on Indigenous Population

NDHS National Demographic Health Survey

NEC National Epidemiology Center

NEDA National Economic and Development Authority

NGO Nongovernment organization


NOH National Objectives for Health

NPS/NTPS National TB Prevalence Survey

NTP National Tuberculosis Control Program

NTRL National TB Reference Laboratory

OOP Out-of-pocket

P2P Public-to-public

PBG Performance-based grant

PCC Provincial Coordinating Committee

PIPH Provincewide Investment Plan for Health

PhilCAT Philippine Coalition Against Tuberculosis

PhilHealth/PHIC Philippine Health Insurance Corporation

PhilPACT Philippine Plan of Action to Control TB

PHO Provincial health office/officer

PHS Philippine Health Statistics

PIR Program Implementation Review

PP Private practitioners

PPMD Public-Private Mix DOTS

PTSI Philippine Tuberculosis Society Inc.

QAS Quality assurance system

RCC Regional Coordinating Committee

RDC Regional Development Council

RHU Rural health unit

RICT Regional Implementation and Coordination Team

RITM Research Institute and Tropical Medicine

SA Situational assessment

SteerCom Steering Committee on the TB Control Strategic Plan Development

TA Technical assistance

TACT Technical Assistance and Coordination Team

TB Tuberculosis

TBDC TB Diagnostic Committee

TB-DOTS OPB Package TB-DOTS Outpatient Benefit Package

TB LINC Linking Initiatives and Networking to Control TB

TDFI Tropical Disease Foundation Inc

TF Task Force on the TB Control Strategic Plan Development

TSR Treatment success rate

USAID United States Agency for International Development

WHO World Health Organization

WPR Western Pacific Region

WPRO Western Pacific Regional Office

WV World Vision


EXECUTIVE SUMMARY

From January to September 2009, the National Center for Disease Prevention and Control (NCDPC) of theDepartment of Health (DOH) led the process of formulating the 2010–2016 strategic plan to control TB in thePhilippines in collaboration with partners. To do this, two groups were formed: a Steering Committee thatprovided oversight and guided the planning process, and a Task Force that conducted the situationalassessment, drafted the plan, and convened consultation workshops with stakeholders.

In drafting the plan, the Task Force considered the following key findings from its situational assessment ofthe TB burden and control efforts in the Philippines:

Tuberculosis is a major public health problem in the Philippines. The country ranks ninth in the listof 22 high TB burden countries. The 2007 National TB Prevalence Survey found that the prevalencerate of smear (+) TB was 2 per thousand and culture (+) was 4.7 per thousand. TB prevalence andmortality rates have been declining since 1990; but based on the 2007 NTPS, the current annual rateof decline will not be enough to meet the MDG on prevalence. In 2005, TB was the number 6 causeof deaths with a mortality rate of 31.2/ 100,000.

Through the National TB Control Program (NTP), the Philippines achieved the global targets of 70%case detection rate (CDR) and 85% treatment success rate in 2004 and has sustained them. However,eight of the 17 regions did not achieve the CDR target while performance of provinces and citiesshowed wide variation.

The DOTS strategy, introduced in 1996, is available in almost all rural health units and health centersas well as some privately initiated Public-Private Mix DOTS (PPMD) facilities. However, other healthcare providers such as hospitals, private practitioners, and other government health facilitiesgenerally provide TB services that are not in accordance with NTP policies and standards.

Direct sputum smear microscopy (DSSM) is generally available in most municipalities but relativelyinaccessible in some cities and underserved areas. Only around 60% of the microscopy center (MCs)provide DSSM within the external quality assurance (EQA) standards. Drugs for the entire durationof treatment are provided free of charge. In 2008, there was a widespread shortage of first-lineanti-TB drugs in the DOTS facilities due to problems with central procurement.

Initiatives are in place to engage all the health care providers through the PPMD, the hospital DOTS,the Comprehensive Unified Policy (CUP) mechanism, and the promotion of the InternationalStandards of TB Care (ISTC).

Although awareness of TB is high among the general population, knowledge on causation,transmission, and DOTS is generally low. Health-seeking behavior leaves much to be desired asmajority still consult non-DOTS providers. Poor treatment outcomes are registered in someprovinces and cities while DOTS is not strictly observed in several areas. Efforts to increase access toDOTS by vulnerable populations have to be strengthened.

Advocacy, social mobilization, and communication (ACSM) activities are being done in collaborationwith partners but the quality of information, education, and communication (IEC) materials isuneven and support is inadequate. Community participation in TB control through the barangayhealth workers (BHWs) and community-based organizations remains minimal.

Strong political commitment exists at the national level but local government unit (LGU) supportand ownership of the TB control program varies.

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Although routine recording and reporting are in place to track program performance and surveys areconducted to measure the TB burden, there are problems in generating, reporting, and using TBdata.

Various studies attest to the financing gap for the TB control program. Although the nationalgovernment has substantially increased its budgetary support to NTP, LGU support is variable andoften not sustained. PhilHealth provides some funding for the TB control through the outpatientbenefit package and payment for inpatient services of its members with TB. Resources are alsoprovided by the foreign assisted projects (FAPs). Still, the TB program is characterized by fundinginadequacy and inefficiency of fund utilization, such that out-of-pocket expenditures remainsubstantial and serve as an access barrier to DOTS.

Using the key findings of the situational assessment as the starting point for discussion, the TF formulatedand developed the 2010–2016 Philippine Plan of Action to Control TB (PhilPACT) in consultation withstakeholders. The vision is a TB-free Philippines. The goal is to reduce by half TB prevalence and mortalityrates compared to 1990 figures. The CDR target is marked at 85% of incident cases; the treatment success rateshould be at least 90%.

To achieve the goal and targets, PhilPACT has four objectives, eight strategies, and 30 performance targets.

OBJECTIVE STRATEGY PERFORMANCE TARGET

Reduce local variation 1. Localize implementation of 1.1. 70% of provinces and highlyin TB control program TB control urbanized cities (HUCs)performance include clear TB control plan(Governance) within the Provincewide

Investment Plan for Health(PIPH) or ARMM InvestmentPlan for Health (AIPH) or CityInvestment Plan for Health(CIPH)

1.2. 70% of provinces/HUCs are atleast DOTS compliant

1.3. 90% of priority provincesand HUCs with performancegrants have achieved programtargets

1.4. DOH and partners have capacityto provide technical assictance(TA) to provinces and cities

1.5. Public-private coordinatingbody on TB control atnational, regional, andprovincial levels establishedand sustained to includeComprehensive Unified Policy(CUP) mechanism

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2. Monitor health system performance 2.1. Trend of TB burden tracked

2.2. TB information generated on time,analyzed, and used

2.3. TB information system integratedwith national monitoring andevaluation (M&E) and FieldHealth Services InformationSystem (FHSIS)

Scale up and sustain 3. Engage both public and private health 3.1. 60% of all DOTS facilities in thecoverage of care providers provinces with provincialDOTS implementation private practitioners (PP)(Service delivery) mechanisms have a functional

public-private collaboration/referral system (service deliverylevel)

3.2. 90% of public hospitals and 65%of private hospitals areparticipating in TB control, eitheras DOTS provider or referringcenter

3.3. 70% of 9,000 targeted PPs arereferring patients to DOTSfacilities

3.4. All frontline health workers areequipped to deliver TB services

4. Promote and strengthen positive 4.1. Proportion of TB symptomaticsbehavior of communities who are self-medicating and not

consulting reduced by 30%

4.2. Default rate of provinces andcities with >=7% reduced by 40%

4.3. Number of barangays that haveorganized community-basedorganizations (CBOs)participating in TB control andthat are linked with DOTSfacilities increased by 50%.


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5. Address MDR-TB, TB/HIV, and needs of 5.1. A total of at least 15,000 MDR-TBvulnerable populations cases have been detected and

provided with quality-assuredsecond-line anti-TB drugs

5.2. TB/HIV collaborative activitiesestablished in areas withpopulations having high riskbehavior and with at least 80% ofTB cases tested for HIV

5.3. Nationwide implementation ofchildhood TB control program

5.4. DOTS services accessible to allinmates with TB

5.5. Policies, operational guidelines,and models developed,disseminated, and locallyadopted to address needs ofvulnerable populations

Ensure provision 6. Regulate and make available quality 6.1. TB laboratory network managedof quality TB services TB diagnostic tests and drugs by the National TB Reference(Regulation) Laboratory to ensure that 90% of

all microscopy centers are withinEQA

6.2. TB microscopy services expandedin cities and underserved areas

6.3. Every province and HUC withaccess to functional TBDiagnostic Committee

6.4. Quality-assured anti-TB drugsalways available in DOTSfacilities

7. Certify and accredit TB care providers 7.1. At least 70% of DOTS facilitiesare DOH/PhilCAT-certified andPhilHealth-accredited

7.2. Standards for hospitalparticipation in TB controlincluded in DOH licensing andPhilHealth accreditationrequirements



7.3. Infection control measures inplace in all treatment centers/sites and DOTS centers

Reduce out-of-pocket 8. Secure adequate funding and improve 8.1. Reduced redundancies and gapsexpenses related to allocation and efficiency of fund by harmonizing financing of TBTB care utilization prevention and control(F inancing)

8.2. National government fundsleveraged to secure LGU andPhilHealth commitments

8.3. PhilHealth’s role expandedthrough greater availability ofaccredited providers andincreased utilization of TB-DOTSpackage

The total cost of the plan is PhP23 billion with Strategies 5 and 6 accounting for 62% of the requiredresources. Funding sources are foreign assisted projects (33%), national government (38%), local governmentunits (14%), out-of-pocket (14%), and PhilHealth (1%). The estimated total funding gap is PhP6.9 billion.

PhilPACT has an M&E plan that defines the plan’s indicators and data management system. M&Eimplementation will be coordinated by the Health Policy Development & Planning Bureau, with support fromthe National Center for Disease Prevention and Control and the National Epidemiology Center. Throughoutthe plan’s implementation, annual performance reports will be prepared and disseminated. Midterm andterminal evaluations will be conducted as well.

The Department of Health, through NCDPC, is the overall coordinator for PhilPACT implementation withsupport from the Center for Health Development at the regional level and PHO/CHO at the provincial/citylevel. Public-private coordinating groups will assist these organic units: National Coordinating Committee,Regional Coordinating Committee, and provincial/city PP group. Public and private DOTS facilities will act asservice delivery points.

The plan is aligned with the Philippine health sector reform initiatives and the global TB control plan. Itsemphasis on governance, especially localized implementation and the universal access to DOTS, as well asresponding to the needs of MDR-TB, TB/HIV coinfection and vulnerable populations, may well serve as amodel for other countries in their respective TB control programs. The next critical steps for PhilPACT includethe development of implementing guidelines, enhancement of its implementing arrangements, andmobilization of support from various stakeholders.


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TB BURDEN ANDCONTROL EFFORTSIN THE PHILIPPINES

BACKGROUND

Brief Profile of the PhilippinesSituated in Southeast Asia, the Philippines is an

archipelago of 7,107 islands with a land area of300,000 square meters. As of March 2008, thecountry was divided into 17 regions, 81 provinces,136 cities, including 16 highly urbanized cities(HUCs) and one urban munic ipality, 1,495municipalities, and 42,008 barangays.

Its 2007 population based on the national censuswas 88,574,614; this went up to an estimatedpopulation of 92,230,0002 in 2009 based on an annualpopulation rate of 2.04%. In 2000, the female-maleratio was 101:4, with life expectancy higher amongfemales at 74.34 years compared to males at 68.81years. In the same year, the population distributionaccording to age groups was 37% for the 0 to 14years old age group, 59% for the 15 to 64 years oldage group, and 4% for those 65 years old and above.

In 2006, 24% of Filipino families were not ableto earn enough to meet the daily food and nonfoodrequirements, with 4.7 million families in thecountry considered poor. Among the regions,poverty incidence was highest in the AutonomousRegion in Muslim Mindanao (ARMM), where it wasestimated that more than 55% of families werepoor. NCR had the lowest percentage of poorfamilies at 7.1%. In 2008, the national povertyincidence was 26.9% of the population with averageannual family income at PhP147,000.3 The literacystatus in the country, based on the 2003 FunctionalLiteracy, Education, and Mass Media Survey(FLEMMS), was 93% simple literacy, 84% functionalliteracy, and higher among females.2

The country has a decentralized health deliverysystem that is managed by the DOH andimplemented by the local government units (LGUs)in accordance with the Local Government Code of

1991. The private sector is also a substantial providerof health care. Total health expenditures in 2005were PhP180.8 billion (3.3% of GDP).2 The majorsources of health care financing were out-of-pocketexpenses, followed by the government. The socialhealth insurance program managed by thePhilippine Health Insurance Corporation(PhilHealth) covers 66 million active membersserved through 1,536 hospitals and 1,211 healthcenters.

Basic Facts about TuberculosisTuberculosis is a disease caused by a bacteria

called Mycobacterium tuberculosis that is mainlyacquired by inhalat ion of infectious dropletscontaining viable tubercle bacilli. Infectiousdroplets can be produced by coughing, sneezing,talking, and singing. Coughing is generallyconsidered as the most efficient way of producinginfectious droplets and exposing other people tothe TB bacilli. These droplets are produced mainlyby patients with respiratory TB, especially thosewho are positive by sputum smear microscopy. Only10% of those infected with TB will develop thedisease.4 Majority of cases have TB of therespiratory tract particularly the lungs, andapproximately 15% of cases have extra-pulmonaryTB. Infectiousness and case fatality among TB casesare generally higher among smear positive cases.5

Diagnosis is primarily through the direct smearsputum microscopy. Treatment is for at least sixmonths. BCG vaccine prevents fatal forms of TBamong children.

MAGNITUDE OF TB PROBLEM

TB Prevalence, Incidence, and MortalityWorldwide, there were 9.27 million incident

cases of TB in 2007, of which 4 million were smearpositive cases. Asia accounted for 55% of the caseswhile Africa contributed 31%.6 Table 1 shows thatin 2007, the estimated TB incidence, prevalence,and mortality rates of the Philippines were highercompared to the average global and regional(Western Pacific Region) levels.


The Philippines ranked ninth among the 22 high-burden countries that accounted for 80% of the TBburden. This is two ranks lower than the seventhplace that the country occupied in 1998.

The national TB prevalence survey carried outin 2007 showed that the prevalence rate of smearpositive TB was 2 per 1,000 (200 per 100,000) whileculture positive was 4.7 per 1,000 (470 per100,000).7 Prevalence increased with age.Bacteriologically confirmed TB was higher amongmales compared to females, with rates of 3.5/1000versus 1.9/1000 for smear (+) TB, and 9.3/1000versus 3.5/1000 for culture (+) TB, respectively.There were, however, no statistical differences inprevalence of X-ray positive, smear positive, andculture positive by strata. In 2009, bacteriologicallypositive TB cases in the Philippines was estimatedto be around 430,000. Twelve million (13% of thepopulation) were est imated to be TBsymptomatics, i.e., had signs and symptoms of TB.

The increase of TB prevalence with age iscorroborated by the results of the WHO analysis ofTB notification rates from 2000 to 2006.8 The rate ofsputum smear-positive TB for both males andfemales increased with age, peaking for the agegroup of 55 to 64 years old, and decreasing starting

at the age of 65 years old. The sex rat io(male:female) was about two to one for all agegroups.

The last 25 years experienced a declining trendin prevalence of smear positive and culturepositive, as well as annual risk of TB infection inthe Philippines as shown by Table 2.7, 9 , 10

Comparing the 1997 and 2007 findings, the 2007study concluded that the “burden of the TB diseasehas declined over the past ten years since thelaunching of the DOTS program.” It estimated a “38%decline in the prevalence of culture-positive PTBand a 28% decline in smear positive PTB.” However,the prevalence of those with X-ray findingssuggestive of TB was “significantly higher in allstages of the disease.”

Based on an analysis done by WHO, global TBprevalence and mortality have cont inuouslydeclined from 1990 until 2006. In the Philippines,these two indicators had declined by around 45%from 1990 until 2006.8 In 2006, WHO projectedthat the Philippines would meet the MDG targetsin 2015. This projection, may not be met giventhe lower annual rate of decline of the TBprevalence of only around 2% as revealed by the2007 NTPS.

TABLE 1. TB Burden for Global, Western Pacific Region, and Philippines, 2007

Indicator Global WesternPacificRegion Philippines

TB incidence rate, all forms (per 100,000) 139 108 290

Estimated incident cases 9.27 million 1.92 million 255,084

TB incidence, smear positive (per 100,000) 61 48 130

Estimated smear positive cases 4 million 0.86 million 114,701

TB prevalence rate (per 100,000) 206 197 500

Estimated prevalent cases 13.7 million 3.5 million 440,035

Mortality rate 20 16 41

Number of deaths 1,756,000 36,305

Source: Global TB Control 2009, WHO

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Due to the prohibitive cost of a national TBprevalence survey, TB burden data could only begenerated on a national basis. Regional variationsin TB burden, though, were demonstrated by asurvey done in three regions in 1992. The studyrevealed that the risk of TB infection in childrenaged 6–8 years was 1.9% in Region 5, 1.6% in Region8, and 1.2% in Region 10.11

TB was number 6 among the 10 leading causesof mortality with 26,588 deaths and a mortalityrate of 31.2 per 100,000.12 The sex-specificmortality rate for males was 42.5, or a total of18,229 deaths, vis-à-vis 19.7 for females, or a totalof 8,359 deaths. Of these TB deaths, 63.8% or 9,632were not medically attended, hence diagnosis wasbased on data provided by lay informants. Thecompleteness of mortality data was also affectedby compliance with report ing on deaths. Forexample, deaths in ARMM were generally leftunreported as a cultural practice. TB mortalityvaried greatly by region and by province. In 2004,the highest TB mortality rate was registered bythe Western Visayas Region (51.4) while thelowest rate was reported by ARMM (5.2). The topfive provinces and cities in terms of TB mortalityrate were Guimaras, Silay City, Himamaylan,Bacolod City, and Bago City. All these areas are inWestern Visayas.

WHO has a higher estimate of TB mortality inthe country compared to the PHS report. In 2005,the WHO estimate was 47 per 100,000 while the

PHS figure was 31.2. The 1990 baseline data forMDG also diverged at 87 for WHO and 39.1 for PHS.

MDR-TBThe 2003–2004 national Drug Resistance Study

(DRS) revealed that the prevalence of MDR-TBamong new cases was 3.8%; among previouslytreated it was 20.9%; the resulting combined figurewas 5.7%.13 This placed the Philippines at 9th placeamong the 27 countries with 85% of the globalburden of MDR-TB. In 2007, WHO estimated 12,125MDR-TB cases in the country (all forms) and 6,451among the smear positive cases.6 Based on the 2007NTPS, the “combined MDR-TB rate was lower in 2007at 3.9% compared to 1997 at 4.3%.”

TB/HIV CoinfectionIn 2007, an estimated 7,490 adults were living

with HIV with the prevalence of 0.0168%.14 Theestimates were based on the Workbook Methodprescribed by UNAIDS/WHO for countries with lowlevel and concentrated epidemics. The most-at-riskpopulation groups were partners of former andcurrent overseas F ilipino Workers (OFWs), femalepartners of men having sex with men (MSM), andmale clients of female sex workers. The WHOestimated the prevalence of HIV among TB patientsin the country at less than 1%. No rout inesurveillance system for HIV and TB coinfection is inplace in the country.

TABLE 2. TB Magnitude in 1982, 1997, and 2007, Philippines

Indicator 1981–82 1997 2007

Estimated prevalence of

Smear positive TB cases/1000 6.6 3.1 2.0

Culture positive TB cases/1000 8.6 8.1 4.7

Radiographic findings suggestive of TB (percent) 4.2 4.2 6.3

Multidrug resistant among new cases (percent) 1.5 2.1

TB symptomatics (percent) 17.0 18.4 13.5

Annual risk of infection (percent) 2.5 2.3 2.1

Source: National TB Prevalence Survey, 1982–83, 1997, 2007


Socioeconomic Burden of TBIn 2003, it was estimated that over 500,000

disability adjusted life years (DALYs) were lost dueto illness and premature mortality from TB in thePhilippines annually. This was equal to 9% of allyears of life lost. The combined economic lossesdue to premature mortality and morbidity totaledPhP8 billion.15

The economic burden of TB largely due topremature deaths and lost productivity in thePhilippines from 2006 to 2015 is $US131.24 billionwithout DOTS. With sustained DOTS, this could bereduced to $US81.49 billion and with the GlobalPlan, to $US8.04 billion. The benefit cost ratios are263 and 219, respectively.16

PERFORMANCE OF THENATIONAL TB CONTROLPROGRAM (NTP)

In 1997 the DOH, through the NTP, adopted theWHO-recommended DOTS strategy. The DOTSstrategy has five key elements:

Political commitment to implement andsustain the program;

Diagnosis of cases using TB bacteriologyparticularly quality-assured sputum microscopy;

Regular and uninterrupted supply of anti-TBdrugs and other supplies;

Standardized TB chemotherapy with directobservation of treatment (DOT) by aresponsible treatment partner; and

Standardized recording and reporting systemthat allows the monitoring and evaluation ofthe program, and of the individual cases whounderwent treatment.17

The NTP has a passive case finding policy anddiagnosis is mainly through three sputum smearexaminations done over two days.18 However,pat ients with negat ive smears, or thosesuspected of having extra-pulmonary TBundergo further examinations (e.g. , chest X-ray), a trial of symptomatic treatment, andevaluat ion by the TB Diagnostic Committee

(TBDC). Treatment policy for active cases utilizesthe internationally recommended anti-TB short-course regimens that are administered topatients under the daily direct observation of atrained treatment partner throughout the entirecourse of treatment (DOT). The variouscategories of treatment regimen are:

Category I for new smear positive PTB, newsmear negative PTB with moderate and/or far-advanced parenchymal lesions on chest X-rayexamination;

Category II for treatment failure, relapse,return after default, and others;

Category III for new smear-negative PTB withminimal parenchymal lesions on chest X-rayexamination; and

Category IV for chronic (still smear positiveafter supervised retreatment).

Standard case holding polic ies requirescheduled follow-up sputum examinations duringthe treatment period.

The two major programmatic indicators thatcapture TB control program performance are: (a)case detection rate (CDR), which represents theproport ion of TB cases detected out of theestimated incident cases, and (b) treatmentsuccess rate (TSR), which represents the proportionof those who completed treatment (cured pluscompleted) out of a cohort of registered TBpatients.19 The Philippines also set a target for curerate (CR). This measures the number of TB caseswho completed treatment with two smearnegative results of which one is at the end oftreatment. At the provincial level, due to thelimitation of CDR, the case notification rate (CNR)that indicates the number of notified TB cases per100,000 population is used.

Overall TB Control Performancein the PhilippinesWith a CDR of 75% and a TSR of 88% in 2007, the

Philippines performed better in TB case finding andcase holding compared to the average globalperformance of 63% and 85%, respectively.6


F igure 1 shows that in the six-year period of2003–2008, the programmatic indicators namelyCDR, TSR, and CR have increased. Targets in CDRand TSR were initially met in 2004 and have beensustained since then. The CR, though, is still slightlybelow the 85% national target.20

FIGURE 1Trends of CDR, Cure Rate, and Treatment

Success Rate, 2003-2008, Philippines

Source: NTP

At the subnational level, Figure 2 reveals thateight regions (CAR, IV-A , III, I, II, VIII, ARMM, andNCR) were not able to reach the CDR target of 70%.

FIGURE 2Case Detection Rate (%) by Region, 2008

Source: NTP

Figure 3 below shows that of the 84,715 newsmear positive TB cases registered and evaluatedin 2007, 81% were cured and 9% completed,resulting in a TSR of 90%. Four percent, however,defaulted from treatment.

FIGURE 3Treatment Outcome (%) of 2007 Cohort

of New Smear Positive TB cases

Although all the regions had reached the 85%target for TSR, 12 regions failed to reach the 85%cure rate target as shown in Figure 4.

FIGURE 4Cure and Completion Rates by Region,

2007 Cohort


Based on December 2008 analysis of TB data, WHOobserved that an increased number of notifications isconsistent with improved case finding efforts and donot reflect an increase in incidence.21 TB mortality rate,however, was deemed questionable. The WHO furthernoted that there is a wide variation of performanceamong and within regions which could either be dueto inconsistent case finding or reporting, or to lowincidence in CAR and high incidence in Caraga. Thisfinding is supported by the analysis of the 2006 NTPperformance in 21 provinces conducted with theassistance of TB LINC. It showed wide variations in casenotification rates of new smear positive cases and curerates. There were provinces with high CNR and high CR(“high performers”) but there are also with low CNRand low CR (“low performers”).

The conclusions during the programimplementation review (PIR) done by the DOH ofselected public health programs in January 2008were as follows:22

Extent and quality of nationwide TB-DOTScoverage have reached levels necessary foreventual control since 2004 up to the present.

Program indicators support this conclusion.

Many program activities, outputs, andachievements made this possible.

NTP continues to add enhancements andimprovements.

Lessons can also be extracted from theexperiences of the Western Pacific Region (WPR).The following factors were cited in the attainmentof the two global targets by WPR; (a) strongleadership, (b) strong commitment, (c) effectivepartnership, and (d) persistent efforts of front-lineTB programs in NTP.23

ASSESSMENT OFTB SERVICE DELIVERY

Provision of TB Services

Strengths and opportunities Nationwide, a wide array of health facilities

provide health services, including TB care tothe general population. There are 2,266 RHUsand HCs; 16,219 barangay health stations(BHSs); 1,771 public and private hospitals;2,373 TB microscopy centers; 2,671 clinicallaboratories; and thousands of privateclinics.24

Health human resources under the LGUsinclude 3,047 doctors, 4,577 nurses, 16,821midwives, and 1,717 medical technologists.There are 199,546 active Barangay HealthWorkers, or a ratio of one BHW per 443population or 74 families.25 It is estimatedthat there are 15,000 private practitioners.16

Coverage of DOTS services, at least in thepublic primary care network, reached 100% inlate 2002. In addition, DOTS services are alsoprovided by some public or privatehospitals—including public non-DOHhospitals, and by some private clinicsincluding the nonprofit NGOs.

TB diagnostic and treatment services areintegrated with the basic health servicesprovided by the public health centers. DSSMand anti-TB drugs, in the public health sector,are generally free.26

Despite the varying knowledge, attitudes, andpractices (KAP) on TB by the privatepractitioners (PP), most of them were willingto collaborate with the NTP (83.3%) providedthey are paid (38.4%).27 Majority of thehospitals in Metro Manila said that they arewilling to support NTP .

Training on TB care for different types ofhealth workers such as physicians, nurses,midwives, microscopists, supervisors, privatepractitioners, and barangay health workers isbeing conducted.


The DOH issued Department Circular 104 s.2004, which defined the operationalguidelines for the public-private mix DOTSand Administrative Order (AO) No. 154 s. 2004that organized the National and RegionalCoordinating Committees (NCC/RCC) tooversee PPMD implementation. PPMDprovides the venue for private health careproviders to support the TB control programeither through provision of TB diagnostic andtreatment services or referral of TBsymptomatic and patients to DOTS facilities.28,

29 Currently, there are 220 public-initiated andprivate-initiated PPMDs in 16 regions,covering a population of 36 million. In 2008there were 6,914 new smear positive casesdetected leading to 6% contribution tonational CDR and 18% to local CDR. The 2007cohort analysis of 5,593 smear positiveshowed a cure rate of 84% and treatmentsuccess rate of 90%.30

AO No. 24-A, issued in 1997 and revised in2004, defined how government hospitalsshould implement DOTS strategy. Somehospitals adopted the strategy, either byestablishing a DOTS clinic or by referring TBcases. Many hospitals did not adopt thestrategy because of limited resources.31 Staffmembers of a number of provincial anddistrict hospitals have been trained on DOTSwhile some of their medical technologistshave attended basic courses on DSSM. Somedistrict and provincial hospitals provide DSSM.Public-to-public Mix DOTS (P2P) was pilotedwith the assistance of USAID-funded LEAD forHealth project in 2005 to 2006 to improve thereferral of TB patients between hospitals andRHUs/HCs in ten hospitals in Pangasinan,Tacloban City, and Davao del Norte. P2Pcontributed from 8% to 45% of the CDR inthese pilot areas.32 P2P has been replicated byother areas, notably Region XI.

The Comprehensive and Unified Policy (CUP),defined by EO No. 187 that was signed by thepresident in March 2003, instructed 17government agencies and enjoined fiveprivate organizations to adopt DOTS.33 This

policy has been disseminated to stakeholdersat the national and regional levels. DOLEissued DO No. 73-05 in August 2005,prescribing policy guidelines on handling TB inthe workplaces. DepEd, DOJ-BJMP, and NEDAhave also issued circulars on TB managementin compliance with CUP. In 2007 and 2008, TBLINC assisted in the orientation of CUPmembers at the regional/provincial level andin assessing its implementation. Quarterlymeetings with CUP members are beingconvened by the NTP.

The Health Human Resource DevelopmentBureau (HHRDB) of the DOH is implementingthe Health Human Resource Strategic Planthat addresses general human resource issuessuch as health staff turnover and inadequacyof skills.34

The International Standards for TB Care, whichdescribes a widely accepted level of care inthe diagnosis and treatment of TB as well asthe public health responsibilities of allpractitioners, public and private, has beenissued and endorsed by many internationalorganizations such WHO, Center for DiseaseControl, and International Union against TBand Lung Diseases.33

Weaknesses and threats Most health care providers are located in the

urban centers. Population to health providerratio is high in areas such as ARMM andgeographically isolated and depressed areas(GIDA).36 Turnover of health workers is rapid.

Local studies done in the last seven yearshave shown that the KAP of private healthcare providers are not consistent with NTPpolicies and guidelines. Interviews with 1,355private practitioners showed that TB wasdiagnosed mainly through X-ray (87.9%) andusually treated with inappropriate regimensof anti-TB drugs (89.3%). The PPs did notfollow up their TB patients, did not trace thedefaulters (97.9%), and did not identifycontacts (91.4%). Only 24.2% knew the NTPpolicies in depth.27 A 2003 survey conducted


among private physicians in Manila DoctorsHospital showed that all respondents usedchest X-ray as the initial diagnostic tool. Only14.6% requested sputum AFB smear as aroutine diagnostic work-up.37

A private provider study done by U.P.School of Economics Foundation (UPECON) in2005 supported the previous studies.38 Of the1,535 private physicians who wereinterviewed nationwide, non-TB treatingphysicians referred only 20% of adult suspectTB patients to DOTS facilities. Only 60% of TBtreating physicians indicated sufficientknowledge about clinic practice guidelines asshown by vignette score; general practitionersposted the lowest scores. Among TB treatingphysicians, 45% of them still used X-rayexclusively as primary diagnostic tool forsuspected TB patients. Only about a fourth ofTB treating physicians belonging to referencespecialties employed treatment regimensthat coincided with SCC. Only 10% relied onreliable monitoring devices for treatmentcompliance. General practitioners reportedlow completion rates and high failure rates.Seventy percent (70%) of all physicians wereaware of TB-DOTS; the percentage was lowestamong work-based doctors. Of those aware,only 29% adopted the strategy.

A survey done by NTP in 2005–2006 of 74public and private hospitals in Metro Manilashowed that a majority had not yet adoptedthe DOTS. Almost half of private hospitalswere using X-rays as diagnostic tool and anti-TB drugs were not provided for free.39

Paradoxically, many cities failed to meet thenational standard of one microscopy centerper 50,000–100,00 population, includingQuezon City, San Fernando, Antipolo,Batangas, Puerto Princesa, Legaspi, Bacolod,and Tacloban.40 Furthermore, due to lack ofplantilla positions, other health center staffmembers, such as the nurse, midwife, orsanitary inspector, manned the microscopycenter instead of a medical technologist.

Utilization of TB Services

Strengths and opportunities Awareness of TB was high among the general

population. The NTPS 2007 findings indicatedthat most (86.9%) have heard about TB. Thebelief that TB can be cured is held by amajority of the population especially in urbanareas.41, 42

Various communication strategies toinfluence the behavior of clients have beendeveloped and implemented by the NTP incoordination with the National Center forHealth Promotion (NCHP) and by differentpartners such as PhilCAT, World Vision,Catholic Relief Services, TB LINC, and manyothers. Communication campaigns, using TBand radio to disseminate TB messages, havebeen launched on World TB Day, March 24, andNational TB Day, August 19.

Templates for information, education, andcommunication (IEC) materials such asposters, pamphlets, and radio plugs have alsobeen developed by NCHP and produced byCHDs and PHOs/CHOs. Most of the RHUs andBHWs have some form of TB IEC materialdisplayed.8

Findings from the Joint Program Review inApril 2008 showed that most health staff andvolunteers are strongly committed toundertake ACSM activities, involvingsubstantial use of peer and interpersonalcommunications.

Communities have also been mobilized toimprove the KAP of the community membersand to increase their access to TB care.Barangay health workers have long beenhelping the TB control program by (a)disseminating TB messages in the community,(b) motivating TB symptomatics to seek care,(c) sending sputum specimens to TBlaboratory, and (d) supervising treatment ofTB patients.26

Community-based organizations wereorganized to facilitate communityparticipation in the fight against TB. World


Vision (WV) has organized 384 TB Task Forcesunder Global Fund that include BHWs,barangay officials, and other communityleaders to coordinate TB control activities andensure early detection of TB cases andcompliance with treatment.43 A WVevaluation in 2004 found that “a strong senseof community awareness and communityownership of the problem and the programwas evident” but “it is difficult to specificallyand solely link the community-based effortsto the successful program results given themultiple interventions employed by the KB IIproject.”44 The initiative is being expanded byWV with the support of Global Fund.

The USAID-assisted ENRICH project inARMM in 2004 to 2006 implemented variousactivities through the community-basedorganizations (CBOs).45 These are beingcontinued in ARMM by another USAID fundedproject, the Sustainable Health Improvementand Empowerment in Local Development(SHIELD) project. Currently, there are 427barangays in ARMM with CBOs helping in TBcontrol in ARMM.

TB patients have also been organized to helpdisseminate TB information, identify TBsymptomatics, and facilitate treatment of TBpatients. A representative of the Lusog Baga,based at Lung Center of the Philippines, sits inthe Country Coordinating Mechanism ofGlobal Fund.

Weaknesses and threats Knowledge of communities about the cause

and transmission of TB is sorely inadequate.The 2007 NTPS showed that only 8.3%considered bacteria as the cause of TB, while46.1% attributed TB to smoking, 37.9% toalcohol drinking, 14.2% to fatigue, and 9.1% togenetic causes. More than 38% did not knowthe cause of TB. The 2003 NationalDemographic Health Survey (NDHS) showedthat only about half of the respondents knewthat TB is transmitted through the air whencoughing (51% for women and 46% for men).41

Other answers regarding the cause of TBincluded poor living conditions, air pollution,smoking; and 31.2% believed it was aninherited disease.46 About two decades ago,only 14% said that TB was acquired through“contact with TB case.”47

Studies have also shown varying perceptionsregarding disease susceptibility that coulddelay consultation and lead to self-medication. The 2003 NDHS revealed that 53%of respondents did not consult since theyperceived TB as harmless. Patients also oftenattributed TB signs and symptoms, such asprolonged cough and weight loss, to drinkingand/or smoking and considered theseharmless.48 Many still perceived TB as anordinary disease. The perception ofsusceptibility to TB was low even among closecontacts of TB patients and in the generalpopulation.42

The stigma surrounding TB prevails. Phrasesused when people think of TB in generalinclude “batik sa pamilya” (bad mark for thefamily), “nakahihiya” (shameful), “habag”(pity), and “iniiwasan” (to be avoided).42

Terms such as “weak lungs” are used by bothlaymen and health providers to avoid stigma.However, this practice encourages self-treatment with anti-TB drugs that areconsidered “vitamins for the lungs” and canlead to drug resistance. Stigma is moreextrafamilial than intrafamilial.49 Six in tenwho have heard of TB say they are willing towork with someone who has previously beentreated for TB. The higher the respondent’sage, level of education, and wealth indexquintile, the greater the percentage ofwillingness to work with a treated TB patient.ARMM has the lowest level of acceptance of aTB patient, followed by ZamboangaPeninsula.41

Among TB symptomatics, only 32% consulteda health provider, 25.1 % took no action, and43% self-medicated, according to the 2007NTPS. A little less than half of the women andmen who have ever had at least one symptom


of TB sought consultation or treatment for thesymptom.

The percentage seeking consultation ortreatment (for both sexes) increases with age,education, and wealth index quintile.41

Majority of TB symptomatics consulted healthcare providers who in general have notadopted DOTS as shown in the followingtable. Despite the free service and drugsavailable in public facilities, majority of TBpatients sought diagnosis and treatmentoutside of the public sector. According to the2007 NTPS, nearly two out of every five TBsymptomatics sought treatment in the privatesector (37.7%) with 21.7% contacting privatephysicians and the remaining 16% going toprivate hospitals.

The preceding table shows that from 1997to 2007, the number of people who went tohealth centers and DOTS centers increasednegligibly ( from 24.5% to 26.7%). In 2007,although majority (53.1%) went to publichealth facilities (DOTS centers and publichospitals), more than a third (37.7%) werebeing managed by the private practitionersand private hospitals. A worrisomedevelopment was the doubling of those whowent to hospitals (both public and private),42.2% in 2007 compared to 19.9% in 1997,since most hospitals had not adopted DOTS.

In the 2003 NDHS, the most common reasonsgiven for going to a government health centerwere: proximity (46%); cost (28%); and service(18%). On the other hand, reasons given forgoing to a private doctor were: service (65%);proximity (14%); and quality of drugs (10%).These statistics suggest that proximity is astrong factor in the selection of type of healthprovider. For TB symptomatics, service was astronger factor, as they chose a private doctor(65%) compared to an RHU (18%).

In Metro Manila, health-seeking behavior incase of TB symptoms correlated with averagefamily income. Those with low incomes (lessthan PhP2,000 monthly) were seven timesmore likely not to seek care compared tothose with medium or high incomes. Theywere also two times more likely to self-medicate than the others.46

Only 62% of symptomatics who sought carefollowed the doctor’s advice for diagnosis.41

A comparison of survey results of TBprevalence among males and females andNTP service reports showing proportions of TBpatients initiating treatment suggest genderdisparities in terms of access to treatment.The NTPS 2007 shows that prevalence of TBsymptoms for males was 14% and for femaleswas 12.8%. In terms of treatment however,the 2006 NTP report shows that among those

TABLE 3. Health Care Providers Consulted by TB Suspects (%), 1997 and 2007

2007 NPS 1997 NPS

DOTS center 26.7 Private MD 36.2

Public hospital or clinic 26.4 Health center 24.5

Private physician 21.7 Hospital 19.9

Private hospital 16.0 Traditional healer 10.0

NGO clinic 1.5 Family member 9.4

Outreach clinic 1.1

Source: NPS 2007, 1997


who initiated treatment, majority were males(66%) compared to females (28%). Reports onTB case notification show more male thanfemale cases being detected; no clear reasonis provided for this.

Poor compliance with treatment protocol is amajor concern. Among TB patients, durationof intake of drugs is well below the prescribedperiod of six months. Only 49.5% are able tocomplete six months of treatment or longer.The default rate is 21.2% among females and18.8% among males.7 Likewise, a 2007 TB LINCstudy indicated that only about 90% of thepatient-respondents were still undermedication at the time of the survey, implyingthat 10% had either discontinued or defaultedon their treatment. The main reasons fordefaulting were: (1) an improvement in bodilyconditions, (2) not being able to get theirsupply of drugs because of the distance oftheir house from the health center or becausetheir treatment partner failed to send theirsupply of drugs, (4) transfer of residence, and(5) size of the drug. In 2008, Lagrada foundthat treatment completion was most likely tobe higher among the middle-aged female,those above the per capita poverty threshold,the unemployed, and those with at least onesign and symptom of TB.50

Awareness of the government’s TB controlprogram is relatively low.7, 41 Awareness ofwhat “DOTS” stand for is even lower. Theadvantages of DOTS are not well known tomost of the general population, or even tomost of the patients.

Availability and accessibility to TB services arestill limited in many areas especially inremote island or mountain villages where TBservices are available only in the main towncenters (poblacions), and wheretransportation is expensive and not alwaysavailable. Travel itself can be difficult becauseof geography, and in some areas, because ofsecurity concerns. The opportunity cost forvisiting the RHU is generally high for the poor.

The following key weaknesses wereidentified in the ACSM activities during the2008 Joint Program Review: (a) The overallquality of print materials disseminated inDOTS facilities was variable with some poordesign elements. Many materials containedinappropriate messages (i.e., fear-basedmessages that reinforce stigma and leadpeople to the private sector) or had no usefulor usable message; (b) ACSM work was nottargeted at anyone other than the “generalpublic,” with many of the activities donearound World TB Day or Lung Month; (c) printmaterials were in short supply and weregenerally not provided to supportconsultation work done by RHU health staff;and (d) financial support for ACSM activitieswas limited at all levels. The reviewersconcluded that the wide variation in thequality of ACSM implementation withinprovinces, districts, and municipalitiesreflected the lack of leadership, technicalcapacity, and coordination for ACSM.

Community participation in TB control is stilllow. Most of the areas where organizedcommunity support for TB control exists are inexternally-funded project areas. Most of thelocal initiatives to organize communityparticipation for TB control come from NGOs,faith-based groups, and other civil societyorganizations. Government support forcommunity or social mobilization, whether atnational or local levels, remains inadequate.

Access to services is also limited forvulnerable or marginalized groups particularlythe urban and rural poor, those in prisons,workers in the informal sector, internallydisplaced people, indigenous people, and theelderly. Residents of urban poor settlementsand prison inmates are at a particularly higherrisk of developing TB because of the livingconditions associated in their settings.


ASSESSMENT OF THE REGULATORYENVIRONMENT OF TB CONTROL

Strengths and opportunities AO No. 2007-0019 provides the policies and

guidelines for quality assurance of the directsputum smear microscopy not only for thepublic but private TB laboratories as well. Theexternal quality assurance (EQA) system thatensures the provision of quality-assuredDSSM is through onsite visits and blind sliderechecking. This system is being implementedby the National TB Reference Laboratory(NTRL) of the Research Institute of TropicalMedicine (RITM) that manages a network ofregional and provincial quality assurance (QA)centers.51

Laboratory supplies such as reagents, sputumcups, and slides are provided by the DOH.Some LGUs buy lab supplies when there areshortages.

There are five laboratories providing culturenamely NTRL, Cebu TB Regional ReferenceLaboratories, TDFI, LCP, and Philippine TBSociety Inc. (PTSI). Only NTRL and TDFIconduct drug and sensitivity tests (DSTs).52

New TB diagnostic tests have beendeveloped.

The TB Diagnostic Committee was organizedin 1998 to improve the quality of diagnosisamong smear negative PTB cases (but withfindings in X-ray examination suggestive ofTB) by reducing the over-diagnosis and over-treatment of these cases and ensuring thatactive cases are detected and treated.18 ATBDC is composed of the provincial/citymedical and nurse coordinator, radiologist,and clinician/internist. Meetings are heldonce or twice a month. Some are financiallyassisted by the LGUs; part of PhilHealthreimbursements can also be used to supportits operations. In 2004, 34 of 74 functionalTBDCs were assessed. Of the 12,725 smearnegative and extrapulmonary casesevaluated, a decision was made not to treat

49% compared to 51% in 2002. The decision totreat varied widely from 1% to 100%.53 As of2007, there were 67 TBDCs in the country.

TB patients are managed in the DOTS facilitiesaccording to the disease category. Fixed dosecombination (FDC) anti-TB drugs, packaged asTB kits I and II, are provided for free to TBpatients. Daily treatment supervision is eitherdone by the health staff, barangay healthworkers, and family member. Anti-TB drugsthat are provided at the DOTS centers werepurchased by the DOH from Global DrugFacility (GDF) from 2004 to 2007 and fromdomestic suppliers in 2008. These aredistributed to the Provincial Health Officesthrough the CHDs through a push mechanismwhile distribution to DOTS centers is mainlythrough a pull system.54

Philippine Health Insurance Corporation(PhilHealth) issued Circular No. 17 series of2003 that provides for accreditation of theDOTS facilities as providers of the TB-DOTSoutpatient benefit package (TB-DOTS OPBpackage). The DOH and PhilCAT startedcertification of DOTS facilities (public andprivate) using ten standards in 2003. Regionalcertifiers visit health facilities that areinterested and recommend action on theapplication. RCC approves the applicationwhile the NCC issues the certificate. Thosecertified can apply for accreditation byPhilHealth and are eligible to receivePhP4,000 for new TB patients who arePhilHealth members. Those not certified canalso apply for accreditation using the“meritorious path.” The allocation of thereimbursement has been defined by the DOHand endorsed by PhilHealth.55 Currently,PhilHealth, with assistance from USAID, isconducting a comprehensive review of itsoutpatient benefit package including TB-DOTSthat will be completed in September 2009. Itis also reviewing NTP’s proposal to develop anoutpatient benefit package for MDR-TB.56


Weaknesses and threats The 2008 Joint Program Review Team noted

the organizational and technical weaknessesof NTRL to effectively oversee the TBlaboratory network. These include inadequatehuman and financial resources and a weakinformation and monitoring system.Furthermore, the team observed incompletecoverage of quality assurance and inadequateperformance of some microscopy units. NTRLis also not yet within infection controlstandards.57

In mid-2009, NTRL initially identified at least120 microscopists who needed to be trainedand at least 100 microscopy centers withnonfunctional microscopes.

In 2007, TB LINC conducted a comprehensiveassessment of 498 microscopy centerscovering 23 million or 27% of the country’spopulation in 29 USAID-supported provincesand cities. Some of the key findings were:58

(a) The capacity of the provincial QA teams,regional coordinators, and NTRL to providetechnical support to lower level laboratoriesis limited largely by logistical constraints; (b)Of the 21 project sites, 17 (81%) wereimplementing QAS during the assessmentperiod but only 43% did so in ARMM; (c) Only388 of the 498 (78%) TB laboratories submittedslides for assessment in 2006 while reports onslide rechecking results were available foronly 13 of 17 (71%) provinces; (d) Assessmentof 13,692 slides showed that smear qualityneeds improvement in most of the projectsites. Rechecking microscopy results showedthat of the total slides rechecked, 790 slides(6%) had discrepant results; and (e) Most ofthe QA teams experienced difficulties incarrying out the activities for EQA, particularlyon-site supervision, slide collection, andproviding feedback due to limited travellogistics available to the QA teams.

Anti-TB drug shortages were reported in 2008due to delayed procurement that resultedfrom the strict implementation of a fiscalpolicy regarding use of government funds for

drug procurement outside the country.59

Some LGUs purchased anti-TB drugs but mostwere single drug formulation and of a highercost than the GDF-supplied drugs.Weaknesses in the storage of drugs wereobserved in some DOTS facilities.26

Program monitoring showed that dailysupervision of drug intake is not strictly donein some areas.8, 26

Anti-TB drugs can be easily purchased fromthe private drug stores. Although selling islegally limited to those with prescription,over-the-counter sales are widespread. In2006, the TB Alliance reported that the totalmarket value of TB drugs in 2005 wasapproximately US$31.2 million, of whichpublic expenditures was at 2.6 Million Dollars(7%) with the balance of US$28.9 million (93%)accounted for by the private sector. In fact, inthe private sector, TB drugs made up the 15thtop selling category in the Philippinesreaching US$23 million or 2% of the total drugmarket.60 Most of the sales were FDCs. Twelveleading branded manufacturers accounted for96% of the TB market; only three are MNCs.The cost of a drug regimen purchased fromthe private local market is 7.6 to 9.6 timeshigher than those purchased by the DOH fromthe GDF.

As of March 2009, the DOH registry showedthat only 745 health facilities were certified:701 public and 44 private while 587 facilitieswere PhilHealth accredited: 545 public and 42private.

In 2007, PhilHealth reported that 1,214 TBpatients had submitted claims; this numberwas less than 1% of total TB patients. A totalof PhP4.72 million was released asreimbursement for claims; again, this was anegligible fraction of the PhP18.5 billion paidfor claims by PhilHealth. PhilHealthreimbursements make up, on the average,only 20% of total income of PPMDs. Focusgroup discussions and interviews withproviders revealed that private sectorparticipation increased when private


providers were given a share of the PhilHealthreimbursement. On the other hand, publichealth facilities did not renew accreditationnor pursue certification because they did notreceive their share from reimbursementswhich were given to the LGUs.61, 62 The 2007NTPS pointed to a low utilization rate (28.8%)of PhilHealth benefits among eligiblemembers. Even in urban areas where privateproviders are mostly present, utilization waslikewise low (26.2% in Metro Manila, 27.2% inother urban areas). Moreover, most of thereported utilization of the benefit was forinpatient or hospital-based services (23.1%).

ASSESSMENT OF GOVERNANCEIN TB CONTROL

Strengths and opportunities The national government has demonstrated

strong political support to NTP primarilythrough increases in budgetary support. Asearly as 1998, the DILG issued DepartmentCircular No. 98-115, which instructed all localgovernment units (LGUs) to adopt DOTSstrategy for their local TB control efforts.

The DOH provides strong leadership incoordinating the country’s response to the TBproblem through the National TB ControlProgram (NTP) that is being managed by IDOof the NCDPC. Various DOH offices supportNTP. NTP is a priority public health programunder the PPA “Intensified Disease Control”as articulated in the health sector reforminitiative called Fourmula One based on AONo. 2005-002 issued on August 2005. The 2006–2010 National Strategic Plan to Control TB hasbeen formulated and is congruent with theMDG and Stop TB Partnership’s global TBcontrol strategy.63 The DOH has also issuedadministrative orders that specified theguidelines and standards for various TBcontrol initiatives.

A team of national, regional, and provincialstaff provides managerial and technicalsupport to NTP implementation. The group of

NTP staff members—four regular and tenGlobal Fund-supported contractual—coordinates the development of the nationalTB control plan as well as policy andstandards, provision of technical support,monitoring and evaluation, and resourcemobilization. A team of regional TBcoordinators composed of a physician, nurse,and medical technologist from the 17 CHDsprovides technical back-up and oversees thatimplementation of provincial TB controlefforts.

The Philippine Coalition Against TB (PhilCAT),organized in 1994 and currently with 69member-organizations from the public andprivate sector, is a strong ally of the DOH inthe fight against TB. It manages a GF-supported project that mobilizes the privatesector to participate in the control of TB.64, 65

Local TB coalitions have also been organizedin some regions.66

Seventeen government agencies, under theumbrella of the Comprehensive UnifiedPolicy, have been organized to ensure thatthey contribute to the TB control efforts in thecountry. F ive have health service deliverycapacity (DOH, DND, DOJ, DILG, and DepEd);six are with large constituents (DOLE for theworkers, DA and DAR for the farmers, DSWDfor the marginalized groups, OWWA for theOFWs and NCIP for the indigenous people);four have capacity to finance TB controlefforts (PhilHealth, SSS, GSIS, ECC); while twoassist in the areas of research and policy(DOST and NEDA).

The 2005 NTP manual of procedures (MOP)defines the functions of different institutions,namely the DOH, LGUs, international partners,etc., and specifies the tasks of individualsfrom national, regional, provincial, municipal,and barangay offices. It also contains thepolicies and technical guidelines for thediagnosis and treatment of TB cases andmanagement of the TB control program at thelower levels.


The local TB control program is managed bythe Local Government Units (LGUs) throughtheir provincial health/city health officer(PHO/CHO) assisted by the provincial/citymedical/nurse coordinator. TB services areprovided by both public and private healthcare providers. Almost all RHUs and HCsimplement the national TB policies andguidelines in the diagnosis and treatment ofTB. LGUs provide program support in terms ofpurchasing Category III anti-TB drugs andlaboratory supplies; providing funds formonitoring, supervision, and training; issuinglocal policies; and providing support toinitiatives such as TBDC and childhood TB,etc.26

Under Fourmula One, 44 provinces havecrafted their provincewide investment planfor health since 2006. The PIPH, since itincludes a TB control plan, facilitates themobilization and coordination of fundingsupport.

Successful implementation of TB controlefforts due to strong local leadership havebeen documented.67 Following the success ofmultisectoral participation in addressinghuman immunodeficiency virus/acquiredimmunodeficiency syndrome (HIV/AIDS),Zamboanga City organized the Hermosa TBCouncil in 2007 by virtue of an executive orderissued by the city mayor. In Bohol, theparticipants of a provincial orientation on CUPattended by various government andnongovernment organizations decided toorganize themselves into PROCAT (ProvincialCouncil Against TB–Bohol). Under GlobalFund, PhilCAT has been organizing provincialcoordinating committees (PCCs) to “providetechnical support, oversee engagement of allcare providers, and ensure sustainability ofpartnership.”

Interlocal health zones (ILHZs) have beenorganized all over the country as acooperating mechanism among LGUs througha Memorandum of Agreement as provided inAO No. 2006-0017. The mechanism involves

resource sharing, procurement, informationsharing, and a patient referral system such asthose in Sorsogon and Negros Oriental. InCapiz, the ILHZ mechanism was utilized toimprove local TB program performance.Through the mechanism, LGUs sharedstrategies and the performance among zonesand among ILHZ members were tracked. Poorperforming LGUs felt the pressure to improveas their outputs could affect the zone’s overallaccomplishments.68

Weaknesses and threats NTP has only four regular staff members since

the DOH reengineering initiative in 2000.Despite the presence of contractual staff, theissue is staff adequacy and sustainability ofgains beyond Global Fund assistance.

Varying LGU support for NTP has resulted invarying performance as measured by the casenotification rate and treatment success rate.69

Health is generally not a top priority of theLGUs. LGUs also perceive the NTP to be a DOHprogram because it is national.

Of the 392 municipalities in TB LINC sites, only121 or 32% have purchased TB drugs toaugment DOH-supplied stocks. Stockout ratescan reach up to 39% and only 26% have issueda local ordinance on TB.69

Provinces/cities also vary in their capacity toimplement DOTS. Although there aredesignated provincial and city TBcoordinators, due to limited PHO manpower,many have to multitask and have other healthprograms to supervise. The presence of keyDOTS success factors such as budgetarysupport, provincewide QA system, monitoringand evaluation, network among health careproviders, availability of drugs is not the sameacross provinces/cities.

The level of program implementation by CUPpartners, specially other governmentagencies, is not the same.

The 2010 national and local elections may leadto leadership changes in the DOH and in LGUs.


FINANCING OF TB CONTROL

Strengths and opportunities The funding support of the national

government, primarily through the NTP, hasbeen increasing. From PhP236 million in 2007,the NTP budget went up to PhP680 million in2008. The 2009 General Appropriations Act(GAA) allocated an even higher budget atPhP1.3 billion.70

The added budgetary support has enabledNTP to substantially increase the programscale and scope. The 2008 NTP budget allowedfor the coverage of MDR patients (250 cases)as well as for support for TB in children (68,000cases), increased capacity building andtechnical assistance, and improved quality ofcare. The 2009 NTP budget was further markedby additional increases. Provision for second-line drugs to treat MDR cases increased inscale from 250 to 1,500 MDR cases. Support forquality care expanded in scope withadditional funding for facility upgrades inaddition to technology upgrades.

To assess the adequacy of funds for serviceprovision, anti-TB drug allotments werecompared with estimated prevalence. Usingbacteriologic prevalence as size measure forthe TB population based on the 2007 NTPS, theestimated number of TB cases seekingtreatment was compared with the anti-TB drugallotments (expressed in number of TB casescovered). The 2008 NTP budget allowed for223,000 cases while the 2009 NTP budgetallowed for 268,000 cases. Even allowing for anincrease in TB cases due to population growth,the allotment for anti-TB drugs exceeds the159,000 cases projected to seek treatment frompublic facilities and approximates theprojected 229,000 cases projected to seektreatment in both public and private facilities.

Many LGUs support various TB initiatives suchas meetings of the TB diagnostic committee,procurement of drugs for Category III patientsand laboratory supplies, monitoring andevaluation, etc.26

Various TB control efforts are supported bythe foreign assisted projects (FAPs) namely,the Japan Anti-TB Association/ResearchInstitute of Tuberculosis (JATA/RIT), GlobalFund Against AIDS, TB and Malaria, WorldHealth Organization, Korean InternationalCooperation Agency, and United StatesAgency for International Developmentthrough its cooperating agencies—TB LINC,HPDP, HealthGov, HealthPRO, and SHIELD.

FAP covers most TB control activitiesparticularly those not funded by nationalgovernment. Global Fund financing in the TBcontrol effort has been significant. Its fundingcovers most of the major TB control activitieswith particular focus on MDR and technicalassistance.

PhilHealth benefit payments to TB patientswho are PhilHealth beneficiaries are coursedthrough two mechanisms—inpatient benefitsaccruing from the regular PhilHealth benefitpackage and case payments through the TB-DOTS outpatient benefit package. The latterinvolves a case payment of PhP4,000,distributed in two tranches—PhP2,500 for theintensive phase and PhP1,500 for themaintenance phase. TB-DOTS claim paymentsamounted to PhP4.5 million in 2007. Thisamount, however, pales in comparison to theinpatient claim payments of PhP55 millionpaid for inpatient benefits of PhilHealthbeneficiaries.

Weaknesses and threats While the distribution of NTP coverage

approximates the distribution of TBprevalence, NTP coverage is consistentlylower than estimated prevalence (both AFBpositive and bacteriologic positive) in all theregions except NCR. The observed gapbetween the number of TB cases treated inthe DOTS network (public sector plus PPMDs)with TB prevalence is partly explained by thehigh proportion of TB patients who self-medicate (47% according to 2007 NTPS).


It is projected that if there is a sudden changein behavior leading to a comprehensivetreatment seeking scenario, the allotment foranti-TB drugs programmed in the NTP budgetsmay not be sufficient to cover the increase inanti-TB drug requirements due to addeddemand.

While allocation for TB drugs to LGUscoincides with the number of TB cases, TBdrug allotments are not congruent with CDR.

Budget capacity is not fully utilized (with theexception of 2006) while disbursed funds arenot fully exhausted.71

There is greater potential for increased LGUsupport given the PhP63 million allocated forTB control activities in the 2009 PIPHs. A quickcomparison of the proposed allocations for TBcontrol activities and estimatedbacteriological TB prevalence, however,shows that the two figures do not necessarilyconverge.

The absorptive capacity of the localinfrastructure to translate allocated funds intorealized expenses was generally not achievedas shown by Pangasinan. A cursory look of2005 and 2006 appropriations, allotments, andobligations shows that while allotmentsmirror appropriations, obligations fell short ofallotments in 2005 but approximated them in2006.

The distribution of non-Global Fund FAPS inPIPH does not seem to address perceivedneed (as measured through bacteriologic TBprevalence). Perhaps this is accounted for bythe non-service provision nature of FAPS.Nevertheless, a reconciliation and comparisonof sources and uses of funds for TB controlwould provide a better picture of how fundallocation across different sources matchesuses and ultimately need.

Available FAPs are not fully utilized and FAPsfunding is not always assured.

The PhilHealth Web site reports the latestmembership coverage at 76% of population.Estimates from the 2003 NDHS and 2007 NTPSare significantly lower at 30% and 50% ofpopulation respectively. PhilHealthmembership data indicate a relatively widecoverage of the population. The membershipcoverage however does not translate intobenefit claims. When estimates ofbacteriologic prevalence among PhilHealthmembers are compared with claims (intensivephase), the TB-DOTS claim rate turns out to bequite low.

PhilHealth data indicate an increase inaccredited DOTS facilities from 387 in 2006 to474 in 2007. Preliminary results from aPhilHealth study indicate a subsequentincrease to 735 centers in 2008.

IMS reports that in 2005 TB drug sales in theprivate sector accounted for 2% of the totalprivate drug market, or roughly US$23 million.

Patients incur substantial out-of-pocketexpenses in availing of TB services even fromthe public sector. These cover transportationand meal costs, payment for X-ray servicesand other diagnostic tests, purchase of non-TBdrugs, etc.


ASSESSMENT OF THE 2006–2010 NATIONALSTRATEGIC PLAN TO CONTROL TB

VISION: TB-FREE PHILIPPINES

Goal/Strategy Status Recommendation

To reduce the prevalenceand mortality by half by2010 contributing to theachievement of theoverall MDG

1.Ensure the highpolitical support forTB control as apriority of the nationalhealth plan andamong the localgovernment units

2.Improve thecapabilities of acritical mass of DOTSworkers, both publicand private, to sustainqualityimplementation ofDOTS services

The target of achieving the MDG goals in2010 was aligned with the target of theWestern Pacific Region set in its 2006–2010 Regional Plan to Control TB. It isprojected that the Philippines will not beable to achieve the MDG targets in 2010.

National government’s budgetary supportto NTP has substantially increased frombelow PhP200 Million prior to 2006 toPhP1.3 Billion in 2009. Consequently,more resources were made available forthe purchase of pediatric and second-linedrugs, capacity building, quality careenhancements, and infrastructureupgrade. Under the Fourmula Oneframework, 44 provinces and citiesdeveloped their multiyear PIPH/AIPH thatincluded a TB control plan. There isvarying LGU support in terms of thepurchase of anti-TB drugs and laboratorysupplies, issuance of TB local policies,mobilizing local partners, etc. The CUPthat provides the legal basis forparticipation of 17 government agenciesin TB control has been weaklyimplemented especially at the local level.

Training courses for various categories ofhealth workers have been conducted. Almostall RHU/HC and PPMD staff have beentrained. However, there is rapid turnover ofhealth staff and less than 25% of privatehealth care providers and an insignificantnumber of hospital staff have been trainedon DOTS. Although some training activitieswere need-based, most are budget driven.

Reset the attainment of MDGs to2015

Strengthen local implementation ofTB control. Secure commitment forsupport of TB control especiallyamong LGUs through advocacyand counter-parting of nationaland FAPs assistance and provisionof performance-based grant.

Tap accredited non-DOH traininginstitutions. Integrate some aspectsof DOTS training such as microscopyand infection control with otherinfectious disease control trainingactivities. Coordinate with specialtysocieties to adopt ISTC.Support national HRM strategicplan.



3. Strengthen theimplementation ofDOTS certification andaccreditation

4. Maintain the support tokey managementfunctions, particularlymonitoring andevaluation of NTP-DOTSimplementation

5. Scale up and enhancepublic-private mixDOTS units in strategicsites

6. Strengthen Public-to-Public collaborationsbetween public hospitalsand health centers toincrease access to andimprove efficiency ofDOTS services

7. Support the existingDOTS (+) initiatives andinstitutionalize these inthe public sector

There was an increase in the number ofhealth facilities certified and accreditedfrom 2005 to 2008 but the rollout is quiteslow. Less than 25% of DOTS facilities havebeen accredited and certified as of 2008and less than 1% of total TB patients haveclaimed for PhilHealth reimbursements.

An M&E structure and tools are in place.National and regional PIR are regularlyconducted. However, local monitoring andsupervision are not being done regularlydue to inadequate logistical support.

220 PPMDs had been established as of theend of 2008 and had contributed 6% tonational CDR and 18% to the local CDR.Sustainability mechanisms have beendeveloped and implemented. Some PPMDshave shown high sustainability potential.However, a big proportion of privatepractitioners and private hospitals havenot yet adopted DOTS.

Majority of hospitals did not comply withthe AO issued in 2004. Pilot testing of P2Pwas done and replicated in a few areas.

The number of MDR-TB detected andmanaged increased with good treatmentoutcomes. LCP capacity is being developedto be the referral center for MDR-TB. NTRLis also being developed to provide overalllaboratory support to PMDT. Six treatmentcenters were established (five in Metro

Improve performance throughstreamlining of processes, socialmarketing of package, andensuring flow of PhilHealthreimbursements to DOTS facilities.

Strengthen local programimplementation and monitoringthrough (a) introduction of DOTScompliance standards for provincesand cities, (b) PBG, and (c)enhanced TA support from theregion and partners.

Shift strategy to developingprovincial and city capacity toimplement PPMD and establishnetwork/s among health careproviders.

Develop an operational manual onhospital participation in DOTS toinclude P2P.Expand hospital involvement eitheras DOTS provider or referral centerusing financial incentive, orregulatory power.

Expand implementation of PMDTand develop a DOH unit to act asPMDT manager.



Manila and one in Cebu). Treatment siteswere also organized in Metro Manila. TheDOH issued a policy for the programmaticmanagement of MDR-TB (PMDT). The DOHallocated funds for the treatment of 250MDR-TB patients in 2008; this wasincreased to 1,500 in 2009.

In 2007, the DOH issued a policy on TB/HIVcoordination. Coordinated activities arebeing implemented only in 10 cities of NCR.1,500 TB cases were provided with PICTand screened for HIV/AIDS.

Expand coordinative activities inhigh HIV/AIDS risk areas.

8.Strengthen theintegration of TB/HIV inaccordance to thecountry’s diseasescenario.


THE 2010–2016PHILIPPINE PLAN OFACTION TO CONTROLTB (PHILPACT)

PHILIPPINE HEALTH SECTOR REFORMAND STOP TB PARTNERSHIP

In 2005, the DOH adopted Fourmula One as theimplementation framework for the health sectorreforms that were designed to implement “criticalinterventions as a single package, backed byeffective management infrastructure and financingarrangement” as provided by Administrative OrderNo. 2005-0023.

Its specific objectives are to:

Secure more, better, and sustained financingfor health,

Assure the quality and affordability of healthgoods and services,

Ensure access to the availability of essentialand basic health packages, and

Improve performance of the health system.

F1 has four implementation pillars: financing,service delivery, regulation, and governance. TBcontrol is one of its priority programs under“ intensified disease control.” The implementingarrangement for F1 is explained in the above AO.To provide clear guidance to managers andimplementers, PhilPACT is organized in accordancewith the four implementation pillars of F1.72

In the international arena, the STOP TBPartnership developed the 2006–2015 Strategic Planto Stop TB.73 Its development was triggered by thesignificant changes in the social context of TBcontrol and the need for more resources requiredby emerging public health challenges.74 In turn, theWHO developed a six-point agenda for TB controlin 2006–2010, namely:

Pursue high quality DOTS expansion andenhancement;

Address TB/HIV, MDR-TB, and otherchallenges;

Contribute to health system strengthening;

Engage all care providers;

Empower people with TB and theircommunities; and

Enable and promote research.75

Prior to this plan, the Western Pacific RegionalOffice led the development of the 2006–2010Regional Plan to Stop TB.76

The eight strategies of PhilPACT support theseglobal and regional plans.

GUIDELINES FOR A STRATEGIC PLANThe strategic plan must:

Contribute to the achievement of theMDG 6 (combat HIV/AIDS, malaria andother diseases) and target 8 (to havehalted and begun to reverse theincidence of malaria and other majordiseases);

Take off from the 2006–2010 National TBControl Plan and be consistent with thePhilippine health sector reform,National Objectives for Health, andSTOP TB Partnership/WHO Strategy toStop TB;

Recognize the current and potentialcontribution of various stakeholders,both public and private, to TB control;

Adapt to the decentralized healthdelivery system by contributing tostrengthened local health systems; and

Include strategies that scale up andsustain the gains as well as addressprogram weaknesses and threats andthat have been demonstrated to beeffective and feasible, internationallyor nationally.

Ensure the plan’s sustainability vis-à-visresources and the health system’sabsorptive capacity


2010-2016 PhilPACT Strategic Logical Framework

Goals FinalOutcomes

Impact

IntermediateOutcomes

ReformOutputs

VISIONTB FREE PHILIPPINES

Reduce TB burdenin the Philippines

Reduce Out of Pocketexpenses related to TB

ACCESS

Increase andsustain coverage

of DOTS

QUALITY

Ensure provisionof quality TB

services

EFFICIENCY

Decrease cost percase treated

Increase support andallocation to poor

performing provinces

SERVICE DELIVERY

Increases ServiceDelivery outlets

Increase PPM DOTScoverage

Expand DOTS servicesin public hospitals

Improve positivebehavior of familiesand communities

REGULATION

Assureavailability ofhigh quality,low cost TBdrugs

Createguidelines forTB subplan inPIPH/CIPH/AOP/AIPH

FINANCING

Increasenationalbudget for TB

Increase LGUcommitment toTB

Increase PHICreimbursementfrom TB-DOTS

GOVERNANCE

Provide DOHTA packageand guidelines

EstablishPublic PrivateMix (PPM)coordinatingbody


2016 TARGETS

Impact Reduce TB mortality from 87/100,000 in 1990 to less than 44 per 100,000 in 2016

Reduce TB prevalence of all forms of TB from 799 per 100,000 in 1990to less than 400 per 100,000 in 2016

Outcome At least 85% of new smear positive TB cases are detectedand at least 90% have successful treatment.

A total of at least 15,000 MDR-TB cases have been detected and providedwith quality-assured second-line anti-TB drugs.

Output PhilPACT Beneficiaries in 2016

INDICATOR NUMBER

Total number of TB symptomatics to be provided with DSSM 5 million

Total number of adult TB patients (all forms)to be provided with treatment 1 million

Total number of children to be provided with treatment or preventive therapy 730,000

Total number of MDR-TB cases to be detectedand provided with second-line anti-TB drugs 15,000

Total number of TB patients to be provided with provider-initiatedcounseling and testing on HIV/AIDS 15,000

Objectives and Strategies of PhilPACT

OBJECTIVE STRATEGY

1. Reduce local variation in TB control 1. Localize implementation of TB control

program performance 2. Monitor health system performance

2. Scale up and sustain coverage of 3. Engage both public and private health care providersDOTS implementation 4. Promote and strengthen positive behavior of communities

5. Address MDR-TB, TB/HIV, and needs of vulnerable populations

3. Ensure provision quality of TB services 6. Regulate and make available quality TB diagnostic testsand drugs

7. Certify and accredit TB care providers

4. Reduce out-of-pocket expenses 8. Secure adequate funding and improve allocation andrelated to TB care efficiency of fund utilization


STRATEGIC THRUSTS FOR 2010–2016The 2010–2016 Philippine Plan of Action to

Control TB is the Philippines’ medium term plan toachieve the TB-related MDGs and the NationalObjectives for Health on TB Disease Prevention andControl. The Plan is part of the health sector reforminitiatives on disease control management.

Consistent with the Health Sector ReformAgenda, PhilPACT mobilizes the LGUs as the maindrivers of the TB control program implementationin accordance with the Local Government Code. Thisis the first major thrust of the plan. Moreover,PhilPACT has adopted an inclusive governanceframework and a broader engagement process forplanning and implementation. These processesprovide another experience for the health sectorto decentralize program management whilemoving the nexus of control into the LGUs. Thisdirection, in effect, brings the TB program into thehands of local leaders and stakeholders, and moreparticularly, of the patients whose successfultreatment is the ultimate goal of the program.National agencies, headed by the DOH, have toprovide appropriate and adequate technicalguidance and logistical support to enable the LGUsto implement an effective local TB control program.

The second major thrust of the plan is to ensurethat the internationally recommended DOTSstrategy is scaled up and sustained to enable notonly the general population to continuously accessquality TB services but also to address the needs ofvulnerable populations.

STRATEGIES, PERFORMANCETARGETS, AND ACTIVITIES

STRATEGY 1: Localizeimplementation of TB control

This strategy aims to have the LGUs at theprovincial, city, and municipal levels manage andimplement the TB control program within thedecentralized health system setup and in support ofthe health sector reform initiatives. This strategy

responds to the 2008 NTP PIR by the DOH, whichrecommended the reduction in the gaps and risks ofprogram implementation, including local variationsin extent and quality of TB-DOTS coverage and LGUnon-ownership of local TB control objective. The PIRconcluded that the best approach to sustaining TBcontrol is the adoption of province/citywidemodel(s) of implementation. The situational analysisaffirmed the above findings and highlighted thefollowing challenges in implementing a localizedapproach to the TB program such as:

varying TB control program performanceamong provinces and cities;

perception of NTP as a predominantly“national” or central DOH program causingsome LGUs to declare “non-ownership” of theprogram;

inadequate LGU support in many areas; and

lack of coordination among programstakeholders.

The health systems approach for the effectiveimplementation of the TB program requires theintegration of the national and local health systemsin the planning, implementation, and monitoringand evaluation of the program. It also demands thatboth health systems subscribe to the same programvision, mission, goals, and strategies. As such, thegovernance framework, TB program plans, andimplementation design are tailored to local healthsystems in a devolved setup. This approachnecessitates that the roles and relationships of thedifferent levels of governance structures andhealth service delivery providers be defined.

In support of PhilPACT, the LGUs must do thefollowing for TB control:

Provide leadership in the development andimplementation of local TB control plans,policies, and programs consistent with thenational direction;

Coordinate public-private sector participation;

Mobilize finances for the local TB controlprogram;

Ensure an adequate and trained workforce;


Implement the Quality Assurance (QA) systemfor TB laboratory services

Manage logistics including drugs from allsources; and

Collect, analyze, and use TB data for localprogram management.

In support of PhilPACT, the nationalgovernment’s key roles for the TB control programinclude:

Developing national plan, programs, policies,and standards consistent with internationalrecommendations;

Providing technical assistance to LGUs andother program partners;

Regulating the quality of TB service provision;and

Monitoring and evaluating programperformance.

An environment should be set up, supportiveof the scaling up of local TB control implementation.This may include “establishing national and localperformance targets, developing appropriatestandards and protocols for service delivery,coordinating financing from various sources, andproviding enabling environment.”77

To implement Strategy 1, the specif icperformance targets and activities are:

Performance Target 1.1. Seventy percent(70%) of provinces and highly urbanizedcities (HUCs) include clear TB control planwithin the Provincewide Investment Planfor Health (PIPH) or ARMM InvestmentPlan for Health (AIPH) or City InvestmentPlan for Health (CIPH).

The PIPH/AIPH/CIPH and the Annual OperationalPlan (AOP) are the current frameworks for LGUs todeclare their development plans for the healthsector including the investment requirements oftheir health goals. These health plans should beintegrated in their comprehensive developmentplan and include a section on the TB program

consistent with PhilPACT. As of 2008, 44 provincesalready had PIPHs and the ARMM had completedits AIPH. CIPHs are currently being developed bythe chartered and highly urbanized cities.

Activities at the local level will focus on assistingthe LGUs develop their capacity to assess their TBprogram implementation and develop TB strategicplans based on their current situation. Theincorporation of the PhilPACT in their PIPH/AIPH/CIPH will be guided by a standard TB subplanendorsed by NTP. Technical assistance will beprovided by the national and regional offices fordeveloping the LGU plan which will be annuallyreviewed and updated. To support these activities,NTP will formulate guidelines and assist LGUs indeveloping TB control strategic and operationalplans for the PIPH/CIPH/AIPH and the subsequentAOPs. These plans will then be regularly collated,analyzed, and used as inputs for the PhilPACTannual plans and reviews. They will also bereviewed by the Joint Appraisal Committee (JAC).

Performance Target 1.2. Seventy percent(70%) of provinces/highly urbanizedcities are at least DOTS compliant.

The following proposed eight standardsnecessary for effective DOTS implementationshould be attained by an LGU to be DOTS-compliant.

1. A province/citywide multiyear TB control planincorporated within the PIPH/AIPH/CIPH thatresponds to the local situation;

2. A governance structure that managesimplementation of the province wide TBcontrol program and that coordinates public-private participation in TB control;

3. A network of provincial and municipal TBlaboratories, both public and private, thatmaintains quality-assured DSSM;

4. An efficient TB drug management system thatensures uninterrupted supply of anti-TB drugsin all the DOTS facilities within its catchment;

5. A DOTS service network for TB care anddiagnosis, involving both public and privatehealth care providers at different levels ofhealth care


6. A program of activities being implemented toincrease demand for TB services;

7. A system that regularly analyzes programperformance (e.g., regular monitoring andevaluation), at least an annual PIR, andquarterly reporting to CHD; and

8. Secured funding for TB control programimplementation.

A classification scheme on the stage of DOTScompliance is also proposed:

DOTS compliant – meets all eight standards

DOTS performing – DOTS compliant, andachieves the case finding and case holdingtargets and EQA standards

DOTS sustaining – DOTS performing, achievestargets for at least three consecutive years,and with initiatives on MDR-TB and vulnerablepopulations

To guide the LGUs adherence to the DOTScompliant criteria, the DOH will pretest and finalizethe above standards in coordination withstakeholders, develop implementing guidelines aswell as assessment, advocacy tools, and servicepackages. The capacity of the national and regionalunits will be strengthened in the areas of assessingprovinces/c ities vis-à-vis the DOTS compliantstandards and in providing technical assistance forprovinces/HUCs to be at least DOTS compliant.

Performance Target 1.3. Ninety percent(90%) of priority provinces and HUCswith performance grants have achievedprogram targets.

AO No. 2006-0023, which gives details on thefinancing of the Health Sector Reform, providesthat budget allocations and releases shall be shiftedfrom historical or incremental budgeting to thoseconditioned on the achievement of performancetargets. The NTP performance-based grants (PBGs)are intended to assist the provinces strengthentheir management of the program, improvedelivery of TB services, and engage other

stakeholders and community partners to achievethe provincial performance targets for TB control.Preferential support for poor performing provinceswill be provided through PBGs which will specifyincreases in case detection and treatmentoutcomes as performance targets. Achievement ofDOTS-compliant standards will be secondarytargets. The PIPH/AIP/CIPH of these provincesshould indicate how these increases can besustained. The NTP will look at the ongoingperformance-based grant (PBG) components ofother programs to distill best practices.

The DOH will identify priority provinces/HUCsbased on their TB burden, performance, andabsorptive capacity. These factors will form the basisfor their performance grants for which grantimplementation and monitoring schemes will bedeveloped. The LGUs will be provided assistance inimplementing their AOPs which will include theperformance grants. LGUs who receive performancegrants will be assessed as to their compliance withagreed targets set mutually with the DOH.

Performance Target 1.4. DOH and partnershave capacity to provide TechnicalAssistance to provinces and cities.

An integral part of the NTP is the capacitybuilding of the DOH and partners to provide TA toLGUs in support of the PhilPACT in general and tocomply with DOTS standards in particular. This is avery important activity considering that the newstrategies and approaches require new knowledgeand skills from national and regional staff.

The DOH will develop guidelines for theprovision of TA to provinces and cities whilestrengthening regional level coordinationmechanisms like the Regional CoordinatingCommittees, Regional Social DevelopmentCommittees (RSDC), and Regional Implementationand Coordinating Team (RICT). TA requests fromCHDs and other partners will have to be classifiedaccording to priority and then scheduled in orderto ensure the equitable provision of TA. TArequests will be developed by LGUs based on thedeficiencies in their TB control program. The


request for and provision of requested TA isexpected to result in enhanced TB program plansof LGUs for their subsequent implementation,monitoring, and evaluation.

Performance Target 1.5. Public-privatecoordinating body on TB control atnational, regional, and provincial levelsestablished and sustained to includeComprehensive Unified Policy (CUP)mechanism.

The successful implementation of PhilPACTrests on the effective collaboration between thepublic and private sectors in implementing variousTB control interventions. As described in theimplementing arrangements for PhilPACT, anat ional TB coordinating committee will beestablished based on the current NationalCoordinating Committee for PPMD (NCC-PPMD).The functions and membership of the RegionalCoordinating Committee for PPMD (RCC-PPMD) willbe correspondingly expanded.

Because there already are various mechanismsin the provinces and cities that coordinate thehealth efforts of public and private organizations,PhilPACT promotes the use of these, such as thelocal health board, the provincial coordinatingcommittee being established by PhilCAT, theprovincial CUP, or other provincial public-private(PP) bodies such as the AIDS council. The selectedgroup will facilitate the development of localpolic ies, guidelines, and initiat ives to addressissues especially related to non-NTP health careproviders’ involvement in TB control. The group willstrengthen TB control efforts in the province andcity through coordinated assessment and planning,sharing of resources, and involvement of widerconstituencies. Key local activities includeidentification and orientation of partners, as wellas planning and tracking of plan implementation.

Through the CUP TB mandate and coordinationmechanisms, intergovernment agencycoordination for TB control will be enhanced at thenational and local levels. Nationally, CUP memberswill meet regularly for joint planning activities in

order to develop and issue policies and guidelineson TB in accordance with the agency’s mandate andsectoral needs. Regional and provincial CUP TBorientation and planning activities will also beconducted to establish coordination and referralmechanisms. Locally, the LGUs will coordinate theimplementation of the various agencies’ policiesand establish the referral mechanism for thecoordination and documentation of the TBprogram outputs/activities. Local issuances insupport of the multisectoral initiative for TB andinter-agency coordination will also be pursued inthe various LGUs.

STRATEGY 2: Monitor healthsystem performance

NTP performance is influenced both by differentprogrammatic initiatives of public and privateinstitutions and by actions in health systemstrengthening such as health human resourcedevelopment, logist ics management, healthinformation integration, local system development,financing system harmonization, etc. It is importantfor NTP to regularly determine the progress in TBcontrol efforts vis-à-vis these influences. The M&Eof PhilPACT which goes beyond programmaticmonitoring is described in detail in the Monitoringand Evaluation section.

Performance Target 2.1. Trend of TBburden tracked.

The impact and outcome of health systemperformance are usually measured throughnational surveys. In the last five years, NTP usedthe results of the following surveys to monitor theTB burden in the country: 2004 Drug ResistanceSurvey; 2007 National TB Prevalence Survey; andthe 2003 National Demographic and Health Survey.Results of the 2008 NDHS have yet to be released.

Reporting of mortality data has been noted tobe poor and has affected the quality of TB mortalityreports. An activity of this strategy aims to improvethe capacity of local health staff in quality


documentation and timely reporting of TB mortality.A TB mortality study through verbal autopsies isplanned at the local level. At the national level,the following surveys will be conducted todetermine the trend of the TB burden in thecountry: Drug Resistance Survey in 2011 and 2016;1st TB mortality study in 2011; and 4th NationalPrevalence Survey in 2014. To capture more dataregarding the disease, specifically on health-seeking behavior and other socioeconomicdeterminants of TB, specific questions on TB willbe included in the 2013 NDHS and 2011 AnnualPoverty Index Survey (APIS).

Performance Target 2.2. TB informationgenerated on time, analyzed, and used

Complete, accurate, and timely information isnecessary to guide program implementation.F indings of the PIRs and program evaluationsindicate a six month delay in reporting, as well asdata inconsistency in some areas. To address these,training courses on TB data and informationmanagement will be conducted at the local level.The LGUs will also be assisted in the use of theexpanded Web-based TB information system thatwill serve to enhance program planning,monitoring, and evaluation.

NTP will develop the courses on TB data andinformation management and coordinate with NECin the expansion of the Web-based TB informationsystem. Technical assistance will be provided to theLGUs on the conduct of the courses and initiationof a Web-based TB information system. The annualperformance reviews to be participated by both thepublic and private stakeholders based on theseimproved data and information systems will thenserve as inputs for the program planning andimplementation activities of the DOH, LGUs, andpartners.

Performance Target 2.3. TB informationsystem integrated with national M&E andField Health Services Information System

Harmonization and integration of various healthinformation subsystems is key to effective decision

making. Currently, NTP performance is separatelyreported through the F ield Health ServicesInformation System (FHSIS), managed by NEC andthrough the provincial and regional TB coordinators,resulting in discrepancies in NTP reports andadditional work for field health staff. Two TBindicators, namely CDR and Cure Rate, are includedin the LGU scorecard that is coordinated by theBureau of Local Health Development (BLHD) of theDOH. At the local level, there is a need to collect,consolidate, and analyze the LGU scorecard todetermine local performance in health, specificallyin TB control, so that corresponding actions can betaken. At the national level, the activities will focuson enhancing NEC’s capacity to develop the TB M&Eand manage an integrated TB information system.

STRATEGY 3: Engage bothpublic and private health careproviders

Health care providers (HCPs) and theircorresponding actions are critical to patients’ accessto quality TB services. WHO states that “competenthealth care providers and managers are critical inthe successful implementation of the DOTSstrategy to reach and sustain the targets for globaltuberculosis control. The development andmaintenance of a competent workforce for TBcontrol is therefore a key component of theactivities of national TB control program.”78

In 2001, WHO strongly urged countries toengage the private sector due to attendant risksand opportunit ies in TB control programimplementat ion. Lack of private sectorinvolvement leads to many undetected anduntreated TB cases and reduct ion of theepidemiological impact of DOTS. It furthercontributes to evolution and spread of MDR-TB andworsens the financial burden of patients.79 Thepublic-private mix (PPM) strategy utilizes acomprehensive engagement approach not just forthe private sector but for all relevant health careproviders. “Evidences from many countries showthat PPM is feasible, productive and cost


effective.”80 As of 2008 there were 220 PPMD unitsthat contributed 6% to the national CDR and 18% tothe local CDR. For the government sector,involvement is mandated through Executive OrderNo. 187 signed by the president in 2003, instructing17 government offices and urging four privateorganizations to adopt DOTS. Regional orientationwas conducted and a few provinces organizedprovincial level CUP coordinating groups.

Performance Target 3.1. Sixty percent(60%) of all DOTS facilities in the provinceswith provincial PP mechanisms have afunctional public-private collaboration/referral system (service delivery level).

The biggest challenge is to rapidly increase theparticipation of non-NTP health care providers todetect the “missing TB cases,” and hence contributeto the attainment of the MDGs. This would alsoreduce exposure by TB symptomatics and TBpatients to non-DOTS providers, thus, shorteningthe delay in TB care seeking and ensuring properdiagnosis and treatment.81

To ensure that the TB symptomatics and TBpatients receive continuous TB care in accordancewith the national protocol, all service deliverypoints such as the rural health units/health centers,hospitals, private/NGO clinics, TB diagnostic centersin the municipalities or component cities mustadopt DOTS and participate in an effective referralnetwork. The process for collaboration has to beclearly described in the guidelines and agreementsamong participating units expressed in memorandaof agreement (MOAs). Mechanisms should bestrengthened and optimized to ensure adequateand prompt feedback on referrals for diagnosis andtreatment between private and public providers.82

The NTP will develop and disseminateguidelines on how to establish, sustain, and monitorDOTS referral networks. It will also specify theservice delivery packages and how their provisionshould be managed, coordinated, and supportedby key stakeholders. An example of this package isin Annex 3. Existing national policies and guidelineson PPM will be updated and disseminated. LGUswill map out the TB service providers in the area,

advocate for participation in the delivery of TBservices, and establish the DOTS referral network.Establishment of public-private partnerships willbe continued and measures to sustain such will beimplemented. Examples of enablers and incentivesare attendance in capability-building activities,access to free anti-TB drugs, support by the LGUs,and availment of financial incentives from thePhilHealth TB-DOTS outpatient benefit package.

Performance Target 3.2. Ninety percent(90%) of public hospitals and sixty percent(60%) of private hospitals are participatingin TB control either as DOTS provider orreferring center

Hospitals are critical partners in TB control sincefour out of ten TB symptomatics consulted ahospital and TB is one of the leading causes ofhospital admissions and deaths. Of the 1,771hospitals nationwide, only a few have maintaineda DOTS clinic while a few refer TB cases to DOTSfacilities on an irregular basis.

Hospital participation will be systematized andexpanded every year to include both public andprivate providers either through the establishmentof a DOTS clinic that provides diagnostic and treatmentservices or through strengthening their referralsystems to peripheral DOTS centers for the dischargedand outpatient TB patients. The two-way referralsystem will be enhanced using the tools developedunder the P2P initiative. Major activities will includeadvocacy to hospital management, training of staff,and putting the intra- and interhospital referralsystem in place. Financial incentives through thePhilHealth packages, both inpatient and outpatient,will be maximized to enhance hospital participation.Other regulatory measures for hospital participationare described in Strategy 6.

Performance Target 3.3. Seventy percent(70%) of targeted 9,000 private practitionersare referring patients to DOTS facilities.

One in three TB symptomatics consult privatepractitioners who use different protocol fordiagnosis and treatment. They also do not report


their cases to NTP. International organizations haveendorsed the International Standard for TB Care foradoption by health care providers with itsaccompanying document on pat ient rights. Itcontains specific standards on diagnosis, treatment,and public health responsibilities related to TBservices. There is ongoing training of privatepractitioners on DOTS and around 50% usually referTB cases to DOTS facilities.83

At the local level, members of the sixprofessional societies who endorsed the ISTC willbe given priority for training and will be linked toDOTS facilities for referral. The PhilHealthoutpatient package will be used to motivate themto participate in TB control. At the national level,the ISTC will be adapted to the local setting andincorporated in all DOTS training courses. A majorindicator for its acceptance is referral to a DOTSfacility. ISTC will also be advocated for other healthcare providers and health related institutions suchas schools.

Performance Target 3.4. All frontlinehealth workers are equipped to deliver TBservices.

Turnover of staff especially in the peripheralhealth facilities and engagement of other non-NTPfacilities require systematic and regular capacity-building mechanisms that are anchored on trainingneeds rather than on budget availability. All frontlinehealth workers must have the knowledge, skills, andattitude to deliver TB services in accordance withthe national protocol and adapted to the patient’sneeds. NTP has developed various training coursesfor specific health worker, e.g., modular DOTS fordoctors and nurses, referring course for privatepractitioners, basic microscopy for microscopist, andDOTS for barangay health workers.

NTP will improve its capability-buildinginterventions by integrating all training courses onDOTS, e.g., basic DOTS and childhood TB, to reducetime spent by health workers on training. Sometraining courses on DOTS will also be integrated withother training courses on communicable diseasesthat could start with the integrated microscopy

training and training on infection control for publichealth care settings. NTP will outsource conduct ofsome training courses to other educationalinstitutions and will develop a regular schedule fortraining of newly hired health workers. At the locallevel, training needs analysis will be conducted toidentify health staff who need skill enhancement.The training officers at the CHD and province/citylevel will be involved in doing training needs analysisespecially of the priority provinces/cities.

A human resource information system on TB thatwill generate information on the number of trainedand untrained TB workers will be established. Toaddress broader problems such as shortage ofhealth workers, NTP will support theimplementation of the HR strategic plancoordinated by the Health Human ResourceDevelopment Bureau (HHRDB).

STRATEGY 4: Promote andstrengthen positive behavior ofcommunities

Care-seeking behavior among many Filipino TBsymptomatics is often characterized by non-action,prolonged delays in consultation, self-medicationwith traditional remedies or with anti-TB drugs, andpoor adherence to treatment. Social, economic,cultural, and political factors on both the providerand consumer sides strongly influence care-seekingbehavior.84 These factors are either intrinsic orextrinsic, and serve as barriers in practically everystep in the pathway towards successful TB care. Otherfactors are extrinsic, but are equally important,including stigma in the community and amonghealth providers; and the accessibility, affordability,acceptability, and quality of DOTS services.

Advocacy, communication, and socialmobilization (ACSM) initiat ives have beenimplemented in the NTP but improvements are stillneeded in terms of quality, financing, andleadership. The coordination and evaluation ofthese activities have been inadequate. At the locallevel, the health workers’ insights andunderstanding of the TB patients’ behavior need


further improvement. The utilizat ion of DOTSservices, especially by the poor and marginalized,can still be improved through interventions thatfacilitate care seeking at DOTS facilities, compliancewith diagnostic procedures, and adherence totreatment. Community participation in TB controlremains limited.

Performance Target 4.1. Proportion of TBsymptomatics who are self-medicatingand not consulting health care providersreduced by 30%.

The 2007 national TB prevalence survey showedthat 68% of TB symptomatics did not take any action,and 43% of them self-medicated. The activitiesunder this target will contribute to the increase inthe number of TB symptomatics who are takingappropriate action including full compliance withdiagnostic procedures.

IDO will coordinate with NCHP to develop anational ACSM plan to serve as the blueprint forthe strategies and activities to be implemented atsubnational level. Communication materials will bedeveloped targeting specific audiences to:

increase their awareness on TB signs andsymptoms, as well as mode of transmission;

correct misconceptions; and

reduce stigma.

Information materials promoting DOTS services,and highlighting their advantages and benefits forpatients will also be developed and disseminated.The development of prototype materials will beled by NCHP/IDO, including the establishment ofsystems for f inancing, quality assurance, andmonitoring and evaluation of communicat ionactivities and materials.

Capability building of health providers, andpartner NGOs and community organizations will bedone to improve their skills in disseminatinginformation effect ively including skills ininterpersonal communication and counseling, andto reduce stigma among health workers andprogram managers. Advocacy to LGUs will be

undertaken to solicit their financial and logisticalsupport for the production and distribution of IECmaterials, and the conduct of mass mediacampaigns. The private sector and faith-basedorganizations will be tapped to help disseminateTB information.

Local strategic communication plans anchoredon the results of TB service barrier analysis, suitableapproaches, and available resources will bedeveloped.

Advocacy for TB at the national and local levelwill be strengthened so that it will be a continuousrather than seasonal undertaking, and will helpaddress strategic concerns in TB control especiallydelayed consultation and self-medication, servicequality and accessibility, stigma, lack of socialsupport for TB patient care, and other program gaps.Well-targeted and participatory local informationcampaigns will be conducted to highlight theimportance of timely and appropriate TB care-seeking. Researches aimed at improving theunderstanding of patients’ behavior, as well astrainings to increase health workers’ capacity forinterpersonal communication and counseling willbe conducted.

Performance Target 4.2. Default rate ofprovinces and cities with >7% reducedby 40%.

Unfavorable treatment outcomes of TB casesinclude deaths, failures, defaulters, and transfer-outs and are due to patient and program factors.Recent program reports show high default ratesexceeding 7% in some areas. Treatment default isusually the strongest factor that reduces the levelof treatment success.

The application of DOT throughout the entireduration of treatment will be improved throughbetter counseling skills among health workers,better clinical care, and stronger communityinvolvement to make DOTS more accessible topatients and accommodate their needs better.

Health workers and community volunteers willbe trained in interpersonal communication andcounseling focusing on the use of relevant messages


important to patient care. The recruitment ofcommunity volunteers who will act as treatmentpartners to allow community or home basedtreatment will also be pursued through communitymobilization. Advocacy to LGUs and barangayleaders, as well as the private sector, to providefinancial and logist ical support for treatmentpartners will be done.

Enabling mechanisms (e.g. , food aid forimpoverished families) will be developed tofacilitate treatment adherence, particularly amongthe poor and marginalized patients. IEC materialsfor patients under treatment will be developed tohelp maintain their motivat ion to completetreatment especially during the continuationphase. Again, advocacy for LGU and private sectorsupport for this initiative will be undertaken.

Performance Target 4.3. Number ofbarangays that have organized community-based organizations (CBOs) participating inTB control and that are linked with DOTSfacilities increased by 50%.

Assessment of community involvement in TBcare, implemented in some countries in Africa, LatinAmerica, and Asia revealed varying modes ofparticipation and showed a positive correlation withgood treatment outcomes and higher cost-effectiveness.85 Hence, WHO recommends that“NTPs, health service providers, and communitiesshould take steps towards harnessing communitycontribution to TB care.”86

At the local level, more community-basedorganizations will be organized or mobilized toprovide support to TB control activities at thebarangay level. These groups are envisioned todisseminate TB information, assist in DOTS, providesocial support for patients and/or their family,participate in advocacy for local political and financialsupport for the program, and assist in networkingamong health providers. Guidelines for communitymobilization will be developed by the IDO/NCHP, inpartnership with other relevant agencies.

Capacity building activities for communitysupport groups will be led by the IDO/NCHP with

the support of other government agencies, and theprivate sector. A scheme for financing, coordinating,and the monitoring and evaluation of theseinitiatives will be developed. Operational researchwill also be conducted to help identify and addressoperational gaps.

STRATEGY 5: Address MDR-TB, TB/HIV, and needs ofvulnerable populations

At the 62nd World Health Assembly in May 2009,the 193 member states of the World HealthOrganization adopted a resolution urging countriesto strengthen the prevention and control of drugresistant tuberculosis.87 This resolution was basedon a Call for Action agreed on during the ministerialmeeting in Beijing in April 2009 of which thePhilippines was a signatory. MDR-TB cases threatensthe gains of the NTP because they are costly anddifficult to treat, hence, may lead to transmission,development of XDR-TB, and death. Aside fromstrengthening basic DOTS implementation to avoidemergence of MDR-TB, there is a need to implementa program that would detect most of the MDR-TBcases and ensure that they receive quality-assuredsecond-line anti-TB drugs.88 The Philippines is oneof the few countries that had earlier recognized theneed to address MDR-TB and has piloted it in MetroManila since 1998 through the Tropical DiseaseFoundation Incorporated under the guidance of theGreen Light Committee and scaled up under GlobalFund.89 The issuance of a DOH policy on theprogrammatic management of MDR-TB in 2008initiated the integration of this initiative with theNTP. The country also recognizes the threat of HIV/AIDS to TB control efforts. The DOH has issued a policyfor collaboration between the NTP and the NationalAIDS and STI Prevention and Control Program(NASPCP) to jointly address this comorbidity.

Generally, vulnerable populations such as thepoor, children, elderly, refugees, inmates and thoseliving in geographically isolated and depressedareas have difficulty accessing health services.Usually, their health status is worse compared to


the general population.90, 91 , 92 Except for itsprograms for children and inmates, NTP has not yetintroduced interventions to address the needs ofthese populations.

Performance Target 5.1. A total of at least15,000 MDR-TB cases have been detectedand provided with quality-assuredsecond-line anti-TB. drugs.

Management of MDR-TB started in 1998 and hascontinued until the present through the assistanceof Global Fund. F ive treatment centers and manytreatment sites have been established in MetroManila. Treatment of about 500 MDR-TB cases wasinitiated in 2008.

PMDT implementation will be expanded toother regions to ensure better access to diagnosticand treatment services by MDR-TB cases. This isquite challenging since an enormous amount ofresources is needed for a two-year treatment withsecond-line anti-TB drugs, upgrading ofinfrastructure that will provide a safe andconvenient environment for staff and TB patients,longer training activities, and ACSM efforts toaddress the stigma attached to MDR-TB. Quality-assured second-line anti-TB drugs for MDR-TB caseswill be purchased with the support of thegovernment and Global Fund. The necessaryinfrastructure and systems to diagnose and treatMDR-TB cases will be established. These include:

25 culture centers and five Drug SusceptibilityTesting sites where these cases will bediagnosed and treatment response can bemonitored;

35 treatment centers where patients will becorrectly assessed and provided withtreatment and psychological support;

treatment sites where those who haveconverted to culture negative can be referredfor continuity of treatment;

integrated management system of thesecond-line anti-TB drugs;

conduct of regular monitoring, supervision,and evaluation;

a referral system for MDR-TB suspects fromboth the public and private DOTS facilities; and

an information system.

Capacity building of the program managers andthe service providers will be conducted. Thepossibility of including MDR-TB services in theoutpatient benefit packages of PhilHealth will beexplored.

A DOH unit will be designated and capacitatedto support the NTP so that the management of MDR-TB is kept within the NTP’s strategic direction,policies, and standards. The Lung Center of thePhilippines (LCP), which will establish and operatethe National MDR-TB Referral Center with theassistance of the Korean International CooperationAgency (KOICA), is being considered to be themanager of the MDR-TB network under the oversightof NTP. Likewise, the NTRL, as the manager of TBlaboratories, shall serve as the overall laboratorystructure for MDR-TB laboratory management.

Performance Target 5.2. TB/HIVcollaborative activities established inareas with populations having high riskbehavior and with at least 80% of TB casestested for HIV.

Experiences in other countries with highprevalence of HIV/AIDS like those in Africa showthat HIV/AIDS fuels TB epidemic by increasing theprobability of latent TB progressing to active TB by50% among those with HIV and leading to a highmortality rate.93 There is a strong call to intensifyHIV and TB control program collaborat ion to“effectively treat those infected with both diseases,to prolong their survival and to maximize limitedhuman resources.”94 WPRO has issued a frameworkon how to address HIV/TB coinfection.95 Althoughthe Philippines has low prevalence of HIV/AIDS,there is a need to be vigilant and measures mustbe put in place to prevent the threat of HIV/AIDS tothe TB control program and at the same timerespond to the needs of those with TB/HIVcoinfection. TB/HIV collaboration has beenimplemented in the ten cities of Metro Manila.96


Two strategic actions will be taken:

expand the collaborative activities in areasidentified as having populations with high riskbehavior that includes 23 cities andmunicipalities (on top of the 10 in NCR)identified by NASPCP, and

conduct surveillance of HIV among TBpatients.

Expansion areas were prioritized due to thefollowing reasons:

burden of TB/HIV coinfection is expected tobe higher due to presence of high riskbehavior;

HIV/AIDS care and support services areexisting and can easily be extended to the TB/HIV coinfected patient; and

presence of a unit that has staff who has beensystematically trained in both programs.

Major activities include provision of providerinitiated counseling and testing (PICT) to TBpatients, conduct of HIV testing, and provision ofantiretroviral treatment (ART) for those identifiedwith TB/HIV coinfection. The staff of the HIVtreatment hub will also be trained to manage HIV/AIDS cases with concomitant TB.

Performance Target 5.3. Nationwideimplementation of childhood TB program.

Although prevalence and infectiousness of TBamong children are lower than among adults, therisk of being infected and progressing to active TBdisease is higher especially for the preschool agegroup. With the issuance of guidelines on themanagement of TB among children that areconsistent with those of WHO, the TB controlinitiative which started in 2005 is currently beingexpanded to other provinces.97

Nationwide coverage of a TB control program forchildren is planned to be completed by 2013. Localactivities include training of frontline workers todiagnose and treat children and also to provide

preventive therapy for those who are contacts of TBcases, distribution of drugs and PPD supplies,coordination with stakeholders, and monitoring. Atthe national level, collaboration with the PhilippinePediatric Society (PPS), the Philippine AmbulatoryPediatric Association (PAPA) and other agenciesdealing with children such as DSWD and DepEd willbe conducted. Policy-wise, single dose formulationwill be changed to fixed dose combination to enhancecompliance and facilitate drug supply management.

Performance Target 5.4. DOTS servicesaccessible to all inmates with TB.

International and local studies have shown thatprevalence of TB among prisoners is more than fourtimes that of the general population and that thechances of having drug resistant TB are also higher.98

WHO encourages NTP to coordinate with theappropriate authority to provide TB services toprisoners since they have the same rights aseverybody else. Besides, the prison could be an idealenvironment for TB control since prisoners are acaptive audience. The prison situation could“facilitate identification of prisoners with TB,promote adherence to treatment, and accuraterecording and reporting.”99 DOTS has been irregularlyimplemented in some prisons and jails.100

The strategic direction is to ensure that this groupwill have access to TB diagnostic services such assputum microscopy and treatment, either from thehealth clinic within the jails/prisons or bycoordinating with the nearest DOTS facility forprovision of services. The prevalence survey that iscurrently being conducted by the PTSI will provide abetter estimate of the TB burden in prisons and willprovide information on the KAPs of inmates and jailworkers. They can guide the crafting of TB servicesresponsive to the needs of the inmates. Technicalpolicies and guidelines have been issued by the DOHand adopted by the DILG. This initiative will beimplemented by the Bureau of Jail Management andPenology (BJMP) of DILG for inmates in 1,075 prisons,by LGUs in 103 provincial/city jails, and by the Bureauof Corrections (BuCor) of the Department of Justice(DOJ) for its inmates from seven prisons and penalfarms. Technical and logistical support will be


provided by the DOH, LGUs, Global Fund, and theInternational Committee of Red Cross for anestimated 130,000 inmates.

Performance Target 5.5. Policies,operational guidelines, and modelsdeveloped, disseminated, and locallyadopted to address needs of vulnerablepopulations.

Vulnerable groups have a higher risk of gettingTB and dying from it because of their:

poor health status;

poor TB care-seeking behavior due to theirdisadvantaged position such as low level ofliteracy and inadequate access to healthservices due to lack of communication andtransportation facilities, and financial barrier.

Many are in geographically isolated areas suchas the mountains, island barangays, ormunicipalities that are inaccessible due toinclement weather. WHO has called on countriesto address the needs of the vulnerable populationsand has issued guidelines for these, e.g., the poor,children, refugees, and displaced population.102

The priority activity at the local level is to identifyand map these vulnerable groups such as the urbanand rural poor, indigenous people, internallydisplaced persons due to man-made or naturaldisasters, cross-border users of care, the elderly, andthose in congregate settings. Studies will beconducted to generate information on theirsociodemographic situation, health status, andhealth-seeking behavior that affects their access toTB services. Study results will be used to guide theformulation of policies and models that respond totheir specific needs. Concerned governmentagencies such as the NCIP for indigenous people andDSWD for the elderly will be assisted in developingpolicies and implementing guidelines and pilotinitiatives to reach the TB patients. NTP will developand issue policies and guidelines on appropriateinterventions for the vulnerable groups and put inplace an information system to monitoreffectiveness of these efforts.

STRATEGY 6: Regulate andmake available quality TBdiagnostic tests and drugs

Quality health service is defined as effective,efficient, accessible, acceptable, patient-centered,equitable, and safe. Availability of quality-assureddiagnostic tests and standardized treatment are keyto prompt diagnosis and treatment of TB cases.

Performance Target 6.1. TB laboratorynetwork managed by the National TBReference Laboratory (NTRL) to ensurethat 90% of all microscopy centers arewithin the quality standards.

Direct sputum smear examination, the main toolused to detect TB cases under the NTP, is providedby more than 2,000 TB microscopy centers (MC) inthe country. DSSM is quality-assured through theEQA system that is managed by the National TBReference Laboratory (NTRL) with the assistanceof the regional and provincial/city QA centers. Inaccordance with the protocol of EQA, provincial andcity TB coordinators collect quarterly apredetermined number of slides from the MCs andthese are read by the provincial or city validator.Results are provided to the participating MCs.

The major activity to achieve the performancetarget is to strengthen the capacity of NTRL tomanage the TB laboratory network by ensuring:

adequate and trained manpower;

increased and secured funding support for itsactivities;

established systems such as human resourcedevelopment for TB laboratory staff andinformation management; and

linkage with supranational laboratory andlaboratory experts.

An NTRL organizational assessment and a TBlaboratory strategic subplan will guide the activitiesto enable NTRL to effectively perform its role as


overall TB laboratory manager. NTRL will developand implement a certification system for public andprivate laboratories providing DSSM and thiscertification will be linked with the PhilHealthaccreditation for health facilities. Regional andprovincial QA centers will also be capacitated toimplement and sustain the EQA. Coverage of EQAwill be expanded to microscopy units based inhospitals and private laboratories. This will requirestrict implementation of the DOH administrativeissuance that mandated NTRL to scale up the qualityassurance to include all microscopy centers doingsputum microscopy. In addition to EQA for DSSM, aquality assurance system for TB culture and DST willbe established. As part of the retooling process,NTRL will also pilot new diagnostic tests that shouldbe “cost-effective and robust enough to be used atperipheral levels“ and “should allow sensitive,specific, and timely detection of TB cases.”103

Performance Target 6.2. TB microscopyservices expanded in cities andunderserved areas.

To ensure access and adequate workload tomaintain the proficiency of microscopists, theinternational standard for microscopy center topopulation ratio is one per 50,000–100,000. Bigcities such as Quezon City, San Fernando, Antipolo,Batangas, and Puerto Princesa have a worse ratiothan provinces. Residents of geographicallyisolated and depressed areas such as islandmunicipalities of ARMM have no access tomicroscopy services at all.

For big cities, the intervention is to establish newmicroscopy centers through advocacy to the localgovernment units or to utilize the microscopy unit ofhospitals or private laboratories. In difficult areas,innovative strategies will be adopted to bring theservices closer to the communities. These may include:

utilization of community volunteers to dosmearing, fixing and to transport the slides tothe microscopy centers, and

inclusion of smear examination during outreachservices or itinerant team’s visits to areas.

Performance Target 6.3. Every provinceand Highly Urbanized City with access tofunctional TB Diagnostic Committee.

Many studies have shown that no radiographicpattern is diagnostic of tuberculosis. This lowspecificity of X-ray examination as a diagnosticprocedure for smear negative TB cases leads to overdiagnosis and a waste of resources. Thus, the TBDiagnostic Committee has been established.

Systematic evaluation of the TBDC will beconducted to improve its operations and ensure itssustainability. Operational guidelines for TBDC willbe revised to adopt its composition to the area,incorporate additional information in its reportingsuch as quality of X-ray film, reduce the delay inthe release of reading, and provide options tosupport its operations. Additional TBDCs will beestablished in priority sites where they are mostneeded—those with a big populat ion, a highnumber of smear negative cases that exceeds thesmear positive cases, and with many privatepractitioners and private hospitals. The TBDC’sperformance will be regularly monitored throughreports and PIRs. Its sustainability will be assuredthrough a share of PhilHealth outpatient benefitpackage, advocacy for issuance of local policybacked with budgetary support, conduct of regularassessment, and monitoring of performance. Anoperational study on the effect iveness andfeasibility of a QA system for it will be conducted.

Performance Target 6.4. Quality-assuredanti-TB drugs always available in DOTSfacilities.

A critical element in ensuring compliance by TBpatients is the continuous availability of quality-assured first-line anti-TB drugs at DOTS centers. Thisin turn is dependent on an effective drugdistribution system that includes the selection andquantif icat ion of drug needs, procurement,distribution, and utilization.104 This also includesensuring the quality of anti-TB drugs through a drugregulatory authority and a drug information system.

To ensure that TB patients have an uninterruptedsupply of anti-TB drugs, budget allocation and


procurement of all anti-TB drugs for both adult andpediatric TB cases will be the responsibility of theDepartment of Health. This is a shift from theprevious policy of having the LGUs provide anti-TBdrugs for Category III TB cases. The LGUs will insteadallot contingency funds for unforeseen disruptionin drug supply and for adverse drug reactions toFDC.. The advantages of this mechanism are:

uniform formulation and packaging of thedrugs that facilitates patient compliance(fixed dose combination in blister pack andpackaged as TB kit);

procurement of quality-assured drugs; and

cost reduction due to bulk procurementcompared to small scale purchases ofindividual LGUs.

However, there is a need to strengthen theprocurement process within the DOH to preventdelay. The distribution pathway will be shortenedby distributing the drugs directly to the provincesand cities. CHDs will be provided with informationto monitor drug allocation and distribution. Thecapacity of the program managers and supplyofficers for drug management will be strengthened.Modern communication technology such as theInternet or SMS will be explored to assist in managingthe supply of drugs at the peripheral levels. Theprogram will participate in the reforms on anti-TBdrug regulation that will be initiated by the NationalCenter for Pharmaceutical Access and Management(NCPAM) and the Food and Drug Administration(FDA). At the same time, LGUs will be strengthenedto monitor compliance on regulatory policies fordispensing/selling of anti-TB drugs in local drugoutlets. These will be done to ensure access to andavailability of quality and safe drugs and preventirrational use of anti-TB drugs.

STRATEGY 7: Certify andaccredit TB care providers

There are many strategies to ensure quality healthcare—some are internal and others are external to

health care providers.105 The three common externalquality assurance interventions are:

licensure - a process by which a governmentalauthority grants permission to an individualpractitioner or health care organization tooperate or to engage in an occupation orprofession;

accreditation - a formal process by which arecognized body, usually a nongovernmentalorganization (NGO), assesses and recognizesthat a health care organization meetsapplicable predetermined and publishedstandards; and

certification - a process by which anauthorized body, either a governmental ornongovernmental organization, evaluates andrecognizes either an individual or anorganization as meeting predeterminedrequirements or criteria.

Performance Target 7.1. At least 70% ofDOTS facilities are DOH/PhilCAT-certified and PhilHealth-accredited.

PhilHealth’s contribution to ensuring quality TBservices through its regulation of accredited facilitiesso that only DOTS compliant services are provided isless than exceptional. The TB situational assessmentindicated that only a limited number of TB providerswas accredited for the TB-DOTS outpatient benefitpackage. Likewise, payments for TB-DOTS weredwarfed by reimbursements for TB inpatient casesthat were not necessarily treated with NTP protocol.

The relatively low number of PhilHealthaccredited TB-DOTS centers has been attributed tothe cumbersome TB-DOTS certification andaccreditat ion process as well as the lack ofincentives for RHU staff to work for PhilHealth TB-DOTS accreditation. PhilPACT thus calls for thestreamlining and harmonization of the certificationand accreditation processes by removing redundantactivities and by replacing taxing requirements withless tedious processes. To secure the activeparticipation of the RHU staff not only in obtainingPhilHealth TB-DOTS accreditation but also inimproving the quality of provided TB-DOTS services,


a review of guidelines for TB-DOTS case paymentswill be made so that RHU staff can benefit directlyfrom the provision of TB services. One possibilityconsidered is incorporating a provision in the TB-DOTS case payment mechanism to allow for aproportion of the PhilHealth claim reimbursementto accrue to the TB-DOTS center staff.

Performance Target 7.2. Standards forhospital participation in TB controlincluded in DOH licensing and PhilHealthaccreditation requirement.

The 2007 NTPS shows that 42.2% of TBsymptomatics consult hospitals, both public andprivate. Hence, it is imperative that management ofTB within these institutions adhere to the nationalpolicies and the International Standards of TB care.Two major regulatory instruments would be thehospital licensing by the Department of Health andthe hospital accreditation by PhilHealth. NCDPC willcollaborate with the Bureau of Health Facility Servicesand National Center for Health Facility Developmentto explore ways of incorporating the DOTS standardsin its licensing requirements to ensure that patientsin the hospitals are effectively managed. NCDPC willalso advocate with PhilHealth to include DOTSstandards in its benchbook that contains qualitystandards for health facilities that provide healthservices to its members. These standards will then bedisseminated to hospitals through policy issuance,orientation and advocacy activities. Assessors will betrained, organized, and supported to enable them todetermine adherence by hospitals to prescribedstandards and requirements. At the local level, thesestandards will be incorporated in the various DOTStraining courses and necessary TA will be given toenhance the enabling environment for participationin TB control by local hospitals.

Performance Target 7.3. Infection controlmeasures in place in all treatment centers/sites and DOTS centers.

An undiagnosed or an untreated TB patient hasthe potential to infect other patients and healthstaff. In the Philippines, many hospitals do not have

the capacity to provide adequate isolation areaswith ventilation systems that prevent isolationroom exhaust from reentering the generalcirculation. Congestion, late detection due to lowsuspic ion, late initiation of treatment, andinsufficient or improper use of personal protectiveequipment (N95 masks) all compound thetransmission of TB in hospitals. The same holds truefor most DOTS facilities. The uninterruptedtransmission of TB and threat of MDR-TB compelthe national government to develop clear policieson infection control in all DOTS facilities.

WHO strongly recommends that “all health-carefacilities, public and private, caring for TB patients orpersons suspected of having TB should implementinfection control measures based on the localepidemiological, climatic and socioeconomicconditions, as well as the burden of TB, HIV, MDR-TB,and XDR-TB” to reduce transmission of TB in healthfacilities.106 The administrative controls should becomplemented by the environmental controls andpersonal protective equipment (PPEs), becauseevidence shows that these measures also contributeto further reduction of transmission of TB.

In accordance with the recommendations ofWHO, the following nat ional and subnationalmanagerial activities will be pursued:

integrate TB infection within other TB controlactivities such plan and policy development,training, and monitoring;

in coordination with NCHFD, developstandards and policies to ensure that thedesign, construction, renovation, and use ofhealth facilities including the treatmentcenter adhere to TB infection controlstandards; and

monitor and evaluate the TB infection controlmeasures.

At the local level, LGUs will ensure that properinfection control measures are being implementedin the DOTS facilities as part of the certification andaccreditation requirements of the DOH, PhilCAT,and PhilHealth. In community settings such asprisons, isolat ion and use of ventilation and


personal protective measures will beimplemented. Establishment of treatment centerscatering to MDR-TB will be monitored to ensurecompliance with proper administrative andenvironmental measures.

LGUs should seek assistance from the nationalgovernment to craft their own infection controlguidelines based on national standards. Regularmonitoring and reporting of all infectious diseasesand rational antibiotic use should be part of theseinfection control measures.

STRATEGY 8: Secure adequatefunding and improve allocationand efficiency of fund utilization

Out-of-pocket spending for TB, in general, is dueto the inadequate funding of the TB controlprogram. The key challenge in financing thatPhilPACT seeks to address is ensuring that there isadequate financing for its key strategies,particularly in strengthening local implementationof TB prevention and control. To achieve this, it iscritical that adequate resources are secured frommultiple funding sources. Securing these resourcesrequire instruments and mechanisms to estimateneeds, identify and secure fund commitments, andoptimally allocate resources. With public sectorfunding as the predominant source with substantialFAPs support in specific areas and aspects of TBcontrol, there is need to leverage these resourcesagainst each other and other underutilized sourcesof TB financing. Managing funds coming frommultiple resources demands greater efforts atcoordination in terms of sources and uses,particularly in a decentralized health system wheremore than half of patients either do not seek careor self-medicate, and where, of those who seekcare, around 40% end up in the private sector. Lastly,ensuring efficiency in fund utilization needsmechanisms and tools to ensure proper and timelydisbursement of funds as well as a trackingmechanism that provides feedback to the planningcomponent of the program.

Performance Target 8.1. Reducedredundancies and gaps by harmonizingfinancing of TB prevention and control.

Securing nat ional and local governmentfinancial commitments to TB control is critical inensuring adequacy of available funds. Despiteincreasing NTP budgets from national governmentand sustained FAPS support, full funding of TBcontrol remains inadequate and uncertain. Withmore than half of TB cases currently not seekingcare, resources currently mobilized by nationalgovernment alone may not be sufficient to satisfyfunding requirements if demand for DOTSincreases dramatically. Furthermore, the recentround of budget increases are subject to annualbudget deliberations and dependent on the fiscalsituation and priorities of government. FAPssupport, on the other hand, is characterized byfinite project lives with no systematic pipelinedevelopment effort to ensure a continuous andsustained flow.

Obviously, funds within the ambit of nationalgovernment influence will have to besupplemented by financing from local government,PhilHealth reimbursements, FAPs, and out-of-pocket expenses to meet the financingrequirements of TB control. Satisfying fundingrequirements for TB control, however, is not asimple matter of consolidating available funds sinceredundancies (e.g., duplicate funding of the sameactivity) and restrictions to fund use (e.g., FAPSlimited to training and other TA) could easilydissipate potential funding. It also involves properplanning mechanisms and tools, advocacy forsustained funding, and deliberate pipelinedevelopment for FAPs.

A financing road map that identifies the fundingrequirement as well as financing commitment ofalternative sources of TB financing is needed. Amultisectoral financial plan for TB control thatidentifies the funding commitments of the differentstakeholders in the TB control effort, e.g., nationaland local government, FAPs, PhilHealth, other thirdparty payers, and out-of-pocket must bedeveloped. It should describe not only how muchis allocated to specific TB control activities but also


who pays for specific activities. In addition, themultisector financial plan ensures continuity byoutlining financing commitments through time(e.g., commitment and allocation of funds for eachyear of the medium-term plan 2010–2015).

Given the multiyear character of the financialplan, f lexibility in projected budgets andexpenditures is a requirement. One such flexibilitymechanism would be the use of rolling multiyearadjustment. Operationally, this implies an annualreview of the financial plan and the allowance forchanges in budget and cost parameters, e.g.,financial worksheets would have to be developedto allow adjustments should realized budget andcost parameters vary relative to projections.Another feature to enhance flexibility would bethe development of separate national and localprovincewide financial plans. The national financialplan would reflect the Philippine aggregate whilelocal provincewide financial plans would beintegral to the PIPH through the incorporation ofTB subplans in the PIPH.

The use of local provincewide financial plansrequires the development of the TB subplantemplate as well as TB costing protocol of the PIPHcosting module. The TB subplan template and TBcosting protocol standardize investment andcosting formats, thereby allowing for consolidationand comparability across AOPs/PIPHs/AIPHs/CIPHs.As multiyear rolling plans, the national and localprovincewide f inancial plans will have to bereviewed and presented on an annual basis.

Since substantial support is expected from FAPs,pipeline development for FAPs needs to beprogrammed on a periodic basis, following the lifecycle of projects in TB. As a matter of principle, FAPSshould be directed at raising resources forinnovations in TB control and meeting servicedelivery gaps.

Performance Target 8.2. Nationalgovernment funds leveraged to secureLGU and PhilHealth commitments.

To obtain the commitment of partners such aslocal governments and PhilHealth, it may be

necessary to leverage resources within the ambitof the national government (e.g., nationalgovernment funds and FAPs). One way would be tooffer performance-based grants to LGUs in returnfor either achieving desired TB outcomes orundertaking needed local TB control activities.

This requires the development of a performance-based grant mechanism and the correspondingmonitoring tool. Both mechanism and tool shouldhave the ability to deploy scarce TB resources to areasthat have high TB prevalence as well as improve theabsorptive capacity of LGUs to employ the nationallyprovided resources, e.g., funds or commodities.

Performance-based provision of centralresources will be in terms of fixed (lifeline) andincremental (variable) tranches. A fixed amount ofresources, specifically the historical allocation ofthe anti-TB drug requirement of the LGU, will beprovided by national government. The deploymentof both the variable ( incremental) and fixednational government transfers to LGUs, however,will be governed by agreements between thenational government through its CHD agents andLGUs and will be enforced with the use ofappropriate monitoring and evaluation tools.

Performance Target 8.3. PhilHealth’s roleexpanded through greater availability ofaccredited providers and increasedutilization of TB-DOTS package.

Increasing PhilHealth share in TB expendituresentails rapid expansion of DOTS-accredited providersto service members. This effort ties up with:

increasing PhilHealth enrolment in LGUs;

technical assistance and capital support foraccreditation;

improving the TB-DOTS benefit structure tofocus payments on current funding gaps in TBcare; and

ensuring that its payment mechanismsprovide incentives for providers to offerhigher quality services and for local healthsystem managers and decision makers toprovide funding and logistic support by linkingbenefits with overall public health goals.


TABLE 4: Strategies, Performance Targets, Activities, and Time Frame

Strategy Performance Activity 2010 2011 2012 2013 2014 2015 2016

1. Localize TB 1.1. 70% of provinces LOCALimplemen- and highlytation of urbanized cities Assess status of local TBTB control (HUCs) include control program

clear TB control implementationplan within theProvince wide Develop local TBInvestment Plan strategic plan based onfor Health (PIPH) the analysis consideringor ARMM the absorptive capacity ofInvestment Plan the LGUs and national planfor Health (AIPH)or City Investment Incorporate TB strategic/Plan for Health operational plan within(IPH) the PIPH/AIPH/CIPH and

AOP

Update TB control planyearly and incorporateinto AOP

Support advocacy tointegrate PIPH/AIPH withthe Comprehensivedevelopment plan of theLGUs

NATIONAL

Formulate guidelines indeveloping TB controlstrategic and operationalplan for PIPH/AIPH/CIPHand AOP

Provide technical assistancein the development of TBcontrol plan

Consolidate, review, andanalyze all PIPHs/AOPs


STRATEGY PERFORMANCE ACTIVITY 2010 2011 2012 2013 2014 2015 2016

1.2. 70% of provinces/ LOCAL HUCs are atleast DOTS Conduct self-assessmentcompliant versus DOTS standards to

identify gaps and needs

Develop and implementplan to be DOTS-compliant

NATIONAL

Develop standards,assessment tools, andimplementing guidelinesfor a DOTS-compliant,performing, andsustaining province/city

Build capacity of nationaland regional units to usethe assessment tools

Asses provinces/citiesvis-à-vis standards

Provide TA based onlocal needs

1.3. 90% of priority LOCALprovinces andHUCs with Conduct annual PIRperformancegrant have Submit quarterly progressachieved monitoring report to CHDprogram targets

NATIONAL

Identify priority provincesbased on TB burden,performance, and absorptivecapacity

Develop and implementperformance-based grantmechanism



Conduct quarterlyassessment of provincesgiven grants

1.4. DOH and partners LOCALhave capacity toprovide TA to Identify TA needs andprovinces and request for assistancecities

NATIONAL

Develop guidelines forprovision of TA to provincesand cities

Building capability ofnational and regional staff

Strengthen RCC to overseePhilPACT implementation

Prioritize requests for TAon capability-buildingactivities for CHDs andpartners and implement

Coordinate TB controlprojects’ plans

Supplement manpowerof IDO

1.5. Public-private LOCALcoordinatingbody on TB Organize provincialcontrol at public-private (PP)national, coordinating body suchregional, and as CUP or similarprovincial coordinating grouplevelsestablished Develop and implementand sustained plan on PP collaborationto includeComprehensive CUP partners implementUnified Policy agency’s policies and(CUP) mechanism guidelines



NATIONAL

Develop and issue policyinstrument that wouldestablish a NationalTB Coordinating Committeeand expand RegionalCoordinating Committee

Sustain NCC and RCC

Coordinate with RegionalCoordinating Councils

Convene CUP members todevelop and issue policiesand guidelines on TB inaccordance with theagency’s mandate incoordination with DOH

Conduct regional andprovincial orientation onPhilPACT

Engage key professionalsocieties

Build capacity of provincesand cities to organize PPcollaborating mechanisms

2. Monitor 2.1. Trend of TB LOCALhealth burden trackedsystem Build capacity in collectingperformance and reporting TB mortality

data by incorporating topicin MOP

NATIONAL

Conduct 4th National TBPrevalence Survey

Conduct National DrugResistance Survey



Conduct TB mortality study

Incorporate TB questionsin NDHS

Incorporate TB questionin Annual Poverty IndexSurvey (APIS)

2.2. TB information LOCALgenerated ontime, analyzed Conduct course on TBand used data management

Utilize program informationto support programmonitoring and evaluationand policy development

Adopt Web-based TBinformation system

NATIONAL

Develop a web-basedelectronic informationsystem

Produce and disseminateannual programperrformance

2.3 TB Information LOCALSystem integratedwith national Implement, collect dataM&E and FSHIS and assess LGU scorecard

NATIONAL

Enhance NationalEpidemiology Center (NEC)capacity to manage andintegrated TB InformationSystem



Develop and implementNational TB M&E

Support reforms in healthinformation system

Consolidate and analyzeTB program data as partof LGU scorecard

3. Engage both 3.1. 60% of all LOCALpublic and DOTS facilitiesprivate in the provinces Collect information onhealth care with provincial different service deliveryproviders PP mechanisms points (RHUs, HCs, PPMDs,

have a government, and privatefunctional clinics, etc) and theirpublic-private capacitiescollaboration/referral system Establish public-private/(service delivery public-public referrallevel) network among service

delivery points (RHUs/HCs,and other non-NTP TBcare providers)

Implement sustainabilitymeasures for the old andnew PPMDs/PP network

NATIONAL

Develop and disseminateguidelines for establishmentand maintenance of DOTSreferral networks

Assess sustainabilitymechanisms

Develop and disseminateDOTS packages for servicedelivery points

Review national policies andguidelines on PPM, updateand disseminate



3.2. 90% of public LOCALhospitals and65% of private Assess hospital capacityhospitals are to participate in TB controlparticipatingin TB control, Conduct a phasedeither as DOTS implementation ofprovider or hospitals as DOTSreferring center referring (P2P) or

service provider

Government 20% 30% 50% 70% 80% 90% 90%

Private 5% 20% 30% 40% 50% 60% 65%

Implement financialincentives and regulatorymeasures in hospitals

NATIONAL

Revise hospital-based DOTSpolicies and guidelines

Develop hospital DOTSmanual

Coordinate with otherorganizations such asPhilippine HospitalAssociation andprofessional societies

Introduce and implementfinancial incentives forhospital adherence to DOTS

3.3. 70% of targeted9,000 PPs arereferring patientsto DOTS facilities



LOCAL

Train members of the 6signatory professionalsocieties on ISTC

Link PPs to DOTS facilitiesand sustain the referralnetwork

NATIONAL

Adapt ISTC to thePhilippine context

Assist the 6 professionalsocieties and LGUs to planand roll out training of itsmembers on ISTC

Advocate to other medicaland paramedical societies,e.g., AMHOP, PNA, PAMET,PHA, PPHA, etc.

Advocate and incorporateISTC in medical andparamedical curricula

Develop and implementmechanism to promptlyoutpatient benefit package

Develop and implementprivate market incentivemechanisms to ensurecompliance (e.g., competitivepricing for both publicand private sector)

3.4. All frontline LOCALhealth workersare equipped Identify appropriate staffto deliver TB for trainingservices

Conduct capability-buildingactivities based on needs



NATIONAL

Integrate some DOTS trainingwith training courses ofother infectious diseases

Establish, update andmaintain HR informationsystem

Outsource training toother institutions

Support implementationof health human resourcestrategic plan managed bythe Health HumanResource DevelopmentBureau–DOH

Develop and implement aregular, semiannual humanresource developmentprogram

4. Promote and 4.1. Proportion of LOCALstrengthen TB symptomaticspositive who are self- Conduct TB service barrierbehavior of medicating and analysiscommunities not consulting

health care Develop and implementproviders local TB Strategicreduced by 30% Communication Plan

Produce and disseminatebehavior changecommunication (BCC)materials

Orient distributors andlocal pharmaceutical

Outlets on policies onanti-TB drug dispensingand advocate for theircompliance



NATIONAL

Develop tools and policiesfor ACSM related activities(e.g. guidelines, ACSMplanning guide, tools forbarrier analysis, recording /reporting systems, referralsystem, etc

Develop and implementnational Advocacy,Communication, and SocialMobilization strategic plan

Develop capacity buildingplans for regional andprovincial HEPOs andinformation officers

Capacitate regional/provincial health educationand promotion (HEPOs)/information officers (IOs)

Establish quality controlfor material developmentwith built-in evaluation

Evaluate effectiveness ofbehavior change strategies

Conduct client satisfactionsurvey

4.2. Default rate of LOCALprovinces andcities with >7% Build capacity of BHWsreduced by 40% and community volunteers

Conduct enhancement ofcounseling skills oftreatment partners(up to 2016)

Provide enablers/incentivesfor treatment partners



Regularly supervise BHWs /community volunteers

Empower patients throughdissemination of ISTC orother means

NATIONAL

Conduct ORs related todefaulters and ontreatment partners

Develop Standard BCCpackages for clients andproviders based on TBservice barrier analysis

Develop and disseminateguide on enhancinginterpersonalcommunication (IPC)by health care providers

4.3. Number of LOCALbarangays thathave organized Conduct an inventory ofCBOs and mobilize communityparticipating based organizationsin TB control (CBOs) such as TB Taskthat are linked Force, NGOs, faith basedwith DOTS organizations (FBOs)facilitiesincreased by Build capacity of CBOs to50% support TB Control activities

Establish workingpartnerships with CBOs insupport of TB control

NATIONAL

Evaluate TB interventionsassociated/linked withCBOs support to TB control



Develop and implementpolicies and guidelineson community participationin TB control

5. Address 5.1. A total of at LOCALMDR-TB, least 15,000TB/HIV, and MDR-TB cases Detect and treat MDR-TB 1,174 2,372 2,372 2,372 2,237 2,237 2,237needs of have been (number of patients)vulnerable detected andpopulations provided with Support the operations of

quality-assured MDR-TB treatment centerssecond-lineanti-TB drugs Provide enabler/incentives

for MDR-TB patients under treatment

Strengthen referral networkfor PMDT to include othervulnerable populations

Capacitate treatment sitesto include communitybased treatment partners

NATIONAL

Designate and capacitateDOH unit as manager ofPMDT

Sustain the overallmanagement of PMDTunder the NTP throughLCP-DOH

Establish and maintain25 culture and 5 DST centers 13 12 25 25 25 25 25

Establish and supportoperations of 35 newtreatment centers 35 35 35 35 35 35

Pursue the ongoingdevelopment of PMDTpackages under PhilHealth



Continue developmentalactivities such asdevelopment of guidelines,policy templates, advocacytools

5.2. TB/HIV LOCALcollaborativeactivities Expand TB/HIV collaborativeestablished in activities to high risk areasareas with through the local AIDSpopulations councilshaving highrisk behavior Conduct PICT for TB casesand with atleast 80% of TB Provide appropriatecases tested for treatment for identifiedHIV HIV/TB cases

NATIONAL

Conduct joint surveillanceof HIV/AIDS among TBpatients

Establish and maintainTB HIV collaborationactivities in priority areas

Strengthen the HIV/AIDStreatment hubs to manageTB/HIV coinfected clients

5.3. Nationwide LOCALimplementationof childhood Implement childhoodTB control TB programprogram

Engage the private sector atthe local level through thelocal pediatric chapters

Detect and treat childrenwith TB



Provide chemoprophylaxisto children

NATIONAL

Revise and implementpolicy on pediatric drugs—shift from SDF to FDC

Conduct external evaluationof current guidelines andreview current estimatesof childhood TB cases

Continue collaborationwith government agencies,such as DSWD, DepEd, NCIP

Train school healthpersonnel

5.4. DOTS services LOCALaccessible toall inmates Conduct phased expansion 40% 50% 60% 75% 90% 100%with TB of TB in prison initiative to of

cover all inmates. inmates

Detect and provide treatment

NATIONAL

Coordinate implementationof TB prison initiatives withnational governmentpartners (BuCor, BJMP,and others)

Conduct external evaluationof current guidelines forTB in prisons

Conduct regular monitoringof the implementation ofTB in prison initiatives



5.5. Policies, LOCALoperationalguidelines, and Identify and profilemodels vulnerable groups in thedeveloped, localitydisseminated,and locally Implement local initiativesadopted to in accordance with nationaladdress needs guidelinesof vulnerablepopulations NATIONAL

Conduct a comprehensivestudy on the size, distribution,health-seeking behavior, andneeds of vulnerablepopulations (IPs, displacedpopulation, elderly, PWDs,children in conflict withthe law (CICL))

Develop plan, policies, andmodels to ensure access toDOTS services by thevulnerable populations

Develop implementationtools, such as operationalguide, training module,training materials,advocacy, etc.

Coordinate implementationand monitoring of modelswith concerned governmentagencies, e.g., DSWD, NCIP,NASPCP

6. Regulate 6.1. TB laboratory LOCALand make networkavailable managed by the Expand province/citywidequality TB National TB EQA for direct smeardiagnostic Reference sputum microscopytests and Laboratory (DSSM) of both publicdrugs (NTRL) to ensure and private

that 90% of all



microscopy Provide local support tocenters (MCs) TB microscopy centersare within EQAstandards Capability-building for

provincial/city QA centervalidators

NATIONAL

Capacitate NTRL andregional QA centers

Establish and implementcertification of TBlaboratories

Establish and implementQA for Culture and DST

Explore new diagnosticsthrough ORs

Review and revise QAguidelines for microscopycenters

Conduct semiannual TB labperformance review

Procure and distributelaboratory supplies

6.2. TB microscopy LOCALservices Identify/assess needs ofexpanded in GIDA and urban areascities andunderservedareas

Establish additional TBlaboratories to attain oneTB lab for less than 100,000population either throughestablishment of new TB labor utilizing hospital/privatelab-based TB lab



Conduct capability-buildingactivities for microscopists

Adopt innovative approachesin expanding DSSM in hard-to-reach areas, e.g., trainingof BHWs in slide fixing andtransporting

Augment laboratory suppliesand reagents

NATIONAL

Develop policies andguidelines on innovativeapproaches to expandservices to GIDA and otherpopulation groups

Provide microscopes(for new microscopy centersor to replace non-functional 500 200microscopes) sets

6.3. Every province LOCALand HUCs withaccess to Establish new TBDC’s orfunctional TB network with existing TBDC 40% 60% 75% 100%Diagnostic ofCommittee provinces

Mobilize support for TBDC

NATIONAL

Assess TBDC

Review and revise policiesand guidelines on TBDC toinclude flexibility incomposition, reporting andsustainability

Develop and implementquality assurance for TBDC



Develop and implementsustainability mechanismse.g. LGU support, PhilHealthreimbursements

6.4. Quality-assured LOCALanti-TB drugsare always Allot contingency funds foravailable in unforeseen situations andDOTS facilities for 5% adverse drug

reactions on FDC

Improve local drugmanagement

Monitor compliance onregulatory policies(e.g. prescription policy) fordispensing/selling of anti-TBdrugs in local drug outlets.

NATIONAL

DOH central procurementof all quality-assuredfirst-line anti-TB drugs(FDCs) to include bufferstock.

Establish procurementmechanism for LGU toaccess quality assuredand reasonably priced drugs

Enhance effective drugprocurement/distributionsystem and establishcorresponding informationsystem

Build drug managementskills at regional andprovincial levels



Explore restricting access ofanti-TB drugs in the privatemarket in consultation withFDA, NCPAM and privatesector and implementcorrespondingly

7. Certify and 7.1. At least 70% of LOCALaccredit DOTS facilitiesTB care are DOH/ Address gaps identified inproviders PhilCAT-certified the self-assessment based

and PhilHealth- on Quality Assurance Planaccredited

Implement social marketingactivities

Establish and implementmechanism for public DOTSfacilities to utilizereimbursement based onpolicies, such as trust fundfor TB outpatient package

NATIONAL

Review certification/accreditation process ofDOTS Facilities

Streamline certification/accreditation processesbased on assessment

Organize more certifiers team

Disseminate and implementTB DOTS PHIC manual onaccreditation

Certify and accredit DOTSfacilities 25% 35% 45% 55% 65% 70% 75%

Explore additional financialincentives to influencebehavior of health careproviders



Improve informationdissemination of certifiedDOTS facilities e.g. DOHwebsite

7.2. Standards for LOCALhospitalparticipation Incorporate DOTSin TB control standards for hospitals inincluded in training activitiesDOH licensingand PhilHealth Implement DOTS standardsaccreditation in local hospitalsrequirements

NATIONAL

Incorporate DOTS standardsin PhilHealth benchbook(focus on implementationof DOTS among Hospitals)

Incorporate DOTS standard inDOH licensing requirements

Train assessors

7.3. Infection LOCALcontrolmeasures in Conduct training onplace in all infection controltreatmentcenters/ sites Implement local infectionand DOTS centers control based on national

guidelines

NATIONAL

Develop and disseminatenational policies andguidelines on infectioncontrol

Provide technicalassistance to LGUs inorder to put in placeinfection control


Evaluate and monitorinfection control practices

8. Secure 8.1. Reduced LOCALadequate redundanciesfunding and gaps by Develop the costing moduleand harmonizing for the TB subplan of theimprove financing of AOP/PIPHallocation TB preventionand and control Cost the TB subplan in theefficiency AOP/PIPH using the TBof fund costing moduleutilization

Present the TB cost estimatesto local LCE for approval andsupport

Develop multi-year localbudget plan for TB preventionand control (e.g., to includeprovision of Allotingcontingency funds forunforeseen situations andfor 5% adverse drugreactions on FDC )

Provide local budget for TBcontrol (e.g., to includeprovision of Allotingcontingency funds forunforeseen situations andfor 5% adverse drugreactions on FDC )

Obtain and Utilizeperformance-based grant

NATIONAL

Establish FAPs developmentpipeline and reviewcoordinating mechanism forFAPs for TB




Manage the FAPsdevelopment pipeline andcoordinating mechanism

Develop a national TBaccount and a 5-yearnational rolling TB financialplan

Update yearly 5-year rollingTB financial plan anddetermine TB fundingrequirements

Incorporate TB fundingrequirements in DOH HealthSector ExpenditureFramework

Incorporate a TB module inthe DOH-LGU resourcetracking system

Develop template for TBcosting module

Develop TB performance-based grant (PBG) andmonitoring tool

Implement TB performancemonitoring tool

Sign MOA between CHDsand LGUs for performance-based grants

8.2. National LOCALgovernmentfunds leveraged Submit timely and accurateto secure LGU program reportand PhilHealthcommitments



NATIONAL

Update yearly NTP allotmentand commodity distributionplan based on performancemonitoring tool

8.3. PhilHealth’s LOCALrole expandedthrough greater Help advocate for the LGUavailability of to subsidize the PhilHealthaccredited premium of the informalproviders and near poorincreasedutilization of Adhere to the allocationTB DOTS package guidelines for the TB-DOTS

OPB Package

Use the ratio of TB-DOTSOPB users to the number ofenrolled members asperformance measure

NATIONAL

Enhance PHIC case paymentguidelines based on PHICBenefit Delivery Reviewresults

Expand PHIC coverage ofindigents and retreatmentcases

Develop mechanism forLGUs to follow guidelines onallocation (e.g., trust fundmechanism)

Strengthen social marketingof TB-DOTS package

Propose to Include thenumber of enrolled versusnumber of cases paid forTB-DOTS Package by LGUsin the LGU score card.


FINANCING REQUIREMENTS

Costing MethodologyThe PhilPACT costing tool was developed to

est imate the financing requirements of themedium-term TB control strategy. The costing toolis aligned to the PhilPACT planning horizon andcomputes the associated annual costs for allactivities listed under the eight strategies ofPhilPACT. To encompass the breadth of the PhilPACTplanning horizon, annual costs are estimated forthe period 2010 to 2016.

In addition to the estimation of financingrequirements, the costing tool also allows for theincorporation of identified funding commitmentsfrom the following stakeholders: nationalgovernment (NG), local government units (LGUs),foreign assisted projects (FAPs), PhilHealth (PHIC),and out-of-pocket expenses (OOP). Availableinformation on financing commitments howeverprovides less detail compared to estimates offinancing requirements; consequently moreaggregated estimates of financing commitmentsare presented in the costing tool. The incorporationof financing commitments allows for thesubsequent estimation of potential funding gaps.

To enhance alignment with financial tools on TBcare expenditures particularly those employed byinternational organizations, the costing tool drawsheavily from the WHO costing templates for nationalTB control programs. This is evident in the costingtool’s use of cost structures similar to the budgetingtool developed by WHO for NTPs in other countries.

This alignment also encompasses theconsistency of the costing tool with cost estimatesemployed by the DOH, partner organizations likethe Global Fund and WHO. The alignment is assuredthrough the incorporation of cost parameters fromDOH planning documents in the costing tool.

The cost calculations involve computing cost peractivity given the item list per activity and theassociated unit cost, e.g., unit cost of meetingsmultiplied by number of meetings per LGUmultiplied by number of LGUs. The phasing of

activities also follows the timeline specified in theplanning matrix, e.g., number of warehouses to beupgraded increases or decreases depending on thephasing of warehouse upgrading.

The unit cost parameters used in thecalculations were obtained from the followingsources: national government agency reports, FAPSrecords, project data, and key informants. Theywere agreed upon by the TF members forstandardization. To simplify calculations, financingrequirements are cast in 2010 prices.

Aside from unit costs, estimates of theprospective number of TB patients were derivedfrom TB incidence parameters which were derivedfrom WHO and NTP reports.

To obtain estimates of financing commitmentsin the costing model, information from DOH budgetdocuments, RCC, and other FAPS documents werereviewed. Since the identification of potentialfinancing at the activity level is not always possiblefor future periods, aggregate financingcommitments are estimated at the strategy level.The costing tool thus incorporates financingcommitments per strategy for each year ofPhilPACT.

The funding gap is computed as financingrequirements less financing commitments. This isdone per strategy and aggregated across all eightstrategies and for all years of PhilPACT planning.

Summary of Financing Requirementsand Funding GapsThe total financing requirement for PhilPACT

implementation is PhP23 billion. The breakdownby strategy and year is shown in Table 5.


TABLE 5: PhilPACT Financing Requirements by Strategy and Year in Philippine Pesos

Strategy 2010 2011 2012 2013 2014 2015 2016 Total

1.Localize TB controlprogramimplementation 244,339,691 228,658,174 235,045,176 181,940,003 179,654,329 62,681,057 58,613,557 1,190,931,988

2.Monitor healthsystemperformance 65,392,583 111,323,271 11,828,600 14,811,600 52,060,000 2,060,000 12,060,000 269,536,054

3.Engage bothpublic andprivate TB careproviders 458,167,126 462,142,900 433,152,517 384,588,984 387,497,597 376,161,909 372,526,909 2,874,237,942

4.Promote andstrengthenpositive behaviorof communities 415,087,013 485,016,758 523,858,854 471,234,466 461,965,200 397,437,030 278,030,340 3,032,629,660

5.Address MDR-TB,TB/HIV, and needsof vulnerablepopulations 1,237,744,018 1,633,756,763 1,343,670,417 1,389,579,293 1,511,543,932 1,465,978,706 1,112,225,280 9,694,498,410

6.Regulate andmake availablequality TBdiagnostictests and drugs 734,399,721 535,597,718 677,869,266 609,091,917 771,401,868 569,982,025 712,545,745 4,610,888,260

7.Certify andaccredit TBcare providers 53,860,644 77,050,144 71,652,580 68,689,083 62,843,483 50,643,483 51,676,483 438,415,897

8.Secure adequatefunding andimprove allocationand efficiency offund utilization 22,446,000 127,201,000 136,737,000 146,978,500 157,478,500 165,922,000 165,911,000 922,674,000

TOTAL 3,231,436,796 3,660,746,728 3,433,814,410 3,266,913,845 3,584,444,908 3,090,866,211 2,763,589,315 23,031,812,212


Annual costs vary from PhP3.2 billion in 2010 toPhP2.7 billion in 2016. Frontloading of activitiesoccurs mostly during the first two years.

Strategy 5 and strategy 6 account for most of thefinancing requirements at around 62% of the total.

FIGURE 6Distribution of Estimated PhilPACT Cost

by Major Strategy

The national government accounts for the lion’sshare of prospective PhilPACT funding (38%),followed by FAPs (33%) and LGUs (14%). Projectedout-of-pocket expenditures for TB-DOTS, however,remains significant at 14% due to the payments toprivate providers as well as the transportation costsincurred.

FIGURE 7Share of PhilPACT Financing

by Stakeholder/Source

Despite known commitments by FAPS andexpected national government funding, fundinggaps are expected to persist due to out-of-pocketexpenditures and programmed LGU expendituresthat have yet to be secured. The funding gap isexpected to increase in 2015 due to the end ofGlobal Fund support. The total funding gap isestimated to be PhP6.9 billion. The earlierdiscussion on strategy 8 presents steps to addressthe situation.

FIGURE 5Estimated Annual Financing Requirements of PhilPACT from 2010-2015 in Philippine Pesos


Implementing ArrangementsThe following principles will guide the effective

and efficient implementation and monitoring ofPhilPACT:

There should be unified and coordinatedmanagement of TB control efforts in thePhilippines with clear descriptions of theroles and relationships of implementingstructures.

Existing structures are maximized andimplementing arrangements must ensureefficiency and prevent duplication.

Linkages with the Health Sector Reformimplementing arrangements should be made.

The importance of support of keystakeholders, both public and private,including the LGUs who are the mainimplementers of TB control under adecentralized system, must be recognized.

The implementing arrangement is describedbelow.

National LevelThe Department of Health, through the National

Center for Disease Prevention and Control, will beresponsible and accountable for theimplementation of PhilPACT. It shall ensure thatactivities of various stakeholders are consistentwith PhilPACT. NCDPC will be supported by the NCC

based on the expanded National CoordinatingCommittee for PPMD that was created under AONo. 154 s. 2004, which includes some provisions ofthe CUP. It will coordinate with the SectoralManagement Committee that is responsible for theoverall development, monitoring, andcoordination of policies, mechanisms, andguidelines for the health sector.

The functions of the NCC are:

oversee the implementation of PhilPACT,

ensure that plan is disseminated to variousstakeholders,

review and approve the annual operationalplan of PhilPACT,

monitor plan implementation,

assist in mobilizing resources, and

discuss and resolve strategic issues.

The NCC will also have technical advisersconsisting of both local and international expertswho will be non-voting members. The InfectiousDisease Office of NCDPC will be the secretariat ofthe NCC.

To assist the NCC for PhilPACT in theorganizational and technical preparations, aTechnical Working Group will be created. This shallbe headed by the NTP Manager with memberscoming from DOH agencies as well as private andother public partners. The NTP will function assecretariat of the TWG.

FIGURE 8Estimated Funding Gap, 2010-2016 (in Million Pesos)


COMPOSITION

Chairperson Director IV, NCDPCAlternate Chairperson Director III, NCDPC-IDOCo-Chairperson Director, Health Sector,

Social DevelopmentCommittee, NEDA

Vice Chairperson President, PhilippineCoalition Against TB (PHILCAT)

MEMBERSNational TB Program Manager- DOHSenior Vice-President, Health Finance Policy Sector, PhilHealthHospital RepresentativeLeague of provinces of the PhilippinesLeague of Cities of the PhilippinesNGO RepresentativeHealth Policy Development and Planning Bureau

Regional levelThe Center for Health Development, led by the

CHD Director, in coordination with the RegionalDevelopment Council (RDC) and the RegionalImplementation and Coordination Team, will be themain regional implementing body for PhilPACT. Itwill be supported by the Regional CoordinatingCommittee that will be organized based on theexpanded Regional Coordinating Committee forPPMD that was created by AO No. 154 s. 2004 aswell. It will be chaired by the CHD Director, co-chaired by the Regional Social DevelopmentCommittee of NEDA and its members will becomposed of representatives from CUP agencies,PhilHealth, private sector, local TB coalition, NGOs,and the regional TB Program Coordinator. Theregional TB team will be the technical secretariat.

Provincial/HUC levelThe provincial/city health officer, under the

governor/city mayor, will be responsible for the

overall implementation of the PhilPACT in theprovince or city. S/he will be supported by amultisectoral body that is composed ofrepresentatives from other government agencies,private sector inc luding the NGOs, people’sorganization/civil society, and TB patients. Theprovince will have an option of selecting a PPcoordinating body that is best suited for its situationand needs. It can be any of the existing functionalcoordinating bodies:

provincial health board;

provincial CUP;

provincial coordinating committee beingestablished jointly with PhilCAT; and

local implementation and coordination team(LICT), a body that coordinates health sectorreforms in the province/city.

MunicipalityThe Municipal Health Officer of the Rural Health

Unit, under the municipal mayor, will be responsiblefor PhilPACT implementation in the municipality. S/he will be supported by the municipal health boardthat will also mobilize participation from the privatesector. The DOTS facilities including RHUs/HCs,PPMDs, and TB laboratories will be the servicedelivery points for PhilPACT.

BarangayThe barangay health station will provide TB

services to the communities to be supported bythe barangay health workers and in some areas bythe Barangay TB Task Force or any community/faith-based organizations.

MONITORING AND EVALUATION

Purpose and ContextThe overall purpose of M&E is to measure

program effectiveness, efficiency, and equity, aswell as “ identify problem areas, gather lessonslearned and improve over-all performance.” TheM&E Plan of PhilPACT will take into considerationthe following:


Administrative Order No. 2008-0016 thatdescribes the guidelines on monitoring andevaluation for equity and effectiveness (ME3)in support of the health sector strengtheningthrough Fourmula One for Health;

current NTP monitoring and evaluation structureand system as described in the 2005 MOP;

the Stop TB Partnership’s recommended M&Eas contained in the “Compendium ofIndicators for Monitoring and EvaluatingNational Tuberculosis Programs” issued inAugust 2004; and

the planning framework of PhilPACT.

Specifically, the M&E will be based on the vision,goals, objectives as well as performance targets andactivities presented in an earlier section. This iscoherent with the ME3 framework which is a DOH-developed system that aims to ”determine ifreforms have equitably and effectively achievedgoals in the health system.” It presumes that theconduct of planned activities will lead to theachievement of the performance targets which inturn will contribute to the accomplishment of theobjectives, and eventually the planned outcomesand impact.

Implementing Arrangements for M&EThe National Coordinating Committee will be

responsible for overseeing the implementation,monitoring, and evaluation of PhilPACT. The HealthPolicy Development and Planning Bureau (HPDPB)of the Department of Health will be the technicalunit responsible for the development andimplementation of the monitoring and evaluationsystem for PhilPACT in accordance with the ME3. Itwill be assisted by IDO-NCDPC and the NEC of theDOH. With the assistance of Global Fund, NEC willdevelop the monitoring and evaluation for TB, HIV/AIDS, and malaria, hence, PhilPACT’s monitoringand evaluation system will be further refined andregularly updated. Other units that will participateare DOTS facilities, both public and private, LGUs,international and local partners, and other officesof the DOH.

Indicators, Data Sources, andCollection MethodologiesIndicators include programmatic or technical

indicators and sectoral indicators. Indicators are alsocategorized into impact, outcome, output, andprocess.

Primary and secondary data will be collectedfrom various sources using different data collectionmethodologies to determine the progress ofindicators. The impact of the plan, as measured bythe TB prevalence and TB mortality rates, will betracked using population surveys and studies. The4th National Prevalence Survey will be done in 2014while the National Drug Resistance Survey will berepeated in 2011. TB mortality rate will be calculatedfrom data collected from vital registration by theNational Statistics Office and reported by NEC in itsannual Philippine Health Statistics. Recognizing thelimitation of the NSO-collected data, a TB mortalitystudy will be done in 2012. To track progress towardsthe MDG goals, the prevalence rate and mortalityrate released by WHO in its annual surveillancereport will be utilized.

Outcome indicators such as the case detectionrate, treatment success rate, cure rate and defaultrate will be computed based on the quarterly casefindings and case holding reports regularlysubmitted to IDO by various DOTS facilities, bothpublic and private, through the provincial/cityhealth office and Center for Health Development(CHD). These reports are based on the TB registerand laboratory register maintained by all DOTSfacilities. Timeliness and quality of data will beenhanced through the integrated electronic TBinformation system and regular feedback. Data onthe number of MDR-TB cases detected and treatedand their treatment outcome will be collected andsubmitted by the PMDT treatment centers to IDOthrough the CHDs in coordination with TDFI. TheNPS and NDHS will also generate data on thehealth-seeking behavior of the TB symptomatic.

Process indicators that are not included in theroutine program performance report will becollected through local and international partners.For example, data on private sector participationsuch as number of LGUs with DOTS referral network


and number of private practitioners trained areregularly collected and reported by the TB controlprojects managed by PhilCAT and TB LINC. OtherDOH units, such as the Bureau of Local HealthDevelopment, will provide NTP data on the LGUscorecard, the National TB Reference Laboratory ofthe Research Institute of Tropical Medicine on TBlaboratory indicators, the Bureau of InternationalHealth Cooperation (BHIC) on TB financing fromFAPs and their activities, and the Finance Serviceon the performance grant. CUP partners willprovide information on the initiatives for theirconstituents such as the DOJ and DILG for theinmates with TB. Financing information will begenerated from TB subaccounts and the DOHresource tracking information. Other sources of datawill be from:

NTP program implementation reviews, heldthree times a year at the national level andsemiannually at the regional level, annualPIRs done for specific initiative such as PPM,TB laboratory, and PMDT;

Joint Program Review organized by WHO; and

monitoring reports of NTP and other partners.

A midterm evaluation that will be participatedin by stakeholders will be performed in early 2013and a terminal evaluation will be conducted in early2016.

Information will be encoded into a digital formatand will be stored electronically and on paper.Quality control of data will be done at all levels

Data Analysis, Dissemination, and UseThe IDO and NEC will be responsible for

ensuring that the needed information from thevarious sources are collected, submitted,consolidated, and analyzed. HPDPB will help IDOand NEC enhance the system for regular reportingby partners and dissemination/use of results.

HPDPB will also ensure that a web site thatcontains all the TB information related to PhilPACTwill be developed, updated, and sustained and thatan annual report that analyzes the progress of the

strategic plan implementation will be issued. Thereport will be submitted to the DOH managementand disseminated to partners. Stakeholders’meetings will be conducted after the midterm andterminal evaluation to present and discuss results.Capacity-building activities to ensure effective useof information from the M&E are explained in thesection on Strategy 2.

Annex 4 describes in detail the indicators,sources of data, data collection methodologies, andfrequency of report ing for each performanceindicator/target.


MOVING PHILPACTFORWARD

ALIGNMENT WITH OTHERPLANNING FRAMEWORKS

The table on the following pages shows howthe PhilPACT is aligned with the DOTS strategy, theGlobal TB Control Plan, the 2006–2010 National Planto Control TB, Fourmula One, and the WHO-buildingblocks. Its technical strategies are completelyconsistent with all the planning frameworks. In fact,PhilPACT expands these technical strategies bystrengthening the governance and financing of TBcontrol implementation.

CONTRIBUTION TO GLOBALEFFORTS FOR TB CONTROL

PhilPACT ushers the NTP into the arena of healthsector reform and devolved governance. Thereliance on local governance, sectorwideorientation, and health system strengtheningapproach of PhilPACT could well serve as a modelfor other countries to consider and emulate incontrolling TB.

Since the Philippines is one of the first countriesin the Western Pacific Region to decentralize healthservices, the NTP, through PhilPACT, needs to

develop localized strategies to properly implementthe TB program within a provincial/municipal/citysetting. These should help prepare the country’slocal health systems to integrate specific diseaseprograms such as the TB program into acomprehensive health and development plan. TheLGU Investment Plans for Health developed insupport of the health sector reform initiativeslikewise ensure that the TB program is included andfunded in the LGU programs for the next six years.

The convergence of PhilPACT strategies withthose of the TB related programs of other nationalgovernment agencies and the development ofsectoral TB programs, e.g., Childhood TB Programand TB in Jails and Prisons, broaden the programreach and scope of TB control while engaging awider segment of the government sector.Moreover, the private sector contribution to bothpolicy development and program services evolvesinto more coherent models of public-privatepartnership for the TB program. The broadergovernance framework and approach adopted byPhilPACT now allows a multinodal TB program withmultiple levels of engagement for case detectionand treatment issues.

In all of these, the nexus of control is shiftedfrom the central to local governments. As theselocal governments implement and manage the TBprogram, their local health systems and their linksto the national program are further strengthened.

PhilPACT, HSR, and Global TB Control Plans

TB Control Plan/Planning Framework

Objective Strategy DOTS Stop TB 2006–2010 Fourmula WHO Buildingof PhilPACT Strategy National Plan One Block

to Control TB

1. Reduce localvariation inTB controlprogramperformance

1. Localizeimplementationof TB control

Politicalwill

Ensure the highpolitical supportfor TB control as apriority of thenational health planand among the localgovernment units

Governance Leadershipandgovernance




to Control TB

Contributeto healthsystemstrengthening

Enable andpromoteresearch

Engagehealth careproviders

Empowerpeople withTB incommunities

2. Scale up andsustaincoverage ofDOTSimplementation

2. Monitorhealthsystemperformance

3. Engage bothpublic andprivate TBcareproviders

4. Promoteandstrengthenpositivebehavior ofTB care ofcommunities

Programand patientmonitoring

DOT

Maintain thesupport to keymanagementfunctions,particularlymonitoring andevaluation ofNTP-DOTSimplementation

Improve thecapabilities of acritical mass ofDOTS workers,both public andprivate, tosustain qualityimplementationof DOTS services

Scale up andenhance Public-private Mix DOTSUnits (PPMDs) instrategic sites

StrengthenPublic-to-Publiccollaborationbetween publichospitals andhealth centers toincrease accessto and improveefficiency ofDOTS services

Governance

Servicedelivery

Servicedelivery

Informationsystem

Humanresources

Servicedelivery




to Control TB

5. AddressMDR-TB, HIV/TBcoinfection,and needs ofvulnerablepopulation

6. Regulateand makeavailablequality TBdiagnostictests anddrugs

7. Certify andaccredit TBcareproviders

8. Secureadequatefunding andimproveefficiency offundutilization

Servicedelivery

Regulation

Regulation

Financing

3. Ensureprovision ofquality of TBservices

4. Reduce out-of-pocketexpensesrelated to TBcare

Address TB/HIV, MDR-TB, andotherchallenges

Pursue high-qualityDOTSexpansionandenhancement

Quality-assuredsputummicroscopy

Uninterruptedsupply ofanti-TB drugs

Support theexisting DOTS (+)initiatives andinstitutionalizethese in thepublic sector

Strengthen theintegration of TB/HIV inaccordance withthe country’sdisease scenario

Strengthen theimplementationof DOTScertification andaccreditation

Servicedelivery

MedicalProducts


JUMPSTARTING PHILPACTIMPLEMENTATION

Because the PhilPACT’s strategic directions arequite different from those of the current plan, thereis a need to actively engage the both public andprivate stakeholders to support itsimplementation. The engagement process muststart early and bring on board key partners as soonas possible. Thus, before the start of PhilPACT’simplementation in 2010, the following activities willbe conducted:

Issuance of the DOH administrative orderadopting and endorsing PhilPACT as thecountry’s medium-term plan for 2010–2016 forcontrolling TB. The order will includeimplementing arrangements for the plan.

Reproduction of the entire plan anddevelopment of corresponding advocacymaterials. These will be launched anddisseminated to stakeholders.

Development of detailed PhilPACTimplementation guidelines that will direct theformulation of the TB subplan in the PIPH/CIPH/AIPH and AOPs;

Development of the annual operation plan for2010; and

Crafting of guidelines for the TB performance-based grant that will be part of the ongoingPBGs for other public health programs.



ANNEXES

ANNEX 1COMPOSITION AND TASKS OF THE STEERING COMMITTEE

AND TASK FORCE FOR THE TB CONTROL PLAN

STEERING COMMITTEE

Functions1. Set the direction, policies, and parameters for

the development of the strategic plan andensure that these are adhered to

2. Approve the planning framework andworkplan proposed by the Task Force

3. Critically review the key outputs of the TaskForce and provide inputs andrecommendations

4. Identify and mobilize key stakeholders,including DOH units/offices, to support theplanning process

5. Coordinate and harmonize all activities by theDOH and its partners that are related to theplanning process

6. Work with the TACT to ensure prompt actionon the submitted deliverables

7. Monitor the progress of the planning processto include resolution of identified issues andconstraints

8. Endorse the strategic plan to DOH seniorofficials for approval

9. Recommend to NTP the strategy and activitiesfor the strategic plan’s dissemination andadvocacy

CompositionChairperson Dr. Yolanda E. Oliveros,

Director IV, NCDPC

Alternate

Chairperson Dr. Jaime Y. Lagahid, DirectorIII, IDO

Vice Chairperson Dr. Rosalind G. Vianzon, NTPmanager, IDO

MembersDr. Virginia Ala, Director IV, HPDPB

Ms. Maylene Beltran, Director IV, BIHC

Dr. Lilibeth David, Director IV, BLHD

Dr. Jocelyn Gomez, PHO, Bulacan

Dr. Leda Hernandez, M.O. VII, IDO

Dr. Albert Herrera, CHO, Marikina

Dr. Woojin Lew, Medical Officer,WHO Country Office

Ms. Arlene Ruiz, Chief, HNFP Division,NEDA

Ms. Ms. Amelia Sarmiento, Executive Director,PhilCAT

Dr. Padma Shetty, Chief, Office of Health,USAID

Dr. Dr. Madeleine Valera, SVP, PhilHealth

SecretariatDr. Ernesto Bontuyan Jr., NTP–IDO

Mr. Lorenzo Reyes, NTP–IDO


TASK FORCE

Functions1. Propose the strategic planning framework,

parameters, and work plan including logisticalrequirements, to the Steering Committee

2. Conduct a situational assessment todetermine the TB epidemiological situation;NTP status; and NTP strengths, weaknesses,opportunities, and threats; and present theresults to the Steering Committee

3. Draft a strategic plan to achieve the MDG goalon TB control in 2015 which includes goals,objectives, targets, strategies, financial plan,implementing arrangements, and monitoringand evaluation scheme

4. Conduct consultations with key stakeholders,either in groups or individually

5. Present key technical outputs to the SteeringCommittee and other groups if necessary

6. Act on the comments and recommendationsof the Steering Committee and TACT

CompositionChairperson Dr. Rosalind G. Vianzon,

NTP manager, IDO

Vice Chairperson Dr. Mariquita J. Mantala,Short-term consultant, WHO

MembersDr. Ma. Cecilia Ama, NTRL-RITM

Dr. Dennis Batangan, TB LINC

Dr. Mar Wynn Bello, BIHC

Dr. Arthur Lagos, TB LINC

Dr. Liezel Lagrada, HPDPB

Dr. Carlo Panelo, HPDP

Dr. Ann Remonte, PhilHealth

Dr. Carlos Antonio Tan, HPDP

SecretariatMs. Yasmine Hashimoto, TB LINC

Dr. Winlove Mojica, HPDP


ANNEX 2LIST OF PARTICIPANTS IN THE JULY 8–9, 2009,

AND AUGUST 6–7, 2009CONSULTATIVE WORKSHOPS HELD AT

THE GRAND OPERA HOTEL, MANILA

DEPARTMENT OF HEALTH: CENTRALAND REGIONAL OFFICESDir. Virginia Ala, HPDPBDr. Ma. Cecilia Ama, NTRLDir. Irma Asuncion, CHD–NCRDr. Lorella Averilla, IDO–NCDPC

Dir. Teogenes Baluma, CHD–Southern MindanaoDr. Mar Wynn Bello, BIHCDr. Ernesto A. Bontuyan Jr., IDO–NCDPCDir. Myrna Cabotaje, CHD–CARDir. Lilibeth David, BLHD

Dr. Joel Flores, IDO–NCDPCDr. Celine Garfin, IDO–NCDPCDr. Leda Hernandez, IDO–NCDPCMs. Noraina Kamid, DOH–ARMMMs. Virginia Laboy, BFAD

Dir. Jaime Y. Lagahid, IDO–NCDPCDr. Liezel Lagrada, HPDPBDir. Susana Madarieta, CHD–Central VisayasEngr. Dave Masiado, MMDDr. Amelia Medina, CHD–MMDr. Renato Pangan, CHD–Central Luzon

Dr. Ma. Luisa Paran, CHD–CARMs. Evelyn Perez, NCHPDr. Sadaila Rakiin, DOH–ARMMMr. Lorenzo Reyes, IDO–NCDPCDr. Eloisa Segurra, CHD–Southern Mindanao

Mr. Darwin Taban, IDO–NCDPCMs. Jocelyn Tabotabo, CHD–Central VisayasDr. Marlo Tampon, IDO–NCPCDr. Rosalind G. Vianzon, IDO–NCDPC

HOSPITALS: DOH-RETAINEDDr. Vivian Lofranco, LCP

Dr. Flora Marin, San Lazaro Hospital

Dr. Myrna Rivera, Tondo Medical Center

HOSPITAL: PRIVATEDr. Victoria Dalay, De La Salle University

Dr. Lourdes Ursos, Silliman University Hospital

LOCAL GOVERNMENT UNITSDr. Pascuala Aguho, Manila

Dr. Edgardo Barredo, Negros Oriental

Ms. May Fernando, Bulacan

Dr. Ashley Lopez, Davao City

Dr. Florence Reyes, Baguio City

Dr. Sonia Timbang-Madjus, Parañaque

Ms. Brenda Valdez, Baguio City

Dr. Ma. Elisa Villanueva, Bulacan

Dr. Benjamin Yson, Manila

INTERNATIONAL PARTNERSDr. Maarten Bosman, STC, WPRO

Dr. Woojin Lew, WHO Country Office

Dr. Pieter van Maaren, WHO–WPRO

Dr. Cora Manaloto, USAID

Dr. Mariquita J. Mantala, STC, WHO Country Office

Dr. Padma Shetty, USAID

Ms. Lilly Zhu, WPRO Intern


LOCAL PARTNERSMs. Rhea Alba, World Vision

Dr. Dennis Batangan, TB LINC

Mr. Virgil Belen, TDFI

Dr. Elizabeth Cadena, PTSI

Dr. Dolores Castillo, TB LINC

Dr. Arthur Lagos, TB LINC

Mr. Edwin Onofre Merilles, TDFI

Ms. Nona Rachel Mina, TDFI

Dr. Winlove Mojica, HPDP

Dr. Ruth Orillaza Chi, TDFI

Dr. Carlo Panelo, HPDP

Dr. Roderick Poblete, RIT/JATA

Ms. Aurora Querri, RIT/JATA

Dr. Julio Sabornido, TB LINC

Dr. Cristopher Santiago, HPDP

Ms. Amelia Sarmiento, PhilCAT

Dr. Elmer Soriano, TB LINC

Dr. Carlos Antonio Tan, HPDP

OTHER GOVERNMENT AGENCIESDir. Thelsa Biolena, DSWD

Supt. Carolina Borrinaga, BJMP

Dr. Jose Mari Castro, DSWD

Ms. Viginia Clavel, DILG

Ms. Guidditta Gelera, DOST–PCHRD

Ms. Loreta Labado, NCIP

Chief Ins. Dr. Ilna Maderazo, BJMP

Dr. Minda Meimban, DepEd

Dr. Ann Remonte, PhilHealth

Dr. Giovanni Roan, PhilHealth

Ms. Marissa San Jose, DOLE–OSHC

Dr. Ma. Beatriz Villanueva, DOLE

Ms. Rose Villar, NEDA

MEDICAL SOCIETIESDr. Alex Alip, PAFP

Dr. Jubert Benedicto, PCCP

Dr. Rontgene Solante, PSMID

PATIENT GROUPAnacleto del Rosario

Ms. Melinda Merilles

SUPPORT STAFFMr. Allan Abreo, IDO–NCDPC

Ms. Emelina Almario, Overall Facilitator

Mr. Gualberto Avila, IDO–NCDPC

Ms. Leah Cruz, IDO–NCDPC

Mr. Ramon Eustaquio, IDO–NCDPC

Ms. Rachel Gonato, IDO–NCDPC

Ms. Yasmin Hashimoto, TB LINC

Ms. Emylou Infante, Documenter

Ms. Michele Macalintal, Documenter

Mr. Ricardo Oraya, IDO–NCDPC

Ms. Arlene Rivera, IDO–NCDPC


ANNEX 3PROPOSED DOTS SERVICE PACKAGES

DOTS Description/ Service Regulation Governance FinancingService Contents DeliveryPackage National LGU PHIC OOP

1. HospitalDOTS

2. MDR-TB

Advocacy tohospitalmanagement As DOTS

center:Setting upof DOTSfacilityTrainingDrugsFormsTA oncertification/accreditation

As referringunit:Orientation

Setting up oftreatmentcenter andsite

Training ofhealth staff

Second lineanti-TB drugs

Referral toculture center

Monitoring

Diagnosisandtreatmentinprovincial,districtandmunicipalhospitalsif withDOTSclinic

Identificationandreferral toRHUs ifreferringhospital

Treatmentcenters/sites

Culturecenter

Licensing

Provisionof quality-assuredsecondline drugs

PLCE/PHO

Hospitalowners/administrators

DOH unit tooverseePLCE/PHO

Drugs

Diagnostics

Training

Drugs

Diagnostics

Training

Hospitaloperations

Staff

Staff

Structure

PhilHealthinpatientand OPDbenefits

Diagnostics

X-rayexam



3. Basic DOTSservices atthe RHU/HClevel

4. TB inchildren

5. TB inprison

DOTStraining

First lineanti-TB drugs

Lab reagentsif with TB lab

Forms

Supervisionfrom province

Datamanagement

TA oncertificationandaccreditation

EQA of DSSM

Training

PPD

Pediatricanti-TB drugs

Training

Anti-TB drugs

Forms

Datamanagement

Supervisionfrom province

Access to TB lab

RHU/HC

DOTSfacility

DOTSfacilitywithintheprison/jai l

DOTScertification

DOTScertification

Compliancewithpolicieson DOTSin jails

MLCE/MHO

PLCE/PHO

BJMP/PLCE/PHO

Drugs

PPD

Forms

Training

Drugs

PPD

Forms

Training

Drugs

Diagnostics

Forms

Training

Staff

Structure

Operations

Staff

DOTSpackage

DOTSpackage

X-ray exam

X-ray exam



X-ray examDOTSpackage

DOTSpackage—forreferral

DOTSpackage—forreferral

Training

BHWallowance

Enablers

IECmaterials

6. PPMD

7. PrivatePractitionersDOTSpackage

8. CommunityDOTSpackage

9. Family/patient DOTSpackage

DOTStraining forstaff

Anti-TB drugs

Forms

Sustainabilitytraining andtools

Supervision

Access to TBlab

DOTS referralcourse

Certificationby PhilCAT

Referral forms

Training oftreatmentpartners, e.g.,BHWs

Capacity-building ofcommunity-basedorganizations

Referralforms

IEC materials

Enablers

PPMDunit

NGOs/CBOs,BHWs

Family

DOTScertification

MLCE/MHO

MHO

MHO/BHS

Drugs

PPD

Forms

Training

Training


ANNEX 4MONITORING AND EVALUATION MATRIX

Strategy Indicator Baseline/ Target in Source of/ Data Collection Frequency/and Source 2016 Responsible Methodology Date ofPerformance for Data ReportingTarget

GOAL

Attain MDG TB prevalence 799 /100,000 400/100,000 WHO Estimate based Annualgoals rate, all (1990, on national

forms WHO est.) prevalence survey

TB mortality 87/100,000 44/100,000 WHO Estimate Annualrate (1990, WHO)

OUTCOME

Achieve Case detection 75% 85% WHO Data collected Annualprogram rate (2007, WHO) by WHOtargets

Treatment 88% 90% WHO Annualsuccess rate (2006, WHO)

Cure rate 82% 85% NTP Quarterly reporting Annual(2007, NTP) by DOTS facilities

No. of MDR-TB 500 15,000 cases NTP Quarterly reporting Annualcases detected (2008, NTP) in seven years by treatment centersand treated

STRATEGY 1: Localize implementation of TB control

1.1. 70% of % of provinces/ 44 provinces 70% BLHD–DOH Review of plans Annualprovinces HUCs with clear with varying of provincesand highly TB control plan quality and HUCsurbanized within PIPH/ (2008)cities (HUCs) AIPH/CIPHinclude TBcontrol planwithinPIPH/AIPH/CIPH



1.2. 70% of % of provinces/ No data 70% NTP National registry Annualprovinces/ HUCs that are of provinces kept by NTP basedHUCs are at DOTS compliant and HUCs on assessmentleast DOTS-compliant

1.3. 90% of % of priority No data 90% NTP Quarterly reporting Annualpriority provinces/cities of provinces/ by provincesprovinces/ with performance HUCs withHUCs with grants have performanceperformance achieved targets grantsgrants haveachievedprogram Extent of No data Demonstrated NTP Evaluation Midtermtargets contribution of significant effect of scheme

grant to of grant on End ofperformance performance plan

1.4. DOH and % of CHDs with Limited All (based on NTP Regional Annualpartners capacity to (could not be criteria to be assessmenthave provide TA to quantified) developed)capacity to provinces/HUCsprovide TAto provincesand cities Extent of 4 regular and Additional NTP NTP capacity Annual

capacity of NTP 15 contractual regular NTP staff assessmentstaff

With capacity toLimited provide TAcapacityfor localenhancement

1.5. Public- Extent of National Present NTP Monitoring Annualprivate existence of Coordinating at nationalcoordinating PP mechanism Committee level, allbody at regions and 70%national, National CUP of provincesregional, groupandprovincial Regionallevels Coordinatingestablished Committeeand in 16 regions



sustained toinclude Very few PPCompre- at provincialhensive levelUnifiedPolicy (CUP)mechanism

STRATEGY 2: Monitor health system performance

2.1. Trend of Status of 2007 NPS 2014 NPS NTP Population survey 2015TB burden surveys to completedtracked determine

TB burden 2004 DRS 2011 DRS NTP Population survey 2012completed 2016 DRS 2017

Questionable 2011 TB NTP/NEC Random survey 2012quality of mortality studyTB mortality

2008 NDHS 2013 NDHS NSO Population survey 2014completed

Not included 2011 APIS NSO Population survey 2012in APIS

2.2. TB Status of Six-month Integrated NEC Review of project Annualinformation Integration of delay in electronic TB performancegenerated TB integration informationon time, information of electronic system generating Consolidationanalyzed, system TB information outputs within of regional /and used system 3 months provincial NTP

(2009, NTP) reports and PIRsAnnual TB report NTP

2.3. TB Status of TB 2 TB indicators Yearly results BLHD LGU performance Annualinformation information in LGU from LGU assessmentsystem system within scorecard scorecardintegrated national ME3 (2009)with nationalM&E andFHSIS



Status of TB TB information TB information NEC Review of project Annualinformation system not system integrated performancevis-à-vis FHSIS integrated with FHSIS

with FHSIS(2009)

STRATEGY 3: Engage both public and private health care providers

3.1. 60% of all Percent 6% 12% NTP Review of project AnnualDOTS contribution of (2008, NTP) report, e.g., PhilCATfacilities in PPMD to case and TB-LINCprovinces findingwithprovincial PPmechanisms % of component 220 PPMDs 60% NTP Monitoring and PIR Annualhave a cities/ (2008, PhilCAT) of componentfunctional municipalities HUCs and Review of projectcollaboration/ with functional municipalities reports, e.g.,referral system PP collaboration/ in above PhilCAT and TB-LINC

referral system provinces

3.2. 90% of % of hospitals Estimated to 90% of public NTP/NCHFD Monitoring of PIRpublic participating in be less than hospitals and hospitals Annualhospitals DOTS either as 10% of total 65% of privateand 60% of DOTS provider hospitals hospitals NTP reportprivate or referring by hospitalshospitals centerareparticipatingin DOTSeither asDOTSprovider orreferringcenter

3.3. 70% of % of trained 50% of 70% of NTP Review of Annualtargeted private providers trained 9,000 trained project9,000 PPs are referring 4,000 PPs PPs reports, e.g.,are patients to (Global PhilCAT andreferring DOTS facilities Fund) TB-LINCpatients toDOTSfacilities



3.4.All frontline % of RHU/health Estimated to All HWs NTP Report of the Annual health center/DOTS be less than TB Humanworkers are facility staff 90% Resourceequipped to trained in DOTS Informationdeliver TB Databaseservices

STRATEGY 4: Promote and strengthen positive TB behavior of communities

4.1.TB % of TB 68% 48% NTP National 2016sympto- symptomatic (2007, NPS) Prevalence Surveymatics who are self-who are medicatingself- and notmedicating consultingand notconsulting % of pharmacies No data 70% NTP Operational study 2016reduced by complying with30% TB drug

dispensingpolicy

4.2.Default % of provinces/ 8 provinces, 90% will have NTP Review of Annualrate of cities with 19 cities, reduced default cohort analysisprovinces default rate of and 9 NCR rate by 40% of provinces/and cities more than 7% cities citieswith >= 7% that have been (2008reduced by reduced by 40% provincial/40% city reports)

4.3.Number of Number of TB Task Force 50% increase NTP Report of projects Annualbarangays barangays with = 384 of the to NTPthat have organized CBOs baselineorganized CBOs in numbersCBOs ARMM = 427participatingin TB controland that arelinked withDOTSfacilitiesincreasedby 50%



STRATEGY 5: Address MDR-TB, HIV/TB, and needs of vulnerable populations

5.1. A total of at Percent of Around 70% 75% NTP Review of cohort Annualleast 15,500 MDR-TB cured (2008, NTP) analysis ofMDR-TB treatment centershave beendetected Number of 500 Total of 15,000 NTP Review of Annualand MDR-TB (2008, NTP) in 7 years quarterly reportsprovided detected and of treatmentwith quality- given second centersassured line anti-TBsecond-line drugsanti-TBdrugs insix years Number of 5 treatment 35 treatment NTP Monitoring Annual

treatment centers centerscenters established Review of project

(2008, NTP) performance oftreatment centers

5.2. TB/HIV Number of areas 10 cities in 23 cities and NTP/NASPCP Monitoring Annualcollaborative with TB/HIV NCR doing municipalitiesactivities in collaborative PICT and as identified Review ofareas with activities HIV testing by NASPCP performancepopulations (NCR report) reports ofwith high priority areasriskbehaviorand with at Percent of TB Less than 80% of TB cases NASPCP/NTP Quarterly report Annualleast 80% patients tested 20% in NCR in priority sites to NTP/NASPCPof TB cases for HIV/AIDS in (NCR report) by sitestested for high risk areasHIV

5.3. Nationwide Number of 16 cities All provinces NTP Monitoring report Annualimplemen- provinces/cities in 2008, to be and citiestation of implementing expanded to PIRchildhood a childhood one provinceTB control TB program per region inprogram 2009



Number of No data At least 254,065 NTP Review of quarterly Annualchildren with in 2008 in 7 years reportTB detected andgiven treatment PIR

5.4. DOTS % of prisoners 23% 100% NTP Review of BJMP/ Annualservices with access to in 2009 BuCor reportaccessible DOTS services to NTP/PIRto allinmateswith TB

5.5. Policies, Number of CUP DOLE, DepEd, 16 CUP members National Reports at Annualoperational members with DILG-BJMP, CUP group CUP meetingguidelines, policies, NEDA andand models guidelines, and DOJ-BuCordeveloped, models on TB policiesdisseminated, control for (July 2009)and locally vulnerableadopted to populations No national With national National CUP Reports at CUP Annualaddress policy for policy on group meetingneeds of vulnerable vulnerablevulnerable population populationpopulations

Types of Partly urban Expanded to NTP Review of CUP Annualvulnerable poor, children, at least 4 types member reportsgroups given prisoners of vulnerable to NTPinitiatives for populationsincreasedaccess toTB services

STRATEGY 6: Regulate and make available quality TB diagnostic tests and drugs

6.1. TB laboratory Extent of Limited staff Increased NTRL Review of Annualnetwork institutional and budget staff and plantilla, budget,managed by capacity of NTRL budget and performanceNTRL to to manage TB Weak of NTRLensure that network information Systems for90% of system information, HRmicroscopy & certificationcenters are in placewithin EQAstandards



% of provinces Less than 95% NTRL Monitoring PIRwith functional 80% AnnualQA center

% of microscopy 75% 95% NTRL Review of Annualcenters quarterly labimplementing reports of QAEQA centers

% of microcopy 74% 90% NTRL Review of Annualcenters within quarterly labEQA standards reports of QA

centers

Number of TB 530,000 5 million NTRL Review of Annualsymptomatics in 2008 In 7 years quarterly labexamined reports of QA

centers

6.2. TB Number of new 15 cities At least one NTRL Monitoring Annualmicroscopy microscopy with poor MCservices centers MC: Popn established PIRexpanded established standard inin cities and (>one per identifiedunderserved 100,000) citiesareas

Access to Undocumented Guidelines and NTP Assessment of Annualmicroscopy initiatives initiatives for guidelinescenters in GIDA and no clear increasing access

guidelines to MCby GIDA

6.3. Every Access to TB 67 provinces/ All provinces and NTP Monitoring Annualprovince Diagnostic cities with HUCs withand HUC has Committee TBDC access to TBDC PIRaccess tothe TBDiagnosticCommittee

6.4. All DOTS % of DOTS Widespread No shortage in NTP Systematic Annualfacilities with facilities with shortage all DOTS facilities assessment andavailable available anti- in 2008 monitoringanti-TB drugs TB drugs



Number of TB 140,000 I million NTP Quarterly reports Annualpatients TB cases, all in 7 years of DOTS facilitiesprovided with forms inanti-TB drugs 2008

STRATEGY 7: Certify and accredit TB care providers

7.1. At least % certified and Less than 70% of DOTS NTP Review of Annual70% of DOTS accredited DOTS 20% of DOTS facilities national registryfacilities are facilities facilities (RHUs/HCs/ PhilHealthDOH-/Phil were PPMDs) PhilHealthCAT-certified accredited in certified and informationand 2008 accredited system reportPhilHealth- (PhilHealth)accredited

7.2. Standards Not included Included Bureau of Health PhilHealth Assessment of DOH/ Annualfor hospital Facility PhilHealth policyparticipation Development issuancein TB controlincluded inDOHlicensing andPhilHealthaccreditationrequirements· DOTSstandards for hospitalsincluded inlicensingandaccreditationstandards

7.3. Infection Percent of health All treatment 100% of treatment NTP Monitoring Annualcontrol facilities centers and in centers and DOTSmeasures in adhering to less than 25% facilities List of certifiedall treatment infection control of DOTS and accreditedcenters/sites guidelines facilities facilitiesand DOTSfacilities



STRATEGY 8: Secure adequate funding and improve allocation and efficiency of fund utilization

8.1. Reduced Out-of-pocket No baseline 50% reduction NTP NPS or APIS 2012redundancies expenses onand gaps by TB care 2016harmonizing financingof TB TB control P7 billion gap Reduced NTP Review of all Annualprevention financing gap by 50% sources ofand control funds

Functionality of No TB Functional at NSCB/NTP Review of outputTB subaccount subaccount least at the

national level

Level of PhP1.2 billion At least GAA Review of Annualgovernment in 2009 sustained allocationbudget/spending from NG NSCB/TBon TB subaccount Review of

annual reportof TB subaccount

% of provinces/ No data 90% of those BLHD Project reports AnnualHUCs with PIPH/ with PIPH/AOPAIPH that includea budget for TBcontrol

TB care GF, USAID, Proposals in the BIHC/NTP Review of contracts/ Annualfinancing from WHO, JATA, pipeline project reportsdonors EU, KOICA

8.2. PhilHealth’s PhilHealth share Less than 5% Benefit utilization PhilHealth Report on Annualrole in TB control of PhilHealth increased by at PhilHealthexpanded members least 30% claimsthrough utilized benefitgreateravailabilityof accreditedproviders andincreasedutilization ofTB DOTSpackage



8.3. National Number of 0 50% of BLHAD Report of BLHAD Annualgovernment provinces provinces/HUCsfunds granted withleverage to PBGsecure LGUandPhilHealthcommitments


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DEPARTMENT OF HEALTHManila, Philippines

An electronic copy of thispublication can bedownloaded at:http://www.rchsd.doh.gov.ph/

Documents

Monograph No. 11HSRA Monograph No. 11 5 TABLE OF CONTENTS FOREWORD 7 PREFACE 8 ACKNOWLEDGMENTS 9 ACRONYMS 10 EXECUTIVE SUMMARY 13 TB BURDEN AND CONTROL EFFORTS IN THE PHILIPPINES 18