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Systematic Approach to Engaging Hospitals:
Philippine Experience
“Seventh Meeting of the Subgroup on Public-Private Mix for TB Care and Control “
Lille, France, October 23 - 24, 2011
ROSALIND G. VIANZON, MD, MPH
NTP Manager
Department of Health, Philippines
Flow of Presentation:
DOTS Implementation
Public-Private Mix DOTS (PPMD)
Engaging large hospitals
Started in 1996 in the public health sector
and expanded up to 2002
Good treatment success but still low in CDR
of new Sm+s; (“missing cases”)
Mainly from the Public Sector; Needs to be
expanded beyond public sector
Private sector needs to be engaged due to
wide variations in case management
DOTS in the Philippines
Analysis of the DOTS Implementation
DOTS is feasible, with the Public Sector setting the direction
potential sources: private clinics/MDs
PhilCAT aided in enticing private sector
PPMD started in 2004; CDR rose to 70%
Contribution to CDR: 10-12% (local)
6-8% (national)
Private participation may either be:
A) through referral of their cases
B) through actual DOTS service provision
Department Order No.154 s.,2004
“Operational Guidelines on PPMD”
PPMD Seal
Memo #45 s.2004 – “DOTS Certification”
A.O.#26 s.,2006 – “Implementing Guidelines on DOTS Certification” PhilHealth Circulars on Accreditation
Supporting Policies and Structures
National Coordinating Committee on PPMD (NCC) (IDO-DOH - - -PhilCAT- - -PhilHealth)
Regional Coordinating Committee on PPMD (RCC) (CHD-DOH---Regional Private/Coalition Counterpart---Regional PhilHealth)
Province/City Health Office (PHO/CHO, NTP Coordinators, Local Coalition Members)
PPMD Unit(s)
PPMD Organizational Level
2,029
2,430
3,259 5,190
5,951
5,328
5,281
70,000
75,000
80,000
85,000
90,000
2004 2005 2006 2007 2008 2009 2010
Cases Contributed through PPMD
Private
Public +
private
0%
20%
40%
60%
80%
100%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
CDR, Philippines, 1997-2010
Pub + Pri
Public
Analysis of Program Outcomes
1. Stagnating TB case
detection rate in Phil
2. Estimated 100,000 TB
cases all forms, were
undetected in 2009
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
CDR
Cure
Success
Trend of CDR, CR and TSR
Case Detection of All Forms of TB
145,500
258,536
258,234
258,090
255,054
254,604
254,203
253,609
252,917
252,160
251,377
250,559
119,914
107,133
118,408
143,807
140,588
147,305
137,100
130,530
132,759
100,000
130,000
160,000
190,000
220,000
250,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Est. Incd (TB all forms) Cases Detected (all forms)
Health Care Worker/
Facility Consulted by
TB Symptomatics
Public Health Center
(DOTS)
26.7
Hospitals (Public and
Private)
43.0
Private physician 21.7
Others 2.6
3. Hospitals are consulted by majority of TB symptomatics
12,444
10,284
2,1601,582
578
0
2000
4000
6000
8000
10000
12000
14000
Estimated no. of TB patients detected by
hospitals
Leakage from internal referral
No. of patients seen by TB Clinic
Leakage from external referral
No. of patients
reported to NTP
83%
12%
5%
Rapid assessment survey of 14
hospitals in Metro Manila, 2010
2007 National TB
Prevalence Survey
Percent
Analysis of Program Outcomes
Strategy 3:
Performance targets (2016):
*90% of all public hospitals and
60% of private hospitals must be
participating in TB control
4. Presence of NTP medium-term plan and DOH policy
Analysis of Program Outcomes
Hospital Engagement
CATCH TB Project (Collaboration for Additional TB cases
through Contacts and Hospitals)
- involves 14 government hospitals
in Metro Manila
- bed capacity: 150-1,500
- WHO-CIDA assistance
Enrol/ Register
and
Report to NTP
TB patients
(OPD)
TB or DOTS
Clinic
TB patients
(ward)
Refer to a
DOTS
facility
Hospital TB-DOTS Framework
Internal Referral
External Referral
TB symp logbook
Intrahospital
referral form
NTP
Referral
Form
TB Referral
registry
TB-DOTS installation activities
Situational assessment
Talk with management
Assign hospital team
Role definition
Policy and plan
Logistics
Advocacy
Capability-building
Enablers
Referral system
Supervision & monitoring
1,251 (18%)
Registered
6,913
TB cases
5,331 (77%)
Referred to
other DOTS
facilities
1,251 (100%)
Reported to
NTP
331 (5%) Died, not
referred (eg. bought
own drugs, etc.), shifted
to SDF due to allergic
reaxn, Non-DOTS
Results of hospital implementation (14 hospitals)
% Managed
by TB clinics:
18% 3,247
accepted
Referral
Acceptance
Rate: 61%
1,070
TB suspects Referred for
DSSM,TBDC etc.
TB Clinics 9,359
6,913 (74%)
TB cases
66 TB cases
Hospital’s Contribution to NTP,
June to September, 2011
1,251
(18%) Registered
5,331 (77%)
Referred to other
DOTS facilities
3,247
accepted
1
3
2
n=4,564 Contribution
Destination of referred TB patients,
June 2010- Sept 2011
(37
%)
(23%
)
Metro Manila 3978
(74.%)
Outside Metro Manila 1344
(25.2%)
No address 9 (.2%)
Mode of knowing the outcome of referrals (n=3,247)
Return slip returned
68%
Cross-checking TB Registers
7.1%
Cross-checking ETR 3.2%
SMS 12.3%
Calling DOTS facilities
5.1%
Email 0.0%
No info0.5%
Others2.1%
Fax 0.1%
Postage 2.3%
Aside from Private MDs, hospitals also contribute
to increasing case detection.
Hospital engagement is facilitated by clear and
flexible guidelines, active hospital TB team
logistical support and regular monitoring.
Hospitals contribute to case detection either
through referrals or provision of direct TB services.
Regular dialogue between hospitals and health
centers clarified their respective issues.
Lessons Learnt
Challenges
Many are still lost during referrals
Manpower concerns (rotation, lack of
medtech, no volunteers at the hospitals)
Limited engagement of private doctors
practicing within the hospital
Limitation of hospital staff to default-trace
losses from external referrals
Harmonize all PPM efforts of stakeholders
as part of PhilPACT (strategy 3)
Localize PPM management to Provincial
and City levels
Scale-up hospital linkage through policy
revision, advocacy and logistical support
Upgrade the certification/accreditation
system to facilitate engagement of all care
providers
Moving Forward the PPM Approach
THANK YOU
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