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