Guidance on TB Patient Care for the Urban Poor (The RJPI Experience) 2014

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Guidance on Tuberculosis

Patient Care for the Urban Poor

The RJPI Experience

2014

Research Institute of Tuberculosis

Japan Anti Tuberculosis Association Philippines,

Inc. (RJPI)

2nd Floor PTSI Bldg., 1853 Tayuman, St. Sta. Cruz,

Manila

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Table of Contents

Acknowledgement 6

Acronyms 7

Background 8

Purpose of the Operational Guidelines 9

Target Audience 10

Diagram of RJPI Process of Private and Public Engagement and Collaboration 10

The Map of the Republic of the Philippines 11

The Map of District 1, Tondo, Manila 12

The Map of Payatas, Quezon, City 13

A. Planning and Preparation 14

1. Coordination / Consultative Meeting 14

2. Situational Assessment 15

B. Implementation 19

Strategy 1. Engagement of NGOs and other private organizations 20

Strategy 2. Capacity Building 21

a. Improving the supply side 21

b. Improving the Demand Side 24

Strategy 3. Advocacy, Communication, and Social Mobilization 24

a. Establishment of Referral Mechanism 25

b. Development of Recording Forms 26

c. Community Advocacy Campaign 28

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d. Organize TB Support Group

29

e. Development of IEC Materials 30

C. Conducting Operations Research 30

D. Evaluation 32

1. Conducting on site Joint Monitoring and Evaluation 33

2. Program Evaluation 36

E. Scaling up Private and Public Mix Engagement and Collaboration 38

ANNEXES

Annex 1. Baseline Survey : Data Collection Form For Local Government Unit Health Centers 39

Annex 2. Baseline Survey : Data Collection Form For Non Government Organizations 43

Annex 3. A Sample Project Design Matrix 49

Annex 4. A Sample of Plan of Operations 51

Annex 5. Memorandum Of Agreement ( NGO DOTS Facility ) 56

Annex 6. Memorandum of Agreement ( NGO Referring Facility) 60

Annex 7. Assessment Sheet for Imaging Quality of Chest Radiography 64

Annex 8. CHV TB Symptomatic Referral Masterlist 65

Annex 9. NTP TB Symptomatic Referral Form 71

Annex 10. Modified Masterlist B 74

Annex 11. Contact Investigation Tool for Community Health Volunteers 78

Annex 12. MDR Suspect Referral Masterlist 80

Annex 13. MDR-TB Decentralized Masterlist 82

Annex 14. TB/ HIV Masterlist 84

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Annex 15. A Sample Project Indicators

89

Annex 16. Monitoring Tools 94

a. Laboratory Case Finding Tool 97

b. Laboratory Checklist 98

c. Laboratory Feed Back Sheet 99

d. Validation Sheet for IPT 100

e. Validation Sheet for Child Screened 101

f. Validation Sheet for IPT Outcome 102

g. Quarterly Report on All TB Cases 103

h. TB Cases Treatment Outcome 106

i. Contact Investigation ( Modified Masterlist B ) 107

j. Validation Sheet on TB Diagnostic Committee 111

k. MDR TB Suspects Data Collection Form 112

l. TB Infection Control Monitoring Tool 113

m. Logistics Monitoring Form 114

n. Data Validation 115

o. Health Worker Interview ( DOTS facility ) 118

p. Patient Interview 120

q. NTP Monitoring Tool for Referring Facilities: Data Collection Form 121

r. NTP Monitoring Tool : Feedback Sheet

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Developed by the Research Institute of Tuberculosis / Japan Tuberculosis Association,

Philippines, Inc. (RJPI)

Authors:

Akihiro Ohkado, RIT/JATA Philippines Inc., (RJPI) Manila, Philippines; Research Institute of

Tuberculosis (RIT) / Japan Anti Tuberculosis Association (JATA), Tokyo, Japan

Aurora Querri, RIT/JATA Philippines Inc., (RJPI) Manila, Philippines

Shoji Yoshimatsu, Research Institute of Tuberculosis (RIT) / Japan

Anti Tuberculosis Association (JATA), Tokyo, Japan

Leveriza Coprada, RIT/JATA Philippines Inc., (RJPI) Manila, Philippines

Evanisa Lopez, RIT/JATA Philippines Inc., (RJPI) Manila, Philippines

Gian Patrick Pili, RIT/JATA Philippines Inc., (RJPI) Manila, Philippines

Yuka Inoue, RIT/JATA Philippines Inc., (RJPI) Manila, Philippines

Akira Shimouchi, Research Institute of Tuberculosis (RIT) / Japan Anti Tuberculosis

Association (JATA), Tokyo, Japan

Funded by:

TB Control and Prevention Project in Socio-Economically Unprivileged Areas in Metro

Manila, The Philippines under the technical cooperation for grassroots projects of Japan

International Cooperation Agency (JICA), Japan:

The research project of the International Medical Center of Japan (IMCJ), A socio-medical

study for facilitating effective infectious diseases control in Asia funded by the International

Medical Cooperation Research Grant, the Ministry of Health, Labour and Welfare, Japan; and

the double barred cross seal donation of Japan Anti-Tuberculosis Association (JATA), Japan.

Citation: http://bit.ly/RJPIUrbanPoorGuidance

Contact information:

Akihiro Ohkado

Aurora Querri

Research Institute of Tuberculosis / Japan Anti Tuberculosis Association, Philippines, Inc.

(RJPI)

1853 Tayuman, St. Sta. Cruz, Manila, Metro Manila, the Philippines

Telephone Number: 02-740-8054

REFERENCES

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Acknowledgement

We appreciate the significant contributions of the following organizations in enriching the RJPI

experience for the TB in the Urban Poor.

This Guidance on Tuberculosis Patient Care for the Urban Poor - The Research Institute for the

Tuberculosis Association Experience will not be put into writing without their collaborative

effort.

National Tuberculosis Control Program

Center for Health Development Metro Manila

Manila Health Department

Quezon City Health Department

Partner Organizations the Non-Government Organizations working within the project site

Other Partner Organizations

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ACSM Advocacy Communication and Social Mobilization

CBO Community Based Organization

CHD-

MM

Center for Health Development- Metro Manila

CHV Community Health Volunteer

DOTS Directly Observed Treatment Short Course

FBO Faith Based Organization

FDS Free Discussion Session

HIV Human Immunodeficiency Virus

IEC Information Education Communication

IPT Isoniazid Preventive Therapy

JICA Japan International Cooperation Agency

LGU Local Government Unit

NGO Non Government Unit

NTP National Tuberculosis Control Program

NTRL National Tuberculosis Reference Laboratory

MDR-TB Multi Drug Resistant Tuberculosis

MHD Manila Health Department

MOA Memorandum of Agreement

OR Operational Research

PDM Project Design Matrix

PhilPACT Philippine Plan of Action to Control Tuberculosis

PLHIV People Living with HIV

PoOs Plan of Operations

QCHD Quezon City Health Department

RJPI Research Institute of Tuberculosis / Japan Anti Tuberculosis Association,

Philippines, Inc.

SLH San Lazaro Hospital

STI Sexually Transmitted Infection

TB Tuberculosis

TBCAP Tuberculosis Coalition Assessment Program

TBCTA Tuberculosis Coalition for Technical Assistance

TBIC Tuberculosis Infection Control

WHO World Health Organization

ACRONYMS

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I. Background

Tuberculosis (TB) remains to be the global major public health problem for the past several

decades. The problem of TB is still predominant in the Philippines and its control is a

continuing concern of the National Tuberculosis Control Program (NTP). The Philippine Plan

of Action to Control TB (Phil PACT) was developed to systematically assess the TB burden and

TB control efforts in the Philippines in 2010. Likewise it is intended to serve as a road map in

reducing TB to a level where it is no longer a public health threat in the country (1). In the study

conducted by Tupasi et al., on the TB in the urban poor settlements in the Philippines, it was

noted that the prevalence of TB was 2.7 times in the urban than the general population (2). The

poor and vulnerable have longer pathway to health care than other social groups (3, 4). Studies

from a number of developing countries reveal that the poor have much less access to TB care

services than the nonpoor or can be excluded from TB care (5, 6 and 7). Emp, et al., observed

that TB services should also focus on the geographically poor areas such as slums or to specific

population group such as the homeless and the migrants who are likewise considered TB

vulnerable groups (8). In the study conducted by Murthy, et al., it concluded that engaging the

service providers used by the poor is substantial in reducing barriers to TB care (9).

The Research Institute of Tuberculosis / Japan Anti-Tuberculosis Association Philippines Inc,

(RJPI) was established in 2008, which aims to improve the access of the community people to

quality DOTS implementation through strengthening the linkage among the local government

units (LGUs) and non-governmental organizations (NGOs) in District I Tondo, Manila and

Payatas, Quezon City in Metro Manila, Philippines. The project as guided by the NTP and

Center for Health DevelopmentMetro Manila (CHD-MM) with the cooperation of the LGUs

and NGO partners identified the urban marginalized sector in District I-Tondo, Manila and

Barangay Payatas, in Quezon City as the strategic site of intervention. The RJPI has been

providing technical assistance since the first phase of the project through the Japan Ministry of

Foreign Affairs and now on its second phase through the grassroots project of Japan

International Cooperation Agency (JICA). The projects purpose of the RJPI is for the TB

infection and prevention and treatment to be implemented upon maintained quality DOTS

(Directly Observed Treatment, Short Course) program. For this purpose, the RJPI has been

conducting five kinds of activities in addition to assisting organizations concerned to maintain

quality DOTS program:

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1. To strengthen Advocacy, Communication Social Mobilization (ACSM) about TB

and its treatment among community; the activities underneath this component

comprises of capacity building, encouraging partners and the community to

participate in advocacy campaigns, network and linkage with government and

NGOs and organization of TB support groups.

2. To assist governmental organizations (GOs) and NGOs to provide TB screening

(contact investigation for contacts) in the project areas; the project conducts

monitoring and evaluation and facilitated development of relevant recording

forms.

3. To support treatment failure and other retreatment TB patients to take anti-TB drug

susceptibility test (DST); the project ensures the multi-drug resistant TB (MDR

TB) suspect referred by the DOTS Facility was able to access the treatment center.

A DOTS Facility is a facility that provides TB care, management, treatment to

patients including diagnostics and serves as referring unit for MDR suspects. A

Treatment Center provides complete care, management, diagnostics and

treatment of MDR-TB patients.

4. To assist / support to provide TB screening among HIV positive patients at HIV

hospital (San Lazaro Hospital, Manila); the RJPI together with TB and HIV

experts from San Lazaro Hospital (SLH) facilitated the development of an

operational guideline for HIV infected TB patient care at the hospital and a

recording form was developed.

5. To assist / support to implement TB Infection Control (TBIC) at the health

facilities in the project area. The project oversees the TBIC health practices of

health staff through monitoring and evaluation visits.

II. Purpose of the Operational Guidelines

The purpose of the operational guidelines is to provide guidance to NGOs, Community Based

Organizations (CBOs) and NTP in implementing communitybased TB prevention,

management, care and support in urban poor settings. It describes activities for effective

collaboration among NTP, NGOs and CBOs. It is aligned with the Stop TB Partnership (10),

ENGAGE TB Approach (11) and PhilPACT Strategies (1) for engaging all health care

providers including NGOs as part of the public and private mix approach.

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A. PLANNING AND PREPARATION

Coordination / Consultative Meeting

Situational Assesment

B. IMPLEMENTATION

Engaging GOs , NGOs, and other partners

Improving the supply side

Improving the demand side

C. CONDUCTING OPERATIONAL

RESEARCH

D. EVALUATION

Joint Monitoring and Evaluation Visits

Program Evaluation

Project Indicators

E. SCALING UP PRIVATE AND PUBLIC MIX

ENGAGEMENT AND COLLABORATION

III. Target Audience

This document is for the NGOs and other CBOs providing health care services that intend to

integrate community-based activities for TB prevention, management, care and support of

patients. The NTP is also an important audience of this document to assess and provide

recommendations and amendments to improve TB care in the community.

All community members in the community including women urban poor, youth, children,

elderly and family affected by TB could utilize this guide to generate demand for TB service.

IV. RJPI Process of Private and Public Mix Engagement and Collaboration

The diagram shown above represents the RJPI Collaboration Process in establishing and

strengthening linkage mainly between the GOs and NGOs. This is composed of five phases.

The first step is Planning and Coordination (consultative/conceptualization of the project),

followed by Implementation (actual execution of the activities based on the project design),

conducting operational research (documenting the current situation vis-a-vis resources and

absorptive capacity of the health staff to identify strategic interventions for the enhancement of

service delivery), then evaluation (regular assessment of the development of the project with

particular focus on its effectiveness and impact), and finally Scaling up of relevant organization

partnership (the success of a certain model or project introduced is replicated in other sites). The

Stop TB Partnership Six Point Agenda forges to engage all health care providers both the public

and private organizations to bring TB care services closer to the community (1). This process

could be adopted by private organizations which are willing to contribute to the NTP

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The Map of the Philippines (12)

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The Map of Project Sites

The project sites are in District-I, Tondo, Manila and Payatas, Quezon City. The project period

is from 2008-2014. The title of the project is TB Control and Prevention Project in Socio-

economically Unprivileged Areas in Metro Manila, the Philippines. Its focus is reaching the

underprivileged people in the community by bridging the gap through the networks among the

NGOs, CBOs and LGU in support of the NTP to improve the access to the quality DOTS

implementation.

1. Tondo Medical Center

2. Gat Andres Bonifacio Memorial Medical Center

3. Juan Posadas Health Center

4. Vitas Health Center

5. Canossa Health and Social Center Foundation Inc.

6. Velasquez Health Center

7. Aurora Quezon Health Center

8. Dagupan Health Center

9. Sto. Nino de Tondo Medical and Indigency Center

10. Bo. Fugoso Health Center

11. Parola Health Center

12. Tondo Foreshore Health Center

13. Bo. Magsaysay Health Center

14. Smokey Mountain Health Center

15. Youth With A Mission

16. Philippine Christian Foundation

17. Couples for Christ- Gawad Kalinga

18. San Pablo Apostol Clinic

19. Center for Community Transformation -Pritil

20. Encourage Families in Need and Care for Education

21. Center for Community Transformation -Parola

22. 4 People

23. Education Research Development Assistance-

Samahan ng Batang Nananambakan

24. Aspiring Citizen for Community Empowerment

25. Caritas

District-I Tondo, Manila

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1. Lupang Pangako Health Center 4. Payatas Orione Foundation

2. St. Luigi Orione 5. Payatas A Health Center

3. Committee of German Doctors 6. Center for Community Transformation - Payatas

4. Payatas B Health Center

Payatas, Quezon City

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A) PLANNING AND PREPARATION

The initial step in the RJPI process of engagement and collaboration is planning and preparation

of the project. The involvement of the NTP, CHD-MM including the City Health Offices is

significant in providing directions on how we will implement the project. Thus coordination and

consultation should be conducted at each level.

1. Coordination / Consultative Meeting

Initially we will have to coordinate the focal persons on when we plan to seek an audience with

them through a consultative meeting. A consultative meeting provides a venue to seek for expert

opinion on project conceptualization, For the RJPI experience; we solicited the advice of the

NTP and CHD-MM. Their participation is vital in the whole aspect of project implementation

and yet crucial at its preparation stage. The involvement of NTP / CHD-MM is specified in the

following stages in project planning and preparation.

Stages in the Preparation of the Project

a. Identifying goals: Goals are necessary in the preparatory phase of the engagement and

collaboration process. This is a guide that will direct the organization into the success of

the project. Most of the time, respective organization based their project goal which ought

to contribute to the broader social objective. Ultimately, the positive effect or impact that

we desire to achieve for the beneficiaries of the project must be the focus of the activity.

The RJPI goal is that TB infection prevention / treatment model is implemented by

maintaining quality DOTS services which is in line with the PhilPACT plan in reducing TB

mortality and morbidity. This aimed to improve the access of the TB services in the

community.

b. Identifying the beneficiaries: After the goal has been set, the identification of the

beneficiaries follows under the guidance of the NTP and CHD-MM. The beneficiaries are

the recipients of the intended positive effect from the implementation of the project. For the

RJPI project, they are the elderly, children and family or community members living in the

marginalized community who are experiencing impediments in accessing TB services.

c. Selecting a project site: When the beneficiaries had been identified, the next stage will be

selecting the project site. The project site refers to where we could strategically provide the

interventions that we will determine during the stakeholders analysis meeting as

mentioned below. In selecting a project site, we have to consider the performance of the

health facilities based on NTP indicators, extent of TB services they provide and other

baseline data which will be discussed in detail under situational assessment. The NTP and

CHD-MM who manages the data will guide us on where we could intervene.

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d. Coordination with the Government Institution / City Health Office: After seeking the

expert opinions of NTP and CHD-MM, the next step is to coordinate with the government

institutions and to lay down the project plan again, through a consultative meeting.

Soliciting the advice of the City Health Office through their NTP Coordinators will help us

in arriving at a decision on where we could strategically place our interventions since they

know the intricacies and peculiarities of their sites and each of the health facilities. The

RJPI usually pays a courtesy visit to the City Health Office as part of coordination to

introduce RJPI project, the intention of possible collaboration and when to seek audience

with then through a consultative meeting.

2. Situational Assessment

This is the second part under the planning and preparation stage in the RJPI process of

development and collaboration. On this stage the RJPI employs the situational assessment in

order to have an accurate finding of the present situation of the area. Situational assessment is a

process utilized to systematically collect and evaluate the socio-cultural, economic and

geographical and health system data of each organization aimed at identifying the current TB

services strategies opportunities, strengths and barriers in providing quality TB care service in

the community.

a. Baseline Assessment of Health Facilities in the Proposed Project Sites

We need to collect and analyze the situation in the possible areas for further discussion

with the staff concerned. A baseline survey to identify all NGOs and private clinics

(mapping of existing GOs and NGOs), the extent of TB care and management and health

services they offer to the community and to identify their needs in providing quality TB

services will be conducted. This is composed of socio-demographic profile (relates to the

development / structure of each organization and the population characteristics in a certain

community), health resources (refers to materials, personnel, facilities and funds that can

be used for providing health care and services), health staff capacity (refers to the ability of

the health staff to perform quality TB services based on the number of TB trainings

received), NTP performance (the assessment of the program implementation vis-a-vis the

indicators set by the NTP including current activities and barriers to TB care). See baseline

Data Collection forms for LGUs and NGOs (Annexes 1 and 2).

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b. Stakeholders Analysis Meeting

A stakeholders analysis meeting happens as a follow through activity, after the baseline

survey has been conducted. The activity has six phases and it aims to solicit inputs with the

partner institutions such as central and local governments (e.g., NTP, CHD-MM, MHD

and Quezon City Health Department (QCHD) and NGOs specifically in analyzing the

baseline data, to identify barriers on TB care access encountered, possible solutions and

interventions / strategies in order to address those barriers identified. It is also on this phase

that the Project Design matrix (PDM) is created.

Phases of Stakeholders Analysis Meeting

Phase 1 (Baseline Data Analysis): The baseline data obtained during the situational

assessment such as NTP performance and demographics will be presented to stakeholders

for analysis. By reviewing and evaluating the NTP performance together with the

acceptable performance target, we could better understand how the program is working.

Phase 2 (Identification of strengths of the GOs and NGOs on TB services): This

identified strength will be a medium for the sustainability and development of the project.

Phase 3 (Identification of barriers to access in TB Care): The stakeholders will identify

the different problems that they have encountered. The identified barriers are necessary in

developing core interventions for the project.

Phase 4 (Identification of strategies to address the barriers to TB Care): These relate

to the result of needs assessment. The strategies or interventions determined by the

stakeholders should correspond to the needs identified. Given the situation above, the

following strategies were recommended by the stakeholders to address the gaps to TB care

access. The identified strength in the second phase will be useful in making solution to the

problem. A thorough study in the strategies that will be used in the problem solving should

be necessary in order to cater the health needs, problems, and concerns that may surface

during the project implementation.

Phase 5 (Formulation of Project Design Matrix (PDM): After the systematic approach

in the identification of the strategies that will address the barriers of the TB care, the

agreed interventions will be now converted into a log frame or PDM. We need to formulate

a PDM to guide us how we are going to manage and implement the project. Without the

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major components plans and strategies explicitly written on this document, there will be

confusion in running the project, hence its success would be uncertain. A log frame or

PDM specifies the goal, purpose, activities, inputs, assumptions, indicators for monitoring

/evaluation of a project. In concert with the PDM, is the formulation of the Plan of

Operations (PoOs) which exemplify the details of the activities, time, period, budget and

person-in-charge to perform the specified tasks. (See Annex 3 and 4: PDM and PoOs).

Both the PDM and PoOs are the pillars in planning, implementing, monitoring and

evaluating the project activities.

Phase 6 (Tasking and formulation of Memorandum of Agreement (MOA)): This is

the final phase on this activity. The designed PDM will be the heart of the MOA. The

MOA will be the avenue for the implementation of the project by both parties. All the

stakeholders involved in this project such as CHD-MM, City Health Offices (MHD and

QCHD) and NGO DOTS and Referring facilities, identify their tasks or roles /

responsibilities to formulate a MOA (See Annex 5 and 6).

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Example: Output of the Stakeholders Analysis conducted in 2008

RJPI Baseline Data Gathering

Location: District 1-Tondo, Manila and Payatas, Quezon City

Date: 2008

Particulars

District I-Tondo, Manila

Payatas, Quezon City

Socio-demographic profile

320,916 ( 47.5% Urban Poor )

128,736 (90% Urban

Poor )

Health Resources:

Shortage of NTP logistics such as TB medicine, reagents and other consumables

Lack of manpower and microscopy center

8 DOTS Referring Facilities to 12

3 Referring Facilities to 15

5 Microscopy Centers

3 DOTS Facilities to 6

1 Referring Facility

1 Microscopy Center to 6

NTP Performance 2007

New Smear Positive

Pulmonary TB ( NSP )

Case Notification Rate:

(CNR per 100,000

population)

127 ( 407/320916 ) 66 ( 85/128,736)

Cure Rate of NSP

76% ( 310/407 ) 74% ( 63/85)

Health Staff capacity :

NGO health staff and CHVs need training on NTP.

Issues / concerns/barriers:

Most of the NGO staff and CHVs need training, no referral system, no monitoring and

evaluation visits conducted and only some have network and linkage with the LGUs. This

part will be tackled comprehensively in the Stakeholders Analysis Meeting.

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B) IMPLEMENTATION

This is the second step in the RJPI process of project development and collaboration. On this

step, the actual execution of the planned activities will be specified in the PDM. By this time,

the partner organizations have entered into a MOA. Implementation must be built with strong

commitment and camaraderie to be able to achieve the goal of the project. This stage is divided

into three strategies:

Stakeholders: Manila Health Department, Quezon City Health Department, NTP, CHD-MM,

RJPI

Output: The most common gap identified for the economic barriers are possibly lack of

transportation both by the patient and health staff, and unstable commitment by the health staff.

For the geographical barriers the gaps may be the distance of the health facility and frequent

relocation and demolition in the area. Accordingly, lack of knowledge on TB, stigma,

uncooperative patients and local authorities (e.g. barangay in the Philippines) maybe identified

by the health staff as socio-cultural barrier. For the health system barriers, lack of manpower,

untrained health staff and volunteers, lack of networking among the public and private sectors,

improper referral system, irregular monitoring, lack of equipment and the lack of health

volunteers as treatment partners are possibly identified by the health staff.

Needs: Training, referral system, logistics and regular monitoring and evaluation visits by

LGUs.

Strength: Health facilities in different capacities complement the health system i.e. The DOTS

facility, Referring Facilities, Community Health Volunteer, DOTS facilities

Strategies Identified: These relate to the result of needs assessment. The strategies or

interventions determined by the stakeholders should correspond to the needs identified. Given

the situation above, the following strategies were recommended by the stakeholders to address

the gaps to TB Care access: Capacity building, Network and linkage, ACSM activities and

conduct of operational researches.

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Strategy 1. Engagement of NGOs and other private organizations: It is defined as a

commitment of mutual collaboration among the CHD-MM, City Health Offices (MHD/QCHD)

and partner organizations such as NGOs. The action of fulfilling the responsibilities, can

determine the success of the project. In this area, those NGOs identified during the mapping,

baseline data gathering and who expressed commitment to support the project are the ones

engaged. In engaging the NGOs / other private organizations, the steps below can be adopted:

Step 1 - Project Orientation. This is the initial step on NGO engagement. We need to

orient the other partner organizations to the project, its goal, objectives, the interventions as

well as the duties and responsibilities of each institution. The RJPI together with a

representative of MHD or QCHD visit the different identified NGO within the catchment

project site. The project is introduced to them together with the beneficial effects that it

intends to provide to the community. It is necessary for the RJPI to explain the duties and

responsibilities of the partner for the understanding and success of the project.

Step 2 Facility Capacity Review. The second step is to review the facilitys capacity in

providing TB care services. Again, the baseline data gathered during the situational

assessment will be utilized for this purpose. At this point, we will have to assess the facility

if they are suited as DOTS or Referring facility. The definition is described below:

NGO Referring Facility: refers to a nonprofit, voluntary citizens group which is

organized on a local, national or international level. The functions of this are (1) to find

presumptive TB in the community and refer them to a DOTS facility, (2) to conduct

contact investigation guided by the health worker staff, (3) to trace the interrupters or

defaulters of treatment, (4) to keep records or documents. To improve the case holding

activities, the CHVs sometimes take up the role as treatment partner and an educator to

motivate the TB patients to adhere with their treatment regimen until the end of the

treatment course.

NGO DOTS Facility: They function in the same way as the Local Government Unit

(LGU) DOTS centers do from case finding to case holding activities. NGO DOTS health

staff receives the same recording forms provided to the LGU DOTS such as MDR Suspect

Referral Masterlist, MDR Decentralized Masterlist, TB Symptomatic Masterlist, Modified

Masterlist B, etc.

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Step 3 MOA signing. This defines the formal engagement of the NGOs as they affix

their signature and entered into a MOA with the CHD-MM, City Health Office and RJPI.

This signifies that they fully embrace the mission, tasks, interventions indicated on the

PDM and MOA. A sample MOA can be found on Annexes 5 and 6.

Strategy 2. Capacity Building: These are actions directed to improve knowledge, behaviours,

skills and techniques through training, sharing of information and transfer of knowledge among

each individual / partner organizations. The identified Health Care Workers (HCWs) and

Community Health Volunteers (CHVs) who need to be capacitated were trained in full

coordination with CHD-MM, MHD and QCHD to set a standard level in delivering quality TB

care in every health facilities. Consequently, it aims to strengthen and sustain the engagement of

each organization in implementing and scaling up communitybased TB activities. In capacity

building, there are two subjects that are in focus. The first one is supply side. These refers to the

health care provider, the person, institution or services it render to the community. The second

is the demand side which refers to the beneficiary of the health care delivery system, i.e., the

community members.

The following types of training were conducted both for the LGUs and NGOs in DOTS and

Referring Facilities:

a. Improving the Supply Side. This refers to the activity that would enhance the

competency or skills of health care workers and improve knowledge of CHVs to

provide quality DOTS services.

a.1 Improving the capacity of HCWs at DOTS Facility

Basic Directly Observed Treatment Short Course Chemotherapy Strategy

(DOTS) Training This is a four-day training to hone the knowledge, attitude and

skills needed by the doctors and nurses in providing quality TB Control Program

specifically in identifying presumptive TB, diagnosing and treating TB patients. It is

composed of lectures, group discussions/ presentations, workshops, role play and

plenary.

TB in Children Training This is a four-day training to enhance the skills and

knowledge of the doctors and nurses in identification, diagnosis and treatment of TB

in children. It is composed of lectures, group discussion, plenary and practical

examination on Tuberculin Skin Testing.

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Basic Course on Direct Sputum Smear Microscopy (DSSM) for Medical

Technologist and Microscopist - This is a five-day training to improve the Medical

Technologists / Microscopists competence in performing sputum smear examinations

and additional knowledge on the NTP, laboratory technique on sputum smear

examination and quality assurance for sputum smear examination. It is composed of

lectures, discussions and practice exercises in proper smearing, staining and

microscopy reading.

Basic Training on DSSM for Laboratory Assistants This is a three-day training to

hone the skills of the laboratory assistants in the proper smearing and staining of

sputum specimen. It is composed of lectures and practise exercises in proper smearing

and staining of sputum specimen.

Chest Radiography Training

i. Training on Quality Chest Radiography Taking This is a four-day training to

improve radiologic technologists competence in performing accurate / standards in

chest radiography taking. It is composed of lectures and practice of the TBCAP

assessment tool (Annex 7) developed by Tuberculosis Coalition for Technical

Assistance (TBCTA) to ensure quality of chest radiography.

ii. Chest Radiography Appreciation Course This is a one and half day training

conducted among doctors and nurses to develop their skills in assessing the quality of a

good chest radiograph. It is composed of lectures and practice exercises by using the

TBCAP assessment tool (Annex 7) to ensure the quality chest radiography. After the

training, the doctors and nurses can now conduct prescreening on the quality chest

radiographs before referring those suggestive TB findings for Tuberculosis Diagnostic

Committees (TBDC) evaluation. Those identified with poor quality chest radiograph

will be requested to have another chest radiograph taken in another facility rather than

submitting to TBDC for evaluation knowing that it will be returned since the TBDC

could hardly interpret it due to its unacceptable quality. This will help in reducing

diagnosis delays as well as reading misinterpretations.

23

Training on HIV/TB

i. Training of Trainers This is a four-day training for TB coordinators, selected

doctors and nurses to equip them with knowledge and skills in imparting the basics of

STI, HIV AIDS education. It is composed of lecture and practical examination on

facilitation skills to become effective preceptors.

ii. Orientation to Health Care Workers (HCWs) This is a half-day or one day

orientation / for HCWs on the basics of STI, HIV and AIDS education for early

prevention and diagnosis of HIV and AIDS.

Training of Health Worker on Tuberculosis Infection Control (TBIC) This is a

two-day training for doctors, nurses and medical technologists to protect healthcare

workers since they are at risk of contracting TB infection. Likewise they are expected

to develop their TB Infection Control policy per health facility based on their TB

Infection Control Risk Assessment Plan. It is composed of lectures, demonstrations,

practical exercises, group discussion, work and site visit and evaluation of a TB

Facility.

Electronic TB Register (ETR) Training - This is a two to three days training of TB nurse to

enhance their skills and knowledge in the Standard Operating Guidelines of ETR, system

reporting, management of dispatch file, Internet and basic computer trouble shooting. It is

composed lectures and actual encoding of data.

a. 2 Improving capacity of CHVs in Referring Facility:

Orientation on Directly Observed Treatment (DOT) for Community Health

Volunteers - a one-half day orientation on DOT composed of lectures, role play

and group discussion which focuses on the following:

(1) Identifying TB presumptive (adult/ children)

(2) Patients drug intake supervision

(3) Contact Investigation

(4) Defaulter Tracing

(5) TB Infection Control practices

24

One of the important parts of this activity is the introduction of the referral

mechanism between the NGO Referring and DOTS Facilities. The steps on how

to identify/refer the TB symptomatic to the DOTS facilities and how to

accomplish the recording forms were tackled step by step. Please see Annexes 8.

The situation below illustrates the RJPI referral process:

The CHVs utilize two recording forms namely the CHV TB Symptomatic

Referral Masterlist (Annex 8) and NTP Referral Form (Annex9). The CHVs

accomplish half of the columns (1-11) of the said referral Masterlist, the process

of the TB symptomatic referral indicating the date when the patient is identified

as the TB symptomatic until he/she seeks consult. The remaining columns (12-

22) about the process from the diagnosis to treatment completion are updated by

the health staff every two weeks. The NTP Referral Form is utilized to refer TB

symptomatic to the DOTS facilities. The CHVs retrieved half of the

acknowledged referral form from the DOTS facility every week; however some

of the NGO referring facilities have agreements that they will retrieve the half of

the referral form after a month.

b. Improving Demand Side. In order to become successful in the implementation of the

project, we must create activities that will increase community TB awareness and

motivate them to participate in TB response. This is in turn would make them demand

for the needed services which is also beneficial to enhance TB Care policy. Thus, they

need to be empowered. This empowerment is discussed in strategy 3.

Strategy 3: Advocacy, Communication and Social Mobilization (ACSM). These are distinct

to one another but are used collectively to create more impact. This should capture the

policymakers, HCWs and the community to work hand in hand in support of NTP and its

related activities. The following are the activities conducted by the RJPI in the project sites to

improve case detection / treatment outcomes, reduce stigma / discrimination, empower the

community and mobilize political will / resources.

25

a. Establishment of Referral Mechanism

This is the process wherein a trained CHV oriented on Basic TB DOTS finds TB

symptomatic in the community and refer them to the nearest DOTS facility with proper

referral slip for diagnosis and treatment where appropriate. Once the trained CHV

identified TB symptomatic in the community she / he will register the name and basic

information on the CHV TB Symptomatic Referral Masterlist (Annex 8), and

afterwards shall accomplish the NTP Referral form (Annex 9) and hand it over to the

TB symptomatic. The purpose of the CHV TB Symptomatic Referral Masterlist is to

account the referrals done by the CHVs to the DOTS facilities and to ensure that all

patients referred by the CHVs accessed in the DOTS facilities. This recording

Masterlist are used by the trained CHVs to list all the identified TB symptomatic in the

community. This contains information from the time the TB symptomatic was

identified, assessed for TB, diagnosed as TB, initiated TB treatment including the

outcome. This is accomplished by CHVs and some columns are accomplished by

HCWs to update the progress of each TB symptomatic listed on this recording form.

The updating of this record is every two weeks. Sometimes the CHVs accompany the

patient in going to the DOTS facility for diagnosis. The CHVs will make a follow up

visit to the patient who did not access in the DOTS facility. Through the CHV

Masterlist and NTP referral forms we could document the contribution of the CHVs to

the NTP and the process of the referral mechanism itself.

The purpose of the NTP Referral form is to keep track of the care received by the

Patient of the actions taken by the health staff. Correspondingly, it works to review the

flow of the referral system. Consequently, this form should be accomplished

completely and accurately. It has two parts:

i. For the first part or the upper portion, it contains the basic details of the TB

symptomatic referred to the DOTS facilities such as the time of referral,

current signs / symptoms, previous treatment and the name of the referring unit

and CHVs.

ii. The second part or the lower portion, it is the actions taken by the receiving

DOTS facility. The CHVs retrieve the lower portion of this form from the

DOTS facility every two weeks to account the numbers of TB symptomatic

who were able to access the DOTS facility.

26

b. Development of Recording Forms and Enhancement of the NTP Monitoring Tool:

Development of Recording Forms: This refers to creating a tool to document the

current activities in the DOTS and referring facilities. This is necessary in data sage

guarding and accuracy of reports. The RJPI developed the CHV TB symptomatic

Referral Masterlist (Annex 8) and other recording forms in order to provide updates

and report to the NTP and Partner Organizations.

Enhancement of NTP Monitoring Tool: This refers to the incorporation of other

indicators specific to the project but pertinent to the NTP for the improvement of

existing tool and the program itself. The RJPI incorporated the following to the

existing NTP monitoring tool: (1) NTP Referring facility which covers from the time

TB symptomatic was identified, diagnose, treated including the treatment outcome;

(2) Contact investigation which focuses on all age groups, TB diagnosis yield /

treatment outcome; (3) MDR-TB which covers the referral of DOTS treatment center,

diagnosis and treatment; (4) TB Infection Control which focuses on the health

practice of health staff based on the National TBIC guidelines; and (5) Exit interview

for health staff / patients which covers how DOT is implemented on both perceptions

and how it can be improved. The side effects experienced by the patients are also

included in this activity.

Modified Masterlist B: The purpose of this is to identify and register all

household contacts of index TB cases (first one to contact TB in the household) for

early case detection and prompt initiation of treatment to reduce further transmission

of infection to others. Again, this should be accomplished completely and accurately

for ease of following up patients. This is an enhanced tool from the existing Masterlist

B of NTP which contains the information of index TB cases and their contacts which

covers all age groups, i.e., children and adults. The NGOs have been conducting

contact investigation among contacts or household members of their registered TB

cases (index cases) for the past several years. The contact investigation included all

age groups of contacts of index case; however, it was not documented. Currently, this

will serve as a relevant reference to improve contact investigation strategies. The

contacts with or without symptoms, are listed on this form including their diagnosis

and progress of treatment. Those under surveillance can likewise be tracked on this

form. Please see Annex 10.

27

Contact Investigation Tool for CHVs: This was developed for the CHVs to note

the TB household contacts that they have encouraged to go to the DOTS facility for

TB screening and evaluation. This tool came up after the CHVs and the NGO heads

of referring facilities agreed to assist the DOTS index cases, the name / age / signs /

symptoms of the household contacts and the date of their actual house visit (Annex

11). By reviewing the Modified Masterlist B together with the Contact

Investigation Tool for CHVs we can evaluate the contact investigation process and

find ways to enhance it.

MDR TB Suspect Referral Masterlist: The purpose of which is to document the

process of MDR Symptomatic Referrals to treatment center for possible policy

changes in improving access, turn-around time in diagnostics and prompt initiation of

treatment. The development of this Masterlist was based on the expressed need of

partner organizations. The DOTS facilities depend on the acknowledgement slips

returned by the treatment centers to track the number of the MDR suspects who were

able to access the treatment center. Through the development of the MDR Suspect

Referral Masterlist, the DOTS Facilities were able to officially document, track and

analyze the pathway of the MDR suspects. This covers the basic information of

patient, the dates the MDR suspect was referred to the treatment center including the

diagnostics performed, the diagnosis and treatment outcome (Please see Annex 12).

MDR-TB Decentralized Masterlist: The purpose of this is to account the number

of MDR-TB patients referred by the treatment center to the DOTS facility for

continuation and compliance of treatment. This came out as a recommendation of the

partner organization and covers the basic information of confirmed MDR-TB patients

who were decentralized to DOTS facilities. MDR-TB patients can be decentralized if

culture result is negative and the preference of the said patients to continue treatment

in the DOTS facilities or treatment sites. Currently, MDR-TB patients decentralized

by the treatment center are listed on this Masterlist. This document helps the HCWs

track the treatment outcomes of MDR-TB patients. Please see Annex 13.

The MDR-TB Suspect Referral Masterlist and MDR-TB Decentralized

Masterlist are currently utilized not just in the project sites but in the whole city of

Manila and Quezon City. This indicates a positive impact for the project.

28

TB / HIV Masterlist: This was developed by the RJPI and TB/HIV experts from

SLH to enhance the referral mechanism between the two departments at SLH. The

TB HIV Masterlist covers the identification of TB symptomatic of People Living

with HIV (PLHIV), diagnostics and treatment outcomes. From 2012, the TB and HIV

centers of SLH were able to document the number of PLHIV who were referred to

TB Center, were recommended for Isoniazid Preventive Therapy (IPT) or TB

treatment and started / completed treatment. Consequently, all referrals from the TB

Center were acknowledged and managed by the HIV Center where they were

screened and managed accordingly. The referral and recording systems were

institutionalized which facilitated the documentation and data analysis at SLH. Please

see Annex 14.

c. Community advocacy campaign: The RJPI initiated the conduct of community

assembly in 2010 which focuses on TB disease, how it is transmitted, when and

where to seek consult, including infection control measures and the important role of

the community leaders and other organizations in reducing the number of TB cases

within their family and the community. The target participants were officers of

Tricycle Operators and Drivers Association (TODA) together with people from the

community. The purpose of which is to create TB awareness in the community and to

encourage other organizations to participate in the TB activities. The TODA officers

and members actively participated on the TB response by referring and education

their passengers on symptoms of TB and where to access services. In addition to this

activity, the RJPI always joins the global community in celebrating the lung month

every August and World TB Day during March.

a. Community Assembly: This refers to the gathering of individuals who reside in

the same particular setting in order to tackle issue and concern that affect them. The

RJPI employs this community activity to share knowledge about TB and to increase

the awareness and improve the health seeking behaviour of the people in the

community.

a.1 Health Education: It is another intervention in providing the community

knowledge about TB. This can be conducted by groups through pre-clinic lectures or

bench conference and on oneone basis. There are different teaching methods to

deliver this activity such as role play, lecture discussion and learning exercises.

Usually, IEC materials such as flip chart are utilized and brochures provide to

intended participants to support the ideas they learned during the session.

29

a.2 Lung Month Celebration: It is an annual activity which celebrated every August

of the year in the Philippines. This activity stimulates the community to take care of

their health and their lungs. The purpose of this activity is to raise the awareness in

the prevention and control of Tuberculosis.

a.3 World TB Day: celebrated on the 24th of March every year was created to build

public awareness that tuberculosis today remains an epidemic in much of the world,

causing the deaths of nearly one-and-a-half million people each year, mostly in

developing countries. The partner organizations, barangay officials are invited on this

event including TB patients and their families. The usual activities are: TB patients

testimony, gallery presentation of health facility services, contests related to

increasing TB awareness, when and where to seek consult. The theme used every

three years is patterned after the WHO theme i.e Stop TB in my Lifetime (2010-2013)

and Reach the Three Million, A TB test, treatment and cure of all .(2014-2017). This

is where we based the criteria for activities such as slogan-making contest, poem-

making contest, song writing contests, etc.

d. Organize TB Task Force: The task force is composed of CHVs who are active in the

TB response. The purpose of which is to improve CHV performance in conducting

TB activities in the community. There are two (2) CHV task forces in the project

sites: one (1) for District I- Tondo and one (1) for Payatas, Quezon City. A CHV task

force meeting is being conducted twice a year. The agenda for the said meeting are:

presentation of accomplishment of each referring facilities, sharing of community

experience, gaps /good practices identified and possible solutions offered by each

facilities or CHVs with relatively good accomplishments. The RJPI facilitates and

provides technical support during those meetings.

Organize TB Support Group: TB support group is composed of previous TB

patients who were successfully treated. The purpose of this is to improve the health

care seeking behaviour of people in the community and mobilize them to take action

for their health. The TB support group conducts weekly house to house visit, follows

up interrupters of treatment and sometimes act as treatment partners of TB patients.

Ideally, all health facilities must create a TB support group to assist them in TB

activities. The RJPI facilitates the creation of TB support groups among DOTS

Facilities. After the DOTS Facilities have selected the members of their support

group, the RJPI will help them conduct the initial meeting concerning about the basic

facts about TB disease, how it is transmitted, objectives of having a support group and

30

the roles that they have to play once they become a member of the TB support group.

After which, the election of officers and members will be conducted. From then, the

subsequent meetings (i.e. activity updates, sharing of experience, and presentation of

TB support Group contribution to NTP) will be spearheaded by the DOTS facilities

and the RJPI will attend to provide technical support.

e. Development of Information Education, Communication (IEC) materials to seek

early consult: IEC materials such as poster, tarpaulin, stickers and flyers and video

are developed to facilitate community members to seek early consultation. The

purpose of this is to inform the community that seeking early consult at the DOTS

facility is important to detect TB cases early and for treatment to be initiated promptly

to reduce TB transmission in the family and community. The IEC materials need to

be field tested to the community and revision to be made accordingly based on the

comments raised by the community members.

C) CONDUCTING OPERATIONAL RESEARCH (OR)

One of the six-point agenda for TB Control developed by WHO and Stop TB Strategy (2010-

2016) is to enable and promote research (1). The project sees this as a vital component in

improving access to TB Care services. It helps the HCWs analyze their current operations,

existing problems and concerns, problems in decision making, interventions and optimize the

use of their resources. The following are the ORs so far conducted by the RJPI:

Example: This IEC material on the timing

and where to seek consult was converted into

a poster, tarpaulin and sticker. The posters /

tarpaulins were strategically placed in health

facilities, barangay stations and in the

community while the tarpaulin were

distributed to TODA and placed at the back of

their tricycles and stickers are placed inside

the tricycle. The stickers and flyers were

handed to the participants after thorough

explanation of its content during community

assemblies.

31

1.) Effectiveness of a training course on the quality assurance of chest radiography in the

Philippines

Chest radiography is regarded as a secondary tool in diagnosing TB among smear negative

cases with chest x-ray (CXR) findings. Unsatisfactory quality of CXR for diagnosing smear

negative leads to over and under diagnosis, resulting to mismanagement and waste of resources.

The RJPI provided training on Quality Chest Radiograph to ten facilities in Manila and nine

in Quezon City from 2009 to 2010. The aim of the study was to determine the effectiveness of a

training course in a quality chest radiograph. The study was conducted in 2011 participated by

36 from the training. After obtaining consent, the RJPI collected six CXR films composed of

three males and females among the participants. These were assessed by two senior radiologic

technologists using the TBCTA Tool Assessment Sheet (Annex 5). The factors assessed were

Identification marking, patient position, density, contrast, sharpness and presence of artefacts.

The significant improvement in the total score of the six assessment factors suggests a positive

impact of the training course (12).

Impact: This study is currently being utilized by the Philippine Association of Radiologic

Technologist (PART) for their research on developing a model intervention to sustain the

quality of chest radiograph in pulmonary TB and other lung diseases nationwide. The NTP,

together with the Center for Device Regulation Radiation Health and Research and the PART

recommended this training module for staff development and the formulation of quality control

mechanisms to assess and monitor the competence of radiologic staff.

Please check http://www.ncbi.nlm.nih.gov/pubmed/22640452 for the complete details of this

research.

2.) Health care seeking behaviour of Pulmonary Tuberculosis Patients in Socio-

Economically Depressed areas in the Philippines

The delay in diagnosis can be hazardous both to TB patients and community members since it

leads to the progression of the disease and continuous spread of bacilli to others. This study

described the current health care seeking behaviour in terms of delay to TB diagnosis and care

in new smear positive pulmonary TB patients in highly urbanized depressed areas in District I-

Tondo, Manila and Payatas, Quezon City. All new smear positive patients aged 15 years old and

above registered at the twelve DOTS facilities in District I and six in Payatas, Quezon City from

April 2010 to March 2011 were included in the study. The physician and nurses interviewed the

new smear positive patients using a structured questionnaire. This study revealed a half month

delay on the part of the health system and health providers and a one month delay on the part of

32

the client in Tondo and Payatas. This highlighted the importance of a short turnaround time

between diagnosis and prompt initiation of treatment to prevent TB transmission (13).

Impact: The patient, diagnosis and treatment delays noted on the health-care seeking behaviour

research was able to provide important data on how the TB services can be tailored to the needs

of the community and health system be improved and strengthened.

3) Tuberculosis Diagnostic Committees contribution to the National TB Program in

Manila and Quezon City

The RJPI conducted this study in 2011 to determine the current TB activities, obstacles and

possible solutions for improvements in the quality of diagnosis of smear negative PTB patients

in Manila and Quezon City. A record review was conducted, with interviews of 33 out of the 49

current members. During the 2nd

and 3rd

quarters of 2009, respectively 1142 and 1563 smear

negative cases were evaluated by the TBDCs in both cities. Of these, 53% in Manila and 65% in

Quezon City were classified as active TB patients. There were significant variations in the

percentage recommended for anti-TB treatment by the TBDC. The participation of its members

is based on commitment for program sustainability (14).

Impact: The TBDC study was able to elucidate the important role of peer review mechanism in

diagnosing smear negative PTB and ensuring judicious use of resources.

Please check:

http://www.ingentaconnect.com/content/iuatld/pha/2012/00000002/00000003/art00012 for the

complete details of this research.

D) EVALUATION

Monitoring and Evaluation Visits (M & E visits)

A Monitoring and Evaluation visit is one of the keys to improve the provision of TB care

services in the community. This provides an opportunity for the Monitoring Team to oversee the

performance of HCWs. During the visit, we can observe how DOT is being done, review

records and reports, and conduct exit interview among patients to give the monitoring team a

better grasp on how TB program is being implemented. More importantly, this is a good venue

to reinforce the HCWs good performance and correct inadequacies. Through the regular on-site

M & E visits, major problems could at least be prevented before it arises. It is important that the

team is prepared and HCWs are informed on when / where / how the on-site M & E visit will be

33

conducted. Likewise, there must be tool to make this activity effective and efficient. Please see

the step by step procedure in conducting M & E visits below:

1) Conducting on-site joint Monitoring/ Evaluation (M&E) Visits

a. Composition / Tasks: Monitoring Team

City/District NTP Coordinator: Oversees the work of the Monitoring Team.

Records review is conducted by the following on:

District Supervisor: Case Finding All Cases;

RJPI staff-1: TBDC and observes the infection control health practices of

HCWs;

RJPI staff-2: Case Finding, Laboratory Activities, and Contact Investigation;

RJPI staff-3: TB in Children and MDR Referrals;

RJPI staff-4: NGO referrals, treatment outcomes, interview;

RJPI staff-5: logistics and data validation.

b. Frequency:

M & E visits shall be conducted regularly on quarterly basis for those health

facilities with good performance and those which were not able to achieve the

program target, on a monthly basis.

c. Indicators:

These are parameters which will help the team to monitor how well the program is

being implemented and evaluate its progress. Likewise, this will be our guide in

determining the frequency of our M & E visits. Below are examples of indicators

utilized by the RJPI to monitor its project implementation.

No. of TB Symptomatic identified No. of TB symptomatic referrals,

Completion of INH Preventive Therapy (IPT), Treatment Success Rate of

New Smear Positive with low defaulter rate, and No. of MDR Suspect

Referrals to treatment center. Guideline about TB screening and IPT for

PLHIV at San Lazaro Hospital (SLH) is developed. A summary description

of these indicators is found in Annex 15.

d. Planning / Preparation (for the Monitoring and Evaluation)

Responsible Persons: Technical Coordinator/ Technical Officer

34

d.1 Coordinate with City / District NTP Coordinators / Supervisors and NGO Heads

regarding the purpose; proposed site / date of M & E visit. Remember that this is a

joint M & E visit and the participation of the NTP Coordinators / NGO Heads is

vital to be able to solve immediate concerns and come up with a consensual

solution.

d.2 Write a letter of permission to the City Health Office for the on-site M & E. The

purpose, method, date, time and name of the health facility to be visited should be

stated clearly.

d.3 Remind the City / District NTP Coordinators / Supervisors at least one week

before the scheduled visit. This will help ensure that there will be a responsible

person who will respond to the inquiries of the monitoring team and all pertinent

records / reports needed are in place during the visit at the health facility.

d.4 Prepare all the materials needed for this activity such as:

d.4.1 Monitoring Tool (Please see Annex 16)

d.4.2 pencil, ballpen, ruler, calculator

d.4.3 Laptop for data encoding

d.4.4 Camera for documentation purposes

e. Actual M & E Visit

e.1 Conducts records review based on their assigned tasks and validates them with

the health facility responsible person for any data inconsistencies (Responsible

Persons: Monitoring Team).

e.2 Utilizes a tool in monitoring the health practices of Health Care Workers

(HCWs) on TB infection control. The TBIC tool was developed by RJPI in

consultation with the partner organizations based on the DOH guidelines. The tool

is divided into four (4) levels of infection control such as managerial,

administrative, environmental and respiratory controls. There are specific health

practices underneath each level. Observation and interview of HCWs are the

Case Finding: Laboratory Activities

MDR Suspect Referrals

0-4 years old on IPT Infection Control TB in Children Screened Logistics IPT Outcome Data Validation Tool Contact Investigation Monitoring Tool for Referring Facility Case Finding: All TB Cases Treatment Outcome

Monitoring Tool Feedback Sheet with carbon paper

TBDC

35

methods used to evaluate the health practices of HCWs trained on TBIC. For every

ideal health practices performed, letter Y is indicated and letter N for not done.

The letter Y stands for yes and letter N for no. The ideal health practices

are then summarized per level of TBIC and per health facility. The HCWs are

expected to perform 50% of the ideal health practices per level of infection control.

There are five (5) ideal health practices under the managerial and administrative

levels. There are six (6) ideal health practices under environmental and four (4) for

respiratory controls (i.e. 3 ideal health practices out of five (5) were performed

under the managerial level 60%). After computing per level of IC and per health

facility, the health facilities are grouped into two (2)- ratings 1 and 2. A health

facility with rating 1 means that less than 50% of the health practices are performed

while rating 2 means 50% or more of those were performed or accomplished.

e.3 Conducts exit interview to patients/HCWs where appropriate (Responsible

Persons: Community Development Officer)

e.4 Provide Feedback to the HCWs. The findings together with the proposed

recommendations (conferred with the HCW concerned during the validation) are

presented to the HCWs. This is also a form of brainstorming to specifically discuss

the challenges encountered by the HCWs in their course of implementation.

Moreover, actions to address the challenges and ways of maintaining the good

performance are dealt at hand. The recognition of the HCWs collaborative efforts

in improving the quality of TB Care services can serve as a motivating factor to

them while pointing out the bottlenecks; make them more sensible in their actions.

The original copy of the feedback sheet signed by both the HCWs and the

monitoring team is provided to the HCWs while the carbon copy is left for the

team. The feedback sheet corresponds as reference for the next visit. With the

Integrated TB Information System (ITIS) in place, the monitoring team perceives

efficiency in generating reports and analysis of data. This could also facilitate

effective M & E visits (Responsible Persons: Assigned member of the Monitoring

Team).

36

2) Program Evaluation

This is an assessment of program performance of GOs and NGOs semi-annually or

annually. All stakeholders are invited including the NTP, CHD-MM, and sometimes the TB

patients. Each partner organization will have to present their accomplishment for the

specified period based on the NTP and project indicators. Apart from looking at statistics,

reviewing / analysing the data, it is also a good venue to share the experiences of each

organization and how they were able to address the challenges they encountered in the

course of implementation. The presence of NTP, CHD-MM and the City Health

representatives is significant in providing directions on how the project could further

improve. Consequently, regular activity such as this keeps the camaraderie and stewardship

of the stakeholders.

Example by RJPI:

Annual Program Evaluation Workshop - January 30, 2009

Attendees: All stakeholders, NTP, CHD-MM, MHD, QCHD, NGOs and WHO

Findings: GOs and NGOs presented their accomplishment and noted an

improvement in case finding / case holding activities, program implementation

improved through capacity building of staff / installing of microscopy center in

Payatas. The CHVs are active in finding TB symptomatic but their contributions

were not documented.

Recommendations: Develop a CHV TB Symptomatic Referral Masterlist and

referral form to document the accomplishment / contribution of CHVs

Annual Program Evaluation Workshop - February 22-24, 2010

Attendees: All stakeholders, NTP, CHD-MM, MHD, QCHD, NGOs, PTSI and a

TB Patient.

Findings: Need to improve turn-around time in DSSM from 3 days to 2 days

revise the CHV TB Symptomatic Masterlist/ TB Symptomatic Referral

Form.

Recommendation : Capacitate the CHVs as Laboratory Assistants to improve

DSSM turn-around time to reduce delay in diagnosis.

: CHV TB Symptomatic Masterlist shall include the TB diagnosis and

Treatment Outcome parts.

37

: CHV TB Symptomatic Referral Form shall include questions on

finding MDR suspects (i.e. previous intake of TB drugs), TB

symptomatic serial number for ease of monitoring and the specific

actions taken by the receiving DOTS facility.

Annual Program Evaluation - February 14- 16, 2011

Attendees: All stakeholders, NTP, CHD-MM, MHD, QCHD and NGOs

Findings: Decreased in the number of TB symptomatic referred by CHVs

There are no M & E tools to cover TB infection Control, MDR and

Contact investigation.

Recommendations : Conduct a FGD among CHVs to investigate possible reasons

of the decline of the referred.

: Develop a TB Infection Control Checklist based on National

Guidelines.

: Create Contact Investigation/ MDR M & E tool based on project

indicators

Annual Program Evaluation Workshop February 16-17, 2012

Attendees : All stakeholders, NTP, CHD-MM, MHD, QCHD and NGOs

Findings : NSP Success Rate not achieved for both project sites

High Defaulter/ Transferred out rates

Recommendations : Conduct a FGD among HCWs and orient them on IPCC

: Conduct program evaluation twice a year (semi-annual and

annually) to identify gaps/ solutions encountered for the past six

months and give HCWs more time to improve their performance

before the year ends.

Semi- Annual Evaluation : QCHD with NGOs -July 19-20, 2012

MHD with NGOs- August 29-31, 2013

Findings: No training on infection control conducted among HCWs

: No documentation on the number of MDR Suspects referred / access to

treatment center.

Recommendations : Train HCWs on Infection Control

: Develop MDR Suspect referral Masterlist

: Enhance Masterlist B, i.e., the adult contacts of a registered TB case

should be listed and progress of consultation should be tracked.

38

Annual Program evaluation Workshop January 30-31, 2013

Attendees: All stakeholders, NTP, CHD-MM, MHD, QCHD and NGOs

Findings : Improved turnaround time in DSSM from 5 days to 2 days

: Treatment Success rate did not achieve the program target due to high

defaulter and transferred out rates

Recommendations : Conduct IPCC among HCWs.

E) SCALING UP PRIVATE AND PUBLIC MIX ENGAGEMENT AND

COLLABORATION

This is the final step in the RJPI process of project development and collaboration. Once the

GO and NGO partnership is successful, it is ready on its take off to expand to other areas.

Expanding to other sites requires careful planning and evaluation of the model introduced. It

should be integrated with the overall objective for an effective expansion. Important persons

like our current partners who were part of this promising collaboration should be included

and not to be taken for granted. Sustaining the involvement of our current partner will be the

key in expanding; they will share their experience for effective planning and preparation for

the expansion. Lessons learned must be taken into consideration to enhance the program

implementation. Ownership must be instilled in the GOs and NGOs framework to keep the

sustainability of the activities.

The RJPI introduced the NGO referral mechanism and was able to accelerate service points

in the community. Seeing the contributions of these NGOs who mainstreamed TB services

in their program, the City Health Offices included in their sustainability plan to continue M

& E visits among the NGOs engaged by the project.

39

Annex 1: BASELINE SURVEY Data Collection Form for Local Government Unit Health

Centers

Name of Health Center (Facility):_____________________________________________________

Address:________________________________________________________________________

Telephone Nos. : ________________________ Fax No:_________________

Contact Person (Physician In Charge /Nurse): ________________ Mobile No.: _______________

Population coverage: __________________

No. of Barangays (Bgy) Covered: ______Depressed Bgy: _________Non-Depressed Bgy: ______

No. of Depressed Population: _________ No. of Non- Depressed Population: ________

No. of Health staff: ____________ (Pls. enumerate names below)

No. of Barangay Health Workers (BHWs): _________________ (Pls. enumerate names below)

No. of Community Health Team (CHT) volunteers: ___________

NO. NAME DESIGNATION TB Trainings/Orientation

1

2

3

4

5

6

7

8

9

10

11.

12.

13

14

15

40

QUESTIONNAIRE:

1. When was your health facility established? ________________________________

2. Do you have current partner NGOs or private health facility? ___ Yes ___ No

If yes, what kind of assistance or partnership you share in terms of health service network? _____________________

3. How many possible partner NGOs or private facility you have in your catchment population?

4. Is this a microscopy center? ___ Yes ___ No

If no, where do you send the sputum for examination? ____________________

Schedule of Sputum collection: ________________________

Schedule of Transport of Sputum Specimen or stained smear slides: _________

5. Do you conduct contact investigation? ___ Yes ___ No

If yes, do you utilize a Masterlist for this? ___ Yes ___ No

What age groups are covered by the contact investigation? _____________

6. Health education/promotion: ____ Yes ____ No

7. Do you utilize a Masterlist for referrals of MDR Suspects to Treatment Center?

8. Do you have MDR decentralized case as of now? ___ Yes ___ No

If yes, do you utilize a Masterlist for this? _____________________

9. Do you have any problems in the implementation of DOTS strategy? ____ Yes ___ No

If yes, what are the problems encountered during the implementation of DOTS strategy?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

10. Do you have any idea or roughly could you estimate the percentage population of the following? :

Roman Catholic: _______ Muslims: ______ Protestants: ___________ Iglesia Ni Cristo (Church of Christ): _______ Others: _______________

Name of Private Facility

Classification

(NGO or Private Clinic)

Kind of services offered

TB Trainings/Orientation

41

BASELINE DATA

A. Case Finding

a. No. Of TB symptomatic examined ______________ b. No. With 3 sputum specimen __________________ c. Three sputum collection rate __________________ d. No. of Smear positive discovered _______________ e. Positivity Rate ______________________________

B. Population________________________________________

New Smear Positive Cases ___________________________ Case Notification Rate ______________________________ Case Detection Rate ________________________________

C. Case Holding a. New Smear Positive Cases ____________________ b. New Smear Negative Cases ___________________ c. New Smear Negative Cases ( ODT ) _____________ d. Relapse __________________ e. Treatment Failure __________ f. Return After Default ________ g. Transfer In ________________ h. Other Positive _____________ i. Other Negative ____________ j. Extra Pulmonary ___________ k. Total patient initiated to Treatment

D. Treatment Outcome (registered in _____Q of _____ Year)

New Smear Positive Cases No. Percentage

Initiated to Treatment

Cured

Treatment Completed

Success

Died

Failed

Defaulted

Transfer out

New Smear Negative Cases (Treatment Outcome category same as applied to New smear positive cases except for Cured)

New Smear Negative Cases ( Other Diagnostic Test) (Treatment Outcome category same as applied to New smear negative cases)

Relapse(Treatment Outcome category same as applied to New smear positive cases)

Return After Default(Treatment Outcome category same as applied to New smear positive cases)

Treatment Failure(Treatment Outcome category same as applied to New smear positive cases)

Other Positive(Treatment Outcome category same as applied to New smear positive cases)

Other Negative(Treatment Outcome category same as applied to New smear negative cases)

Extra Pulmonary(Treatment Outcome category same as applied to New smear negative cases)

42

E. TBDC Report ( ___Q ____Year) a. Total No. of Smear negative / CXR suggestive TB symptomatic referred to TBDC _______________

TBDC Diagnosis: b. Total number of active TB case diagnosed by TBDC ______________

i. Classification of active TB cases diagnosed by TBDC________ 1. New _______ 2. Retreatment _______ 3. Total _____________

c. Total number of inactive TB patients __________ d. Total number of patients diagnosed as other lung disease_________ e. Total number of patients evaluated by TBDC this quarter_________ f. Total number of patients recommended by the TBDC for anti TB treatment______ g. No. Initiated to treatment ________ h. Other Recommendations :

i. Surveillance___________ ii. Repeat Chest X-ray ___________

iii. CT Scan ___________ iv. For AP Lateral View __________

F. Children 0-4 yrs old on IPT

i. TB Exposure:_________ j. TB Infection : ________ k. Total _______________

G. IPT Outcome ( ___Q ____Year)

TB Exposure No. Percentage

Initiated to Treatment

Treatment Completed

Died

Failed

Defaulted

Transfer out

TB Infection

Initiated to Treatment

Treatment Completed

Died

Failed

Defaulted

Transfer out

Total Cases

Initiated to Treatment

Treatment Completed

Died

Failed

Defaulted

Transfer out

H. MDR Suspect Referrals

l. No. of MDR suspects registered:__________ m. No. of MDR suspects referred to treatment center _________ n. No. of MDR suspects screened at the treatment center ________ o. No. of confirmed MDR cases ___________ p. No. of MDR cases initiated to treatment :________ q. No. of MDR cases decentralized _____________

43

Annex 2: BASELINE SURVEY Data Collection Form for NonGovernment Organizations

Name of the Health/Facility Organization: __________________________________________

Address: ____________________________________________________________________

Telephone Nos. : ________________________ Fax No. : ___________________

Contact Person: _________________________ Mobile No.: __________________

Population coverage: ____________________

No. of Bgys. Covered: ____________ Depressed Bgy:________ Non-Depressed Bgy: _______

No. of Depressed Population__________ No. of Non- Depressed Population____________

QUESTIONNAIRE:

1. When was your organization established? _____________________________________

2. Is your organization an independent organization? ______________________________

3. Does your organization received grants from other private organization? __Yes __No

If yes, what kind of grant? __________________________________________________

4. Does your organization receive grants from the government? __ Yes __ No

If yes, what kind of grant or assistance? _____________________

5. What are the services provided by the health facility/organization?

a._______________________________________

b. ______________________________________

c. ______________________________________

d. ______________________________________

e. ______________________________________

f. ______________________________________

6. Does your organization have clinic for patients? ___ Yes ___ No

7. If yes, how many staff do you have in the clinic? ___________ (Please enumerate below)

NO. NAME DESIGNATION TB Training/s Conducted by:

1

2

3

4

5

6

44

8. Do you have a volunteer staff? ___ Yes ___ No

If yes, how many? ________________________

9. Are you providing services for :

Adult TB cases? ___ Yes ___ No

TB in Children: ___ Yes ___ No

MDR TB: ___ Yes ___ No

10. When did your organization start providing TB services? _________________________

11. Are the staffs aware of the DOTS strategy of NTP? ___ Yes ___ No

12. Are the staffs following the DOTS strategy of NTP? ___ Yes ___ No

a. If yes, since when? _____________________________________________________

b. If no, are you willing to adopt the DOTS strategy? ___ Yes ___ No

13. What service/s is your clinic providing for TB patients?

a. Diagnosis: Sputum examination: ____ Chest X-ray: _____ PPD:_____ Others:_____

b. Treatment: Free TB medicines: ______ Prescribed medicines: ___________

If anti-TB medicines are for free, where do you get it? __________________

If anti-TB medicines are prescribed, what kind of medicines?_____________

And for how long? ___________________________________________

14. Do you conduct contact investigation? ___ Yes ___ No

If yes, do you utilize a Masterlist for this?

What age groups are covered by the contact investigation? _____________

15. Health education/promotion: ____ Yes ____ No

16. Are the diagnostic work-ups for free? ____ Yes ____ No

If No, how much? Sputum examination: ______ CXR: _______ PPD: ____

No. Name Function/s TB Trainings/Orientation Conducted By:

1

2

3

4

45

17. Does your organization have a laboratory? ____ Yes ____ No

If yes, what services are being provided by the laboratory?

______________________________________________________________________________________________________

__________________________________________________________________________________________________

18. If your clinic is providing sputum microscopy, who does the quality assurance of the smear?

_________________________________________________________________

19. If your clinic is not providing diagnostic work-ups for the following where do you refer the patient?

a. Sputum Microscopy ___________________________________

b. Chest X-ray __________________________________________

c. PPD ________________________________________________

d. Others ______________________________________________

20. If you are providing treatment services for the TB patients, are you doing DOT in the whole course of treatment?

________________________________________________

a. If you are not doing DOT, how frequent is the follow-up of the TB patients? ________________________

21. If you are doing DOTS, are you following the standard recording system provided by the NTP (DOH)? __ Yes __No

If yes, what reporting forms, do you utilize? _______________________________

a. If yes, who does the recording? _____________________

b. If no, do you have a recording system of your own? ____ Yes ____ No

c. If no, are you willing to adopt the standard recording format of the DOH? ____ Yes ____ No

22. If you are not providing services for TB patients, where do you refer them?

a. Health Center: ________________________________________________________

b. Hospital: ___________________________________________________________

c. Private clinic: _________________________________________________________

23. Does your organization have collaboration with other private organization? ___ Yes ___No

If yes, what organization?

__________________________