Scale up of MDR TB Management in the Philippines: Lessons Learned Tropical Disease Foundation in collaboration with the NTP, Department of Health Ma. Imelda D. Quelapio, MD
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Scale up of MDR TB
Management in the
Philippines: Lessons Learned
Tropical Disease Foundationin collaboration with the
NTP, Department of Health
Ma. Imelda D. Quelapio, MD
� 83M population; 17 regions
� 9th of 22 high-burden countries
� 3rd in WPRO
� 16th of 25 priority countries for
MDRTB
� 4.4%MDR in new and 21% in
previously treated (2004, DRS)
� 4,469 estimated MDR cases every
year (Global MDR/XDR Response,
2007-2008)
Philippines: Magnitude of the TB
problem
DOTS and MDR TB management
� DOTS coverage: nationwide in 2003
� Case detection rate: 75%, 2005; Success rate: 87%, 2004
� MDR TB management:
� 2000: Green Light Committee (GLC) PILOT project for 200
patients
� 2003: 500 patients through Global Fund (GFATM) Round 2
� 2004: DECENTRALIZATION of MDR services to public
health centers
� 2006: MAINSTREAMING of MDR TB management into
the NTP through GFATM Round 5 (2,500 patients)
“Mainstreaming”
� Integrating MDR TB Management into the routine
activities in the National TB Program
� Careful and stepwise process of shifting procedures one
by one from project mode to program
� Moving from centralized to decentralized services;
from specialized treatment centers to DOTS facilities in
the community (public health centers or private-public
mix DOTS/PPMD units)
MDRTB Patient accrual (Apr ‘99- Aug ‘07)
Current = 808 Total target Y2011 = 3200
GFATM)TDF, PCSO, DOH
7 15
86 99
191133
199
7 22
106164 186
285
476
609
808
55 21
(14 GF)
0
100
200
300
400
500
600
700
800
900
1999 2000 2001 2002 2003 2004 2005 2006 2007
New patients Cumulative
GFATM = 642
PilotDecentralization
Mainstreaming
GFATM support in the expansion
MDRTB N=13,330 till 2013
6 15 84 87 92 94 0 0 0 0 00 0 0100 19121
(14 GF)
55
640
640640
396184
100
700
2100
3100
4100
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1999
2001
2003
2005
2007
2009
2011
2013
pre GF/GF2 GF 5 RCC
6
4030
6130
9230
13330
728474283
1216
2690
1950
0
2000
4000
6000
8000
10000
12000
14000
1999
2001
2003
2005
2007
2009
2011
2013
Cumula
Cumulative no. to treatYearly no. to treat
Political Commitment: setting the policy
environment
� Mainstreaming into the NTP
� Memorandum of agreement with key partners:
� NTP: central, regional, local
� Laboratory
� Implementing sites: private, public
� Consultations with partners
� Implementing Guidelines for MDR TB
� MDR TB Training Modules
Department of Health
Regional Health Office
National TB Reference Lab
Lung Center Philippines
Local government Units - MM
Tropical Disease Foundation
Political Commitment: setting the policy
environment: Memorandum of Understanding
Department of Health
Lung Center of the Philippines
Tropical Disease Foundation
Consultative meetings with partners
National TB Control Program Regional Health Offices
City Health Offices Local health units
• Microscopy
• DOT
• Uninterrupted supply of drugs
• Recording and reporting
MDRTB
Symptomatic/Suspect
• Microscopy, culture and DST
• DOT: with support mechanisms
• Uninterrupted supply of SLDs
• Recording and reporting
MDR TB
REFERRAL SYSTEM
MDR TB Treatment Center
DOTS Facility/Public/PPMD Unit
� SM, link to culture and DST centers
� Infection control measures
� Management of severe adverse reactions
� Supportive care:
� Psychosocial sessions
� Patient general assemblies
� Livelihood activities
� Drug management
� Recording and reporting
MDR TB Treatment Center
Comprehensive
services for MDR TB
• In house facility
• Out-patient facility
DOTS Facility/Public/PPMD Unit
MDR TB Treatment Center
• DOT of SLDs
• Management of mild
adverse drug reactions
• Simple drug management
• Recording and reporting
Sputum-negative MDRTB
patient Sputum-positive MDR
patient
DECENTRALIZATION
• Microscopy, culture and DST
• DOT: SLDs; Uninterrupted SLDs
• Recording & reporting MDR TB
Treatment Center
METRO MANILA
• 6 Specialized MDR TB
Treatment Centers
• 89 Treatment Sites (DOTS
facilities)
• 76/452 (16%) local health
centers (Treatment Sites)
• 13 FBO/NGO/PPMD
Units (Treatment Sites)
• 15 of the 17 (88%) cities in
Metro Manila DOTS
facilities trained in MDRTB
management
Treatment Site
Metro Manila
Region 10M
population
36 (6%)36 (6%)36 (6%)36 (6%)
69 (12%)
20 (4%)
162 (29%)
19 (3%)
6 (1%)
15 (3%)
30 (5%)
11 (2%)
122 (22%)
25 (4%)
6 (1%)
13 (2%)13 (2%)13 (2%)13 (2%)
8 (1%)8 (1%)8 (1%)8 (1%)
6 (1%)6 (1%)6 (1%)6 (1%)
10 (2%)10 (2%)10 (2%)10 (2%)
Places of residence99- July ‘07
Metro Manila
Region
17 Regions in the Philippines
Region IRegion II
Region III
Region V
Region IVA
Region IVB
Region VIIRegion VI
Region X
Region VIII
Metro Manila
CAR
Region XIII
Region IX
Region XI
Nationwide coverage –
ALL regions by 2010
ARMM
Treatment Center
Treatment Site
DST CentersNTRL
TDF,
CTRL
TDF, RITM/NTRL
LCP, PTSI
Microscopy centers in
Treatment Centers
Supranational laboratory
RIT/KIT
Level III/central
Level II/intermediate
Level I/peripheral
Establishing the Laboratory
Network: Metro Manila
Microscopy
Centers
Culture Centers
Laboratory Network
Nationwide coverage –
ALL regions by 2009
Metro Manila
Region2 DST Centers
6 Culture Centers
DST Center
Culture Center
Drug Management
Inventory
Use
Distribution
Procurement
Forecasting
Selection Department of Health
Materials Management Division
Regional Health OfficesCenters for Health Dev’t Warehouses
MDR TB Treatment
Centers
DOTS Treatment
Sites
City health offices
Recording and Reporting
Department of Health
Regional Health OfficesCenters for Health Dev’t
MDR TB Treatment
Centers
DOTS Treatment
SitesRecording
Recording and
Reporting
City health offices
TB Register
Lessons learned
� Consult with partners
� Engage as many partners as possible
� Build on existing system(s)
� Simplify
� Pilot sites and procedures
� Take advantage of available financial support
� Continue to strengthen DOTS
Challenges
� Absorptive capacity – HR and physical
structures
� Laboratory strengthening
� Sustainability
� Shifting focus from project mode to program
� Infection control
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