ATTAINMENT OF GLOBALLY
ACCEPTABLE CURE RATE
THROUGH QUALITY DOTS
SERVICES IN SELECTED AREAS OF
THE NATIONAL CAPITAL REGION
(2006-2009)
Amelia C. Medina, MD, MPH
Head, Infectious Disease Prevention and
Control Cluster
Center for Health Development-Metro Manila
The Philippines ......
Total Population : 84,241,341
(2005)
Land area
: 300,000
sq. kms.
Regions
: 17
Provinces
: 79
Cities
: 115
Municipalities : 1,495
National Capital Region (Metro Manila)
Population
: 10,485,356
(2005)
Land Area
: 636 sq. kms.
Urban Poor Pop.
: 39.9%
Pop. Density
: 16,486/sq.km.
Annual Growth Rate : 1.06%
Literacy Rate
: 94%
Cities
: 14
Municipalities
:3
Barangays
: 1,697
TB and NTP…..
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The Philippines is 9th among the 22 HBCs
3rd in the Western Pacific Region
6th leading cause of morbidity and 5th leading
cause of mortality
Region wide implementation of DOTS in 2000
DOTS reporting centers
 433 health centers
 4 CHD-MM retained hospitals
 18 PPMD Units
29 QA Centers
14 TB Diagnostic Committees
128 Microscopy Centers
Case Detection Rate, 2000-2004
80
60
40
20
0
CDR
2000
2001
2002
2003
2004
45.8
51
53.6
53
58
Treatment Outcome 2003,
New Smear (+) Cases
6.7%
7.6%
1.6%
1.2%
7.6%
75%
Cured
Trans-out
Completed
Defaulter
Failure
Died
Cure Rate by City / Municipality,
2003
100.0
80.0
60.0
40.0
20.0
0.0
Mal Nav Val Mar
Pat
Ma San Las Mu Par
Qu Cal
CH
Pas
Tag Ma
Ma
Pas
abo ota enz ikin
ero
nda Jua Piñ ntin aña
ezo ooc
Dig
uig kati
nila
ay
n
s uel a
s
luy n as lup que
n an
MM
Cure Rate 67.7 84.4 62.4 66.5 87.6 94.7 87.4 75.1 78.3 68.8 56.6 63.9 82.4 75.0 77.8 74.6 76.8 75.0
Cure Rate vs. Completion Rate,
2000-2003
100%
80%
60%
40%
20%
0%
2000
Completion Rate 11.6%
69%
Cure Rate
2001
2002
2003
3.3%
9%
7.6%
78%
73.3%
75%
Stakeholders Analysis
Beneficiaries
TB
cases
Health
Workers
Community
City Health
Offices
Health
Centers
Microscopy
Centers
Local
Government
Units
Implementing
Agencies
City
Health
Offices
Health
Centers
PPMD Units
CHD-MM
Retained
Hospitals
Selected
DOH
Hospitals
NGOs
Mass Media
Faith-based
Organizations
Local
Coalitions
Decision
Makers
Local
Government
Units
Center for
Health
Dev’tMetro
Manila
Infectious
Disease
OfficeDOH
Partner
Agencies
JICA
LEAD
for
Health
ProjectMSH
WHO
TDFIGFATM
PhilCAT
PhilTIPS
-USAID
CATiMM
Funding
Agencies
Local
Governm
ent Units
CHD-MM
IDO-DOH
GFATM
LEAD for
Health
ProjectMSH
JICA
Potential
Opponents
Private
Practitioners
Private
Clinics
Private
Hospitals
Government
Hospitals
Poor socioeconomic condition
PROBLEM ANALYSIS
Increase morbidity and mortality from TB
Low Cure Rate
Health workers do not
Implement NTP
Policies and guidelines
Poor adherence
to treatment among
TB cases
Poor case holding
management
Inadequate health education
Provided to patients
Lack of commitment and
Low morale of
Health workers
Low salaries and
benefits
Health workers lack
Knowledge on NTP
Untrained newly hired
personnel
Defaulter mechanism
Not implemented
Lack of vehicle and
Transportation allowance
For defaulter tracing
Monitoring patient response
To treatment is not
Strictly followed
Weak monitoring and
Evaluation of the
program
Lack of IEC materials and
collaterals
Insufficient number of
Staff to conduct
Health education
Limited budget for health
Promotion activities
Undermanned health
centers
Referral system not
In place
Insufficient budget for
training
Non-filling up of
vacancies
Exodus of health workers
Low salaries and compensation
PROBLEM ANALYSIS
Health workers
Do not implement
The NTP policies
And guidelines
Poor adherence
To treatment
Among TB cases
Low Cure Rate
Weak
Monitoring
And Evaluation
Of the
program
Monitoring patient
Response to
Treatment is not
Strictly followed
Poor quality
Of laboratory
services
TB patient unable
To collect
Sputum
specimen
Inadequate
Number of
Microscopy
Centers
Lack of trained
Staff to conduct
Monitoring &
Evaluation
Lack of superVision to the
patient
Insufficient
Number of
Med. Techs
Lack of budget
For program
reviews
Multiprogram/
Multifunction
Supervisors &
coordinators
Lack of
Knowledge on
NTP monitoring
No specific training
On monitoring
Supervision &
Evaluation
No vehicle/
transportation
allowance
For monitoring
purposes
No standardized
Monitoring tool
At all levels
Lack of health
budget
OBJECTIVE ANALYSIS
Improved socioeconomic condition
Decrease morbidity and mortality from TB
High Cure Rate
Strict implementation of
NTP Policies and
Guidelines by health workers
Excellent case holding
management
Committed and highly
motivated
Health workers
High salaries and
benefits
Good adherence
to treatment among
TB cases
Monitoring patient response
To treatment is Strictly
Followed as scheduled
Effective and
Regular monitoring and
Evaluation conducted
Adequate health education
Is provided to patients
Health workers are
Knowledgeable on NTP
Trained newly hired
personnel
Defaulter tracing
mechanism
Is implemented
Adequate IEC materials
and
collaterals
Sufficient number of
trained
Staff to conduct
Health education
Provision of budget for
health
Promotion activities
Well staffed health
centers
Functional
Referral system
Vehicle and
Transportation allowance
For defaulter tracing
provided
Sufficient budget for
training
Vacancies filled up
CAPABILITY BUILDING
APPROACH
Health Education
Approach
Health workers stick with
Their jobs
High salaries and compensation
OBJECTIVE ANALYSIS
Strict
Good adherence
Implementation
To treatment
Of NTP policies Among TB cases
And guidelines
High Cure Rate
Quality
Laboratory
services
TB patients
Collect sputum
For follow-up
examination
Adequate
Number of
Microscopy
centers
Quality Assurance
Approach
Sufficient
Number of
Med. Techs
QUALITY
SERVICE
APPROACH
Effective and
Regular
Monitoring and
Evaluation
conducted
Monitoring
Patient compLiance to treat
Ment is
strictly followed
Adequate no.
Of trained
Staff to
Conduct
monitoring
Improved
Patient
supervision
Regular
Conduct of
Program
review
NTP
Monitoring is
A priority of
Coordinators
& supervisors
Adequate
Knowledge on
NTP
monitoring
Training on
Monitoring,
Supervision
& Evaluation
conducted
Vehicle/
Transportation
Allowance
provided
Existence of
A standard
Monitoring tool
At all levels
Allocation of
Specific budget
For monitoring
purposes
Monitoring and
Evaluation
Approach
PROJECT NAME : ATTAINMENT OF GLOBALLY
ACCEPTABLE CURE RATE THROUGH QUALITY
DOTS SERVICES IN SELECTED AREAS OF THE
NATIONAL CAPITAL REGION
TARGET GROUPS
: Health Workers
TARGET AREAS
: Cities of Valenzuela,
DURATION
:Three (3) Years
SCHEDULE
:July, 2006 – July, 2009
Marikina, Muntinlupa
and Las Pinas
Narrative
Summary
Objectively
Verifiable
Indicators
Overall
Goal:
Decrease
morbidity
and mortality
from TB
TB morbidity
and mortality
is reduced by
10% at the
end of the
project.
Means of
Verification
Health
Indices
Field Health
Services
Information
System
Important
Assumptions
The change in
administration
will not affect
project implementation
Comprehensive
Unified Policy
(CUP) on TB is
strictly
followed
by other GOs,
NGOs, POs, etc.
Narrative
Summary
Objectively
Verifiable
Indicators
Means of
Verification
Project
Purpose:
To achieved
a cure rate
of 85% or
more.
Increased
cure rate by
30% in 2009
Cohort
Analysis
Important
Assumptions
Private Initiated
PPMD Units
continuously
network and
coordinate with
their public
counterparts
Outputs:
Health
workers
complied and
strictly
implemented
the NTP
policies and
guidelines on
case holding
management.
1.
1.1 By the end of the
project, all health
workers are trained
and accurately and
effectively implement
the NTP policies and
guidelines on case
holding mechanism.
Baseline and
Endline Survey
Results
1.2 Policies and
procedures for
detecting defaulters
and getting them back
to treatment are
implemented and
monitored for
effectiveness in 100%
of DOTS centers by
2009
Written policy/
protocols on
defaulter tracing
1.3 By 2009, 80% of the
DOTS Centers
developed and
implemented policies
and procedures
ensuring an effective
referral system
Referral/Transfer
Forms
1.4 Defaulter and transfer
out rates is less than
3% by 2009
NTP Register
NTP Records and
Reports
Cohort Analysis
Return Slip from
Receiving Units
Cohort Analysis
Trained health
workers will
remain working
with the health
offices.
Budget will be
provided by both
the Department of
Health and local
government units
as planned.
Outputs:
2. Laboratory
networks
with
Quality
Assurance
System
established.
3.1 All sputum
follow-up
examinations are
performed on
scheduled dates
during the course of
treatment.
3.2 External Quality
Assessment
conducted every
quarter by qualified
controllers by the
end of 2007.
3.3 All microscopy
and quality
assurance centers
have functional
microscopes and
adequate laboratory
supplies.
NTP Register
Feedback
Sheets
Follow up
Sheets
Annual Slide
Reading Quality
Check and
Smear
Preparation
Quality Check
Inventory
Reports
Stock Cards
Patients do not
have the difficulty
of collecting
sputum specimen
towards the end of
treatment
Controllers will not
be assigned to
other sections of
the public health
laboratory
Trained medical
technologists stick
on with their jobs
Outputs:
3. Effective
and
comprehensive
monitoring
and evaluation
is regularly
conducted.
3.1Quarterly
monitoring and
supervision
conducted.
3.2 DOTS
centers with
improved
recording and
reporting
system
increased by
95% at the end
of the project.
3.3 Standard
monitoring tool
developed and
used at all
levels.
Interview of
health workers
Written reports
and
recommendatio
ns made during
supervisory
visits.
NTP records
and reports
Filled-up
monitoring
tools
Other
funding
agencies like
Global Fund,
JICA and
MSH will not
require
specific
monitoring
tool for their
projects.
Outputs:
4. DOTS
Centers are
certified and
accredited
90% of DOTS
centers are
certified and
accredited by
2009.
List of
Certified and
Accredited
DOTS Centers
from NCCPPMD
Certification
Standards
are
sustained
by the
certified
and
accredited
facilities.
ACTIVITIES:
1.1 Training Needs Assessment
1.2 Capability Building
1.3 Development and maintenance
of a database on human resource
development
1.4 Workshop on policy formulation
1.5 Formulate and implement a
DOTS Centers networking and
referral system.
ACTIVITIES….
2.1 Setting-up of quality assurance
centers
2.2 Training of Controllers on External
Quality Assessment
2.3 Training of untrained Medical
Technologists on Basic NTP Microscopy
2.4 Training of laboratory technicians on
sputum smearing and staining
procedures
2.5 Inventory and provision of
microscopes and laboratory supplies
2.6 Provision of recording and reporting
forms.
ACTIVITIES….
3.1 Development of a monitoring tool
3.2 Development of a Monitoring and
Evaluation training syllabus
3.3 Training of coordinators and supervisors
on NTP monitoring and evaluation
3.4 Supervised field practicum on M&E
3.5 Quarterly monitoring and supervision
3.6 Quarterly program implementation review
3.7 Year-end evaluation and consultative
planning workshops
ACTIVITIES….
4. DOTS Centers certification and
accreditation
4.1 Organize and train TA teams for
DOTS certification
4.2 Actual provision of technical
assistance on DOTS Certification and
Accreditation
4.3 Conduct assessment and
certification of DOTS Centers
4.4 Coordinate with PhilHealth for
accreditation
4.5 Quality check of certified and
accredited DOTS Center for
sustainability
ACTIVITIES….
5. Support activities
5.1 Operational research on
patient’s delay
5.2 Pilot study of a surveillance
system for NTP
INPUTS:
Manpower:
NTP City Medical Coordinator
NTP City Nurse Coordinator
Controller
HEPO
Supervisors – at least 3/city
Sentrong Sigla Coordinator
Assessors and Certifiers
TA Team for DOTS Certification and Accreditation
Statistician
Physicians
Nurses
Midwives
Medical Technologists
Laboratory Technicians
BHWs
Vehicles
Transportation Allowances
Equipment and Laboratory Supplies
Glass slides & glass slide boxes
Sputum cups
Immersion oil
Reporting and Recording Forms
Microscopes
Facilities
DOTS Centers
QA Centers
AFB Staining Kits
Transport Boxes
Disinfectants
Alcohol
Project Cost : Php 8,000,000
PRECONDITIONS:
1. The city government and the
city health offices will have a
full support to the project
2. Clear budget allocation from the
national and local government
THANK YOU!
THANK YOU!