ATTAINMENT OF GLOBALLY ATTAINMENT OF GLOBALLY ACCEPTABLE CURE RATE ACCEPTABLE CURE RATE THROUGH QUALITY DOTS THROUGH QUALITY DOTS

SERVICES IN SELECTED AREAS OF SERVICES IN SELECTED AREAS OF THE NATIONAL CAPITAL REGIONTHE NATIONAL CAPITAL REGION

(2006(2006--2009)2009)

Amelia C. Medina, MD, MPHHead, Infectious Disease Prevention and

Control ClusterCenter for Health Development-Metro Manila

The Philippines ......

Total Population : 84,241,341 Total Population : 84,241,341 (2005)(2005)

Land area : 300,000 Land area : 300,000 sq. kms.sq. kms.

RegionsRegions : 17: 17ProvincesProvinces : 79: 79CitiesCities : 115: 115Municipalities : 1,495Municipalities : 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 : 14Municipalities : 3Barangays : 1,697

TB and NTP…..The Philippines is 9th among the 22 HBCs3rd in the Western Pacific Region 6th leading cause of morbidity and 5th leading cause of mortalityRegion wide implementation of DOTS in 2000DOTS reporting centers

433 health centers4 CHD-MM retained hospitals18 PPMD Units

29 QA Centers14 TB Diagnostic Committees128 Microscopy Centers

Case Detection Rate, 2000-2004

0

20

40

60

80

CDR 45.8 51 53.6 53 58

2000 2001 2002 2003 2004

Treatment Outcome 2003,New Smear (+) Cases

1.6%7.6%6.7%

1.2%

75%

7.6%

Cured Completed FailureTrans-out Defaulter Died

Cure Rate by City / Municipality, 2003

0.0

20.0

40.0

60.0

80.0

100.0

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

Malabon

Navotas

Valenzuel

Marikina

Pasig

Pateros

Taguig

Makati

Mandaluy

San Juan

Las Piñas

Muntinlup

Parañaque

Manila

Quezon

Caloocan

Pasay

CHD-MM

Cure Rate vs. Completion Rate, 2000-2003

0%

20%

40%60%

80%

100%

Completion Rate 11.6% 3.3% 9% 7.6%Cure Rate 69% 78% 73.3% 75%

2000 2001 2002 2003

Stakeholders AnalysisBeneficiaries Implementing

AgenciesDecision Makers

Partner Agencies

Funding Agencies

Potential Opponents

TB casesHealth WorkersCommunityCity Health OfficesHealth CentersMicroscopy CentersLocal Government Units

City Health OfficesHealth CentersPPMD UnitsCHD-MM Retained HospitalsSelected DOH HospitalsNGOsMass MediaFaith-based OrganizationsLocal Coalitions

Local Govern-mentUnitsCenter for Health Dev’t-Metro ManilaInfectious Disease Office-DOH

JICALEAD for Health Project-MSHWHOTDFI-GFATMPhilCATPhilTIPS-USAIDCATiMM

Local Government UnitsCHD-MMIDO-DOHGFATMLEAD for Health Project-MSHJICA

Private Practition-ersPrivate ClinicsPrivate HospitalsGovern-ment Hospitals

PROBLEM ANALYSISPoor socioeconomic condition

Increase morbidity and mortality from TB

Low Cure Rate

Health workers do notImplement NTP

Policies and guidelines

Poor adherenceto treatment among

TB cases

Monitoring patient responseTo treatment is not

Strictly followed

Weak monitoring andEvaluation of the

program

Poor case holdingmanagement

Lack of commitment andLow morale of Health workers

Health workers lackKnowledge on NTP

Defaulter mechanismNot implemented

Referral system notIn place

Low salaries andbenefits

Untrained newly hiredpersonnel

Insufficient budget fortraining

Lack of vehicle and Transportation allowance

For defaulter tracing

Inadequate health educationProvided to patients

Lack of IEC materials andcollaterals

Insufficient number of Staff to conductHealth education

Limited budget for healthPromotion activities

Undermanned healthcenters

Non-filling up of vacancies Exodus of health workers

Low salaries and compensation

Low Cure Rate

Health workers Do not implementThe NTP policiesAnd guidelines

Poor adherenceTo treatment

Among TB cases

Monitoring patientResponse to

Treatment is notStrictly followed

Weak Monitoring

And Evaluation Of the

program

Poor qualityOf laboratory

services

TB patient unableTo collectSputum

specimen

Lack of trainedStaff to conduct

Monitoring &Evaluation

Lack of budgetFor program

reviews

No vehicle/transportation

allowanceFor monitoring

purposes

No standardizedMonitoring tool

At all levels

Multiprogram/MultifunctionSupervisors &coordinators

Lack of Knowledge on

NTP monitoring

No specific training On monitoring Supervision &

Evaluation

Lack of healthbudget

Inadequate Number of Microscopy

Centers

Insufficient Number of Med. Techs

Lack of super-Vision to the

patient

PROBLEM ANALYSIS

OBJECTIVE ANALYSISOBJECTIVE ANALYSIS Improved socioeconomic condition

Decrease morbidity and mortality from TB

High Cure Rate

Strict implementation ofNTP Policies and

Guidelines by health workers

Good adherenceto treatment among

TB cases

Monitoring patient responseTo treatment is Strictly Followed as scheduled

Effective and Regular monitoring andEvaluation conducted

Excellent case holdingmanagement

Committed and highlymotivated

Health workers

Health workers are Knowledgeable on NTP

Defaulter tracingmechanism

Is implemented

FunctionalReferral system

High salaries andbenefits

Trained newly hiredpersonnel

Sufficient budget fortraining

Vehicle and Transportation allowance

For defaulter tracingprovided

Adequate health educationIs provided to patients

Adequate IEC materials and

collaterals

Sufficient number oftrained

Staff to conductHealth education

Provision of budget forhealth

Promotion activitiesWell staffed health

centers

Vacancies filled up Health workers stick withTheir jobs

High salaries and compensationCAPABILITY BUILDING

APPROACH

Health Education Approach

High Cure Rate

Strict ImplementationOf NTP policiesAnd guidelines

Good adherenceTo treatment

Among TB cases

MonitoringPatient comp-Liance to treat

Ment is strictly followed

Effective andRegular

Monitoring andEvaluation conducted

Quality Laboratory

services

TB patientsCollect sputumFor follow-upexamination

Adequate no.Of trained

Staff toConduct

monitoring

Regular Conduct of

Programreview

Vehicle/Transportation

Allowanceprovided

Existence ofA standard

Monitoring toolAt all levels

NTP Monitoring is A priority of

Coordinators & supervisors

Adequate Knowledge on

NTPmonitoring

Training on Monitoring,Supervision& Evaluationconducted

Allocation ofSpecific budget For monitoring

purposes

Adequate Number of Microscopy

centers

SufficientNumber ofMed. Techs

ImprovedPatient

supervision

OBJECTIVE ANALYSIS

Quality Assurance Approach

Monitoring andEvaluation Approach

QUALITY SERVICE

APPROACH

QUALITY SERVICE

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, Marikina, Muntinlupa and Las Pinas

DURATION :Three (3) Years Three (3) Years

SCHEDULE :July, 2006 July, 2006 –– July, 2009July, 2009

NarrativeSummary

Objectively Verifiable Indicators

Means of Verification

ImportantAssumptions

Overall Goal:

Decrease morbidityand mortality from TB

TB morbidityand mortality is reduced by 10% at the end of the project.

Health Indices

Field Health Services Information System

The change in administration will not affect project imple-mentation

Comprehensive Unified Policy (CUP) on TB is strictly followed by other GOs, NGOs, POs, etc.

Narrative Summary

Objectively Verifiable Indicators

Means of Verification

ImportantAssumptions

Project Purpose:

To achieved a cure rate of 85% or more.

Increased cure rate by 30% in 2009

Cohort Analysis

Private Initiated PPMD Units continuously network and coordinate with their public counterparts

Outputs:

1. Health workers complied and strictly implemented the NTP policies and guidelines on case holding management.

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.

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

1.3 By 2009, 80% of the DOTS Centers developed and implemented policies and procedures ensuring an effective referral system

1.4 Defaulter and transfer out rates is less than 3% by 2009

Baseline and Endline Survey Results

NTP Records and Reports

Written policy/protocols on defaulter tracing

Cohort Analysis

Referral/Transfer Forms

Return Slip from Receiving Units

NTP Register

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. 2. Laboratory networks with Quality Assurance System established.

3.1 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. 3. Effective and comprehensive monitoring and evaluation is regularly conducted.

3.13.1Quarterly Quarterly 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 recommendations 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 ofCertified and AccreditedDOTS Centers from NCC-PPMD

Certification Standards are sustained by the certified and accredited facilities.

ACTIVITIES:

1.1 Training Needs Assessment1.2 Capability Building1.3 Development and maintenance

of a database on human resource development

1.4 Workshop on policy formulation1.5 Formulate and implement a

DOTS Centers networking and referral system.

ACTIVITIES….2.1 Setting-up of quality assurance

centers2.2 Training of Controllers on External

Quality Assessment2.3 Training of untrained Medical

Technologists on Basic NTP Microscopy2.4 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 tool3.2 Development of a Monitoring and

Evaluation training syllabus 3.3 Training of coordinators and supervisors

on NTP monitoring and evaluation3.4 Supervised field practicum on M&E3.5 Quarterly monitoring and supervision3.6 Quarterly program implementation review3.7 Year-end evaluation and consultative

planning workshops

ACTIVITIES….4. DOTS Centers certification and

accreditation4.1 Organize and train TA teams for

DOTS certification4.2 Actual provision of technical

assistance on DOTS Certification and Accreditation4.3 Conduct assessment and

certification of DOTS Centers4.4 Coordinate with PhilHealth for

accreditation4.5 Quality check of certified and

accredited DOTS Center for sustainability

ACTIVITIES….

5. Support activities5.1 Operational research on

patient’s delay5.2 Pilot study of a surveillance

system for NTP

INPUTS:Manpower:NTP City Medical Coordinator Statistician NTP City Nurse Coordinator PhysiciansController NursesHEPO MidwivesSupervisors – at least 3/city Medical TechnologistsSentrong Sigla Coordinator Laboratory TechniciansAssessors and Certifiers BHWsTA Team for DOTS Certification and Accreditation

VehiclesTransportation Allowances Equipment and Laboratory SuppliesGlass slides & glass slide boxes AFB Staining KitsSputum cups Transport BoxesImmersion oil Disinfectants Reporting and Recording Forms AlcoholMicroscopes

FacilitiesDOTS CentersQA Centers

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!

THANK YOU!