2019 Philippines TB Joint Program Review Report

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REVIEW REPORT

2019 PHILIPPINES TB JOINT PROGRAM REVIEW October 3–14, 2019

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REVIEW REPORT

2019 PHILIPPINES TB JOINT PROGRAM REVIEW October 3–14, 2019

National TB Control Program Joint Tuberculosis Program Review Copyright 2020 Department of Health All Rights Reserved.

First Printing, 2020 The mention (if any) of specific companies or of certain manufacturer’s products does not imply that they are endorsed or recommended by the DOH in preference over others of a similar nature.

Articles may be reproduced in full or in part for non-profit purposes without prior permission, provided credit is given to the Department of Health.

Cover design and layout by Verzoliv Design Enterprises.

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Department of Health San Lazaro Compound, Rizal Avenue Sta. Cruz, Manila, 1003 Philippines Telephone No: (+632) 743-8301 to 23 Website: http://www.doh.gov.ph DOH acknowledges the contribution of the following partners in the development of this publication: The Global Fund to Fight AIDS, Tuberculosis and Malaria through the Philippine Business for Social Progress, United States Agency for International Development and its Implementing Partners, World Health Organization, Philippine Coalition Against Tuberculosis, professional societies, other government agencies, local government units, and patient groups.

TABLE OF CONTENTS

Abbreviations vii Executive summary

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Background and Methodology

1

Introduction 2 The NTP: Current recommended policies and practices

3

The Philippine Strategic TB Elimination Plan: Phase 1

6

2019 JPR methodology

9

Findings and recommendations

13

1

15

The Philippine context and cross-cutting health system issues 1.1 Geography and population

16

1.2 Economy of the Philippines

17

1.3 Health profile of the Philippines

17

1.4 The Philippine health service delivery system

18

1.5 Tuberculosis in the Philippines

19

1.6 Size estimates of TB at risk or vulnerable populations in the Philippines 21 1.7 The major health system needs for the TB response in the Philippines 2

3

Closing the TB incidence–notification gap: TB screening

22 37

2.1 Background

38

2.2 Achievements

38

2.3 Challenges

39

2.4 Recommendations

42

Ensuring accessible, equitable and quality TB diagnosis and testing

49

3.1 Background

50

3.2 Recent DOH policy directives

50

3.3 Achievements

51

3.4 Challenges

54

3.5 Recommendations

59

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5

Treatment: Linking people to high-quality, patient-centered care to enhance TB treatment outcomes

61

4.1 Background

62

4.2 Achievements

62

4.3 Challenges

64

4.4 Recommendations

67

4.5 Health system issues

69

Turning off the tap: TB prevention

71

5.1 Background

72

5.2 Achievements

72

5.3 Challenges

73

5.4 Health systems issues

74

5.5 Recommendations

75

Annexes 79

iv

Annex 1. List of 2019 Joint Program Review team members

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Annex 2. Sites/facilities visited and people interviewed

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

LIST OF FIGURES Fig. 1.

PhilSTEP1 results chain

8

Fig. 2.

Framework of the 2019 JPR

9

Fig. 3.

Philippines population pyramid

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Fig. 4.

Distribution of current health expenditure payment source

19

Fig. 5.

Trends in estimated TB incidence and mortality in the Philippines 2000–2015 20

Fig. 6.

Trends in TB case notification, incidence and projections

20

Fig. 7.

Trends in TB budgets, 2015–2019

24

Fig. 8.

PhilHealth TB DOTS package payments and percent of total TB case notification

25

Comparative yield of screening household contacts in the Philippines, by screening and diagnostic tool used

42

Comparison of true-positive and false-positive yields and number needed to screen according to the screening algorithm used for household contacts and for urban poor

46

Fig. 11.

TB laboratory capacity expansion in the Philippines, 2014–2019

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Fig. 12.

Trends in the use of DSSM and Xpert for TB testing in the Philippines, 2012–2018 53

Fig. 13.

Trends in the proportion of CD-TB versus BC-TB in the Philippines, 2016–2018

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Proportion childhood TB among all registered TB cases in the Philippines by region

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Fig. 15.

Proportion of EP-TB among all registered TB cases by region

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Fig. 16.

Comparison of presumptive TB cases tested with Xpert in the first quarter of 2018 and 2019

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Fig. 9.

Fig. 10.

Fig. 14.

Fig. 17.

Trend of enrollment of MDR-TB and RR-TB patients in the Philippines, 1999–2018 62

Fig. 18.

Trend of treatment outcome of MDR-TB and RR-TB patients in the Philippines, 1999–2016

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TABLE OF CONTENTS

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LIST OF TABLES Table 1.

Achievement of PhilSTEP1 targets by 2019

Table 2.

Top 10 causes of deaths in the Philippines, 2007–2017

17

Table 3.

Potential allocation of TB functions and services to populationand individual-based financing categories

27

Table 4.

Trends in private TB referrals and notifications, 2015–2018

28

Table 5.

Sanctions, enablers and incentives for private provider engagement in TB

29

Table 6.

Results of three large case-finding interventions in the Big 3 regions in 2018

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Table 7.

Estimates of risk-group population size, TB burden and screening yields

45

Table 8.

TB testing policy communicated in October 2018

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Table 9.

Trends in DSSM and Xpert testing in the Philippines, 2012–2018

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Table 10. Number of registered DS-TB patients versus PhilSTEP1 targets, 2017–2019

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Table 11. Treatment outcomes of previously treated TB cases, excluding relapse, in the Philippines, 2015–2017 cohorts

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Table 12. Treatment of isoniazid-resistant tuberculosis with first-line drugs: a systematic review and meta-analysis

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ABBREVIATIONS ACF

active case finding

AE

adverse events

aDSM

active drug safety monitoring

aOR

adjusted odds Rratio

ART

antiretroviral treatment

BC-TB

bacteriologically confirmed tuberculosis

Bdq

bedaquiline

BHS

barangay health station

BRICS

Brazil, Russia, India, China, South Africa

CD-TB

clinically diagnosed tuberculosis

CHD

Centre for Health Development

CHE

current health expenditure

CHO

city health office

CI

confidence interval

Cfz

clofazimine

CKD

chronic kidney disease

COBAC

Central Office Bids and Awards Committee

COPD

chronic obstructive pulmonary disease

Cs

cycloserine

CTR

conventional treatment regimen

CxR

chest X-ray

DPCB

Disease Prevention and Control Bureau

Dlm

delamanid

DM

diabetes mellitus

DR-TB

drug-resistant tuberculosis

DST

drug susceptibility testing

DOH

Department of Health

DOT

directly observed treatment

DSSM

direct sputum smear microscopy

DS-TB

drug-susceptible tuberculosis

E

ethambutol

ECG

electrocardiogram

EP-TB

extrapulmonary tuberculosis

EQA

external quality assurance

ExWorks

Price of a product without any additional costs for transportation/insurance/taxes

FAST

Find TB Actively, Separate Safely, Treat Effectively stratgey

FDA

Food and Drug Administration of the Philippines

FLDs

first-line drugs

FQ

fluoroquinolone

ABBREVIATIONS

vii

GF

Global Fund to Fight AIDS, Tuberculosis and Malaria

GDF

Global Drug Facility

GDP

gross domestic product

INH

isoniazid

HC

health center

HH

household

HRH

human resources for health

ICF

intensified case finding

iDOTs

integrated delivery of tuberculosis services

IDPCD-DPCB Infectious Disease Prevention and Control Division, Disease Prevention and Control Bureau IHD

ischemic heart disease

IPC

infection prevention and control

IPT

isoniazid preventive therapy

ITIS

Integrated Tuberculosis Information System

JPR

Joint Program Review

Lfx

levofloxacin

LGU

local government unit

LMIC

lower-middle-income countries

LPA

line probe assay

LTBI

latent tuberculosis infection

MDR-TB

multidrug-resistant tuberculosis

Mfx

moxifloxacin

MHO

municipal health office

MOP

Manual of Procedures

mSTR

Modified Shorter Treatment Regimen

MTaPS

Medicines, Technologies and Pharmaceutical Services

MTB

mycobacterium tuberculosis

NCR

National Capital Region

NHIP

National Health Insurance Program

NTRL

National Tuberculosis Reference Laboratory

NTP

National Tuberculosis Control Program

PBSP

Philippine Business for Social Progress

PCC

patient-centered care

PDL

people deprived of liberty

PHA

Philippine Health Agenda

PhilHealth

Philippine Health Insurance Corporation

PhilSTEP1

Philippine Strategic Tuberculosis Elimination Plan: Phase 1

PHO

provincial health office

PhP

Philippine pesos

PLHIV

people living with HIX

PMDT

programmatic management of drug-resistant tuberculosis

PPD

purified protein derivative

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

PPM

public–private mix

PPPI

Philippines Pharma Procurement Incorporated

PSM

procurement and supply management

Pto

prothionamide

R

rifampicin

RHO

regional health office

RHUs

rural health units

RR-TB

rifampicin-resistant tuberculosis

SLD

second-line drug

SLI

second-line injectable

SL-LPA

second-line line probe assay

SLOR

standardized longer oral regimen

SOP

standard operating procedure

STC

satellite treatment center

STRiders

specimen transport riders

SSTR

standardized shorter treatment regimen

TAT

turnaround time

TB

tuberculosis

TB-LAMP

tuberculosis loop-mediated isothermal amplification

TPT

tuberculosis preventive treatment

TC

treatment center

THE

total health expenditure

TST

tuberculin skin test

TWG

technical working group

UHC

universal health coverage

UNHLM-TB

United Nations High-level Meeting on the Fight to End Tuberculosis

USAID

United States Agency for International Development

WHO

World Health Organization

WISN

Workload Indicator of Staff Needs

WRD

WHO-recommended rapid diagnostic test for tuberculosis

XDR-TB extensively drug-resistant TB Xpert

Xpert MTB/Rif assay

Z

pyrazinamide

ABBREVIATIONS

ix

EXECUTIVE SUMMARY The 2019 Philippines TB Joint Program Review (2019 JPR) was undertaken to assess progress in the implementation and achievement of the goals of the 2017–2022 Philippine Strategic TB Elimination Plan: Phase 1 (PhilSTEP1). The Review focused on the cascade of care for tuberculosis (TB) in the Philippines beginning with screening, diagnosis and testing in an effort to narrow the gap between incidence and notification so that treatment and patient support can be improved, with the ultimate goal of preventing TB infection and halting the progression from infection to disease. The National Tuberculosis Control Program (NTP) was particularly interested in understanding factors that contributed to achievements of targets in certain areas, as well as those factors that hindered progress in areas where the targets were not achieved. The findings and recommendations of this Review will be used to update PhilSTEP1 and also to form the backbone on which the funding request to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) in the next allocation cycle will be anchored.

The planning for the Review was handled by a national technical working group (TWG), comprised of technical experts from the World Health Organization (WHO), the NTP, United States Agency for International Development (USAID), the National Tuberculosis Reference Laboratory (NTRL), Philippine Business for Social Progress (PBSP) and other organizations. With the assistance of engaged local TB consultants, this group developed the Review tools that assisted the Review teams in collecting relevant information in the various thematic areas. A group of international experts was identified to participate in the Review and to provide lead roles in the four identified thematic areas of the review: screening; diagnosis and testing; treatment; and prevention. The 2019 JPR consisted of 62 participants, 18 of whom were from outside the country (external experts). The JPR team was divided into eight teams, with each team visiting a city or a province in eight regions of the Philippines. During the field visits, Review teams visited at least three rural health units or health centers, a Government hospital, a private hospital and a jail or prison.

Additionally, Review teams interviewed at least one private physician and at least one patient, with some Review groups also interviewing community health volunteers. The findings of the field visits were consolidated into thematic area observations from which specific thematic area recommendations were formulated.

While many of the recommendations that follow are contained in the various thematic sections of this report, the 2019 JPR identified the following recommendations as being of paramount importance for the TB response in Philippines.

1. Expand TB screening and testing using the most sensitive tools (CxR and Xpert) with the aim of achieving high coverage for identified high-risk or vulnerable groups. The intention of this recommendation is to ensure that the Philippines finds the 220 000 missing persons with TB and rapidly narrows the TB incidence– notification gap, which currently stands at 37%.

2. Scale up availability and access to rapid diagnostic tests to ensure wide coverage by initially prioritizing high-volume facilities, simplifying diagnostic algorithms to make Xpert, which is the current available rapid TB diagnostic test globally, the initial diagnostic test for all, and enhancing specimen transport systems. The majority of TB patients in the Philippines are either diagnosed clinically with no bacteriological confirmation (over 60%) or if bacteriologically confirmed, the test used is direct sputum smear microscopy (DSSM), an old test that has poor sensitivity and specificity. The continued use of DSSM may be contributing to the pool of missing cases and may also be leading to false-positive diagnosis as clinicians consequently over rely on chest X-rays. By increasing utilization of the Xpert MTB/Rif assay (Xpert), which is a more sensitive and specific test x

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

for TB, the NTP in the Philippines will not only enhance TB case finding but will also be making progress towards universal drug susceptibility testing (DST).

3. Rapidly enhance clinical and programmatic capacity to prevent, detect, treat and care for patients with multidrug-resistant tuberculosis (MDR-TB). This recommendation is based on the observation that the incidence–notification gap for drug-resistant tuberculosis (DR-TB) is higher than that for all TB (greater than 60%) and the treatment outcomes of patients placed on MDR-TB treatment is suboptimal with a treatment success rate of less than 60%. Clinical and programmatic capacity to prevent and manage MDR-TB should be improved through innovative training programs, for example online training programs, and onsite monitoring and mentorship initiatives. The NTP should make efforts to progress towards achieving universal DST as a key measure to detect all patients with DR-TB. 4. Prioritize identification and treatment of people latently infected with TB through expanded contact management and routine screening of other at-risk populations and develop appropriate recording and reporting tools to track progress. This recommendation is based on the finding that contact management and the treatment of latent tuberculosis infection (LTBI) in the Philippines is at a very rudimentary state, yet the country made commitments at the first-ever United Nations High-level Meeting on the Fight to End Tuberculosis (UNHLM-TB) and in PhilSTEP1 to achieve very bold targets. Some experts are argue that finding and treating TB cases alone is not sufficient to end TB, and they propose that treatment of the large pool of latently infected people may hold the key to ending TB by turning off the tap of TB cases.

5. Enhance engagement of private health-care providers by being deliberate about maximizing the contribution of the Philippine Health Insurance Corporation (PhilHealth) to TB care and prevention as the country embarks on the universal health coverage (UHC) reform process.

This recommendation is based on the presence in the Philippines of a large and expanding pool of private health-care providers who must be an integral part of the network of TB service providers.

Additionally, the country is undertaking very bold measures to ensure UHC, and in these endeavors, TB, the most common cause of mortality from a single infectious disease in the Philippines, needs to be part and parcel of the UHC package. The 2019 JPR also recommends that the Department of Health (DOH) should deploy a full range of enablers and incentives, alongside the legal sanctions that are proposed for mandatory notification, in order to support TB patients served by the full range of private health-care providers.

6. Reduce future risk of stock-outs of first-line drugs (FLDs) and Xpert cartridges by urgently increasing the DOH budget, enabling rapid registration of the full range of WHO prequalified TB formulations through use of the WHO Collaborative Registration Procedure by the Food and Drug Administration of the Philippines (FDA), and procurement of Xpert cartridges and FLDs via alternative mechanisms such as Philippine Pharma Procurement Inc. (PPPI), a government entity in a position to make use of the flexibilities in the procurement laws to procure from international sources such as the Global Drug Facility. This recommendation was based on the finding that in 2019 there were disruptions in the supply of Xpert cartridges and also of FLDs, which led to a near complete stoppage of TB case finding in some regions. The procurement challenges are perennial and need to be resolved once and for all, if the Philippine’s ambition to end TB by 2035 is to be achieved.

7. Match the ambition to end TB by 2035 with the proper level of financial investment. To be able to fully implement PhilSTEP 1 and the recommendations of the 2019 JPR (such as screening more people for TB to find more cases, finding them early and supporting all of them to adhere to treatment) will require significantly greater resources. In 2018, the NTP reported that there was a budget gap of 48%. Twenty one percent (21%) of the available budget was from external sources. A marked increase in the available resource envelope is needed, and ideally this budget should come

EXECUTIVE SUMMARY

xi

from domestic sources. A case needs to be made that investing in TB is a smart investment and one of the best buys in public health. It has been estimated that for every dollar invested in TB, the return on investment is US$ 431.

8. Continue efforts, embracing the work of the Human Resources for Health in 2030 (HRH2030) project to ensure that human resources for health (HRH) bottlenecks (numbers, skill mix and distribution) are overcome. This is based on the finding that even though the Philippines is a major producer of health-care workers, the health-care system in the Philippines still suffers HRH inadequacies including shortages, maldistribution and skill-mix constraints at service delivery points. The JPR learned of the HRH2030 project funded by USAID that has taken a very comprehensive approach to support the DOH to address existing HRH challenges.

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Ten years in public health 2007-2017. Report by Dr Margaret Chan, Director-General, World Health Organization.

Towards ending tuberculosis: what gets measured gets done. https://www.who.int/publications/10-year-review/tb/ en/index6.html 2019 PHILIPPINES TB JOINT PROGRAM REVIEW

BACKGROUND AND METHODOLOGY

INTRODUCTION During the development of the 2017–2022 Philippine Strategic TB Elimination Plan: Phase 1 (PhilSTEP1), a decision was made to include midterm and end-term evaluations as integral components of the implementation of this Plan. PhilSTEP1 is currently at the end of its midterm, and thus the Department of Health (DOH), committed to live by the ethos of the plan and undertook a 2019 Philippine TB Joint Program Review (2019 JPR) to determine the progress in PHilSTEP1 implementation and to guide an update of the Plan.

Joint program reviews (JPRs) had been conducted previously: during the midterm period of the previous strategic plan in 2013 and before finalization of the development of the current PhilSTEP1 in 2016. During both reviews, the focus was on a comprehensive look at the various strategies of the plan and its key thematic areas. Hence, the previous reviews comprehensively examined the entire spectrum of the health system building blocks, including governance, financing, regulation and service delivery in relation to tuberculosis (TB) program implementation.

In the current Review, there was a recognition that: 1) there are many reviews that have been undertaken very recently or that are concurrently being conducted to look at different thematic areas of PhilSTEP1; and 2) many of the recommendations in the most recent JPR conducted three years ago had not been fully carried out but remain valid. Examples of recent, ongoing as well as planned assessments are: social protection programs for TB undertaken by the regional Green Light Committee; Human Resource for Health Inventory Mapping and Sustainability Planning, undertaken as part of Human Resources for Health in 2030 (HRH2030) project supported by the United States Agency for International Development (USAID); a situational analysis of Logistics and Supply Chain Management previously carried out with support from USAID through the Systems for Improved Access to Pharmaceuticals and Services project and recently supplemented by the Medicines, Technologies and Pharmaceutical Services (MTaPS) project, also funded by USAID; and the assessment of Department of Health (DOH) budget utilization undertaken by the USAID’s Health Protect Project. There are, likewise, similar assessments planned immediately after the JPR, such as the Assessment of Clinical Diagnosis of TB and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) Transition Readiness Assessment, both being considered by the GF. Given the above, the National Tuberculosis Control Program (NTP) decided that the current JPR will focus on the cascade of care in TB. Specifically, the NTP decided to focus the Review on examination of factors affecting implementation of screening, testing and diagnosis, as well as treatment and prevention, of tuberculosis. Thus, based on the six health system building blocks delineated by the World Health Organization (WHO), the 2019 JPR was geared primarily on service delivery, with the objective of identifying strategies that best contribute to attaining the objectives of PhilSTEP1 for preventing TB and for case finding and case holding. Since service delivery occurs within the context of a health ecosystem, the 2019 JPR also delved, though not as comprehensively as in previous reviews, into current health system support structures at both the central and local levels that either serve as barriers or facilitators for TB prevention, case finding and case holding.

The 2019 JPR was intended to provide valuable information for updating of PhilSTEP1 to make it more responsive to the needs of the TB program over the next three years of implementation (2020–2022), as well as for the funding request to the Global Fund in the next allocation cycle.

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

THE NTP: CURRENT RECOMMENDED POLICIES AND PRACTICES The National Tuberculosis Control Program is one of the core public health programs in the DOH under the Disease Prevention and Control Bureau (DPCB). In the context of a devolved health system, the DOH is responsible for development of policies and standards, as well as providing logistics support for program implementation. The provision of health services is undertaken by the local government units (LGUs), the municipalities and cities, with oversight from the provincial and city health offices and DOH regional offices. DOH also provides health services through regional and specialty hospitals.

The policies and procedures of the NTP are enumerated in the 2014 National Tuberculosis Control Program Manual of Procedures, 5th edition (MOP) and in the 2016 Guidelines for the Implementation of the Programmatic Management of Drug Resistant Tuberculosis. Various DOH memoranda have also been issued since 2015 to update some of these policies and procedures. Currently, a revised MOP has been developed and is awaiting approval by the DOH policy bureau.

Based on the 2014 MOP, the 2016 PMDT implementation guidelines and various memoranda, the following describes the main policies of the NTP across the cascade of care:

I. Screening The program implements both passive and active case finding. Passive case finding is the identification of people self-directed to seek care at health facilities as a result of symptoms compatible with TB (presumptive TB cases). Intensified case finding (ICF) on the other hand is provider-initiated screening for TB among individuals, mostly from populations or clinical groups that are at high risk of the disease. ICF is used most commonly for health-facility-based TB screening, while a similar approach at the community level is most often referred to as active TB case finding (ACF). These terms are sometimes used interchangeably, but in the context of the 2019 JPR, ACF was used as the umbrella term for provider-initiated TB screening and testing both at the facility and community levels.

In the current Philippines context, a person with presumptive TB is any adult with a cough of at least two weeks, or a cough of any duration if the individual belongs to a TB high-risk group.

For children, the NTP follows a scoring system whereby having any three of six symptoms and signs classifies the child as presumptive for TB. There is a proposal in the current revision of the MOP to change the current use of a scoring system in children to just having any one of three major signs and symptoms of TB (that is, cough/wheezing for two weeks or more, unexplained fever, unexplained weight loss or failure to thrive). In addition to the above, anyone, adult or child, who has chest x-ray (CxR) findings suggestive of TB is also considered to have presumptive TB. While symptom screening is the main screening tool used, CxR is increasingly being used, most commonly by NTP implementing partners in community ACF activities. Screening for TB using CxR is mostly targeted at people deprived of liberty (jails and prisons), vulnerable communities (for example, urban and rural poor) and high-risk individuals in health facilities (for example, contacts, diabetics and elderly). A person classified as presumptive for TB who was previously treated for TB or who is a contact of a person with drug-resistant tuberculosis (DR-TB) is further classified as presumptive DR-TB.

BACKGROUND AND METHODOLOGY

3

II. Testing and diagnosis The MOP directs that all people classified as presumptive TB should undergo diagnostic testing using either direct sputum smear microscopy (DSSM) or the Xpert MTB/Rif assay (GeneXpert or Xpert). In limited facilities, the TB loop-mediated isothermal amplification test (TB LAMP) is also available and is used, in a pilot mode, as a replacement test for DSSM. Currently, patients eligible for testing with Xpert, include presumptive DR-TB, presumptive TB among people living with HIV (PLHIV), diabetics, older people (> 60 years), children (< 15 years), people deprived of liberty, all DSSM-positive TB cases, all presumptive TB cases based on a suggestive CxR and presumptive extrapulmonary TB. In ACF activities (community or jails/prisons), Xpert is also used as the primary diagnostic test. For others not fulfilling the above criteria, a DSSM test is still the primary diagnostic test. There are currently only 488 Xpert centers nationwide, but almost all the approximately 3000 TB facilities have a microscopy center.

A person with a positive DSSM or Xpert test is classified as having TB that is bacteriologically confirmed (BC-TB). For a person with a negative TB bacteriologic test (DSSM/Xpert/TB-LAMP), the clinician exercises clinical judgment to diagnose the person as TB and such people are then classified as clinically diagnosed TB (CD-TB). Currently, as many as 65% of TB cases registered in the Philippines are clinically diagnosed.

For children who cannot expectorate or have a negative bacteriologic test, ancillary tests include a CxR and a tuberculin skin test (TST). Clinical diagnosis in children follows a scoring system needing to fulfill three out of five criteria: 1) exposure to an adult with TB; 2) a positive TST; 3) positive signs and symptoms; 4) CxR suggestive of TB; and 5) other laboratory findings suggestive of TB. Changes are likewise recommended in the ongoing MOP revision from this scoring system to clinical judgement by the attending physicians based on the CXR, TST results, clinical signs and symptoms, contact history, and other adjuvant laboratory tests.

A mandatory TB case notification system was introduced in 2018, in which private physicians, who do not refer their TB cases to designated TB facilities for treatment, can directly report their diagnosed TB cases to local health authorities through paper-based or electronic (webbased) reports. In 2018, such providers contributed as much as 10% of the total country TB case notifications, but 97% of these cases were CD-TB.

III. Treatment The regimen used to treat drug-susceptible tuberculosis (DS-TB) is currently 4HRZE/2HR. This is for all patients (new or retreatment) tested with Xpert in which Mycobacterium tuberculosis (MTB) was identified but rifampicin resistance (RR) was absent and all new patients were tested using DSSM or were clinically diagnosed. The NTP phased out the category 2 regimen (2HRZES/1HRZE/4HRE) in 2017.

For DR-TB, including patients with RR based on an Xpert results, the NTP recently introduced the new multidrug-resistant tuberculosis (MDR-TB) regimens recommended by WHO in 2019.

Hence, the following are the DR-TB regimens currently in use: standardized shorter treatment regimen (SSTR) for nine months, standardized longer oral regimens (SLOR-Fluoroquinolone [FQ] sensitive and SLOR-FQ resistant) both for 18â&#x20AC;&#x201C;24 months and individualized treatment regimens.

Prior to the introduction of SLOR, the NTP also used the conventional treatment regimen (CTR) whose duration is 18â&#x20AC;&#x201C;24 months and includes an injectable in the intensive phase. Majority of patients on treatment currently are on SSTR.

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Monitoring of treatment for DS-TB is through clinical symptoms and sputum follow-up examinations during treatment. For DR-TB, aside from clinical and bacteriologic tests (DSSM and culture), patients are tested for second-line drug resistance to the injectable and FQ using line probe assay (LPA) at the start of treatment, and the assigned regimen may be adjusted accordingly once results are available. The results of second-line drug resistance testing, however, could take as long as one month. There are just two LPA laboratories in the country. Active drug safety monitoring (aDSM) is also conducted through laboratory and other examinations, for example, audiometry, electrocardiography (ECG), complete blood count (CBC) and blood chemistry tests.

Serious adverse events or adverse events of special interest are reported to the Food and Drug Administration (FDA) of the Philippines.

Treatment adherence is ensured through directly observed treatment (DOT) usually by a health worker or community volunteer. For DS-TB, family members are also allowed in exceptional circumstances to provide DOT, for example when the patient cannot visit the facility or there are factors constraining community DOT on a daily basis (for example, a bed-ridden patient or a patient with a difficult work schedule). Treatment outcome is assigned at discharge from treatment and include: a) completion of treatment course; b) lost to treatment/follow up if patient interrupts treatment for at least two months; c) dead if patient dies, for whatever reason while on treatment; d) treatment failure if there is lack of reversion of culture to negative or the patient is switched to a new regimen due to severe adverse events (AEs) or drug intolerance; and e) â&#x20AC;&#x153;not evaluatedâ&#x20AC;? if the patient was transferred to another facility and his or her treatment outcome is unknow.

IV. Prevention Previously, the NTP recommended TB preventive treatment (TPT) for only TB household contacts below 5 years of age and PLHIV. In 2019, the NTP has expanded eligibility for TPT to all household contacts of all ages of bacteriologically confirmed TB (BC-TB) cases, close contacts of BC-TB cases and other at- risk clinical groups. A tuberculin skin test is not required to confirm latent TB infection (LTBI) before initiating treatment for the following individuals: 1) child contacts < 5 years of a BCTB index case; 2) PLHIV; and 3) household (HH) contacts > 5 years age of a BC-TB index case and who have other TB risk factors, such as diabetes mellitus (DM), smokers, immune-compromised individuals, malnourished individuals or at least two active TB cases in the HH. For the other eligible groups, TST is required to confirm LTBI (for example, child contacts < 5 years of age of a CD-TB index case, HH contacts > 5 years of age of a BCTB index case but with no other TB risk factors, close contacts of a BC-TB case and other risk groups). To rule out active TB prior to TPT, a CxR is recommended; however, if it is not accessible, screening by symptoms is acceptable and the physician can still prescribe TPT based on the informed decision of the patient. The program has trained most TB facilities on infection prevention and control (IPC). The implementation of administrative, engineering and personal protective equipment measures for IPC are, thus, recommended. The currently recommended TPT regimen is daily isoniazid (H) for six months (6H) and H is made available through Government of the Philippines procurement. The new shorter regimens such as 3HP, 3HR and 4R have been included in the ongoing revision of the MOP.

BACKGROUND AND METHODOLOGY

5

THE PHILIPPINE STRATEGIC TB ELIMINATION PLAN: PHASE 1 The TB response is currently guided by the Philippine Strategic TB Elimination Plan: Phase 1 (PhilSTEP1) which covers the years 2017–2022. This ambitious TB elimination plan is aligned with the Philippine Health Agenda 2016–2022 (PHA). The goal of the PHA is to ensure that the health-care system achieves: 1) financial protection for all Filipinos, but especially the poor, marginalized and vulnerable so they are protected from the high costs of health care; 2) better health outcomes so that all Filipinos attain the best possible health outcomes with no disparity; and 3) responsiveness so that all Filipinos feel respected, valued and empowered in all their interactions with the health-care system. These goals are underpinned by the values of equity and inclusiveness, transparency and accountability, efficient use of resources, and the provision of high-quality services. The tenets of PhilSTEP1 were also influenced by the DOH’s FOURmula One Plus, which is the Philippines’s health sector reform framework to achieve universal health coverage (UHC). The four elements of FOURmula One are: 1) securing sustainable investment to improve health outcomes and ensure efficient use of health resources; 2) ensuring availability of quality health services at appropriate levels of care; 3) ensuring safety, availability and accessibility of health products, devices and services, especially those used commonly by the poor; and 4) strengthening capacities and coordination of management support systems to lead to a participatory approach to the involvement of patients so that functional patient-centered service delivery networks emerge. The additional element – the Plus – is to enhance the use of performance management systems to drive performance in DOH and in the health sector to ensure accountability of all stakeholders.

The current phase of the TB Elimination Plan was developed in the backdrop of the Comprehensive Tuberculosis Elimination Plan Act of 2016 (Republic Act 10767) which mandated DOH to adopt an integrated approach to health development, and towards this end, support and expand efforts to eliminate TB as a public health threat in the Philippines. This comprehensive TB act compels the Government of the Philippines through the DOH to increase its investment in TB, adopt a multisectoral approach to the fight TB, empower communities, allocate and target resources to vulnerable populations, ensure socioeconomic development policies and plans include a TB component, and ensure there is robust performance improvement and quality enhancement.

Outlined below are the goals and objectives PhilSTEP1 including numerical outcome and impact targets for 2017–2022: Goal/impact: Compared to 2016, TB incidence declined by 23% (from 554 to 427/100 000); deaths declined by 50%; and catastrophic costs were eliminated (zero) compared to the baseline value of 35% in 2016.

Outcomes: Identify and treat 2.4 million people for DS-TB; 110 000 people for DR-TB and 1.25 million people for LTBI.

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Table 1. Achievement of PhilSTEP1 targets by 2019 Objective

Numerical target

Status by the time of 2019 JPR

Comment

1. Improve utilization of TB services by patients and communities

50% reduction in the proportion of people satisfying criteria for presumptive TB who do not take any health action

Not possible to collect routinely using the NTP’s health information system

The target was based on the results of the most recent TB prevalence survey. It will require another survey (not necessarily a TB disease prevalence survey) to assess if this target has been achieved.

2. Reduce catastrophic costs among households affected by TB

NTP budget increased by 25%, and 70% of TB cases supported by benefit payments by Philippine Health Insurance Corporation (PhilHealth)

Estimated that about 5.5% of TB patients are currently beneficiaries of payments by PhilHealth

With the new UHC act and accelerated pace of implementation of UHC, it may be possible to achieve the 70% coverage of TB patients supported by payments from PhilHealth if TB is part of the UHC “outpatient” package.

3. Ensure adequate and competent human resources for health (HRH) for TB elimination efforts

90% of HRH involved in TB care adherent to NTP protocols

Not possible to collect routinely using the NTP’s health information system

Obtain numbers needed (adequacy of HRH) using workload indicators of staffing need (WISN) assessment (as is being done by the HRH 2030 project) and define the competencies required.

4. Improve use of TB data for effective TB elimination efforts

90% of TB care providers notifying TB cases

Notification from private providers likely to be incomplete

Consider surveys such capture/recapture to estimate magnitude of under-reporting

5. Enhance quality of services and availability of products at all TB diagnosis and directly observed treatment, short course (DOTS) facilities

95% of facilities certified to be complying with NTP standards.

The proportion of facilities fully adherent to NTP standards was not available.

This was extensively reviewed by the 2019 JPR. Findings and recommendations are included in other parts of this report .

6. Provide integrated patient centeredcare and prevention

100% of new and relapse cases tested with a WHOrecommended rapid diagnostic test (WRD).

No stock-out of diagnostic reagents and pharmaceuticals

80% of priority high-risk groups screened and tested for TB.

Stock-out of both diagnostic reagents and anti-TB medicines were experienced in 2019 36% of people with TB tested using a WRD in 2018.

These issues were extensively reviewed by the 2019 JPR. Findings and recommendations are included in other parts of this report.

HIV testing was carried out in only 27% of all notified TB patients.

90% of household contacts screened for TB.

High rates of lost to follow-up (LTFU) for DRTB persists.

95% of all diagnosed DR-TB patients enrolled in care.

All DR-TB patients enrolled into treatment.

Less than 10% of DRTB patients enrolled in treatment lost to follow-up.

90% of TB patients tested for HIV. 25% of notified cases come from private provider notifications

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7

Table 1. Achievement of PhilSTEP1 targets by 2019 (Con’t.)

Objective 7. Enhance stewardship of the national Government and LGUs for coordination of TB elimination efforts across all sectors

Numerical target 100% of regions, provinces, etc. have costed TB elimination plans.

All administrative levels have active multisectoral committees supporting TB elimination

Status by the time of 2019 JPR

Comment

The TB National Coordinating Committee has been formed at the central level. At the regional levels, regional coordinating committees have been established.

Not evident that administrative levels other than the central level had costed TB elimination plans.

The budget of the PhilSTEP1 was estimated at Philippine pesos (PhP) 66.9 billion or approximately US$ 1.3 billion. Of this, 46.9% was expected to be spent on service delivery, 24.5% on regulation and 16.6 % on “financing”. It was expected that the national Government would provide 48.2% of the required budget, while Foreign Assisted Projects and the Philippine Health Insurance Corporation (PhilHealth) would provide 26.9% and 16.5%, respectively. In 2019, the NTP reported to WHO that US$ 205 million was needed to fund the response in 2019; however, 63% of this budget was unavailable (a budget gap), with 12% of the available budget coming from domestic sources and 25% from international sources. Fig. 1 below shows the PhilSTEP1 results chain Fig. 1. PhilSTEP1 results chain

HRH, Financing and other inputs such as physical infrastructure

8

Plans, Training/ supervision, procurements

Screening, testing, treatment, patient and community support, product availability

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Optimized TB service delivery

Persons with TB infection and disease identified, treated and cured

TB incidence, TB mortality and TB associated catastrophic costs reduced

2019 JPR METHODOLOGY Objectives The primary objective of the 2019 TB Joint Program Review (JPR) was to assess progress being made in the implementation and achievement of the goals of PhilSTEP 1. The review was focused on the cascade of care for tuberculosis in the Philippines. Specifically, the JPR examined continuum of care across the TB care cascade from TB screening, diagnosis and testing, treatment and retention in care until treatment completion to prevention of acquisition of Mycobacterium tuberculosis infection and progression of infection to active disease. The purpose was to a) identify and quantify gaps in the care cascade and to determine factors that are contributing to progress being made (facilitating factors) and those that are hindering progress in relation to the achievement of the PhilSTEP1 goals and b) provide specific recommendations regarding the implementation of PhilSTEP1 including the implementation of the current Global Fund (GF) grant.

Fig. 2. Framework of the 2019 JPR

Testing and diagnosis

Screening

Governance/ Regulation

Financing

Treatment

Human Resource for Health

Health Management Information System

Prevention

Pharmaceutical Supply Management

What strategies/activities are contributing most to reaching the country targets? What are the factors that are facilitating or hindering progress to the achievement of targets?

What recommendations should be provided to the DOH/NTP and partners to accelerate progress towards achievement of targets?

Methodology

Preparatory phase A national TWG, comprising of technical experts from WHO, the NTP, USAID, the National Tuberculosis Reference Laboratory (NTRL), Philippine Business for Social Progress (PBSP) and other organizations, was formed to identify key areas of focus for the 2019 JPR. The TWG identified four thematic areas: 1) TB screening; 2) TB diagnosis and testing; 3) TB treatment; and 4) TB prevention. These thematic areas were communicated to an international group of experts from whom thematic leads were identified and paired with local experts. From a health system perspective, these thematic areas fall in the service delivery area of the health system

BACKGROUND AND METHODOLOGY

9

building blocks. During the review, a fifth area of focus was identified to examine cross-cutting health system issues that impact TB service delivery.

Development of review tools The national TWG with assistance of local TB consultants developed templates of data acquisition or review tools that were then circulated to the pool of external experts for review and input.

Drafts of the review tools were tested by local review teams several weeks before the actual review and were revised appropriately. The final review tools used in the 2019 JPR included: Form 1(background information on health facility); Form 2 (facility interview form); Form 3 (data Extraction); Form 4 (patient interview form); Form 5 (interview with private physician); and Form 6 (daily summary form).

Pre-briefing and briefing sessions The national TWG and all international experts met on 3 October 2019 at the WHO Philippines country office to finalize technical preparations for the 2019 JPR. At this meeting the proposed methodology of the JPR was reviewed with the aim of establishing that, overall, the right approaches had been adopted for the objectives of the 2019 JPR to be met. There was an indepth discussion of the thematic areas to identify areas of focus to be examined during field visits and tweaks to the review tools were made to ensure that these tools were fit for purpose.

On October 4, 2019, a briefing session was held at the Midas Hotel in Metro Manila. This briefing session was attended by all JPR participants and included presentations on the TB situation in the Philippines and the results of the 2019 TB epidemiologic review. The objectives of the 2019 JPR were highlighted and the thematic areas and associated review tools were presented and discussed. The review tools were finalized at this briefing session. The management of the information to be obtained from field visits using the review tools was discussed and agreed upon.

Field visits There was a total of 62 JPR members, which included 18 people who live and work outside the Philippines (the external JPR members). The JPR members were divided into eight teams with each team visiting one region and within the region one province or city/municipality of the Philippines. The regions that were visited and the provinces or cities within each of these regions are listed below: y y y y y y y y

Region 3, Tarlac National Capital Region (NCR), Valenzuela and Caloocan Cordillera Administrative Region, Baguio Mimaropa, Mindoro Oriental Region 8, Leyte Region 9, Zamboanga Del Norte Region 11, Davao Del Norte Caraga, Agusan Del Sur.

Each field team had a team leader. In each visited region/province/city or municipality, the review teams visited rural health units/health centers, a government hospital, a private hospital and a jail/prison. A total of 59 sites/facilities were visited. Additionally, review teams interviewed at least one private physician and at least one patient. Some review groups also interviewed community health volunteers. The overall JPR team lead, together with the focal person for product supply management (PSM), had discussions with several persons at the DOH, MTaPs, the Central Office

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Bids and Awards Committee (COBACs), the HRH2030 project, the Philippine Society for Infectious Disease and Microbiology and also visited some medical stores in Metro Manila.

Workshop for field team feedback, thematic reviews and formulation of recommendations A workshop to allow geographic teams to present their observations and for the review group to distill observations into thematic area-based recommendations was held on October 12â&#x20AC;&#x201C;13, 2019, at the Midas Hotel in Metro Manila.

The 2019 JPR debrief session The in-country JPR activities ended with a debrief session that was held at the Bayleaf Hotel, Intramuros, Manila, on October 14, 2019. This debrief session was attended by the Undersecretary of Health, Public Health Services Team, DOH, Dr. Myrna C. Cabotaje and was attended by a wide array of stakeholders, including technical and implementing partners of the NTP. The findings and recommendations of the 2019 JPR were presented to debrief session attendees by the overall team lead and thematic area leads, including the leads for UHC, the publicâ&#x20AC;&#x201C;private mix (PPM) and PSM. The discussions that followed these presentations were used to refine the 2019 JPR recommendations.

Report writing The overall JPR team lead and the thematic area team leads (both external and in-country experts) drafted the 2019 JPR report, which was then circulated to the entire JPR team for input. This report, therefore, represents the consensus view of the entire 2019 JPR team.

BACKGROUND AND METHODOLOGY

11

FINDINGS AND RECOMMENDATIONS

1â&#x20AC;&#x160;

THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

1.1 Geography and population The Republic of the Philippines is an archipelago of more than 7400 islands in South-East Asia located in the western Pacific Ocean. It shares maritime borders with Japan, Indonesia, China, Taiwan (China), Malaysia and Viet Nam and has a total land mass of about 300 000 square kilometers.

The population of the Philippines was estimated at over 106 million in 2018 and has been growing at a rate of about 1.72% annually (2010–2015). There are slightly more males than females, with a male-to- female ratio of 1.02:1. The population of the Philippines is relatively young, with a median age of 24.3 years. Only about 7.5% of the population is over the age of 60 years, with those over the age of 65 years comprising 4.7% of the total population2 (Fig. 3). Life expectancy at birth has been increasing from a low of 61 years in 1960 to 70.9 years in 2017.3 The Philippines is rapidly urbanizing. In 2015, the urban population comprised 51.2% of the population. Of the 42 036 barangays, 7437 were classified as urban in 2015. The annual rate of increase in the urban population was 4.6% between 2010 and 2015. Other than the National Capital Region (NCR), which is classified as entirely urban, several regions in the Philippines had higher than the average proportion of urban population. These included Region IV-A at 66.4%, Region XI at 63.5%, Region 3 at 61.6% and Region XII at 51.6%4. These observations have implications for TB care and prevention. The interventions selected to achieve desired targets for TB in the Philippines must embrace principles of urban TB care and prevention.

Fig. 3. Philippines population pyramid 100+ 95–99 90–94 85–89 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14 5–9 0–4

0.0% 0.0% 0.0% 0.1% 0.2% 0.3% 0.6% 1.0% 1.4% 1.9% 2.3% 2.6% 3.0% 3.3% 3.7% 4.4% 4.8% 4.9% 5.1% 5.3% 5.5%

Male

10%

8%

6%

4%

PopulationPyramid.net

0.0% Female 0.0% 0.0% 0.1% 0.3% 0.5% 0.8% 1.1% 1.6% 2.0% 2.4% 2.6% 3.0% 3.2% 3.6% 4.3% 4.5% 4.5% 4.8% 5.1% 5.2%

0%

2%

4%

6%

SOURCE: Philippine Statistics Authority

2

Philippines Statistical Authority. psa.gov.ph/statistics/quickstat/national_quickstat/all/*

3

data.worldbank.org/country/philippines

4

http://www.psa.gov.ph/content/urban-population-philippines-results-2015-census-population

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

8%

10%

Philippines – 2019 Population: 106 886 636

1.2 Economy of the Philippines The Philippines is categorized by the World Bank as a lower-middle-income country (LMIC). Its gross domestic product (GDP) was estimated to be US$ 330.9 billion in 2017. The GDP has been increasing at an average of 6.3% between 2010 and 2017. The gross national income per capita was estimated to be US$ 3830 in 2018, thus the categorization as a LMIC; however, national income per capita is expected to continue growing with the country expected to reach upper-middle- income status in the near future. The Philippines is included in the group of 11 countries whose economies are expected to grow to reach those of the BRICS (Brazil, Russia, India, China and South Africa) countries in their capacity to rival the economies of the Group of Seven countries. The growth of the Philippines economy has been more inclusive in recent years with a decline in the GINI co-efficient from 42.9 in 2006 to 40.1 in 2015. The proportion of the population living below national poverty lines has also declined from 26.6% in 2006 to 21.6% in 2015.

There is an increasing shift from an agriculture-based economy to manufacturing and the services sector with these sectors now contributing 23.5%, 18.7% and 57.8% of all employment, respectively. The World Ban indicates that the economy of the Philippines is boosted by urbanization, the rising middle-income class and a large and young population, and is driven by consumer demand, a vibrant labor market and robust remittances.5

1.3 Health profile of the Philippines As in other LMICs, the Philippines is experiencing a triple burden of disease. While infectious (communicable) diseases continue to pose a significant public health threat, noncommunicable diseases and conditions related to urbanization, industrialization, and climate change and global warming are also increasingly contributing to morbidity and mortality in the Philippines.

DOH indicates that the top 10 causes of death in the Philippines include: diseases of the heart (ischemic heart disease or IHD); diseases of the vascular system; pneumonias; malignancies/ cancers; TB (all forms); accidents; chronic obstructive pulmonary disease (COPD) and allied conditions; diabetes mellitus; nephritis/nephrotic syndrome; and other respiratory conditions.6 The Institute for Health Metrics and Evaluation indicates that the top 10 causes of death in the Philippines over the last 10 years have remained IHD, stroke, lower-respiratory infections, neonatal disorders, TB, chronic kidney disease (CKD), diabetes mellitus, COPD, interpersonal violence and hypertensive heart disease; however, there have been significant shifts in the ranking of these diseases over this period as shown in Table 2.7 Table 2. Top 10 causes of deaths in the Philippines, 2007–2017 2007 ranking 1. IHD 2. Stroke 3. LRTI 4. Neonatal disorders 5. TB 6. CKD 7. DM 8. COPD 9. Interpersonal violence 10. Hypertensive heart disease

2017 ranking 1. IHD 2. Stroke 3. LRTI 4. CKD 5. TB 6. DM 7. Neonatal disorders 8. Hypertensive heart Disease 9. COPD 10. Inter-personal violence

% change 2007–2017 38 27.8 24.1 56.4 -2.8 47.2 -23.5 77.6 34.7 8.7

SOURCE: Field Health Service Information System (FHSIS) 2007 and 2017 Report.

5

https://www.worldbank.org/en/country/philippines/overview

6

https://www.doh.gov.ph/node/1058

7

http://www.healthdata.org/philippines THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

17

While not among the most common causes of deaths, many other infectious diseases are still prevalent in the Philippines, although their distribution may be localized to certain settings or certain key populations. These include waterborne (infectious diarrhea, hepatitis A and typhoid) and mosquito- borne diseases (dengue fever, malaria and Japanese encephalitis) and HIV infection.

At the time of the 2019 JPR, the country was battling a dengue epidemic and had reported at least two cases of polio after many years of being polio-free.

1.4 The Philippine health service delivery system A comprehensive review of the Philippine health-care system was recently undertaken, and in this section only a summary of the key observations will be provided.8 The Philippines adopted a decentralized health governance system in 1991, and introduced a National Health Insurance Program (NHIP) in 1995 under the management of PhilHealth. The delivery of health care takes place under a pluralistic or mixed health- care system in which government provision of health care through a hierarchical delivery system funded through taxation occurs alongside the delivery of health care by an expanding private health-care system where a market approach with payment of user fees at point of care is the norm. Governmental health- care delivery is managed by DOH and LGUs. DOH is responsible for managing government corporate hospitals, specialty hospitals and regional hospitals, while LGUs are responsible for the delivery of health care through provincial hospitals, district hospitals, rural health units (RHUs), health centers (HCs) and barangay health stations (BHS). The RHUs, HCs and BHSs form the backbone of the Philippine primary health-care system and is the health delivery system on which UHC is anchored. Currently, there are 1263 hospitals in the Philippines of which 63% are privately owned.

The Philippine primary health-care system comprises 2587 RHUs and 20Â 216 HCs and BHSs. Health, as a basic human right, is guaranteed in the Constitution of the Philippines of 1987, and as result the Government of the Philippines has been making efforts to make essential health services universally available and of high quality through health infrastructure development and improvement, deployment of adequate numbers of health-care professionals and the supply of health products. A more detailed description of the health financing landscape in the Philippines is provided in the section on UHC and PPM of this report. Total health expenditure (THE) in the Philippines has been rising (from PhP737.8 billion in 2017 to PhP799.1 billion in 2018, an increase of 8.3%. THE was 4.6% of the GDP in 2017.9 The per capita health expenditure at current prices was PhP7492 PhP(or about US$ 146). Of the current health expenditure (CHE), government schemes and compulsory contributory health financing schemes contributed PhP260.6 billion (34%), and voluntary health-care payment schemes contributed PhP93.3 billion (12.2%) with the rest, equivalent to PhP413.0 billion (or 53.9% of CHE) being household out-of-pocket health expenditure (Fig. 4). The private pharmacy (PhP206.7 billion) and the private general hospital (PhP148.8 billion ) were the major beneficiaries of out-ofpocket health expenditures.9

8

Dayrit MM, Lagrada LP, Picazo OF, Pons MC, Villaverde MC. The Philippines Health System Review. Vol. 8 No. 2. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018

9

https://psa.gov.ph/pnha-press-release

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Fig. 4. Distribution of current health expenditure payment source

12.2%

33.9%

53.9%

GoP/Compulsory schemes

OOP

Voluntary Health Insurance

SOURCE: Philippine Statistics Authority (https://psa.gov.ph/pnha-press-release/node/144466)

Government financing for health is channeled through the DOH and LGUs and also through PhilHealth.

1.5 Tuberculosis in the Philippines TB is a major public health threat in the Philippines. The country has carried out four national TB disease prevalence surveys over the last three decades (1983, 1997, 2007 and 2016), with the last survey being the first in which a relatively new, more-sensitive and specific tool for the diagnosis of TB, the Xpert MTB/Rif assay (GeneXpert), was used to test survey participants for TB. The prevalence of TB in the most recent survey10 was extremely high at 1159 (95% confidence interval [CI]: 1016–1301) per 100 000 population ,which translates to more than 1% of the Filipino population having TB. The survey revealed a higher rate of TB in males compared to females (1713/100 000 for males versus 627/100 000 in females). Prevalence of TB increased with age and was highest in those aged 45–54 years at 1714 per 100 000 population. The major risk factors for active TB were identified as previous TB (adjusted odds ratio [aOR], 2.3(95% CI 1.1–2.6), age over 65 years (aOR 2.8 [95% CI 1.8-4.4], diabetes (aOR 1.7(95% CI 1.1–2.6), urban residency (aOR 1.6 95% CI: 1.2–2.0), smoking for more than five years in men (aOR 3.3 [95% CI 2.7–4.4] or 1–5 “pack years” in females (aOR 1.9 [95% CI 1.3–2.7] and indicators of poverty such as being enrolled in the 4Ps conditional cash transfer program (aOR 1.6 [95% CI 1.2–2.1]). Of significant concern is the fact the 2016 national TB prevalence results suggested that there had been no major change in the burden of this disease between 2007, when the third national disease prevalence survey was conducted, and 2016, despite the effort that had gone into TB care and prevention over this period.

10

National TB Disease Prevalence Survey 2016, report THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

19

Based on the most recent (2016) disease prevalence survey data and other considerations WHO estimated that in 2018 there were 594 000 (95% CI 332–924) incident cases of TB in the Philippines (rate 554 [95% CI 311–866] per 100 000 population) of whom 371 668 were notified for a TB treatment coverage of 63% (95% CI 40–110). In the same year it was estimated that 26 600 people died of TB who comprised 26 000 (95% 22 000–30 000) people not infected with HIV and 600 (95% CI 0–4, 200) people who were co-infected with HIV. The 2019 JPR was preceded by a TB epidemiologic review (http://ntp.doh.gov.ph/downloads/ publications/assessment_reports/JPR2019_Epi_Review.pdf). The figures below provide a summary of the burden of TB disease in the Philippines that was obtained by the pre-2019 JPR TB epidemiologic review.

Fig. 5. Trends in estimated TB incidence and mortality in the Philippines 2000–2015

Rate per 100 000 population

Estimated TB incidence

Estimated TB mortality (excluding TB/HIV)

750 40 500 20 250

0

0 2000

2005

2010

2015

2000

2005

2010

2015

SOURCE: WHO. 2019 TB Epidemiological Review

Fig. 6. Trends in TB case notification, incidence and projections

Rate per 100 000 population

TB incidence; Current and Projected estimates, and Global targets Current (Green), Projected (Blue), Case notification (Black), Targets (Red)

750

500

250

0 2000

2005

2010

SOURCE: WHO. 2019 TB Epidemiological Review

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

2015

2020

2025

2030

2035

Even though the incidence-case notification gap is narrowing with an increasing number of patients with TB identified and notified, the almost zero change in the estimated TB incidence over the last decade is a major concern. TB mortality is declining much faster in the Philippines; however, there remains a significant risk that the WHO End TB Strategy and PhilSTEP 1 targets will not be reached, certainly for incidence but also for mortality if current trends continue.

1.6 Size estimates of TB at risk or vulnerable populations in the Philippines 1.6.1

The urban poor

In 2014, it was estimated that 38% of the Philippine urban population lived in slums/informal urban settlements.11 If this trend continues to prevail today, then nearly 20 million people, about 51% of the population of the Philippines lives in urban areas, of whom 38% live in slums and are vulnerable to TB infection and disease. While poverty rates are decreasing overall, urban poverty has been stable or may in fact be increasing.12

1.6.2

People living with HIV (PLHIV)

The Philippines is a low HIV prevalence setting. In 2018, the United Nations Joint Programme on HIV/AIDS estimated that the HIV prevalence in adults 15–49 years old was 0.1% (95% CI 0.1–0.2) translating to 77 000 (95% CI 65 000–90 000) PLHIV.13 However, the occurrence of new infection has been on a steep rise since 2010, and the rise has been highest in young people (15–24 years old).14 The proportion of HIV-infected people who were on antiretroviral treatment (ART) in 2018 was 44%. All PLHIV are at an increased risk of HIV infection and progression from infection to disease, but those who are not on ART (about 34 000 people) are at a much greater risk of TB disease.

1.6.3

Diabetics

In 2017, the International Diabetes Federation estimated that of the 60 327 900 adults in the Philippines, 6.2% or 3721,900 people have diabetes. All these individuals have an increased risk of TB as was highlighted in the 2016 National TB Prevalence Survey.

1.6.4

People deprived of liberty (PDL or prisoners)

The World Prison Brief of the Institute of Crime and Justice Policy Research at the University of London reports that by May 31, 2018, there were 188 278 prisoners in the Philippines, representing a rate of 179 prisoners for every 100 000 population.15 This is against a prison capacity of 40 610, implying that the prisons in the Philippines are heavily congested. There is scant data on the burden of TB in the prison population in the Philippines. National TB disease prevalence surveys have so far not included the prison population as is the case in most countries that have carried out national TB disease prevalence surveys; however, active case finding initiatives have confirmed high rates of TB in this population.

11

https://data.worldbank.org/indicator/EN.POP.SLUM.UR.ZS

12

http://documents.worldbank.org/curated/en/904471495808486974/pdf/115310-PN-P156898-PUBLIC-PolicyNotes-Inclusive-Growth-FINAL.pdf

13

https://www.unaids.org/en/regionscountries/countries/philippines

14

https://www.unaids.org/sites/default/files/media_asset/2019-UNAIDS-data_en.pdf

15

https://www.prisonstudies.org/country/philippines THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

21

1.6.5

Recent contacts of TB patients

Recent scientific evidence suggests that the risk of progression to active TB is highest among people recently (within the previous two years) infected with TB.16 The 2015 Philippine population census revealed that the average household size in the Philippines was 4.4 people.17 If the number of recent household contacts of TB is calculated from only notified cases of TB, then in 2018, nearly 1.5 million people (371Â 668 cases notified multiplied by 4, the average household size) were at an increased risk of TB disease as a result of being recent contacts of people with TB.

1.6.6

Tobacco smokers

It is currently estimated that about 33.9% of the adult population (or about 20 million people) in the Philippines regularly smoke tobacco.18 This population was identified to have an increased risk of TB disease in the 2016 national TB disease prevalence survey.

1.6.7

The elderly

People over the age of 65 years comprise about 4.7% (4.9 million people) of the Philippine population and have been identified to have an increased risk of TB disease.

1.6.8

Health-care workers

Health-care workers are known to have a high risk of infection with Mycobacterium tuberculosis and TB disease. The annual risk of infection has been estimated to be between 0.5% and 14.3%, while annual TB incidence ranges from 69 to 5780/100Â 000. Those most at risk of infection and disease include those deployed in inpatient areas, laboratories, internal medicine and emergency services of health-care facilities. The professional categories most at risk include radiology technicians, patient attendants, nurses, ward attendants, paramedics and clinical officers.19 Thus, the hundreds of thousands of health- care workers in the Philippines need to have regular TB screening.

1.7 The major health system needs for the TB response in the Philippines In order to achieve the targets of PhilSTEP1, which are aligned to the WHO End TB Strategy and the United Nations High-level Meeting on the Fight to End Tuberculosis targets, case finding for all forms of TB, including both DS-TB and DR-TB, in all population groups needs to be enhanced so that the current incidence and case notification gap is closed. This may, however, not be enough to change the trajectory of TB incidence if case finding is delayed, a situation that facilitates TB transmission. Additionally, if measures to reduce vulnerability to TB infection and progression to disease following infection are not pursued at a scale large enough to make a difference, the trajectory of the TB incidence in the Philippines is unlikely to change soon for the better. While there are many constraints in the health-care system in the Philippines, the 2019 JPR focused on only three issues: 1) HRH; 2) health financing in the realm of UHC and private provider engagement; and 3) product supply management that were observed to pose significant threats to the progress being made towards delivering high-quality TB services and the achievement and sustainability of a robust continuum of care, from screening to prevention.

Outlined in the following sections are the main observations and the recommendations of the 2019 JPR on these three areas of the health-care system.

16

Mary R.Reichler et al. J Infect Dis.2018 August 14; 218(6):1000-1008.doi:10.1093/infdis/jiy265

17

http://www.psa.gov.ph/content/highlights-household-population-number-households-and-average-household-sizephilippines

18

https://tobaccoatlas.org/country/philippines/

19

Rajnish Joshi et al. PloS Medicine 2006; 3(12):e494

22

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

1.7.1

Human resources for health (HRH)

1.7.1.1

Key achievements

The Philippines is a major producer and exporter of HRH. The training of the health-care workforce is of high quality, which is partly the reason that Filipino health-care workers are in high demand in the global health market.

The NTP has a presence at all levels of the health-care system, including at the community level through the use of community health volunteers. Ongoing training and supervisory activities are intended to keep the health-care workforce engaged in TB care and prevention and abreast of developments in the TB area of work, in addition to promoting adherence to the National Tuberculosis Control Program Manual of Procedures, 5th edition (MOP). A project funded by the USAID called the Human Resources for Health in 2030 (HRH2030) has begun a comprehensive review of the HRH situation in the Philippines in relation to the delivery of TB and family planning services.

The project is also undertaking interventions to influence training, recruitment and retention of the health-care workforce, in addition to tackling current challenges such as inappropriate skill mix, maldistribution of the health-care workforce and suboptimal productivity. The 2019 JPR noted with appreciation that among the activities that are currently being undertaken, include a workload indicator of staffing needs (WISN) assessment and a conceptual plan to transition staff of the TB program that are currently funded by external partners, especially the GF. 1.7.1.2

Key constraints

HRH2030 has identified the following constraints in HRH:

â&#x20AC;&#x160;

y

There are large leakages in the training of HRH. For example, while more than 3 million people enroll in nursing school, only half a million graduate and/or are board certified.

y

Most health-care workers (71%) are stationed in hospitals, with 70% of doctors in the private sector. The Philippine primary health-care system, the main delivery vehicle for UHC, is reported to be underutilized as a result of a preference by the population for hospital care. This results, in some situations, to staff at the RHU level being underworked, while in other situations the RHUs may be relatively starved of HRH.

y

Despite the large capacity to produce HRH, there are major gaps in HRH: for all cadres there are only 3.56 (against a recommended norm of 4.4) healthcare workers for every 10Â 000 population.

y

The GF is supporting over 700 staff for the TB response, and at the central level only the NTP manager and one alternate medical specialist is funded by the Government of the Philippines, which raises serious concerns about program sustainability.

THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

23

1.7.1.3

Key recommendations

The 2019 JPR acknowledged the work that is being undertaken by the HRH2030 project and strongly advises DOH, LGUs and partners to support this work and fully implement the interventions that are being proposed by the project. The 2019 JPR notes that the HRH2030 project includes key activities for HRH development including the following: y

supporting DOH to build its HRH capacity to develop, deploy, train and manage HRH;

y

carrying out a WISN assessment;

y

developing digital means of training staff (education for health-care workers anywhere and anytime) and also programs for mentoring as monitoring is undertaken;

y

developing an HRH management information system; and

y

looking at mechanisms of transitioning staff supported by the GF to DOH, LGUs and even the private sector.

1.7.2 1.7.2.1

Financing of the TB response Achievements and opportunities

Funding for the TB program comes from four main sources: 1) DOH; 2) international donors; 3) LGUs; and 4) the NHIP through PhilHealth. The DOH budget for TB in 2019 is US$ 25 million, down from US$ 59 million in 2018 but up from US$ 20 million in 2017. International donors, notably the GF and USAID, provided US$ 51 million for TB in the Philippines in 2019, up from US$ 34 million in 2018, but down from US$ 55 million in 2017. The GF TB grant (2017–2020) is US$ 118 million. Fig. 7 shows the trend of the TB budget for 2015–2019.

Fig. 7. Trends in TB budgets, 2015–2019

Total budget (US$ millions)

250 200 150 100 50 0

2015

2016

Funded domestically

2017

2018

Funded internationally

2019

Unfunded

SOURCE: WHO. Global TB Reports. 2015-2019.

Tuberculosis financing data reported to WHO does not include resources from LGUs or PhilHealth.

Local governments are expected to dedicate 20% of their budgets to health, supporting shared staff and facilities, and sometimes procurement related to TB. Data on PhilHealth’s support for TB patients via inpatient case rates and the primary health-care package is unavailable. Since 24

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

2003, PhilHealth has also had a TB directly observed treatment, short course (DOTS) package, consisting of PhP2500 for the intensive phase and a further PhP1500 for the continuation phase. In 2018, PhilHealth paid 41 847 claims (including 23 933 intensive phase) for a total of PhP63.5 million (US$ 1.3 million).

The total financial resources for health available under PhilHealth are nearly twice as large as those available to DOH. In 2017, expenditure through PhilHealth was PhP117 billion (48% of government health expenditure), whereas that of DOH was PhP65 billion (27%) and that of LGUs was PhP 48 billion (20%).20 In 2019, the Universal Health Care Act was passed. It is envisaged that through UHC, population coverage by PhilHealth will increase from 93% to 100%, with just two membership categories: those who contribute directly and those with government sponsorship. The act makes a clear distinction between population-based services, to be funded by DOH, and individual services, to be funded by PhilHealth. Provinces and cities will establish Special Health Funds to pool PhilHealth claims payments with resources from LGUs and DOH. Special Health Funds will contract with new Service Delivery Networks, comprising public and private facilities from primary to tertiary levels. The reforms are to be piloted in 15 provinces/cities, and the changes can be expected to play out over several years. Implementing regulations were issued at the time of the JPR (October 2019), but many important issues remain to be resolved.

1.7.2.2

Challenges and constraints

The NTP remains seriously underfunded, with available resources amounting to only 37% of the need in 2019 (Fig. 7), while at the same time the TB program is failing to capitalize on funding available from PhilHealth.

Fig. 8. PhilHealth TB DOTS package payments and percent of total TB case notification Total claims payments under PhilHealth TB DOTS Package, US$, and intensive Phase Claims as Percent of Total Notifications $3 500 000

12%

$3 000 000

10%

$2 500 000

8%

$2 000 000 6% $1 500 000 4%

$1 000 000

2%

$500 000 $0

2011

2012

2013

2014

2015

2016

2017

2018

0%

SOURCE: Philhealth Reports 20

Philippines Statistics Authority 2018 National Health Accounts Table 3 THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

25

Support for TB patients under the TB DOTS package has fallen by 50% over the last three years, from already low levels (Fig. 8). In 2018, payments under this package amounted to just PhP69 million (US$ 1.3 million) and the number of intensive phase claims from PhilHealth corresponded to just 5.5% of total TB notifications (the PhilSTEP1 target is that 70% of TB patients will be supported by PhilHealth by 2022). In 2017 only 66% of PhilHealth-accredited DOTS facilities filed claims.21 The challenges with PhilHealth have been noted by previous JPRs and include: y

Accreditation is based on DOH certification as a DOTS provider, which can be slow: only 109 private providers are accredited for the TB package, although many thousands of private general practitioners and hospitals are accredited under PhilHealth.

y

The claims process is burdensome: although e-filing was introduced in 2013, facilities still have to submit detailed paperwork with each claim.

y

The rates of reimbursement for the service provided were set in 2003 and have not been adjusted.

y

The package does not cover DR-TB treatment, Xpert, LPA or culture.

y

Payment processing of claims is slow, often taking a year.

y

Claims from public primary care facilities are retained at the LGU level.

y

Claims are not linked to the Integrated TB Information System (ITIS) registration.

y

No data are available on PhilHealth funding for TB care under inpatient and other packages.

y

PhilHealth case rate and primary care packages payments may encourage management of uncomplicated TB cases in hospitals and discourage referral of TB presumptives from primary care facilities for testing.22

1.7.2.3

Recommendations

To address TB financing gaps and enhance the utilization of the NHIP through PhilHealth as a sustainable mechanism for domestic resource utilization for this disease, the 2019 JPR advises that: y

y

DOH should match the ambition embodied in both PhilSTEP1 and the Government’s international commitments with increased allocation of funding for TB to close the gap between required and available budget .

The NTP, its technical partners, representatives of the private health-care sector and community organizations should take an active role in designing the details of the UHC reform process in order to optimize its impact on TB.

In the UHC reform, DOH should allocate TB functions appropriately to “population-based” and “individual-based” financing in order to capitalize not only on available funds but also on the strengths and weaknesses of their associated purchasing mechanisms. It will be important to ensure that all critical functions and services are adequately funded, and that they are purchased through the most appropriate mechanism. Table 2 suggests a potential allocation of critical TB functions and services to the two main financing categories and identifies examples of functions and services that could be allocated either way. Note that the funding source need not necessarily dictate the implementing agency: provinces and cities could allocate funds from their Special Health Funds to a national agency, such as DOH or Philippines Pharmaceutical Procurement Inc. (PPPI), for procurement of a call center, drugs, diagnostic cartridges, etc.

21 22

26

Allan Fabella, presentation at Jakarta PPM Working Group July 2019

Wells W, et al, (2019) “How TB programs can navigate the world of social health insurance”, IJTLD 23(1):26–37 2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Table 3. Potential allocation of TB functions and services to population- and individualbased financing categories Category

Population-based

Individual-based

Source

Department of Health, LGU

PhilHealth

Basis

Input budgets

Prospective case rates; Fee-for-service

Critical TB functions and services

• Policy, guidance, leadership • Multisectoral accountability • Surveillance, M&E, ITIS • Supply Chain Management for drugs, cartridges • Advocacy, Communication, Social Mobilization • Support for community-based organizations • Attention to patient rights, gender • Active case finding: high-risk communities; prisons, worksites, etc.

• Household contact investigation • Preventive therapy

• Facility-based screening • Diagnosis • Treatment, both DS-TB and DR-TB • Treatment support, adherence • Notification • Active drug safety monitoring (aDSM) • Prescription reporting • Facility-based infection control

• Find TB Actively, Separate Safely, Treat Effectively (FAST) intensified screening in facilities.

• Ensuring patient accesses all eligible social supports.

y

PhilHealth should revise payments for TB, under all packages, to enhance patient financial protection and adequately incentivize case finding, bacteriological confirmation, completion of appropriate treatment regimens (for DR-TB as well as DS-TB), and referrals that streamline pathways to care.

y

PhilHealth and the NTP should work together to design a streamlined, paperless claims process that integrates seamlessly with ITIS and relies on ex post sample audits rather than ex ante review of medical records.

y

PhilHealth and the NTP should work together to minimize barriers to access of PhilHealth benefits by private patients and their providers by developing a streamlined, online system of provider self-certification/accreditation.

1.7.3 1.7.3.1

Public–Private Mix for TB Care and Prevention (PPM) Achievements and opportunities

Previous reviews and the 2017 PPM action plan detail the scale of the private health-care sector.

The Philippines cannot achieve its TB goals unless this sector is systematically engaged on a scale commensurate with its role in the delivery of health services currently. Efforts to engage private providers for TB in the Philippines date back to at least 1995, and many small, timebound, donor-funded pilot projects have been implemented since then. Table 4 shows the recent trend in private TB notifications.

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27

Table 4. Trends in private TB referrals and notifications, 2015–2018 Description

2015

2016

2017

2017

276 672

332 941

328 773

371 668

41 977

53 394

52 375

56 666

Notifications Total (new and relapse) Private “Mandatory notification” Total private

37 497 41 977

53 394

52 375

15%

16%

16%

94 163

Percent of total notifications Private “Mandatory notification” Total private

15% 10%

15%

16%

16%

25%

SOURCE: DOH-NTP. Integrated TB Information System Reports

Standard private notifications include two scenarios: referrals from private providers to public facilities for treatment, and case management by the 146 private DOT treating centers using government anti-TB medicines. It is not clear how many providers or patients are in each category.

The number of private referrals is understated, since it only includes those who arrive with a written referral slip from a private provider.

The 2016 Comprehensive Tuberculosis Elimination Plan Act Law and 2019 Law on Notifiable Diseases made notification mandatory for all health-care providers, including laboratories. In drafting implementing regulations for the Notifiable Diseases Law, there are plans to specify sanctions, including imprisonment, fines and revocation or suspension of licenses. Under the GF grant, 150 notification agents have been deployed in three regions to help providers comply with the laws, and a module has been developed to enter essential data in a version of ITIS. This initiative contributed 37 497 notifications (10% of the total) in 2018, and in the first half of 2019 had already generated a further 34 063. In the second half of 2018, 2290 providers notified an average of 10 cases each; in the first half of 2019, 8093 providers notified an average of four cases each.

The PhilSTEP1 target was that 25% of notifications would be contributed by the private sector by 2022.23 If mandatory notifications are included, the PhilSTEP1 target was achieved in 2018.

In 2017 the NTP and partners developed a National Action Plan for Public-Private Mix on Private Sector Participation in TB Care and Prevention, 2018–2022. It reviewed PPM experiences to date, set targets, identified three implementation models (hospitals, integrated primary health care and worksites) and included costed action plans.

There is a plan to extend STRiders services to private providers in order to increase access to Xpert by patients accessing care in the private sector and increase the proportion of bacteriologically confirmed cases.

UHC reforms create opportunities to increase PhilHealth engagement of private providers for TB (see financing section). Similarly, trends towards consolidation of private laboratories and pharmacies (there are more than 7000 outlets of the major chains such as Mercury and Watsons) and the development of innovative information technology applications (such as Snap Rx) create the conditions for efficient engagement of private providers on a much larger scale.

23

28

The National PPM Action Plan (2017) set a more ambitious target of 30% 2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Table 5. Sanctions, enablers and incentives for private provider engagement in TB Sanctions

Enablers

Incentives

Current

• Mandatory notification (penalties pending) • Prescription regulations

• Notification agents • Notification module partially developed and not integrated

• PhilHealth TB DOTS package

For Consideration

• Inclusion of TB drugs in S2: mandatory pharmacy reporting

• Automatic online certificationaccreditation • Streamlined notification function within ITIS • App for prescription reporting (e.g. Snap Rx) • Call center assistance for notification, patient support • Sputum transport to free, sameday or overnight Xpert • CxR vouchers for private patients

• Paperless claims • Payment within 30 days • TB drug discount coupons for registered patients • Revised PhilHealth payment rates for TB (expand services covered and adjust incentives)

1.7.3.2

Challenges and constraints

Given the important role of private health care in the Philippines health system, PPM has never received the budgetary and management priority that it deserves. PPM initiatives have been small, time-bound and externally funded.

The PhilSTEP1 target of 25% of notifications coming from private providers is not sufficiently ambitious, given the major role of the private health-care sector, including pharmacies, in careseeking. The PPM national action plan was never disseminated, and one of the three models (integrated primary health care) was not implemented.

Only a tiny proportion of private health-care providers are engaged by the program: 677 providers are registered in ITIS but in the first six months of 2019, only 81 provided program-supported treatment and 285 referred patients, while 311 (46%) were inactive.24 There are only 146 private program-supported DOTS facilities, and only 108 are accredited with PhilHealth.25 Private providers lack access to (and potentially awareness of and confidence in) affordable molecular testing for TB; they rely too much on CxR and clinical diagnosis. As a result, many TB cases may be missed, and many of those treated for TB in the private sector may not have TB. A recently established consortium of 15 private laboratories will soon avail of Xpert cartridges and equipment at reduced prices. However, the expected consumer price will still be about US$ 42 (PhP2150), which will likely be unaffordable for the vast majority of patients, especially given that private doctors are evidently willing to prescribe TB drugs on the basis of clinical signs and CxR. The notification initiative has several important limitations. Its salient feature is not so much the passage of the law requiring notification or the availability of a module in ITIS, but rather the deployment of 150 notification associates by PBSP/GF. The main weaknesses are: y

Ninety-five percent of these notifications are clinically diagnosed. The initiative does not include mechanisms to encourage bacteriological confirmation and the quality of

24

Donna Gaviola, personal communication

25

Dr. A. Remonte, personal communication THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

29

treatment (i.e. use of nationally recommended treatment regimen, quality drugs and treatment monitoring) are unknown. y

So far, treatment outcomes for these patients were unknown. There are no systems in place to obtain or validate outcome data for these patients, or to support these patients to adhere to treatment. Mandatory notifications will reduce the national treatment success rate from 91% for the 2017 cohort to 82% for the 2018 cohort, and if they continue to increase in 2019, they could bring the treatment success rate for that cohort as low as 73%.26

y

The notification module is not fully integrated into ITIS. Managers at various levels cannot see mandatory notification cases when they generate reports in ITIS.

y

Many of the mandatory notification cases are likely to be duplicates of referrals that are also registered by DOTS centers. The NCR team visited two mandatory notification providers, both of whom have long been referring almost all their TB patients to DOTS centers for registration and treatment (one for 10 years; the other for 13 years).

y

Almost all (96% in quarters 1 and 2 of 2019) of these notifications have come from three regions in which PBSP has deployed 150 notification project associates whose job is to visit private providers, collect forms in which providers have noted basic data on TB patients and enter the data into ITIS. Implementation has started in other regions without project support, but results have been negligible.

Until the core challenges of bacteriological confirmation and adherence support and monitoring are resolved, this initiative cannot be considered much of an achievement.27 The main plan for increasing private-provider compliance with mandatory notification is to â&#x20AC;&#x153;sensitizeâ&#x20AC;? providers through professional associations, but this is unlikely to be effective.

Program plans are based largely on legal sanctions; incentives and enablers are relatively weak (Table 5).

1.7.3.3

Recommendations28

In order to enhance PPM and ensure maximum benefit to the push to end TB in Philippines, the NTP and partners are advised to undertake the following actions: y

In the short term, the NTP and partners including PBSP and the GF should substantially revise the notification initiative. Notification agents should focus on unengaged providers and avoid duplication when patients are referred to DOTS centers. The mandatory notification module should be fully integrated into ITIS. notification agents should encourage private providers to use STRidersâ&#x20AC;&#x2122; services to increase access to and use of Xpert so that the proportion of BC-TB cases increases with a minimum target of at least 40% as in cases diagnosed in the public sector. Notification agents should conduct or ensure home visits, with counselling, contact tracing and preventive therapy as appropriate, for all privately notified patients, and support them through treatment completion, including by facilitating a switch to program-procured anti-TB medicines,

26

Calculation assuming continued 91% success for the other notifications

27

The Philippines should avoid the experience of of India, which has been encouraging notifications from private providers since 2012, without yet solving these two problems systematically at scale. India recorded 542,000 private notifications in 2018, but recorded treatment success of only 34% among them, and that data are of questionable validity since in most cases it is not based on information directly from the patient.

28

See also recommendations on financing, which are critical to sustained engagement of private providers at scale

30

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

if preferred by the patient. This is likely to require increased management by PBSP and use of digital tools for both data management and adherence support. y

In the revision of PhilSTEP1, the NTP should set ambitious targets for PPM and complement legal sanctions with a full range of incentives and enablers for private provider engagement.

y

As the UHC reforms are piloted, the DOH and LGUs should ensure that provinces and municipalities include all levels and types of private providers in the new service delivery networks, including hospitals, stand-alone physicians, laboratories and pharmacies.

y

In the next GF grant, the Country Coordinating Mechanism should increase the allocation for PPM and expand and intensify enablers for private providers. Specific initiatives could include: automatic online certification-accreditation; a streamlined notification function fully integrated within ITIS; deployment of an app (such as Snap RX or something similar) to facilitate prescription reporting by pharmacies, with patient follow-up by outreach staff; establishment of a call center to support private providers and their patients in notification, referrals and treatment; sputum transport to free, same-day or overnight Xpert, via STRiders or similar mechanisms; and increased use of CxR vouchers for private patients.

1.7.4

Product Supply Management

1.7.4.1

Background

While the focus of the 2019 JPR was on service delivery, during the initial briefing by the NTP to the review teams on October 4, 2019, it became clear that there had been TB commodity supply challenges at the central level and that these had had an impact on the NTP’s TB case finding efforts and treatment outcomes. The PSM specialist was initially placed in the group that was to visit the Davao region; however, as a result of the product supply challenges that were being experienced and in consultation with the NTP, it was decided that the PSM specialist would remain in Metropolitan Manila in order to focus on the key health system aspects such as financing, forecasting, procurement, warehousing, and distribution of TB medicines and diagnostics.

1.7.4.2

Achievements

The 2019 JPR noted the following achievements in terms of TB supply management:

29

y

Increasing domestic funding for TB commodities. While medicines to treat MDR-TB and extensively drug-resistant TB (XDR-TB) are still financed by GF, in principle, first-line drugs (FLDs) and Xpert cartridges are now funded and procured with domestic funds. In 2019, however, the GF and USAID supported emergency procurement of these commodities to prevent a stock-out, as is described below. As TB is a vertical program, there is centralized procurement using government funding. However, there is also decentralized procurement

by LGUs using internal revenue allotment and other funds.29

y

Quality of centrally procured TB formulations. For medicines to treat TB, HIV and malaria, the aspect of product quality is of utmost importance. Therefore, TB medicines are among the formulations actively assessed by WHO. Formulations that have been assessed and found to be acceptable are included in the WHO List of Prequalified Medicinal Products (https://bit.ly/2WluXRS). In the Philippines, the central procurement of first-line TB medicines is carried out using specifications that include a requirement that the products

The internal revenue allotment is a LGU’s share of revenues from the Philippine national Government. Provinces, independent cities, component cities, municipalities, and barangays each get a separate allotment. Some local governments also have additional local sources of revenue such as property taxes and government fees.

THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

31

must have been prequalified by WHO. However, this is not necessarily the case with FLDs procured in the periphery by the LGUs. y

Rapid introduction of new TB formulations and regimen. The NTP has supported and achieved a rapid introduction of the new TB medicines and regimens for the treatment of DR-TB as recommended by WHO. In many other countries, there has been reluctance to make this transition for fear of remaining with unutilized stocks of the kanamycin and capreomycin, which under the new MDR-TB treatment regimens become obsolete. It is commendable that the Philippines have given preference to providing optimal regimens with better treatment outcomes and less toxicity, even though there are remaining stocks of injectable formulations which will have to be written off.

y

Improved central storage conditions. Central storage point conditions for TB medicines and Xpert cartridges have much improved. The Royal Cargo warehouse is rented with GF funding to store GF-financed Xpert cartridges and medicines. At the time of the JPR visit, the estimated (ExWorks) value of the stocks in the Royal Cargo warehouse was US$ 10.5 million, of which US $3.2 million was Xpert cartridges and US $2.8 million was bedaquiline. The third item in terms of value was the now- obsolete kanamycin injection, which represented around US$ 600 000. As can be seen in the picture above, the warehouse provides secure and high-standard storage conditions.

Nonpareil is a private organization contracted by DOH to handle the distribution and storage of medicines procured at the central level for vertical programs, including TB. The Nonpareil warehouse is a considerable improvement over the store that was used before. Nevertheless, at the time of the JPR visit, it was observed that there was a severe storage capacity problem which is listed under challenges below.

32

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

1.7.4.3

Challenges

The JPR observed three major PSM challenges: Stock-outs of FLDs and Xpert cartridges, lack of FLD stock reporting, and overloading of the Nonpareil warehouse.

30

y

Stock-outs of FLDs and Xpert cartridges. In 2019, stock-outs have been the main problem in terms of TB supply management in the Philippines. Both Xpert cartridges and adult FLDs were out of stock for around three months in 2019, while pediatric FLD tablets were not available at all. These stock-outs have resulted in reduced case detection and treatment enrolment. The following paragraphs describe what led to the stock-outs:

y

Adult FLDs. The 2018 procurement was carried out via the default approach of domestic competitive bidding. The supplier that was contracted encountered problems supplying the contracted quantities on time, which mainly resulted from the change in packaging that the NTP became aware of after the selected supplier had already submitted bids.

Both the GF and USAID stepped in by funding emergency procurement of adult FLDs from Stop TB Partnership/Glboal Drug Facility (GDF), which brought some relief but the situation remains vulnerable as there are still outstanding deliveries from the national procurement while the causal factors behind these stock-outs are still in place and are likely to affect supplies in the coming years. Due to the 2018 procurement delays, the budget for that year could not be spent in time. This resulted in severe budget cuts for 2019 and 2020, which means that quantities procured are now based on available budget rather than on actual needs.

y

Pediatric FLDs. The acquisition of pediatric FLDs was even less successful as the domestic central procurement failed to attract any bidders. Providing TB medication to infants and young children is a difficult task. Breaking and crushing of adult tablets is time-consuming and often results in inaccurate dosing and incomplete administration.

Optimized child-friendly flavored dispersible TB tablets have been developed that contain the combination of TB medicines in the right ratio to treat children and that rapidly disperse in a spoonful of water, allowing easy and complete administration. These tablets have been introduced in the Philippines’s NTP guidelines and are included in the National Essential Medicines List. They have been procured in the past from Stop TB Partnership/ GDF, but recent attempts by DOH’s COBAC to procure these formulations domestically with national budget have failed as no manufacturers have registered these products with the FDA. Eventually some of the LGUs were given funding via sub-allotments to enable local procurement of pediatric TB syrups. Such liquid formulations may be easier to administer but are far from ideal as they are more costly and present risks of overdosing and under-dosing.

y

Xpert cartridges. The 2018 central domestic procurement of Xpert cartridges resulted in two failed bidding rounds. The appointed distributor in the Philippines did not partake in the tender as the maximum price that had been set was deemed too low. The price had been set at US$ 15 per cartridge including costs of freight, insurance, etc., which should have been sufficient as the Philippines is entitled to a concessional ExWorks price of US$ 9.98 per cartridge.30 After these failed bids, direct negotiations with the appointed distributor resulted in a price of US$ 20. During finalization of the contract, there were administrative delays which caused the national stock-out. The program already requested GF support when there was a failed bid, and GF responded favorably by financing an emergency procurement

The public sector in eligible countries including The Philippines can purchase test cartridges for TB, hepatitis C, HIV, human papillomavirus (HPV), chlamydia trachomatis (CT)/neisseria gonorrhoeae (NG), and trichonoma vaginalis (TV) at concessional prices as negotiated by the FIND initiative: https://bit.ly/369eDbA. The public sector in eligible countries can purchase instruments and test cartridges by contacting Cepheid directly.

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33

of 400 000 Xpert cartridges directly from the manufacturer (Cepheid). Unfortunately, this consignment arrived late due to delays in custom clearance.

Based on JPR’s observations, the supply problems that resulted in the stock-outs described above are largely explained by a combination of the following four causal factors: a. Increasingly strict market authorization requirements by FDA. In the past, the NTP was able to import TB medicines that had not yet been registered via exceptional import licenses. This is no longer allowed, and even GF- and USAID-procured MDR-TB medicines must now obtain an Accelerated Certificate of Product Registration. b. Procurement being focused on the domestic market. The default procurement approach currently used is via domestic competitive bidding, which in the case of TB medicines and diagnostics resulted in lack of bidders or monopolistic situations and high prices. Meanwhile, Republic Act 9184 or the National Procurement Law permits the procurement of anti-TB medicines and diagnostics from both domestic and foreign sources. Furthermore, based on the 2016 revised implementing rules and regulations of Republic Act 9184, negotiated procurement of specialized goods such as vaccines or drugs through United Nations agencies, international organizations, or international financing institutions is allowed provided that it is done when it is most advantageous for the Government, ensuring both quality and economic benefit. For further guidance, the JPR highly recommends the Stop TB Partnership/GDF Technical report: Feasibility of Government Financing and Procurement of Second Line Anti-tuberculosis Medicines and Diagnostics (December 2018) by Isaac Ireneo Linatoc and Nerizza Muñez, for the NTP DOH Philippines. c. Insufficient available budget. The budget for procurement of FLDs in 2019 and 2020 has been drastically reduced to around US$ 10 million due to incomplete budget utilization in 2018, which was caused by failed procurement attempts. This cut will affect the program for years to come as it is wholly insufficient to provide the FLDs for the expected number of TB cases to be enrolled for treatment. d. Lack of safety stocks. As budgets are insufficient to procure those medicines currently needed, there is certainly no resources to invest in creating a safety stock. The JPR also sensed that the importance of safety stock for TB supplies is not widely appreciated, and it was learned that the Commission on Audit would question the need for such additional stocks. As a result, there are no safety stocks at any level, leaving the program extremely vulnerable to stock-outs in case of any delays in procurement, importation, limited global or local market stock at the time of purchase, distribution or expanded case detection.

All these factors must be addressed, and this will become even more crucial as the country is preparing to take over the financing and procurement of MDR-TB and XDR-TB medicines. For these formulations, each of the above factors will become even more pronounced. y

34

Lack of FLD stock reporting. Treatment sites provide quarterly reports on MDR-TB and XDR-TB stocks and utilization to the NTP, which allows for detailed analysis of the national stock situation and utilization trends. Unfortunately, this kind of reporting is not in place for FLDs. These are used in many more facilities and are procured centrally, as well as locally, with LGU funding. The lack of information at the central level makes it very difficult to manage FLDs, and distribution is basically carried out via a push approach based on assumed needs in the periphery. The JPR understands that DOH/NTP is considering expanding DOH’s ITIS reports to include FLD stock and utilization data.

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

y

Severe overload of stock at the Nonpareil warehouse. At the Nonpareil warehouse, the JPR team observed a severe overload of stock by the various vertical programs for whose product supplies this facility handles. As can be in the pictures below, at the time of the JPR visit, all the isles were blocked with stock that could not be fitted into the four-level pallet racking.

Movement in the warehouse was therefore extremely difficult as forklift equipment could not reach most of the pallet locations. The JPR team could not identify the root cause of this overload. Perhaps the warehouse is simply too small for the commitments it has made to the various programs, but reports were also received that suggested the overload may be due to a payment backlog by DOH for the services provided by the warehouse.

1.7.4.4

Recommendations

To address the myriad TB PSM challenges and ensure a secure and sustainable TB PSM system the JPR recommends that:

y

DOH increase the 2020 TB drug procurement budget from the current US$ 10 million to US$ 24 million. This budget level is based on the following assumption: The program expects to identify and treat around 400 000 adult DS-TB patients per year. Full treatment per person costs around US$ 40 (2000 PhP) based on the most recent local procurement.

Thus, 400 000 treatments x US$ 40 = US$ 16 million. Including a one-time investment in an additional six months safety stock, the required budget is US$ 24 million.

y

For DOH and NTP: For reasons of availability, cost as well as quality, it is important that TB medicines are primarily procured centrally and from the international market.

This is in line with Republic Act 9184. The JPR recommends that Xpert cartridges and FLDs be procured via the Philippines Pharmaceutical Procurement Inc. (PPPI). http://www.pitcpharma.com.ph/. This government entity is experienced and in a good position to make use of procurement laws flexibilities to procure from international sources.

THE PHILIPPINE CONTEXT AND CROSS-CUTTING HEALTH SYSTEM ISSUES

35

36

y

PPPI explore procuring Xpert cartridges from the manufacturer (Cepheid) and TB medicines from the Stop TB Partnership/Global Drug Facility (GDF) which is hosted by the United Nations Office for Project Services. Cepheid should be in position to offer Xpert cartridges at the negotiated concessional ExWorks price of US$ 9.98 per cartridge. The JPR considers that US$ 14/cartridge is sufficient to have the cartridges delivered in-country. The country needs around 500 000 cartridges per year. Compared with the current price of US$ 20 this would yield an estimated annual saving of around US$ 3 million over the current procurement from the in-country distributor. Similar to the United Nations Children’s Fund and vaccines, Stop TB Partnership/GDF offers easy access to the entire range of TB medicines and TB diagnostics of assured quality and at transparent and affordable prices. GDF prices are lower than what the country is currently paying for these products. Including 15% for air freight and other PSM costs, a full treatment of FLDs would cost around US$ 30. The 400 000 treatments, plus additional an additional six-month safety stock would thus cost US$ 18 million. This would yield a saving of US$ 6 million over local procurement of FLDs.

y

To the Philippines FDA: Make use of the WHO Collaborative Registration Procedure (https://bit.ly/31Q8opH) which could enable rapid registration of the full range of WHO prequalified TB formulations.

y

To NTP: Discuss with Stop TB Partnership/GDF and FDA the options of appointing a marketing authorization holder, in case WHO-prequalified TB medicines are registered under the WHO Collaborative Registration Procedure. PPPI has expressed interest of becoming the marketing authorization holder for these medicines.

y

To DOH and NTP: Expand ITIS reports to include FLD stock and utilization data.

y

To DOH and Nonpareil warehouse: Identify and solve the root cause for the stock overload at the Nonpareil warehouse. Solving this issue will benefit the handling of commodities for TB and other vertical programs.

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CLOSING THE TB INCIDENCE–NOTIFICATION GAP: TB SCREENING

2. Tuberculosis screening 2.1 Background The results of the 2016 National TB Prevalence Survey for the Philippines showed a substantial gap in case detection for the country, with approximately 1 million Filipinos estimated to have TB and less than half that number of cases notified per year. The survey also showed that almost half of the people with TB did not experience symptoms that prompted them to seek care: only one third of those with BC-TB reported prolonged cough, and 48% reported no symptoms. The survey also indicated that TB care and prevention strategies cannot rely on self-prompted health seeking, which often does not occur in a timely manner: Six percent of survey participants reported symptoms of TB (prolonged cough), but only 19% sought health care for their symptoms. Of those with symptoms, 41% did not seek care, and another 40% self-medicated. Based on the findings, the first recommendation of the prevalence survey was to conduct systematic screening for TB among high-risk and vulnerable groups.

The observations and recommendations of the 2019 JPR are very much in line with those from the prevalence survey. In order for the Philippines to achieve the ambitious targets of treating 2.5 million people with TB to fulfill the TB-UNHLM and the PhilSTEP1 targets for 2022, there is a need to widely scale up systematic TB screening activities.

2.2 Achievements The 2019 JPR observed many achievements in the area of TB screening in the Philippines.

Starting in 2018, screening activities have been implemented and are starting to be scaled up in the “Big Three” regions of the Philippines, those with the largest population centers – Regions III, IV-A and the NCR. The largest of the screening initiatives consist of three main interventions funded by GF: community-based screening campaigns using mobile CxR vans; vouchers for CxR screening in vulnerable groups; and screening campaigns in jails using mobile CxR. The screening campaigns using mobile vans were also implemented, to a much lesser scale, in other regions funded by DOH, but data are not immediately available. Hence, the data presented below are from the GF activities in the Big Three regions.

The initiatives were introduced in the first half of 2018 and quickly scaled up in the second half, with large numbers of people screened overall (Table 6). Importantly, the active case finding (ACF) interventions contributed of total case notifications in these three regions during the second half of 2018 when they were implemented at large 3–6%.31

31

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Table 6. Results of three large case-finding interventions in the Big 3 regions in 2018 Intervention Community-based ACF using mobile CxR vans

Number of people screened 135 453

Number of TB cases detected BC-TB 1341 (27%) CD-TB 3626 (73%) TOTAL 4968 (3.7% of screened)

CxR voucher program

1631

BC-TB 32 (26%) CD-TB 92 (74%) TOTAL 124 (7.6% of screened)

Screening in jails

50 569

BC-TB 623 (17%) CD-TB 3053 (83%) TOTAL 3676 (7.3% of screened)

SOURCE: Philippine Business for Social Progress (PBSP). ACCESS TB Project Reports

Integrated screening programs are being implemented in hospitals, which combine screening, infection control and notifications from private providers, utilizing the Find TB Actively, Separate Safely, Treat Effectively (FAST) strategy. TB case finders are being deployed in hospitals to find patients with signs or symptoms of TB, refer them for bacteriological testing and notify them to the NTP. Routine screening for TB among people living with HIV (PLHIV) is being conducted in HIV treatment hubs for both outpatients and inpatients. In addition, there have been numerous smaller-scale screening and ACF pilot programs in the country, such as DetecTB, TB Reach projects and other pilot initiatives.

Beyond these initiatives, the JPR team observed many smaller-scale, organic community-based TB screening efforts being conducted throughout the country. Barangay health workers are an important community resource for screening, and in many places they have been utilized to conduct community-based screening activities such as monthly screening campaigns, contact investigations, etc. These campaigns are often locally funded by LGUs and the regional and provincial health offices. In some areas these local screening efforts are linked to 4Ps programs that provide social support to the poorest sector of the community (for example, TB education is included in family development sessions). Lastly, the JPR team observed contact investigation being routinely conducted for contacts of DR-TB patients, including enumeration of contacts, testing of these contacts for TB and rifampicin resistance using Xpert, and the recording of the screening/testing results systematically in TB registries.

2.3 Challenges Along with the achievements noted, the 2019 JPR also observed many challenges associated with planning, implementing, evaluating and scaling up TB screening efforts in the Philippines, which are described below in four primary categories. The overarching challenge in screening is the fact that the scale of screening efforts being conducted in the Philippines is not sufficient to meet the targets of PhilSTEP1 and to decisively begin to overcome the challenge of a large burden of disease in this country. As indicated in previous sections of this report (Section 1.6), the size of the population that is at risk or vulnerable to TB in the Philippines is large but only a very small proportion of this population is currently being reached with TB screening and testing services. Nationally, there is a target for a population testing rate of more than 2% by 2022 as described in PhilSTEP1, with intermediate targets in the interim. Currently, the population testing rate is at less than 0.5%, meaning that the number of people tested needs to more than quadruple in the coming two years to meet targets. In order to achieve this, screening needs to be vastly increased on all fronts.

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2.3.1

Supply chain challenges

The 2019 JPR observed that the shortages and stock-outs of Xpert cartridges and FLDs that affected the entire country as highlighted in Section 1.7.3 brought all case-finding efforts in the country to a standstill. In the second half of 2018 and first half of 2019, several parts of the country experienced major shortages and sometimes complete stock-outs of Xpert cartridges and FLDs for TB, which halted all diagnostic evaluation, including screening activities, as well as routine diagnosis and treatment service delivery. These shortages significantly impacted the large screening initiatives described above. Across all three initiatives, the data show sharp drops in activity from 2018 to 2019.

2.3.2

Challenges in screening the highest-risk groups

The 2019 JPR team observed that the highest-risk groups are not being screened systematically or sufficiently and that contact investigation is inadequate. Household and other close contacts for the majority of TB patients (particularly drug-sensitive patients) are not routinely screened for TB and started on isoniazid preventive treatment (IPT) as appropriate. The screening that is being conducted is clinic-based and passive, including instructing patients to bring any symptomatic household contacts to the clinic for evaluation, and data are not being captured in TB registers.

Insufficient screening is being conducted among people deprived of liberty (PDLs) in prisons and jails. Most jails have entry screening but regular (once or twice a year) screening is not routinely conducted. Screening in municipal jails, where inmates often spend a few months before being transferred to provincial jails, is not routinely being conducted. Investigation of contacts for those diagnosed with TB in jails and prisons is not being carried out, despite the fact that PDLs share very close and confined living space. Screening of health-care workers is inconsistent and while it is being carried out in some areas, it is not carried out in all locations and types of facilities.

2.3.3

Challenges in screening in health facilities

The 2019 JPR team observed that insufficient screening is being conducted in the health-care setting. In health facilities, diagnostic evaluation for TB is primarily conducted for patients presenting with symptoms compatible with TB, rather than providers screening health facility attendees more broadly for TB. The team observed that physicians have a low degree of suspicion for TB in general, and for patients presenting with symptoms compatible with TB, physicians will often evaluate for other differential diagnoses before evaluating for TB. In addition, the availability of chest x-ray (CxR) is limited to selected hospitals and primary care centers. The CxR is not accessible in the majority of primary care health facilities. The lack of access to CxR both at the health facility level and at the community limits the capacity to conduct effective TB screening efforts. It also results in a large proportion of presumptive TB cases being referred to other facilities, public or private, to receive an X-ray before proceeding with bacteriological testing for TB, with associated high costs for patients, delays in diagnosis and care, and high early loss to follow-up as patients drop out of the cascade of care.

The team also observed that screening algorithms are complicated, sometimes involving referrals to outside facilities when tests are not available at the facility, with the resulting delays and loss to follow-up, and sometimes involving testing the same patients with multiple tools.

2.3.4

Challenges in implementing community-based screening activities

While the three large screening initiatives being implemented in the Big Three regions are innovative and promising, the team observed some challenges in the implementation of these initiatives that hindered their effectiveness and impact. First, as a combination of the lack of GeneXpert 40

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

cartridges described above and long turnaround time in receiving results of CxRs conducted for TB screening purposes, there was high loss to follow-up of people in the screening cascade, between being screened and completing bacteriological examination. For the mobile van-based CxR activities, only 35–48% of those who had an abnormal CXR were tested with Xpert, while for the CxR voucher program only 37% of those with an abnormal CxR were tested with Xpert, and in the screening activities in jails, only 67% of those with an abnormal CxR were tested with Xpert. Second, the JPR team noted an increase in rates of clinical diagnosis occurring in active case-finding campaigns, also related to lack of Xpert access, which is alarming. Across all three large TB screening initiatives in the Big Three regions, results show a decrease not only in the total number of people screened and cases diagnosed and notified, but also a decrease in the proportion of cases diagnosed with bacteriological confirmation from the second half of 2018 to the first half of 2019.

More broadly, given the national burden of TB, the team observed insufficient implementation of community-based ACF to close the gap in case detection, especially targeted screening for the very high-risk populations. While the previously described GF initiatives show some promise, they are not enough to address the large case detection gap in the country. A key component of this challenge is the insufficient partnership with the private sector and non-health sector community organizations. These sectors represent not only key partners in gaining stakeholder buy-in for screening interventions, but also for providing linkages between the health screening activity that is being conducted at the community level with TB diagnostic testing and notification at the health facility level.

An important factor to keep in mind for community-based screening efforts is that TB-related stigma is a challenge in the Philippines, and it affects participation in screening efforts, particularly those based in the community. Use of signboards that mention “TB/DOTS Clinics” prominently are likely to be enhancing stigma besides compromising patient privacy and confidentiality. If screening activities and programs are not closely tied to organizations, stakeholders and leaders firmly rooted in the community, the efforts have a higher probability to fail and have adverse and negative effects for those who participate.

Lastly, the team observed universally that data for all screening activities are not being captured systematically and are not routinely reported through the ITIS. While some data for the larger TB screening initiatives are being collected separately, routine data on screening are not being collected. The “presumptive TB registry” in health facilities is being used to capture those referred for laboratory testing, or sometimes just those with test results, but not systematically capturing data on the entry point into the funnel – the group of people being screened. This is essential in order to be able to evaluate and to compare the effectiveness and cost-effectiveness of different types of screening interventions.

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2.4 Recommendations The recommendations of the 2019 JPR in the screening thematic area are organized in the following key areas: 1) overarching recommendations for all screening activities; 2) recommendations for “must-do” screening activities for populations with the highest risk of TB; 3) recommendations for scaling up facility-based intensified case-finding (ICF); 4) recommendations for communitybased ACF; and 5) general considerations for screening.

2.4.1 2.4.1.1

Overarching recommendations for all screening activities Conduct all TB screening efforts using the most sensitive tools possible

The results of the 2016 National TB Prevalence Survey indicate that screening for symptoms of TB will only find one third to one half of people with BC-TB. CxR, on the other hand, had 98% sensitivity for TB in the survey. CxR is a highly sensitive screening tool that captures the vast majority of patients who have TB, while ruling out the majority of patients who do not have TB, thus helping in triaging patients who need further confirmatory testing. For example, if screening all household contacts in Philippines (an estimated population of 1.5 million household contacts of notified cases in 2018), screening with cough followed by DSSM would detect about 21% of the prevalent TB cases, while screening with CxR followed by Xpert would detect over 90% of prevalent cases (Fig. 9).

Screening activities are time- and labor-intensive efforts – if they are going to be done, it is well worth it to ensure they are done with appropriate tools so that they can reach their intended impact. The team also emphasized that all screening activities, including CxR screening, should be provided at no cost.

Fig. 9. Comparative yield of screening household contacts in the Philippines, by screening and diagnostic tool used Maximum case detection (total prevalent cases)

30 000

20 000

10 000

0 Cough -> CxR ->

Cough ->

True Positive SOURCE: Modeling using WHO systematic screening tool.

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

CxR ->

False Positive

As this recommendation requires a vast increase in CxR capacity, including capacity to correctly read the obtained radiographs and provide results, the team provides some suggestions to be explored: y Include CxR in the PhilHealth primary care package under UHC, to ensure everyone in the Philippines can access CxR for screening at least once per year. y

Explore providing CxR capacity in all RHUs. This can be done in many different ways.

Costs of digital CxR units are falling every year, as the quality and safety of the units improve. Mobile handheld units are available even now. Mobile CxR units in vans can service multiple facilities in one municipality or province.

y

Explore avenues for increasing capacity for reading CxRs in a timely manner. Artificial intelligence to read CxR images and provide results immediately shows promise based on operational research, and WHO recommendations are expected soon. Teleradiography, or remote reading of CxRs, is also an avenue for increasing capacity.

y

Explore task-shifting to engage others, such as considering training other health-care workers besides radiologists to read CxRs.

y

Partner with private providers to fully utilize all CxR capacity already existing in the country.

y

Along with this, scale up the free CxR voucher program and expand it to include private facilities with CxR capacity.

2.4.1.2

Ensure data is systematically collected, reported and evaluated for all screening efforts

Screening data, systematically collected and assessed, should be used to inform further program planning and implementation. As the volume of data to be collected for screening interventions is sizable, the 2019 JPR recommends that the NTP consider utilizing electronic data systems for capturing data on screening, which can automate the process of data entry, analysis and summary reporting. Ideally, electronic data collection systems can feed directly into the ITIS electronic reporting, which can utilize electronic tools such as a dashboard.

2.4.2 2.4.2.1 y

32

Must-do screening interventions Contact management

The 2019 JPR team recommends strengthening and systematizing contact investigation and contact management. All household and close contacts of persons with active TB should be screened for TB, using a sensitive screening tool (CxR if possible). The unavailability of CxR should, however, not be a barrier to TB screening. Thus, when CxR is not available, symptom screening using a cut off of one to two weeks for the general population and a cough of any duration for contacts belonging to high-risk clinical groups should be used to identify individuals at the highest risk of having clinical disease. Close contacts of TB patients are one of the groups with the highest burden of TB, with an estimated TB prevalence of 3.1%.32 They also represent a crucial opportunity for TB prevention, including infection-control efforts and TPT for close contacts of TB patients. Contact investigation should be initiated within the household of the index case and in surrounding households and close social or work contacts where feasible, without revealing the identity of the index case, to ensure complete enumeration and initial screening of all contacts. Sputum collection and transport for contacts who are symptomatic for TB, and transport support to a facility with x-ray capacity for asymptomatic contacts, should also be considered. Presently, there are key community Fox et al ERJ 2013 â&#x20AC;&#x2030;CLOSING THE TB INCIDENCEâ&#x20AC;&#x201C;NOTIFICATION GAP: TB SCREENING

43

health worker partners, including barangay health workers and Nurse Deployment Program nurses, who could be engaged in this effort. y

PLHIV should continue to be systematically screened, as well as other groups with a very high risk of TB, including people with diabetes mellitus, people with alcohol abuse disorder, smokers and those who are undernourished.

y

People deprived of liberty (PDL) in provincial and municipal jails should be routinely screened.

Beyond entry screening, routine screening of PDL should be conducted, at least once a year.

When cases are detected, contact investigation and management needs to be conducted.

2.4.2.2

Facility-based intensified case finding (ICF)

y

The 2019 JPR recommends that, in all health-care settings, routine screening for TB should be conducted for all health center attendees. All consults in the health facility should undergo systematic TB screening. Previous operational research has shown that the vast majority of primary care outpatient attendees have either symptoms of TB (prolonged cough, 10%) or risk factors for TB (88% of those without symptoms).33 Further, the prevalence survey shows that one quarter of all TB patients do not have any reported TB symptoms. Given these findings, rather than extend an effort identifying those health center attendees who have symptoms of TB or have any risk factors, all health facility attendees should undergo screening.

y

As described above, the team strongly recommends that screening of health center attendees be conducted using CxR. In situations where that is not immediately possible, screening for TB symptoms (beyond just prolonged cough) should be done at a minimum and CxR screening be prioritized for high-risk groups. Patients with any symptoms compatible with TB accessing care at facilities with no CxR should immediately be sent for bacteriological examination and not referred for further screening.

2.4.2.3

Community-based active case-finding (ACF)

y

The team recommends to resume, as soon as feasible, and scale up community-based ACF activities that were halted due to product stock-outs and start conducting cost and costeffectiveness analyses of the interventions to inform what strategies should be scaled up to other regions.

y

To ensure a systematic approach to planning and implementation of community-based screening activities, the 2019 JPR recommends including ACF activities in official NTP guidelines, from the national to the local level.

y

In order to guide program planning for community screening efforts and ensure that screening activities are targeted to the risk groups that are the highest priority for the region, the team recommends epidemiologic analysis at the regional and local level be conducted to estimate the size of local at-risk group populations to be targeted for screening efforts, the burden of TB in those groups and the expected number of people to be screened to find the prevalent TB cases. This will be essential for planning screening activities including finances, human resources and equipment. If possible, this analysis should be performed at the local level, working with other departments such as Department of Social Welfare and Development to determine the at-risk populations. At minimum, national-level estimates can be applied to local populations to generate local estimates, targets and plans for screening.

33

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IMPACT TB, 2018 2019 PHILIPPINES TB JOINT PROGRAM REVIEW

y

There are many tools available to help with the local estimation of risk group size and TB burden. The Race to End TB application or TB Dashboard, developed to go along with the PhilSTEP1 implementation, is one key tool available for conducting this type of analysis that is preloaded with national and regional level estimates and targets.

Below is an example of a risk-group estimation analysis that was conducted in one province in the Philippines. The risk groups included in the estimation were chosen by the provincial health office. Data for the size of the risk groups and the prevalence of TB were taken from local public health data, the national TB prevalence survey and published literature. Table 7 shows estimated values for the size of the risk groups to be screened, the estimated burden of prevalent TB in each risk group and the number of cases that could be found based on the sensitivity of the screening algorithm used. The graphs show a comparison of the estimated yield of true-positive and false-positive diagnoses in a specific group, as well as the number needed to screen, depending on the screening algorithm used.

Table 7. Estimates of risk-group population size, TB burden and screening yields

Risk groups explored

Number of cases Number of cases that could be found that could be Prevalence Number of through cough found through CXR Population of TB (per prevalent screening followed screening followed estimation 100k) TB cases

by Xpert

by Xpert

General population

1 439 516

1159

16 684

4942

13 354

Urban poor

345 484

1200

4146

1228

3318

Household contacts

20 384

3100

632

187

506

Diabetics

57 581

2100

1209

358

968

Smokers

331 089

1800

5960

1765

4770

Elderly

100 766

1659

1672

495

1338

General outpatients

86 371

1159

1001

297

801

Prisoners

900

26 657

240

71

192

Health-care workers

150

4288

6

2

5

Adult Males 15–64

460 645

1600

7370

2183

5899

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Fig. 10. Comparison of true-positive and false-positive yields and number needed to screen according to the screening algorithm used for household contacts and for urban poor Risk group: Household contacts 600

200 180

500

160 140 120 100

300

NNS

#Cases found

400

80 200

60 40

100

20 0

_x0010_1a. _x0012_1b. _x0017_1c. _x0019_1d. _x0011_2a. _x0013_2b. _x0018_2c. _x001a_2d. _x000e_3a. _x0010_1b.

Cough -> Cough -> Cough -> Any sx -> Any sx -> Any sx -> Any sx -> CXR -> SSM CXR -> Xpert Cough -> Xpert CXR -> SSM CXR -> Xpert SSM Xpert CXR -> SSM CXR -> Xpert SSM

# True cases found

# False positives

0

NNS per true case

Risk group: Urban poor 3500

500 450

3000

400

2500 #Cases found

350

250

1500

200 150

1000

100

500 0

50 _x0010_1a. _x0012_1b. _x0017_1c. _x0019_1d. _x0011_2a. _x0013_2b. _x0018_2c. _x001a_2d. _x000e_3a. _x0010_1b.

Cough -> Cough -> Cough -> Any sx -> Any sx -> Any sx -> Any sx -> CXR -> SSM CXR -> Xpert Cough -> Xpert CXR -> SSM CXR -> Xpert SSM Xpert CXR -> SSM CXR -> Xpert SSM

# True cases found

# False positives

SOURCE: Modeling using WHO systematic screening tool

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

NNS per true case

0

NNS

300

2000

Based on regional and local plans, community screening interventions should be implemented in partnership with local governments, community organizations (including TB survivors) and other local stakeholders. Dedicated budgets and workplans for community screening and ACF activities need to be established to ensure that local and regional government set aside specific funding for health screening to include TB. Throughout this process, TB-related stigma needs to be considered and addressed in how interventions are planned and implemented.

2.4.2.4

Considerations in regard to planning, implementing and evaluating TB screening

y

Consider gender in program planning. The prevalence survey showed that the majority of people with TB in the Philippines are men of working age, which is also the group that accesses health facilities the least and is typically hardest to reach in screening campaigns. Consider screening programs that are men-centric and meet men where they are, including screening in informal employment sectors or over the weekend.

y

Rethink how TB is presented and communicated to the population. Perhaps instead of focusing on TB, the focus can be on screening for health. For example, World TB Day can be rebranded as World CxR Day, with a focus on screening for all health. Review how and where TB information is presented to the public and develop communication tools focused on TB to increase awareness with the public and with health staff and providers in facilities.

2.4.3

Health systems issues and opportunities

The 2019 JPR also identified health system-specific challenges to implementing effective screening in the Philippines. The most significant issue is the availability of financing, tools and human resources. The number of health personnel to carry out screening in health facilities and communities is insufficient, and many existing health personnel are externally funded and their positions within the health system is not stable. However, there are some important opportunities that can be leveraged to increase funding for TB screening activities. These include: y

leverage the UHC health-care provider networks to expand access to screening services;

y

include screening services in PhilHealth to be made available at all primary care facilities nationally, with the costs covered nationally; this should include at least one CxR screening and reading per person per year;

y

engage with the provincial coordinating committee (a multisectoral body) to advocate for resources for health screening at the LGU level;

y

build screening-specific funding into the NTP budget (i.e. improving CxR access);

y

link to 4P program for funding specifically for screening; and

y

explore/consider the UHC special health fund as possible funding source for additional manpower at the provincial level.

Beyond resource limitations, a lack of engagement with the private health-care sector is hindering TB screening efforts nationally. There are some key opportunities for increasing screening capacity at all levels by integrating private and public sector approaches. y

There is a vast number of CxR screening programs that are currently ongoing including annual examinations by corporate employers, the private health-care sector and health management organizations such as pre-employment screening, immigration and overseas clearance, school health screening programs, etc. An estimated 20 million CxRs are

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performed every year, and the vast majority of these examinations are not linked to NTP diagnostic services and notification.

48

y

Beyond these ongoing CxR screening programs, the private sector in the Philippines has a large capacity for screening and diagnosis of TB, including CxR and even Gene Xpert, that should be utilized.

y

The Philippines College of Radiology is a key ally to engage with for TB screening and improving the CxR reading. For instance, the college could advocate with radiologists to avoid providing TB diagnosis based on CxR. Rather, they need to mention in their CxR reports that “the lesions are suggestive of TB” and suggest to the clinicians to “correlate the CxR findings with clinical and bacteriological findings for diagnosis.”

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

3â&#x20AC;&#x2030;

ENSURING ACCESSIBLE, EQUITABLE AND QUALITY TB DIAGNOSIS AND TESTING

3. Tuberculosis testing and diagnosis in the Philippines 3.1 Background The early detection of TB and prompt initiation of treatment have been cited as one of the major approaches for TB elimination in PhilSTEP1. The Laboratory Network Strategic Plan of 2018–2022 guides the delivery of laboratory services in the country with quality assurance. The TB laboratory network is comprised of the NTRL, which has a leadership role, at the top of the network, and other laboratories at national, regional, provincial and city, municipal, and barangay levels. The main task carried out at the barangay level is sputum smears preparation.

Currently, 2872 health facilities offer smear microscopy services, of which, about 2% (55 labs) provide light-emitting diode fluorescent microscopy. The GeneXpert coverage has expanded gradually in the last few years to cover 403 laboratories. There are currently 29 TB culture labs, six of which use the Mycobacterium Growth Indicator Tube technique and nine have the capacity for drug susceptibility testing (DST). Two laboratories have LPA for FLDs and second-line drugs (SLDs) – FQ and second-line injectable (SLI).

3.2 Recent DOH policy directives 3.2.1

Presumptive TB master list

As per the National Tuberculosis Control Program Manual of Procedures, 5th edition, all DOTS facilities are supposed to maintain a presumptive TB master list to be able to track whether all the presumptive TB cases are tested for TB.

3.2.2

Testing policy communicated in October 2018

The policy states the eligible groups of presumptive TB for Xpert testing which is different for the 3 largest regions compared to the other regions.

Table 8. TB testing policy communicated in October 2018 Region

Policy

III, IV, NCR

Xpert MTB/RIF test should be used as the primary diagnostic tool for all presumptive TB cases in addition to presumptive DR-TB.

All other regions

Xpert MTB/RIF test should be used as a primary diagnostic tool for: • presumptive DR-TB • presumptive DS-TB among vulnerable groups (PDL, the elderly, DM, PLHIV, children) • presumptive EP TB specimens • all patients with CxR finding suggestive of TB. Xpert MTB/RIF test should also be used for detecting rifampicin resistance among those new cases who are positive on smear microscopy.

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3.2.3

Testing policy communicated in February 2019

As a result of the temporary shortages in Xpert cartridges new directives were sent out to prioritize Xpert testing as the initial TB diagnostic test in only two patient groups: 1) presumptive DR-TB; and 2) PLHIV.

3.2.4

Testing policy communicated in April 2019

Considering the current utilization and expected availability of Xpert cartridges in the near future, DOH again lifted the restrictions on the use to Xpert as the initial TB diagnostic test to only presumptive DRâ&#x20AC;&#x201C;TB patients and PLHIV, and directed all regions including Region III, IV and NCR to use Xpert as the initial diagnostic test for the patient groups that were listed in the October 2018 communication.

3.2.5

TB LAMP

Six sites in the country under the Centers for Health Development of Metro Manila (three sites), Calabarzon (two sites), and Mimaropa (one site) are implementing TB loop-mediated isothermal amplification (LAMP) through an operations research project being undertaken in collaboration with the Japan International Cooperation Agency. As per DOH directives, these sites use TB LAMP as an initial diagnostic test for all presumptive TB cases in adults who have no known risk for drug resistance, as currently recommended by WHO.

3.3 Achievements 3.3.1

Specimen transport systems

The NTP has been implementing several initiatives to connect health facilities with no TB diagnostic capability to those with this capability. Notable among these initiatives is the Specimen Transport Riders (STRiders) which, by late 2018, was being implemented in all 17 regions. Currently, 264 STRiders have been recruited to serve 242 Xpert sites and 2130 RHUs (> 90% of all RHUs) in the regions. The usual process in place is for a STRider to visit each referring facility under his or her jurisdiction about two or three times a week depending on the distances to be covered, collect samples mainly for Xpert tests and also return the results to the referring facilities. On average one Xpert site serves about eight RHUs. The system has contributed significantly to reducing turnaround-time for Xpert tests, which now averages two to three days. STRiders also collect and pool LPA and culture specimens, which include non-sputum samples for the diagnosis of extrapulmonary TB (EP-TB) and also other specimens such as blood samples for biochemical tests for monitoring patients on treatment for DR-TB. Besides this, there are informal laboratory workers in some peripheral facilities who prepare slides and transport them to DSSM sites. Courier services are being used to transport samples of eligible patients to LPA and culture and DST sites.

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3.3.2

Expansion of laboratory network

Between 2014 and 2019 there was a fivefold increase in the number of GeneXpert sites in the country from 84 to over 400, respectively. The plan is to continue expanding Xpert capacity to over 1000 Xpert sites by 2021. The number of culture and DST labs and labs performing LPA too increased significantly over the same period from 21 in 2014 to 29 in 2019 for culture labs and from one to two for laboratories offering LPA (Fig. 11).

Fig. 11. TB laboratory capacity expansion in the Philippines, 2014â&#x20AC;&#x201C;2019 Expansion of TB Diagnostic Capacity (No. of Laboratories) 450 400 350 300 250 200 150 100 50 0

2014

2017

Xpert SOURCE: National TB Reference Laboratory (NTRL)

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

2018

Culture

2019

LPA

3.3.3

Rapid increase in number of presumptive TB cases tested using Xpert MTB/ RIF

The presumptive TB cases tested using smear microscopy has reduced from about 900 000 in 2016 to close to 700 000 in 2018, corresponding to an increase in cases tested using Xpert that increased from over 150 000 in 2016 to 460 000 in 2018, a threefold increase in the number of presumptive TB cases tested for TB using this WHO-recommended rapid TB test (WRD) (Fig. 12 and Table 9).

Fig. 12. Trends in the use of DSSM and Xpert for TB testing in the Philippines, 2012–2018 1 000 000

100% 901 350

900 000

814 321

800 000 700 000 600 000

759 710 643 151

664 033

85%

85%

90%

806 002 698 768

80% 70%

87%

87%

88%

88%

89%

60%

500 000

50%

400 000

40%

300 000

30%

200 000

20%

100 000 0

15%

15%

13%

13%

12%

12%

11%

2012

2013

2014

2015

2016

2017

2018

AFB Positive

AFB Negative

10% 0%

No. of Cases Examined

500 000

460 721

100%

450 000

90%

400 000

80%

350 000 300 000

59% 74%

66%

70% 74%

76%

250 000

80% 82%

50%

275 468

200 000

40%

156 668

30%

150 000 41%

100 000 50 000 0

60%

26% 12 890

16 803

2012

2013

34%

75 249

25 022

26%

2014

2015

MTB detected

MTB not Detected

20% 24%

20%

18%

2016

2017

2018

10% 0%

Patients tested

SOURCE: National TB Reference Laboratory (NTRL)

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Table 9. Trends in DSSM and Xpert testing in the Philippines, 2012–2018 DSSM

Xpert

Year

Number tested

% testing positive

Number tested

% testing positive

2012

643 151

15

12 890

26

2013

664 033

15

16 803

41

2014

759 730

13

25 022

34

2015

814 350

13

25 249

26

2016

901 350

12

156 668

24

2017

806 002

12

275 468

20

2018

698 768

11

460 721

18

SOURCE: National TB Reference Laboratory (NTRL)

3.3.4

Increasing contribution from mandatory notification

Mandatory TB case notification has been implemented mainly in three priority regions (NCR, Region III and Region IV-A). Despite its limited implementation, the contribution to overall notification reached almost 10%. The NTP has recently appointed notification officers in each of the 17 regions, but the contribution from outside the Big Three regions has been negligible so far (see Section 1.7.2.2).

3.4 Challenges 3.4.1

Missing cases

As previously highlighted in Section 1.5 of this report, over 40% of DS-TB and about 60% DR-TB cases are missed by the NTP. Even though TB case notification has significantly increased over the last decade and reached 348 per 100 000 in 2018, compared to the estimated incidence of 554 per 100 000 in 2018, almost 40% cases were not reported to the NTP that year. In 2018, of the estimated 18 000 incident cases of MDR-TB and rifampicin-resistant TB (RR-TB), only 7276 (40%) were diagnosed by the NTP. There are a number of factors that influence the proportion of TB cases that are missing. In this section the focus will be on those factors that contribute to missing cases that are related to TB testing and linkage to care and treatment.

3.4.2

Insufficient access to molecular diagnostic tools

Access to a highly sensitive and specific TB diagnostic test is facilitatory to TB case finding. This test is currently the Xpert MTB/Rif assay (GeneXpert). In the Philippines only about 15% of all health facilities have GeneXpert on site. Availability of Xpert is suboptimal even in the private sector, where at over US$ 150, the cost of the test, where available, is prohibitive.

3.4.3

Restrictive algorithm for Xpert testing

Use of Xpert as an initial diagnostic tool is restricted to a defined category of presumptive TB cases, which means a large number of presumptive TB cases are offered a less sensitive and specific TB test, such as DSSM. When this is combined with inadequate access to chest radiography, the contribution to the pool of missing cases and or delays in TB diagnosis may be considerable.

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

3.4.4

Inadequate engagement of the private health facilities and laboratories

There are some efforts to engage private laboratories through consortia; however, the engagement is limited in scale and scope. Implementation of mandatory TB case notification is inadequately enforced with only three priority regions contributing to over 90% of total cases of TB notified by private providers through this approach (see Section 1.7.7.2)

3.4.5

Insufficient coverage and scope of existing specimen transport system

The overall number of STRiders and their frequency of visits to RHUs are not sufficient to cope with the increasing expectation to enhance TB case detection.

3.4.6

Concerns regarding the quality of diagnosis

Over 60% of all TB cases notified in the Philippines are clinically diagnosed, and this proportion increases to almost 95% in some private facilities. It is not yet clear what is driving this observation, but inadequate access to Xpert, suboptimal knowledge of clinicians about the most recent practice recommendations for TB diagnosis with overreliance on chest radiography, including high level of trust in the radiologic diagnosis, provided by the radiologists, and the low sensitivity of DSSM may be contributory factors. The proportion of CD-TB has remained almost the same despite the substantial increase in presumptive TB cases tested with Xpert MTB/RIF. Along with the limited access to molecular diagnostic tools, poor knowledge of and nonadherence to the TB diagnostic algorithm possibly play a role. During community TB screening using chest x-ray, local unpublished experience suggests that up to 22% of asymptomatic patients who have abnormal chest x-rays are placed on anti-TB treatment without bacteriological testing.

Fig. 13. Trends in the proportion of CD-TB versus BC-TB in the Philippines, 2016â&#x20AC;&#x201C;2018 Bacteriological confirmation vs clinically diagnosed 100% 90% 80% 70%

63%

61%

64%

37%

39%

36%

2016

2017

2018

60% 50% 40% 30% 20% 10% 0%

Bacteriologically confirmed

Clinically diagnosed

SOURCE: DOH-NTP. Integrated TB Information System Reports

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3.4.7

Variable adherence to the diagnostic algorithm

The 2019 JPR observed that in many peripheral health facilities, health-care workers do not completely adhere to the recommended steps of the TB diagnostic algorithm (e.g., not all eligible clients are referred for Xpert), which has an impact on the quality of diagnosis. Frequent change in policy and practice recommendations, directed by DOH, albeit due to the challenges in laboratory commodity supply, further adds to the confusion.

3.4.8

Possible under/over diagnosis of TB in children and extrapulmonary TB (EP-TB)

The national average for the proportion of child TB cases started on treatment remains around 12%, but it varies widely from 21% in Cordillera Administrative Region and Region III to 3% in Region IX (Fig. 14). The percentage largely depends upon the availability of a pediatrician, tuberculin skin test (TSTs) and CxRs. The proportion of EP-TB is extremely low at about 2% nationally (Fig. 15), suggesting that this form of TB is grossly under- diagnosed, a situation that may be related to inadequate clinical skills and or laboratory capacity to identify and test for TB in this group of patients.

Fig. 14. Proportion childhood TB among all registered TB cases in the Philippines by region % of children among all DS-TB cases, 2015â&#x20AC;&#x201C;2018 CAR Region 2 Region 3 Region 1 NCR Region 4B Region 12 Region 4A Region 13 Region 6 Region 5 Region 8 ARMM Region 10 Region 11 Region 7

National average

Region 9 0

10

20

Percentage (%) SOURCE: DOH-NTP. Integrated TB Information System Reports

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Fig. 15. Proportion of EP-TB among all registered TB cases by region Extra-pulmonary TB (%) CAR Region 8 NCR Region 7 Region 10 Region 13 Region 2 Region 1 Region 6 Region 11 Region 9 Region 4B Region 5 Region 12 Region 4A Region 3

Average

ARMM 0

1

2

3

4

5

Percentage (%) SOURCE: DOH-NTP. Integrated TB Information System Reports

3.4.9

Long turnaround-time for LPA, culture and DST

The turnaround-time (TAT) for LPA results from requesting health facilities varies from one to six months. The JPR team noted that of the two laboratories offering LPA in the country, only one is currently functional and the workload is difficult to manage. The TAT for culture and DST also is quite long, possibly due to a number of reasons, including the use of solid media by most of the laboratories providing mycobacterium tuberculosis culture services, centralized media preparation and limited human resources, among other constraints.

3.4.10 Inconsistent data flow from screening to testing, and testing to linkage to TB care and treatment Although, there are policy directives on recording and reporting of presumptive TB cases (master list), policy implementation is not consistent or complete, and it is therefore difficult to identify leakages across the care continuum â&#x20AC;&#x201C; from the proportion of the at-risk population screened, to the proportion tested, to the proportion of those testing positive for TB who are enrolled in care and treatment. The NTP is also not implementing diagnostic connectivity solutions beyond â&#x20AC;&#x2030;ENSURING ACCESSIBLE, EQUITABLE AND QUALITY TB DIAGNOSIS AND TESTING

57

some pilots, and therefore information flow to referring facilities/physician and the NTP is not optimized.

In terms of Xpert machine calibration, the NTP uses a manual record of the calibration schedule, which is increasingly becoming difficult to follow as the number of GeneXpert machines increases.

This leads to frequent delays in calibration of machines whose consequences are yet to be ascertained.

3.4.11 Frequent interruption of Xpert cartridges and consumables affecting case detection There are reports of the frequent interruption of the supply of Xpert cartridges and laboratory consumables for DSSM due to several factors related to the PSM system as discussed in Section 1.7.3 of this report. As highlighted in the section of this report dealing with TB screening, the disruption in the supply of Xpert cartridges and other laboratory consumables led to the slowing or complete stoppage of intensified and active TB case finding efforts as seen in the lower numbers of TB patients notified in the first quarter of 2019 (a 40% drop) in comparison to the same quarter of 2018.

Fig. 16. Comparison of presumptive TB cases tested with Xpert in the first quarter of 2018 and 2019 Patients tested for Xpert 120 000 100 000

97 912

80 000 60 000

52 402

40 000 17 516

20 000 0

Examined

Positive

Q1 2018 SOURCE: National TB Reference Laboratory (NTRL)

58

10 710 1688

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

RR

889 Examined

Positive

Q1 2019

RR

3.5 Recommendations 3.5.1

Expand coverage and efficiencies of laboratory diagnostic services

y

The NTP is strongly advised to expand coverage of TB testing using a rapid diagnostic test (RDT), essentially the Xpert test currently in use). The country is advised to adopt, as rapidly and feasible as possible, RDT as the initial diagnostic test for most patients and plan to support this policy through an enhanced specimen transport system. The latest diagnostic optimization modeling showed the country needed at least 1254 Xpert machines to meet the demands based on PhilSTEP1 testing targets. Creating hubs and spokes can enable the NTP to rapidly increase the proportion of presumptive TB cases tested with the Xpert. Access to a WRD should be made as equitable as possible with patients accessing care in either the public or the private sector having a similar likelihood of being tested for TB using a RDT.

y

While Xpert machine placement may initially be at high-volume health facilities, this should not limit access to the Xpert test to only patients accessing care in these facilities.

y

The engagement of private laboratories is highly encouraged. Innovative mechanisms for private laboratory engagement should be explored with the aim being to increase access to the Xpert test for Filipinos, while also offering financial protection to TB patients. This holds true also for first-line line probe assays and second-line line probe assays (SLLPAs), culture and phenotypic DST for FLDs and SLDs.

y

The JPR team also recommends that Xpert machines be placed in sites where ACF activities are likely to be undertaken over a long period, such as in large prisons, detention centers, etc.

y

The NTP is also advised to evolve and enhance the STRiders system to make it more efficient, cost-effective and sustainable (e.g. increasing scope, integration, etc.). This may include increasing the number of STRiders, widening the number of facilities (HCs/RHUs, public/private hospitals and private clinics) that are included in the STRider system, and linking community ACF activities with the STRider system.

3.5.2

Improve the quality of diagnosis

y

The quality of TB diagnosis includes quality of all diagnostic procedures/tools and diagnostic behavior. To enhance all components of TB diagnosis, the NTP is advised to regularly monitor the internal quality control for smear microscopy, Xpert and all other laboratory tests. In addition to DSSM, external quality assurance (EQA), the NTP is strongly advised to initiate Xpert EQA, which currently does not exist.

y

There is a need to unravel the reasons behind the high proportion of CD-TB and the JPR advises that an assessment, which may take the form of a clinical audit or some other form of operations research study, be undertaken for this purpose so that appropriate corrective measures can be undertaken.

y

In order to re-enforce the implementation of the standard TB diagnostic algorithm, the NTP will need to carry out extensive training of health-care workers. Classroom-based didactic training is, however, inefficient, takes scarce health-care workers away from their workplaces and may not alter practice. The JPR therefore advises the NTP to design and use digital training approaches such as web-based training that are linked to certification and competency testing. In this training the NTP should pay a high level of attention to the challenges related to the diagnosis of EP-TB and also childhood TB. This needs to

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be complemented by intensive and frequent onsite monitoring and mentoring visits by TB coordinators of all levels. y

The low proportion of EP-TB and the variable proportion of childhood TB among notified TB cases across the various regions needs to be explained, and, therefore the NTP is strongly advised to carry out appropriate assessments, including clinical audits for this purpose and thereafter to develop and implement approaches that will effectively redress these situations.

y

The NTP should regularly monitor TAT for LPA and for culture and DST, and implement corrective actions mainly by improving human resources, training, digital connectivity and uninterrupted commodity supply.

3.5.3 y

3.5.4 y

60

Strengthen flow of information The NTP is strongly advised to strengthen its recording and reporting system to enable leakages in the care cascade to be quantified for corrective action. The entire recording and reporting system should be integrated to include recording and reporting of ACF and ICF activities. Existing partnerships with technical partners such as WHO should be enhanced as ITIS evolves to offer an end-to-end digital health management information system, including interoperable mobile applications and web dashboards. There are several digital connectivity solutions available in the market for connecting digital platforms like Xpert, LPAs, etc. The NTP should evaluate different solutions for cost, need, data privacy, compatibility with existing systems and other context-based parameters to select the most appropriate product to scale up nationwide and for maximum benefit.

Fix the product supply management system This recommendation applies to the broader PSM challenges that have recently led to the stock-out of Xpert cartridges and FLDs. These have been dealt with in the PSM section of this report.

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

4â&#x20AC;&#x2030;

TREATMENT: LINKING PEOPLE TO HIGH-QUALITY, PATIENTCENTERED CARE TO ENHANCE TB TREATMENT OUTCOMES

4. Tuberculosis treatment 4.1 Background In an ideal situation all people – regardless of age, sex or gender, diagnosed with TB of whatever form, including CD-TB, BC-TB, DS-TB, DR-TB, pulmonary TB, and EP-TB – should promptly be linked to care and initiated on treatment using the most efficacious regimen to ensure cure, the lowest risk of acquisition or expansion of drug resistance, and the lowest risk of relapse.

Components of care include patient and family support to cope with the demands of treatment for the disease, such as visits to health facilities for review and medicine replenishment, adequacy of food to cope with the increased demand by the body as it begins to renew itself when treatment begins to take effect, modification of work-related activities as rehabilitation and return to usual level of physical capacity occurs, and support to cope with the social and psychological consequences of TB including efforts to mitigate against self or experienced stigma and discrimination. The term patient-centered care (PCC) has recently come in vogue. The 2019 JPR examined the closeness with which PCC for patients diagnosed with TB is practiced in the Philippines ,and the findings are outlined below.

4.2 Achievements 4.2.1 Enrolment to TB treatment is increasing, although there is a long way to go to reach the PhilSTEP1 target for treatment coverage. For MDR-TB and RR-TB there has been an increased number of patients enrolled as shown in Fig. 17 below. For DS-TB, the number enrolled versus PhilSTEP1 targets are shown in Table 10.

Fig. 17. Trend of enrollment of MDR-TB and RR-TB patients in the Philippines, 1999–2018 35 000 30 000 25 000 20 000 15 000 10 000 500 0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

New Patients

7

15

86

56

22

99

191

134

315

Cumulative

7

22

108

164

186

285

476

610

925 1455 2024 2894 5463 7519 9909 11 919 15 982 21 316 26 957 32 898

SOURCE: DOH NTP Reports

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

530

569

870 2569 2056 2390 2010 4063 5334 5641 5941

Table 10. Number of registered DS-TB patients versus PhilSTEP1 targets, 2017–2019 2017 PhilSTEP1 Targets No. Registered

2018

2019

372 894

371 888

437 291

326 773 (88%)

371 668 (100%)

198 764 (45%) (semi-annual)

SOURCE: DOH NTP Reports and Philippine Strategic TB Elimination Plan

4.2.2 Anti-TB medicines are provided at no cost to all TB patients in the public sector and to patients accessing care in accredited private health-care providers. The NTP provides TB treatment services primarily through RHUs. Intake of drugs by patients assumed or known to have DS-TB, such as those that are clinically diagnosed; patients with BCTB diagnosed using DSSM or Xpert; and those with no rifampicin resistance detected

by Xpert testing, is via self-administered treatment with support by family members.

The amount of anti-TB medicines given to these patients is usually sufficient for one week of treatment in the beginning, but may increase to one month if patients tolerate the medicines well, or if patients reside far from the point of care. On the other hand, MDR-TB and RR-TB patients receive treatment at the Programmatic Management of Drug-resistant (PMDT) Satellite Treatment Center (STC) or RHU directly, observed daily by a health provider.

4.2.3 Treatment regimens for TB and MDR-TB and RR-TB are in line with WHO recommendations.

Non-DR-TB, both new and retreatment, detected by smear and/or Xpert MTB/RIF or CD-TB are treated with a six-month first-line regimen consisting of isoniazid (H) and rifampicin (R) throughout the six months supplemented by pyrazinamide (Z) and ethambutol (E) for the initial two months (2HRZE/4HR).

MDR-TB and RR-TB patients are treated with either a shorter treatment regimen (injectable containing) or an all-oral longer regimen. In 2015, the NTP initiated the WHO-recommended nine-month MDR-TB treatment regimen consisting of high dose moxifloxacin (Mfx), clofazimine (Cfz), ethambutol (E), and pyrazinamide (Z) throughout, supplemented by kanamycin, protionamide (Pto), and high dose H for the initial four to six months (4-6 Am Mfx Pto Cfz E Z H/5 Mfx Cfz E Z) at 10 study sites under operations research. In January 2017, the nine-month MDR-TB treatment regimen was adapted as the standard regimen for MDR-TB and RR-TB (standard short-treatment regimen or SSTR) for patients who are eligible and was scaled up nationwide in November 2017. By 2018, 89% of MDR-TB and RR-TB cases were treated with the SSTR. The NTP has started to phase out the injectable-containing long conventional treatment regimen (CTR), and has introduced the standardized longer oral regimens (SLOR: 18-20 bedaquiline [Bdq], for six months), levofloxacin (Lfx), linezolid (Lzd) and Cfz for fluoroquinolone (FQ)-susceptible MDR-TB and RR-TB, and 18-20 Bdq (6), delamanid (Dlm, for six months), Lzd, Cfz and cycloserine (Cs) for FQ-resistant MDR-TB and RR-TB) and will soon introduce the modified short all-oral treatment regimen (mSTR) consisting of nine Bdq Lfx Lzd Cfz for FQ-susceptible MDR-TB and RR-TB and nine Bdq, Dlm, Lzd, Cfz for FQ-resistant MDR-TB and RR-TB under operations research. A small proportion of patients may be treated with an individualized treatment regimen.

4.2.4 Treatment success for new cases of non-DR-TB is high. Although DOT services have not been provided to these patients, treatment success among 332 028 new and relapse TB patients notified in 2016 was 91%. The proportion of treatment success of new TB patients registered in 2017 remained high (92%). Among MDR-TB and RR-TB patients, the treatment success of those treated with SSTR is higher than those treated with CTR.

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A total of 329 patients were enrolled on the SSTR between July 1, 2015, and December 31, 2016, and 74% (244) were successfully treated, 12% (41) were lost to follow-up, 10% (33) were withdrawn from the study and 3% (10) died. In 2017, the treatment success rate of SSTR reached 69% (1657/2403) and is relatively high in Region 1 (83/99, 84%), CAR (9/11, 82%) and Region 5 (166/205, 81%).

4.2.5 RR-TB care has been progressively decentralized with increasing involvement of the provincial and city NTP teams in supervision, monitoring and evaluation of PMDT at DOTS facilities. PMDT started as a DOTS-Plus pilot project in 1999 by the Tropical Disease Foundation in collaboration with the DOH. The implementation of PMDT was transferred from the Tropical Disease Foundation to the Lung Center of the Philippines in 2010, and later transferred to the Infectious Disease Prevention and Control Division of the Disease Prevention and Control Bureau of DOH (IDPCD-DPCB) in 2014. Services were initially provided through treatment centers (TC) and satellite treatment centers (STCs) in a centralized manner. To integrate PMDT with general TB services, integrated DOTS (iDOTS) was piloted in 2014 in the NCR. As of December 31, 2018, there were 20 TCs and 179 STCs. Of the 2814 RHUs, 2238 (79%) have been trained on iDOTS. There has been an increased proportion (> 50%) of MDR-TB and RR-TB decentralized to iDOTS facilities and the community for treatment.

4.3 Challenges 4.3.1 Non-RR-TB patients with MTB detected by GeneXpert may not always be enrolled on treatment (initial loss-to-follow-up), in part because of insufficient connection between GeneXpert sites and requesting facilities. There are also inadequate mechanisms to look for BC-TB initially lost to follow- up, and support for patients interrupting treatment has not been established. Health workers are not provided with appropriate means to communicate with patients and their families. The initial loss-to- follow-up among RR-TB cases detected was low but still noted to be about 4%. Non-treatment leads to clinical deterioration and facilitates transmission. The decision to initiate MDR-TB and RR-TB treatment was made by the national consilium in the past, which has been decentralized to TC/STC as the TB Medical Advisory Committee. However, the interval between the detection of RR-TB and the initiation of treatment was relatively long in some patients.

4.3.2 The enrolled MDR-TB and RR-TB patients in 2017 and 2018 constitute only 49% and 47% of the PhilSTEP1 targets, respectively. The main target of PhilSTEP1 for PMDT is treatment coverage of 90% of the estimated number of MDR-TB and RR-TB patients by 2022. The estimated MDR-TB and RR-TB cases among notified pulmonary TB cases were 20 000 (18 000–22 000) in 2017, pending targets adjustment based on 2018 Drug Resistance Survey. MDR-TB and RR-TB is estimated to be 2.6% (1.9–3.4) among new TB cases, and 28% (27–28) among previously treated TB cases.

4.3.3 The treatment success among previously treated cases and MDR-TB and RR-TB patients is low. Treatment success among previously treated patients, excluding relapse (n=9223) was relatively low (82%) in 2017, with a substantial proportion of loss-to-follow-up/ outcome-not-evaluated (Table 11). Likewise, among MDR-TB and RR-TB patients treated with the conventional long regimen, the proportion that was successfully treated decreased to 57% in the 2016 cohort from 74% in the 2005 cohort. This was mainly due to an increased proportion of loss-to-follow-up (Fig. 18) as the number of patients in the cohort markedly increased (191 DR-TB in 2005 and 5334 DR-TB cases in 2016). In line with this, the NTP is paying great attention to treatment interruption and has been tracking

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

the number of patients who have interrupted treatment for four or more days in a month (defined as “patients in crisis” of adherence).

Table 11. Treatment outcomes of previously treated TB cases, excluding relapse, in the Philippines, 2015–2017 cohorts Cured Cohort

Total

2015

8728

2016

9761

2017

9223

Completed Success

2062

5049 81%

2791

5061 80%

2565

4986 82%

Died

Failed

Loss-to-follow-up/ not evaluated

408

78

1131

(5%)

(1%)

(13%)

437

67

1405

(4%)

(1%)

(14%)

400

78

1194

(4%)

(1%)

(13%)

SOURCE: DOH NTP. Integrated TB Information System Reports

Fig. 18. Trend of treatment outcome of MDR-TB and RR-TB patients in the Philippines, 1999–2016

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

1999– 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2000

Lost to follow-up

9%

14%

23%

23%

15%

13%

18%

20%

25%

33%

38%

44%

36%

33%

33%

31%

Died

9%

15%

11%

11%

8%

12%

17%

11%

10%

9%

14%

12%

13%

10%

10%

10%

31% 9%

Failure

18%

14%

7%

0%

4%

1%

2%

4%

1%

2%

2%

2%

1%

1%

1%

2%

1%

Success

64%

57%

59%

73%

73%

74%

63%

63%

64%

57%

46%

41%

49%

53%

54%

55%

57%

SOURCE: DOH NTP Reports

4.3.4 The proportion of MDR-TB and RR-TB patients initiating treatment in iDOTS facilities or decentralized to iDOTS after TC/STC-based treatment initiation remains small. This is in part because the training and capacity of iDOTS and community health workers in managing MDR-TB and RR-TB patients is insufficient and institutional stigma against MDR-TB and RR-TB likely remains an issue resulting in reluctance of health-care workers to provide care for MDR-TB and RR-TB patients. Consequently, decentralization remains

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difficult and decentralized patients frequently return to TC/STC when they have adverse events (AEs) during treatment, leading to substantial financial burden on patients and their families.

4.3.5 Active TB drug safety monitoring and management (aDSM) is inadequately implemented.

4.3.5.1 Clinical monitoring using procedures, such as audiometry, ECG and blood tests were not consistently available and not always regularly performed.

4.3.5.2 Support for the clinical management of AEs and co-morbidities among MDRTB and RR-TB patients is insufficient. Clinical management of AEs was mainly handled by nurses, with limited support by clinicians. The Consilium/TB Medical Advisory Committee is not routinely consulted for clinical concerns. Ancillary drugs were not available or were insufficient in some facilities. With new drugs such as Lzd increasingly being used, the capacity to detect and manage its expected adverse reactions is also not in place. Although provincial and city NTP teams have been increasingly active in supervision, they may not be able to provide sufficient support for clinical aspects. The NTP has not yet established capacity for effective clinical management of MDR-TB and RR-TB patients at iDOTS and in the community.

4.3.5.3 Proper recording and reporting of AEs were lacking and aDSM reports of serious and clinically significant AEs may not be accessible to NTP and PMDT sites.

Hence, serious AEs are likely to have been left undetected and unmanaged.

4.3.6 Patients harboring FQ and/or SLI resistance may be on an inappropriate regimen. Shifting from SSTR patients to the appropriate regimen is delayed due to long TAT of SL-LPA and DST of FQ and second-line injectables (SLI), primarily using the line probe assay (LPA), was available only for 20% of MDR-TB and RR-TB patients. Even when available, the turnaround time for SL-LPA was relatively long for some patients, reaching up to three to six months from treatment initiation. Second-line drug resistance based on SL-LPA was 11% in 2017 (n=2401) and 2018 (n=5107) with 3% FQ-resistant, 7% SLI-resistant and 1% resistant to both (NTRL data).

4.3.7 Routine use of the first-line regimen 2HRZE/4HR may not be the best approach for previously treated TB patients found to have no rifampicin resistance by GeneXpert but who have not been tested for susceptibility to isoniazid. The NTP has discontinued the use of the former category II retreatment regimen. Evidence has shown that a six-month regimen consisting of H, R, Z, and E throughout the whole treatment course may perform better than 2HRZE/4HR in patients with undetected resistance to isoniazid (Table 12).

Preliminary results of the 2018 drug-resistance surveillance survey showed 10% isoniazid mono-resistance among previously treated patients.

Table 12. Treatment of isoniazid-resistant tuberculosis with first-line drugs: a systematic review and meta-analysis New

Retreatment

6-9RZE

% Failure

11 (6-17)

6 (2-10)

1 (0-2)

Relapse Acquired resistance

10 (5-15)

5 (2-8)

7 (2-11)

8 (3-13)

3 (0-6)

(0-2)

Source: Gegia M, et al. Lancet Infect Dis 2017;17: 223â&#x20AC;&#x201C;34

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4.3.8 HIV testing among new and relapse TB cases remains relatively low (30% in 2018); however, DOH has already issued a policy that provider-initiated HIV counseling and testing will be a standard of care for all TB patients, not just those in Category A and B sites, which is based on prevalence. However, training for all providers on providerinitiated HIV counseling and testing has not been completed.

4.3.9 Patient support is inadequate particularly for MDR-TB and RR-TB patients who failed treatment and remained chronically ill. Patient counseling, psychologic and material support is also not sufficient for most patients.

4.4 Recommendations 4.4.1 Strengthen measures to reduce patient loss-to-follow-up. To improve treatment outcome of MDR-TB and RR-TB treatment, regional health authorities (Center for Health Development or CHD) and Provincial Health Office (PHO)/City Health Office (CHO) should scale up the adherence tool to monitor the trend of MDR-TB and RR-TB patients who have interrupted treatment for four times in a month (in crisis) and address barriers to adherence to treatment. The CHD and PHO/CHO levels should strengthen case holding of all MDR-TB and RR-TB cases through PCC, build up the capacity for treatment service delivery in iDOTS facilities and the community and provide treatment services that are acceptable and convenient to patients. Engagement of community-based organizations and community health workers (such as those under the nurse/midwife deployment program and barangay health workers) in treatment service delivery and in organizing, utilizing and supervising patient support groups may help prevent treatment interruption.

Further, to improve treatment outcomes of previously treated TB, PHOs and CHOs should pay particular attention to treatment interruption and should address reasons for unfavorable outcomes. To address reasons for initial loss-to-follow-up of BC-TB cases, the NTP should strengthen the linkage between GeneXpert sites and requesting facilities to ensure that patients detected with MTB are enrolled on treatment. Results of the positive GeneXpert test for the presence of MTB should be sent to requesting facilities promptly, through digital technology, with the facility also promptly contacting patients for rapid enrolment into treatment and care. The Presumptive TB Master List is a useful tool for requesting facilities to monitor the outcome of testing and enrollment of patients to treatment, and thus needs to be modified to serve this purpose and be properly maintained. For MDR-TB and RR-TB cases, GeneXpert sites should promptly inform requesting facilities when a RR-TB case is detected, preferably using digital technology, which should ensure prompt initiation of treatment within one week of diagnosis. This will be possible if iDOTS facilities are able to initiate MDR-TB and RR-TB treatment. To achieve this, iDOTS facilities need to be supported and supervised for the initiation of MDR-TB and RR-TB treatment, including building the confidence of iDOTS health workers to comprehensively manage these patients. Interventions for building capacity of iDOTS health-care workers should include strengthened training, mentorship, and support and integration into clinical programs of the TC/STCs, access to support through a hotline or dedicated call center, and the formation of Viber/WhatsApp/Facebook closed groups.

By doing this, seamless DR-TB care can be provided among the iDOTS at RHUs, the community and TC/STCs, a target that is achievable by the end 2020.

4.4.2 Shorten turnaround time of DST and expand NTRL capacity for DST of new and repurposed drugs being used in the program. To obtain results of DST of FQ and SLI in a timely manner, PMDT sites that initiate MDR-TB and RR-TB treatment should always promptly send sputum for SL-LPA and actively follow up results. The NTRL should develop a mechanism to reduce the TAT of SL-LPA to at most two weeks and conventional DST

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to at most two months. In case LPA fails to give results, a repeated LPA may be helpful especially in contacts of XDR-TB. In 2017 (n=2401) and 2018 (n=5107), negative MTB among patient tested with SL-LPA was 18% and invalid results 14%. Furthermore, the capacity of the NTRL for DST to bedaquiline, delamanid, clofazimine and linezolid needs to be established. Also, DST to Z is needed for patients treated with this drug.

4.4.3 To strengthen aDSM, the capacity of health-care workers in facilities and the community in the detection and management of AEs needs to be enhanced through effective supervision and the establishment of a mechanism efficiently providing clinical support in a timely manner (e.g., by establishing a hotline or a dedicated call center for MDR-TB and RR-TB patients and Viber/WhatsApp/Facebook closed groups for their providers).

4.4.4 Support clinical monitoring. Audiometry at baseline and during treatment in patients receiving an injectable agent needs to be performed. The injectable agent could be replaced by linezolid or new drugs following WHO guidelines if audiometry is not available or usable and in patients who begin to show signs of hearing impairment or renal function deterioration. Patients on MDR-TB and RR-TB treatment using Bdq, Dlm, FQ and/or Cfz should have an ECG carried out regularly, including in private facilities if public facilities cannot do it. Adverse reactions of Lzd are relatively frequent and need to be closely monitored (e.g. through patient visits, calls from a dedicated call center).

In case specific services for MDR-TB and RR-TB care are not available in the public sector, PHOs and CHOs need to support patients’ access to private facilities for clinical care and monitoring as needed, with costs covered by the NTP. Ancillary drugs should be consistently provided. For patients who need specialized care, the NTP is encouraged to collaborate with hospital specialists.

4.4.5 Enhance clinical management for better patient care. Regional TB Medical Advisory Committees could be an effective mechanism for providing clinical support for the management of difficult cases at iDOTS facilities and in the community, thus its operation and function need to be strengthened. Some MDR-TB and RR-TB patients, especially those with severe diseases and co-morbidity, would benefit from hospital admission for a short period of time at the onset of MDR-TB and RR-TB treatment. Initial admission and hospitalization any time during treatment, as needed, may help ensure that patients can tolerate second-line anti-TB medicines or effects of co-morbidity.

4.4.6 The procedure in reporting AEs may need to be reviewed to ensure proper reporting and NTP’s ownership and access to reported data. Collaboration with the Philippine FDA’s national pharmacovigilance center also needs to be strengthened to contribute to the monitoring for signals of adverse drug events.

4.4.7 Use novel digital approaches in the cascade of care to support treatment adherence and AE monitoring. Regarding MDR-TB and RR-TB treatment regimens, there has been debates on the relative effectiveness and different profiles of adverse reactions of the injectable-containing short regimen as compared to all oral long regimens. However, any efficacious regimen will not be effective if there is frequent treatment interruption.

4.4.8 The NTP should consider 6HRZE for the treatment of previously treated TB patients without rifampicin resistance detected by GeneXpert who have no DST for isoniazid.

4.4.9 To increase uptake of HIV testing among TB patients, the implementation of providerinitiated counseling and testing needs to be strengthened. It is critical to ensure that HIV testing is provided at no cost to all TB patients countrywide.

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4.4.10 Introduce new regimens in a way that ensures patient centeredness. The NTP should apply lessons learned in the application of SSTR in the national adaptation of WHOrecommended oral regimens. Patients who were interviewed during the JPR mission indicated that they preferred a shorter regimen, even with an injectable agent, so that they can return to their normal life without treatment earlier. On the other hand, some patients on SSTR were also found to have acute renal insufficiency and hearing loss that were either inadequately managed or ignored. Hence, patients’ preference after having been informed of the advantages and disadvantages of the different options of MDR-TB regimens should be greatly respected. But also, providers need to be sensitized to change the regimen relatively quickly, preferably within one month of starting treatment, if the adverse drug reactions cannot be mitigated or if injections cannot be organized within or close to patients’ homes. Travels to distant treatment sites need to be minimized, not just to improve patient-centeredness and reduce loss of income and travel costs, but also to prevent transmission of infection in public transport. Importantly also, the capacity of facilities to implement aDSM should be strengthened and monitored to ensure patient safety against adverse effects of DR-TB medicines. To ensure sustainable cure, post-treatment follow-up (at least until two years) needs to be conducted for both DS-TB patients as well as DR-TB patients.

4.4.11 Provide palliative care for chronically ill and failed patients. These patients need to be counseled and supported. and, when an effective regimen can be designed, treatment needs to be reinitiated. Health providers and family members attending to these patients need to be protected by ensuring infection control measures are in place.

4.4.12 Lessen catastrophic cost. The financial burden of patients and their families needs to be addressed by mobilizing additional funding from all potential sources, including LGUs and CHDs, such as availing of disability benefits for TB patients not only those suffering from hearing or visual impairments, but also patients who are unable to perform essential activities for daily living due to vomiting or weakness.

4.5 Health system issues 4.5.1

Private sector

A substantial number of TB and MDR-TB and RR-TB cases are diagnosed and treated in the private sector but are not reported. In the era of UHC, the role of the private sector in the management of TB is becoming increasingly prominent. The NTP needs to strengthen the engagement of professional societies to update the Clinical Practice Guidelines of tuberculosis care in order to ensure that: 1) sputum examinations will be conducted for all presumptive TB cases; 2) treatment regimens for all TB cases will be in line with national policy; 3) monitoring of treatment will be regularly conducted according to national standards; and 4) the outcome of treatment will be reported to the NTP. Regional health authorities and CHOs and PHOs need to provide public health support for TB patients treated in the private sector, including treatment support, contact tracing and outcome reporting. The NTP should develop clear terms of reference for the private sector in TB prevention and care. (see the PPM section for additional information).

4.5.2

Human resource

In order to accomplish the targets of PhilSTEP1 and in line with the HRH2030 project assessment, it is urgent to ensure that there are adequate numbers of appropriately skilled HRH at the RHUs to manage TB. This includes ensuring that there are doctors to support nurses who are attending MDR-TB and DS-TB patients who have severe disease.

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4.5.3

Financing

As indicated in the section on UHC and PPM, PhilHealth needs to develop a package for MDRTB and RR-TB .

4.5.4

Logistics

It is reiterated that it is absolutely essential to ensure a sufficient and uninterrupted supply of anti-TB medicines to the prevent development and expansion of DR-TB and obtain the best possible TB treatment outcomes for all patients.

4.5.5

Prisons and jails

As plans are developed to enhance ACF in PDLs it is critical to ensure that all elements of PCC (these people are deprived of liberty but have not lost their right to health) are maintained while the person is in prison or jail and on release back to the community. This will require good collaboration and coordination between the penitentiary system and the health units in the LGUs.

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5â&#x20AC;&#x2030;

TURNING OFF THE TAP: TB PREVENTION

5. Prevention of TB infection and progression from infection to disease 5.1 Background The prevention of acquisition of infection by Mycobacterium tuberculosis and the progression of this infection to active TB disease has gained a lot of prominence in recent years, probably as a result of the realization that case finding alone may not be adequate to eliminate TB. Latent TB infection (LTBI) has been described as the seedbed of TB disease, and every effort needs to be made to turn off this tap of future TB disease. Both individual and societal benefits accrue when TB prevention efforts are undertaken on a large scale as was done among the population of Alaska in the United States of America many years ago. The TB-UNHLM, in recognition of the importance of TB prevention, set very ambitious targets (30 million people provided with TPT by 2022) for TB prevention. Because the Philippines is a signatory to the commitments made at the TB-UNHLM, the 2019 JPR identified TB prevention as a critical area of work and undertook to comprehensively review plans, interventions and outcomes of current TB prevention efforts in order to make recommendations to further enhance this area of work to achieve targets. The findings of this assessment are highlighted in this section of the 2019 JRP report.

5.2 Achievements 5.2.1 In 2018 more than 50% of PLHIV who are eligible to receive TPT were offered this intervention.

5.2.2 Overall there is high level of awareness about the importance of TPT and TB infection control practices among health-care providers although implementation remains limited.

5.2.3 In general, health-care workers offered screening and TPT for household contacts, who are under 5 years of age, of BC-TB patients, but with very little follow-up to ensure adherence to this policy recommendation and start of TB preventive treatment. Moreover, children who started isoniazid preventive treatment (IPT) were reported to be completing the treatment course, although there is no national-level data on treatment completion for LTBI. 5.2.4 Capacity exists in the health system to offer the test for TB infection, as at least one nurse at each RHU and in hospitals has been trained on the appropriate administration and reading of the TST. 5.2.5 With regards to TB infection control, most treatment centers for both DS and DR-TB visited by the JPR teams had good natural ventilation or were run under open tent, and surgical masks were available for patients as were N95 masks for staff particularly TCs and SCTs. Provincial hospitals do have isolation rooms. Most of health facility staff are aware prevalence that TB among health workers is one of the indicators to measure effectiveness of infection control.

5.2.6 DOH recently issued a policy expanding the eligibility of IPT in accordance with the recently issued WHO policy. It clearly specifies that IPT could be given to certain eligible population even without purified protein derivative (PPD), which will increase uptake of IPT. In the draft National Tuberculosis Control Program Manual of Procedures, 6th Edition, other short-term treatment regimens for LTBI have been included such as the three-month 12 doses of H and rifapentine. In PhilSTEP1, adoption of short-term TB Preventive Treatment (TPT) is planned for 2020 and onwards with corresponding budgetary requirements.

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5.3 Challenges 5.3.1 Weak and non-systematic performance of contact investigation Contact investigation remains weak and non-systematic. Minimal efforts have been made by health-care workers to ensure evaluation of all household contacts. In facilities that report conduct of contact investigation, there are no records or documentation. Only child contacts are enlisted on index patient treatment cards, no other information with regards to screening, evaluation or start of TB preventive treatment is recorded. No other record or platform exists to record and report on cascade information.

Health-care workers lack clear understanding of the steps involved in effective household contact investigation and the start and completion of TPT, which may be due to suboptimal training with regards to the importance of household contact investigation as well as TPT, hence, there is persistent of fear of causing harm to these children and increasing drug resistance.

Standard operating procedures (SOPs) and roles and responsibilities of health-care workers at different levels of health systems to undertake contact screening, evaluation and systematic linkage to TB preventive treatment are lacking. The feedback mechanism for referral and follow-up of contacts between hospitals and health centers is ad hoc and often accorded low priority.

Contact tracing is nonexistent for index patients diagnosed by private physicians due to lack of capacity to undertake these public health functions in this sector.

5.3.2 Low coverage of TB preventive treatment There is generally low priority accorded to TBPT at all implementation levels: provincial, municipality, barangay. Test for TB infection is recommended as per national guidelines in contacts and other risk populations; however, the availability of PPD has been erratic and some facilities were observed to have been randomly allocated five to 10 vials without considering consumption or the specific requirement.

These factors result to very low coverage (less than 10% in 2018) of TPT among child household contacts of TB patients who are under 5 years of age. TPT among older contacts and other risk populations is not currently implemented.

Health-care workers are not updated on expanded criterion for eligibility of IPT beyond PLHIV and household contact less than 5 years of age. Additional people eligible for TBPT include all other contacts of bacteriologically confirmed index cases and clinical risk groups, such as patients on dialysis or receiving organ transplantation (DOH Memorandum 2019-0257). The memo to this effect has not been disseminated systematically to provincial and municipal health authorities, and training and orientation of health-care workers and providers have not yet been completed across all regions. Shorter preventive treatment regimens are not available despite the issuance of the DOH memo even for the regimen that has previously been used in children, for example 3HR. 5.3.3 The implementation of infection prevention and control measures in facilities is variable There is no systematic symptom screening and triaging of patients with cough at waiting areas in hospitals, RHUs and private clinics that offer TB services as recommended by the IPC policy. Although treatment centers are usually well ventilated, poor ventilation was â&#x20AC;&#x2030;TURNING OFF THE TAP: TB PREVENTION

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noted in public laboratories processing large numbers of sputum specimens, including those laboratories offering the Xpert MTB/Rif test. It was also observed that there was overcrowding in the wards (six to seven patients per room) of some busy hospitals.

Regular fit testing for N95 masks is not performed, and the supplied masks are often of one standard size.

There is limited access to free CxRs for annual evaluation of health-care staff, especially at the level of RHUs, HC and BHS. In many instances the annual X-ray examination is not carried out since the associated cost is not covered by provincial/municipal health authorities.

Although a DOH memo exists, isolation/separation of TB patients from other inmates in jails and prisons is not implemented. In jails, particularly, the inmates undergoing trial do not have access to routine health care, including TB screening and TBPT.

5.4 Health systems issues 5.4.1 There is insufficient supervision of provincial and city NTP coordinators.

5.4.2 With regards to drug supply and logistics, the supplies of PPD is erratic while the 3RH fixed-dose combination of a child-friendly formulation was procured only once in 2017 and was not available at the time of the JPR. Children are prescribed locally procured H syrup, which is more expensive, of uncertain quality and may be associated with uncertain dosing.

5.4.3 There is a lack of mechanism to obtain up-to-date information on the availability of buffer stocks at the RHU level.

5.4.4 There is limited access to CxR services even at provincial hospitals, although facilities exist in private sector that can potentially be tapped.

5.4.5 Health-care staff have multiple tasks with often competing responsibilities.

5.4.6 There is lack of a mechanism for systematic dissemination of DOH policies/memos to all stakeholders at regional and provincial levels, including to the political leadership and the nodal person for TB at provincial and municipality level. The task is not only grossly underfunded but is also grossly under-resourced in terms of HRH with only between four and six staff existing at regional level to undertake dissemination and follow-up implementation of DOH policies and memos.

5.4.7 There are no job aids to support implementation of any new policy or recommended interventions contained in memos from the DOH, DOH Regional Offices or Provincial Health Offices, including job aids that use innovative approaches and digital tools to ensure availability of background information.

5.4.8 There is suboptimal engagement of the community and the private sector. Private physicians are unaware of the protocol for the management of TB infection.

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5.5 Recommendations To enhance IPC and TPT so as to achieve the targets set in PhilSTEP1 and at the TB-UNHLM, the 2019 JPR recommends that the DOH/NTP undertake the following activities: 5.5.1 Emphasize the importance of TB prevention in ending TB at all organizational levels and to all partners by: 5.5.1.1 Including TPT as an integral part of ACF. As efforts to find missing cases are scaled up, TPT therapy should be provided to eligible people identified through these ACF activities.

5.5.1.2 Systematically mobilizing resources and advocate with LGUs at provincial and municipality level to scale up access to tools required for ruling out active TB among contacts of TB patients including CxR and TST. 5.5.1.3 In partnership with LGUs, scaling up use of shorter TPT regimens such as 3HP, 3RH and 4R in line with a DOH memo that provides room for the adoption of any of these regimens. Additionally, ensuring availability of child-friendly fixeddose combination medicines for TBPT in children (such as 3RH).

5.5.1.4 Setting regional targets for number of LTBI to be identified and provided with TPT. 5.5.2 Contact investigations 5.5.2.1 In partnership with the regional health office (RHO), ensuring that updates and new implementation guidelines for TPT are systematically disseminated to health authorities at provincial and municipality level and all concerned health staff are trained on them.

5.5.2.2 Supporting the Provincial Health Office (PHO) to build capacity (orient/ train/ coach) of health- care workers on systematic contact investigations, evaluation of eligibility, provision of TPT, and recording and reporting of TPT. 5.5.2.3 Supporting PHO and municipal health office (MHO) to ensure that all contacts (at least of bacteriologically confirmed cases) are reached and evaluated for TB and eligibility for TPT. 5.5.2.4 Working with RHOs and PHOs to ensure that SOPs are developed for each level of the health system for implementation and monitoring of identification, screening and evaluation of HH contacts and other target populations for TPT. 5.5.2.5 Supporting PHOs and MHOs to ensure that providers at health facilities systematically follow the SOPs and systematically educate index cases and contacts with an emphasis on the importance of prompt screening and initiation of TPT. 5.5.2.6 Prioritizing contact investigation at the earliest following diagnosis and initiation of treatment of the index case. The acceptability of screening and evaluation of contacts is likely to be at a maximum of seven days of diagnosis and initiation of treatment of the index case.

5.5.2.7 Supporting RHOs and PHOs to foster collaboration between private facilities and local government health units to facilitate systematic contact investigation for index patients diagnosed by private physicians and clinics by taking responsibility for this public health function.

5.5.2.8 Dialoguing with and supporting LGUs to mobilize funding resources to actively engage community-based organizations in implementation of HH contact investigation and provision of TPT. 5.5.3 Testing for TB infection 5.5.3.1 In partnership with RHOs, PHOs, MHOs and other partners such as PhilHealth and development partners, facilitating access to CxR screening (as recommended in the national implementation guidance) free of cost, particularly for household contacts > 5 years of age and others.

5.5.3.2 In partnership with RHOs, PHOs and MHOs, establishing mechanism for systematic tracking of all HH contacts of TB patients, screening for TB, evaluation of eligibility and provision of TB preventive treatment.

5.5.3.3 Working with PHOs and MHOs to establish systematic mechanisms for referral and feedback for TB screening and evaluation of HH contacts for TB and provision of TPT between hospitals and health centers.

5.5.3.4 Working with PHOs and MHOs to systematically engage and mobilize all available HRH at the community level (Nurse Deployment Program, barangay health workers) and facilitate implementation of HH contact investigations, TPT and follow-up.

5.5.4 Advocacy and promotion of TB preventive treatment 5.5.4.1 In partnership with PHOs and MHOs, proactively engaging with professional organizations and key opinion leaders to promote TPT. 5.5.4.2 In collaboration with PHOs and MHOs, undertaking a communication campaign to enhance awareness of TPT among health-care providers and the general population to promote good practices and demand creation for TPT services in the general population.

5.5.4.3 Working with PHOs and MHOs in developing tools and materials for systematic health education of index patients, HH contacts, other target populations and community.

5.5.5 Logistics (PPD/medicine) 5.5.5.1 Strengthening the procurement process and working with LGUs to ensure uninterrupted availability of PPD or other tests for TB infection as per national guidelines to be used among contacts of TB patients 5 years and above. The JPR recognizes that PPD availability at the global level is erratic because of market forces and advises that the lack of PPD should not be a deterrent to the provision of TPT, especially to children under 5 who are contacts of BC-TB. 5.5.5.2 Ensuring availability of shorter TB preventive treatment regimens (3HP, 3RH, 4R, 6H) as per the latest MOP. 76

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

5.5.6 Recording and reporting 5.5.6.1 Updating tools for recording and reporting of contact management and TPT. 5.5.6.2 Supporting the provincial NTP coordinators and other supervisors to regularly monitor implementation of contact investigations.

5.5.6.3 Developing targets for coverage of TPT considering all target populations as per national policy (DOH memo and manual for implementation) and establishing mechanisms to provide feedback to regional DOHs and PHOs. PHOs in turn may provide feedback to MHOs. 5.5.7 Infection control 5.5.7.1 Working with health facility managers to ensure that all health facilities, particularly those with high patient volumes, assign a dedicated staff to identify cough-symptomatic individuals among those at waiting areas, provide surgical masks to these patients, and fast track them through appointments with a doctor/nurse, laboratory investigation, drug collection to minimize duration of stay and avoid transmission of infection.

5.5.7.2 Implementing airborne infection prevention measures as an integral part of hospital infection control activities and enhancing natural ventilation where required and feasible by mechanical ventilation to facilitate airflow.

5.5.7.3 Supporting PHOs to advocate to LGUs to support annual physical examinations and investigations for TB in health-care workers and mobilizing domestic resources or tapping into PhilHealth to ensure free access these annual checks.

5.5.7.4 Supporting/working with LGUs to ensure an uninterrupted supply of appropriately fitting personal protection equipment including masks (N-95).

5.5.7.5 Supporting/working with PHOs to establish a mechanism for systematic monitoring of implementation of infection control measure in health facilities.

5.5.7.6 Supporting/working with LGUs to support mandatory screening (CxR) among prison/jail inmates as per existing DOH memo. Jail authorities have a responsibility to protect inmates from acquisition of communicable diseases such as TB. As previously indicated, PDLs have lost freedom of movement but not their right to health, and thus jail authorities are strongly advised to provide space/ room for isolation of inmates who are diagnosed with TB during the period of infectiousness as a way of executing this responsibility. The JPR is, however, cognizant of the fact this may not be possible all the time or everywhere, and in these situations, mechanisms for mitigating the risk of transmission of TB, such as training of inmates with TB on cough etiquette and providing surgical masks to reduce infectious aerosol concentrations in ambient air, may be used.

5.5.8 Health systems 5.5.8.1 Both levels of the health-care system (DOH and LGUs) should work together to provide resources to expand TPT services to geographical isolated and disadvantaged, areas including capacity-building of barangay health workers.

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5.5.8.2 All levels of the health-care system (DOH, RHO, PHO, MHO) should ensure that at least one staff is available per health facility at all levels who is trained/ skilled to perform and read the TST. 5.5.8.3 All levels of the health-care system (DOH, RHO, PHO, MHO) should organize mentoring support for ongoing capacity-building and on-the-job-training of staff to overcome implementation bottlenecks and allay concerns regarding TBPT, for example risk of emergence of drug resistance, serious adverse events, etc.

5.5.8.4 The NTP is advised to work with RHOs and PHOs to establish platforms, with an emphasis on virtual platforms and mechanisms to facilitate cross learning among health providers (physicians, nurses and primary health workers) to overcome challenges in implementation of TBPT services.

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ANNEXES Annex 1. List of 2019 Joint Program Review team members National Capital Region World Health Organization

Mr. Guy Stallworthy

National Tuberculosis Control Program

Ms. Rhea Shella Romero

Taiwan (China) Center for Disease Control

Dr. Anita Chan

Stop TB Partnership

Mr. James Malar

Global Fund to Fight AIDS, Tuberculosis and Malaria

Dr. Mohammed Yasin Mr. Arnyl Araneta

Philippine Business for Social Progress

Ms. Cecile Joy Lagas

National Capital Region Center for Health Development

Ms. Sheena dela Cruz Ms. Ma. Ruby Hanna Cuevas

Valenzuela City Health Office

Dr. John Philip Tiongco

Valenzuela City Health Office

Ms. Famela Ramos

Caloocan City Health Office

Ms. Jennifer Cleofas

Cordillera Administrative Region The Union

Dr. Chiang Chen Yuan

National Tuberculosis Control Program

Ms. Diana Jeane Mallari

Stop TB Partnership

Dr. Sreenivas Nair

Global Fund to Fight AIDS, Tuberculosis and Malaria

Mr. Brian Kanyika

United States Agency for International Development

Dr. Ernesto Bontuyan Jr.

Samahan ng Lusog Baga

Ms. Leah Tambot Mr. Ronald Matitu

Philippine Business for Social Progress

Mr. Randolf Palomique

Cordillera Administrative Region

Mr. Clint Gil Ildefonso

Center for Health Development Benguet Provincial Health Office

Ms. Annelyn Baniqued

Baguio City City Health Office

Mr. Darwin Simsim

Central Luzon University of California, San Franciso National Tuberculosis Control Program

Dr. Cecily Miller Ms. Donna Mae Gaviola Mr. Randolph Capon

National Tuberculosis Reference Laboratory

Ms. Ma. Cecilia Vanessa Serrano

Global Fund to Fight AIDS, Tuberculosis and Malaria

Ms. Caroline Mubangizi

Taiwan (China) Center for Disease Control

Dr. Pin Hui Lee

Philippine Business for Social Progress

Mr. Reno Carter Nalda Mr. John Kirvy Matias

Central Luzon Center for Health Development

Ms. Catherine Toledo

Tarlac Provincial Health Office

Ms. Aileen Javier ANNEXES

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MIMAROPA World Health Organization

Dr. Avinash Kanchar

National Tuberculosis Control Program

Mr. Briccio Echo Jr.

World Health Organization

Mr. Tom Hiatt

United States Agency for International Development (USAID)

Dr. Alex Golubkov

Global Fund to Fight AIDS, Tuberculosis and Malaria

Ms. Thuy-Co Caroline Hoang

USAID TB Platforms

Dr. Karen Dalawangbayan Mr. Jerome Trinona

Philippine Business for Social Progress

Ms. Marie Roderyne Mojica Dr. Emerose Moreno

MIMAROPA Center for Health Development

Ms. Mellanie Montes Ms. Jocelyn Mapagdalita Ms. Rhoda Apacible

Oriental Mindoro Provincial Health Office

Ms. Loriel Dela Pena

Eastern Visayas USAID TASC Adviser

Dr. Ronald Allan Fabella

National Tuberculosis Control Program

Mr. Jeric Perey

National Tuberculosis Reference Laboratory

Mr. Eddie Sistoso Jr.

World Health Organization

Dr. Rajendra Yadav

Stop TB Partnership

Ms. Zhi Zhen Qi

TB Health Education and Livelihood Support

Mr. Daniel Santiago Ms. Clarisa Apuli

Philippine Business for Social Progress

Ms. Agathe Beo Dr. Glendine Porteza

Eastern Visayas Center for Health Development

Ms. Caryl Lapriza Ms. Flor Jimenez Mr. Ernie Oneal Bertiz

Leyte Provincial Health Office

Ms. Karen Piga

Zamboanga Peninsula Philippine Coalition Against Tuberculosis

Ms. Amelia Sarmiento

National Tuberculosis Control Program

Dr. Anna Celina Marie Garfin

USAID TB Innovations Health Systems Strengthening

Dr. Lalaine Mortera Dr. Sein Sein Thi

National Tuberculosis Reference Laboratory

Ms. Elsza Jade Tayactac

SOCCSKSARGEN Center for Health Development

Mr. Kamlon Usman Jr.

Lung Center of the Philippines

Mr. Hernando Caseria

Philippine Business for Social Progress

Mr. Albert Ordonez Mr. Lyndon Bonzon Dr. Maryrose Bugtai

Zamboanga Center for Health Development

Ms. Eastsun Halilou Boniao Mr. Danilo Natividad

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Davao Region KNCV

Dr. Ma. Imelda Quelapio

National Tuberculosis Control Program

Mr. Christian Jay Hontiveros

National Tuberculosis Reference Laboratory

Dr. Ramon Basilio

Global Fund

Ms. Qi Cui

Western Visayas Center for Health Development

Ms. Christine Mosqueda

Xavier University Community Health Care Center

Mr. Joey Tago Mr. Richard Campos

Philippine Business for Social Progress

Ms. Josephine Kaye Adducul Dr. Hansel Amoguis

Davao Center for Health Development

Ms. Sonia Dapitanon Dr. Eleanor Salva

Davao del Norte Provincial Health Office

Ms. Glomerlina Laag Ms. Ruby Rosal

CARAGA Independent Consultant

Dr. Mariquita Mantala

USAID TB Innovations Health Systems Strengthening

Dr. Mary Rosary Santiago Dr. Grace Kahenya Dr. Josep Ryan Macaraya

National Tuberculosis Reference Laboratory

Mr. Earl Christian Mantes Ms. Eidda Agnes

Philippine Business for Social Progress

Mr. Gian Carlo Avanica Dr. Glee Valenzona

CARAGA Center for Health Development

Ms. Arlene Serrano Ms. Erna Cravajal

Agusan del Sur Provincial Health Office

Ms. Melinda Domingo

DOH Central Office World Health Organization National Tuberculosis Control Program

Dr. Jeremiah Chakaya Muhwa Dr. Virgilio Danao Jr. Ms. Princess Allyza Mondala

United States Agency for International Development

Mr. Tito Rodrigo

Stop TB Partnership

Mr. Ron Wehrens

ANNEXES

81

Annex 2. Sites/facilities visited and people interviewed National Capital Region – Valenzuela City and Caloocan City Karuhatan Health Center – PMDT Health Center/Rural Health Unit

Gen. 3 De Leon 3S Health Station Grace Park Health Center – PMDT

Government Hospital

Valenzuela Medical Center PMDT

Private Hospital

ACE Medical Center DOTS

Jail

Valenzuela City Jail

Private Physician Interview

Dr. Isidro Salvatiera of NS Medical and Diagnostic Clinic Dr. Ma. Vida Romano of M/V Romano Medical Center

Cordillera Administrative Region – Benguet and Baguio City Sablan Rural Health Unit Health Center/Rural Health Unit

Aurora Hill District Health Center Pacdal District Health Center

Government Hospital

Benguet General Hospital DOTS Baguio General Hospital PMDT

Private Hospital

Notre Dame de Charles Hospital DOTS

Jail

Baguio City Jail

Private Physician Interview

Dr. Richard Lamar of Epiphany Clinic Dr. Leila Dupiag of D&L Clinic

Central Luzon – Tarlac Moncada Rural Health Unit 1 Health Center/Rural Health Unit

Moncada Rural Health Unit 2 San Manuel Rural Health Unit

Government Hospital

Tarlac Provincial Hospital DOTS and PMDT Concepcion District Hospital DOTS

Private Hospital

Immaculate Concepcion Polyclinic Hospital DOTS

Jail

Tarlac Provincial Jail

Private Physician Interview

Dr. George Martinez of Central Luzon Doctor’s Hospital Dr. (Insert first name) Genilo of Central Luzon Doctor’s Hospital

MIMAROPA – Oriental Mindoro Bulalacao Rural Health Unit Health Center/Rural Health Unit

Gloria Rural Health Unit Naujan Rural Health Unit

Government Hospital

Oriental Mindoro Provincial Hospital PMDT

Private Hospital

Holy Cross Hospital DOTS

Jail

Oriental Mindoro Provincial Jail

Private Physician Interview

82

Private physician from Sebastian Medical and Surgical Clinic Private physician from Maria Estrella General Hospital

2019 PHILIPPINES TB JOINT PROGRAM REVIEW

Eastern Visayas – Leyte Baybay City Health Office Health Center/Rural Health Unit

Leyte Rural Health Unit and Family Planning Center San Miguel Rural Health Unit

Government Hospital

Schistosomiasis Control and Research Hospital PMDT

Private Hospital

Divine Word Hospital DOTS

Jail

Leyte Regional Prison Private physician from Divine Word Hospital

Private Physician Interview

Private physician from Divine Word Hospital

Zamboanga Peninsula – Zamboanga del Norte Sindangan Rural Health Unit Health Center/Rural Health Unit

Roxas Rural Health Unit Dapitan City Health Office

Government Hospital

Dr. Jose Rizal Memorial Hospital – PMDT

Private Hospital

Dipolog Medical Center DOTS

Jail

Manukan Provincial Jail Dr. Philip Limsi of Dipolog Medical Center

Private Physician Interview

Dr. Rosinee Monte of Agape Clinic Dr. Portia Ompoy of Agape Clinic

Davao Region – Davao del Norte Panabo City Health Office Health Center/Rural Health Unit

Carmen Rural Health Unit Kapalong Rural Health Unit

Government Hospital

Davao Regional Medical Center DOTS and PMDT

Private Hospital

Tagum Doctor’ Hospital

Jail

Davao Penal Colony (DAPECOL)

Private Physician Interview

Internist from Tagum Doctor’s Hospital Senior Resident from Tagum Doctor’s Hospital

CARAGA – Agusan del Sur Prosperidad Rural Health Unit Health Center / Rural Health Unit

Talacogon Rural Health Unit Bayugan City Health Office

Government Hospital

D.O Plaza Memorial Hospital PMDT

Private Hospital

San Francisco Doctor’s Hospital DOTS

Jail

Agusan del Sur Provincial Jail Dr. Merriam Barriga of San Francisco Doctor’s Hospital

Private Physician Interview

Dr. Gloria Dela Cruz of Bayugan Doctor’s Hospital

ANNEXES

83

DOH Central Office DOH – Disease Prevention and Control Bureau (DPCB) DOH – Central Office Bids and Awards Committee (COBAC) Philippine Business for Social Progress (PBSP) Medicines, Technologies and Pharmaceutical Services (MTaPS) Philippine Pharma Procurement Inc. (PPPI) Human Resources for Health in 2030 (HRH2030) Philippine Society of Microbiology and Infectious Diseases (PSMID)

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW

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2019 PHILIPPINES TB JOINT PROGRAM REVIEW