TB Dots Program (The Philippines)

Tuberculosis (TB) is a curable disease yet it remains one of the leading causes of death in the Philippines.

Seventy-five (75) Filipinos die of TB every day, most of them in the prime of their life.  If
untreated, a person with tuberculosis can transmit the TB bacteria to as many as 10 to 15 people
during the course of one year, who, in turn, may develop the disease.

In response, Stanfilco and Dolefil have developed partnerships and implemented a TB-DOTS
program to eradicate the illness and raise awareness.  Already in 2004 Stanfilco became the first
company in the Mindanao region to implement a TB-DOTS program, shortly followed by
Dolefil. 

The TB-DOTS program, which stands for Tuberculosis Directly Observed Short-course, has five
components:

1. Political or Management commitment

2. TB diagnosis through sputum microscopy (x-ray is only a secondary diagnostic tool)
3. Availability of complete and quality anti-TB medications
4. Supervised treatment (a responsible person making sure that the patient takes the anti-TB
medication everyday)
5. Recording and reporting of cases and outcomes

The TB-DOTS program complies with the World Health Organization (WHO) standards as a
prescribed, cost-effective strategy to detect, treat and cure TB.  Since the program’s inception at
Stanfilco, it has resulted in the successful treatment of 100 cases out of 400 referrals.

Prior to the formal TB-DOTS program, Dolefil had long been promoting a TB-free workplace. 
Since 2003, Dolefil has been able to identify 70 employees inflicted with the dreaded disease, of
which 39 have fully recovered and 31 are still undergoing treatment.

Thus far the TB-DOTS program has been implemented together with the following partners:

 Philippine Business for Social Progress (PBSP), a foundation of which Dole Philippines
is a member company
 Philippine Tuberculosis Initiatives for the Private Sector, a project supported by the U.S.
Agency for International Development (USAID)
 Philippine Department of Health and the municipal and rural health units
 Kasilak Foundation
 Mahintana Foundation, Inc.

To further secure the success of the program, all Stanfilco doctors and nurses from nine zones in
Mindanao have been fully trained as DOTS providers as of January 2005.  Furthermore, over
1,000 farm clerks and other interested parties have been trained to become TB educators, in turn
giving them the tools necessary to raise awareness and correct misconceptions about TB.  Since
the program’s launch, over 3,000 people (employees, their families, and the surrounding
communities) have been educated about tuberculosis.

Stanfilco’s and Dolefil’s commitment is further illustrated by the fact that they were among the
first companies to comply with the newly signed Department of Labor and Employment
guidelines on TB in the workplace. Furthermore Dole has refurbished an idle facility into a TB-
DOTS facility in the municipality of Lantapan, Bukidnon. The new facility is now serving Dole
associates as well as the barangays- or townships and local agricultural workers in the area. 

What is TB?

Tuberculosis is an infectious disease caused by TB bacteriaa (Mycobacterium tuberculosis) that

primarily affects the lungs.  This condition is known as pulmonary tuberculosis (PTB).  You may
also have tuberculosis in the bones, meninges, joints, genito-urinary tract, liver, kidneys,
intestines and heart and this is called extra-pulmonary tuberculosis.

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What are some of the relevant TB statistics?

The Philippines is among the 22 high-burdened countries in the world according the WHO.  TB
is sthe 6th leading cause of illness and the 6th leading cause of deaths among the Filipinos.  Most
TB pateints belong to the economically productive age-group (15-54 years old) according to the
2nd National Prevalence Survey in 1997.

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How does one get TB?

One gets infected with TB if he inhales the germs released from air dorplets when a pulmonary
TB patient coughs, sneezes and spits.  A PTB patient whose sputum is positive for the TB
germs/bacteria, if left untreated, may infect approximately 10-20 persons in tow years.

top

How is TB diagnosed?

Pulmonary TB is suspected if a person has symptoms of cough for more than 2 weeks, fever,
chest and back pains, poor appetite, loss of weight and hemoptysis.  He should seek medical
consultation and his sputum should be sxamined to detect the presense of TB germs/bacteria.

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How is TB treated?

Tuberculosis is a curable disease.  Patients are prescribed with appropriate regimen to render
them non-infectious and cured, as early as possible.  The treatment for TB is a combination of 3-
4 anti-TB drugs.  NEVER should we prescribe a SINGLE DRUG for TB treatmetn!  This will
worsen the patient's condition.

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What is DOTS?

D.O.T.S stands for Directly-Observed Treatment Short0course.  It is a comprehensive strategy

endorsed by the World Health Organization (WHO) and International Union Against
Tuberculosis and Lung Diseases (IUATLD) to detect and cure TB patients.

There are five elements of DOTS that need to be fulfilled.  These are:

a. political commitment
b. quality sputum microscopy for diagnosis
c. regular supply of anti-TB drugs
d. standardized recording and reporting of TB data
e. supervised treatment by a treatment partner

According to the WHO Report on the TB Epidemic, 1997:

 DOTS cure TB patients and it can produce cure rates as high as 95% even in the poorest
countries.
 DOTS prevent new infections among children and adults
 DOTS can stop resistance to anti-TB drugs.
 DOTS is cost-effective.

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How can we avail of DOTS Services?

DOTS services are available in the rural health units, city health units, city health centers and
government hospitals around the country.  Currently, there are also private facilities that are
offering DOTS services to their clients.

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Is TB curable?

YES! TB can be cured through DOTS.

top

How can private physicians learn to use DOTS?

The Philippine Coalition Against TB (PhilCAT) had already started to adopt DOTS strategy. 
They can contact their different medical societies officers and member offices.  There are already
private DOTs facilities.

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In the meantime, what should patients and physicians do for the prevention and
control of TB?

Those who have symptoms of TB shoul go to the nearest health center to be evaluated for TB. 
Physicians should assure that paitents take their medications regularly and completely.

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What is the National TB Program of the Government?

The National TB Program (NTP) is the Government's commitment to address the TB problem in
the country.  The NTP is being implemented nationwide in all government health centers and
government hospitals.  Its objectives are to detect active TB cases (at  least 70%) and cure them
(at least 85%).  Achieving and sustaining targets will eventually result to the decline of the TB
problem in the Philippines.

86,960,000

TUBE
RCUL
OSIS
PROFI
LE Country
Population
Est. number of new
 TB cases 255,084
Est. TB incidence

(all cases per 100,000

pop) 290
DOTS population
coverage (%) 100
Rate of new SS+

cases
(per 100,000 pop) 130
DOTS case detection
rat (new SS+) (%) 75
e
DOTS treatment

success rate, 2006

(new SS+) (%) 88
Est. new adult TB
cases (HIV) + (%) 0.3
MDR-TB among all
new TB cases (%) 4.0

National TB Control Program

The rising incidence of tuberculosis has economic repercussions not only for the patient’s
family but also for the country. Eighty percent of people afflicted with tuberculosis are in the
most economically productive years of their lives, and the disease sends many self-sustaining
families into poverty. The rise in the incidence of tuberculosis has been due to the low priority
accorded to anti-tuberculosis activities by many countries. The unavailability of anti-TB drugs,
insufficient laboratory networking, poor health infrastructures, including a lack of trained
health personnel, have also contributed to the rise in the incidence of the diseases.
According to the World Health Organization, the Philippines ranks fourth in the world for the
number of cases of tuberculosis and has the highest number of cases per head in Southeast Asia.
Almost two thirds of Filipinos have tuberculosis, and up to five million people are infected
yearly in our country.
In 1996, WHO introduced the Directly Observed Treatment Short Course (DOTS) to ensure
completion of treatment.
The DOTS strategy depends on five elements for its success: Microscope, Medicines, Monitoring ,
Directly Observed Treatment, and Political Commitment). If any of these elements are missing,
our ability to consistently cure TB patients slips through our fingers.
TB Network
What is TB Network?
1. It is the official communication handle of the National Tuberculosis Control Program or NTP
that will stand for DOH’s re-energized fight against TB.
2. It is a product of DOH’s collaboration with the LGUs, PhilCAT, and Philhealth.
3. It is a “special group” dedicated to help/ take care of TB symptomatics and TB patients.
a. Initially, it comprises regular health workers in the RHUs, MHOs and PHOs. b. Eventually, it
will include everyone in the community who wish to help in the administration and financing of
D.O.T.S.; family and relatives of TB symptomatics / patients, church, church organizations,
civic organizations, NGOs, schools, companies/corporations.
1. TB Network comes with several information materials, such as print ads, radio and TV
commercials. Poster of this TB Network as endorsed by Secretary Dayrit himself and with its
battle cry “Kakampi Laban sa TB” will also be distributed as soon as ready.
2. It is participated in by the different stakeholders like donor agencies, private sector, nongovernment
organizations, academe, professional societies, pharmaceutical companies and
other TB DOTS partners and individual advocates united as one for a common cause.
3. Members of TB Network have also expanded to a huge number of other government agencies
as also members of the Comprehensive & Unified Policy for TB Control in the Philippines or
C.U.P.
4. DOH in cooperation with all the involved agencies as members of TB Network continuously
works hand-in-hand in increasing case detection and cure rates in accordance with the NTP
Targets every year.
5. In the end, it can blossom into a systematic, well-oiled, nationwide movement for the
eventual complete eradication and/or control of TB-spearheaded by DOH.
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Creative Considerations
1. Create a strong branding for NTP
2. Establish a human connection between the NTP and Target Audiences
3. Employ a unique visual device that is attractive, impactful, and memorable
Be a TB Networker now !
10 Roles of a TB-D.O.T.S. Advocate
1. Shares experiences and accomplishments in terms of cure and referral to TB Network.
2. Disseminates right information on TB through available Information, Education, and
Communication (IEC) campaign materials.
3. Serves as moral support to TB patients and fellow advocates.
4. Refers individuals with cough for two weeks or more to the nearest D.O.T.S. center for
proper management.
5. Conducts health education activities on how TB disease is acquired and developed.
6. Promotes D.O.T.S. services of TB Partners including private sector.
7. Advocates D.O.T.S. as the Strategy for curing TB.
8. Participates during NTP activities including National Health Events, if possible.
9. Encourages other people from different sectors to be a TB D.O.T.S. Advocate.
10. Assists the treatment partner or may serve as the treatment partner, if necessary.
TB vs. NTP-D.O.T.S
What is TB?
Tuberculosis is an infectious disease caused by TB bacteria ( tuberculosis) that primarily affects
the lungs. This condition is known as pulmonary tuberculosis (PTB). You may also have
tuberculosis in the bones, meninges, joints, genito-urinary tract, liver, kidneys, intestines and
heart and this is called extra-pulmonary tuberculosis.
What are some of the relevant TB statistics?
The Philippines is among the 22 high-burdened countries in the world according to W.H.O. TB is
the 6th leading cause of illness and the 6th leading cause of deaths among the Filipinos. Most
TB patients belong to the economically productive age- group (15-54 years-old) according to
the 2nd National Prevalence Survey in 1997.
How does one get TB?
One gets infected with TB if he inhales the germs released from air droplets when a pulmonary
TB patient coughs, sneezes and spits. A PTB patient whose sputum is positive for the TB
germs/bacteria, if left untreated, may infect approximately 10-20 persons in two years.
How is TB diagnosed?
Pulmonary TB is suspected if a person has symptoms of cough for more than 2 weeks, fever,
chest and back pains, poor appetite, loss of weight and hemoptysis. He should seek medical
consultation and his sputum should be examined to detect the presence of TB germs/bacteria.
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How is TB treated?
Tuberculosis is a curable disease. Patients are prescribed with appropriate regimen to render
them non-infectious and cured, as early as possible. The treatment for TB is a combination of
3-4 anti-TB drugs. NEVER should we prescribe a SINGLE DRUG for TB treatment! This will
worsen the patient’s condition.
What is D.O.T.S. ?
D.O.T.S. stands for Directly-Observed Treatment Short-course. It is a comprehensive strategy
endorsed by the World Health Organization (WHO) and International Union Against Tuberculosis
and Lung Diseases (IUATLD) to detect and cure TB patients.There are five elements of DOTS
that need to be fulfilled. These are:
1. political commitment
2. quality sputum microscopy for diagnosis
3. regular supply of anti-TB drugs
4. standardized recording and reporting of TB data
5. supervised treatment by a treatment partner
According to the WHO Report on the TB Epidemic, 1997: A DOTS cure TB patients and it can
produce cure rates as high as 95% even in the poorest countries.
>A DOTS prevent new infections among children and adults.
>A DOTS can stop resistance to anti-TB drugs.
>A DOTS is cost-effective.
How can we avail of D.O.T.S. Services?
DOTS services are available in the rural health units, city health centers and govern ment
hospitals around the country. Currently, there are also private facilities that are offering DOTS
services to their clients.
Is TB curable?
YES! TB can be cured through D.O.T.S.
What is the National TB Program of the Government?
The National TB Program (NTP) is the Government’s commitment to address the TB problem in
the country. The NTP is being implemented nationwide in all government health centers and
government hospitals. Its objectives are to detect active TB cases (at least 70%) and cure them
(at least 85%). Achieving and sustaining targets will eventually result to the decline of the TB
problem in the Philippines.
Source: Department of Health | Republic of the Philippines

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5
Chapter 2: Current State of Tuberculosis in the Philippines
I. Burden of Illness of Tuberculosis in the Philippines
Tuberculosis (TB) is still a major public health concern in the Philippines, ranking as the
sixth (previously fifth) leading cause of morbidity and mortality based on recent local
data.1,2
Globally, the Philippines is ninth, previously ranked seventh, among 22 high burden
countries and ranks third, previously second, in the Western Pacific region based on its
national incidence of 133 new sputum smear-positive cases per 100,000 population in 2004
(from 145 new cases per 100,000 in 2002)3
The Philippine Health Statistics recorded a total of 27,000 deaths from tuberculosis, at the
turn of the century.1 The National Tuberculosis Program (NTP) reported 130,000 to
140,000 TB cases, mainly discovered and treated in government health units, of which 60%
are highly infectious smear-positive cases.4 As of 2004, the case detection rate (CDR)
improved from 53% in 2003 to 68% and the cure rate increased from 75% in 2003 to
80.6%. Both are however still below global targets of 70% and 85% respectively.
The involvement and participation of the private sector in the NTP implementation was
started in 2003 and private-public mix DOTS (PPMD) facilities were established. An
additional 3% was contributed by the private sector to the CDR, increasing it to 71%.
Success rates, which include cured and completed treatment cases, have reached 88.5% for
the past 3 years. The most important effect of PPMD is that it resulted in a marked
improvement of the public sector performance in the PPMD site itself, from 53% to 68%.
A third national prevalence survey is due in 2007, to determine the impact of the revised
NTP ten years since DOTS has been implemented nationwide.
Economic Impact of Tuberculosis
Tuberculosis in the country exacts serious economic consequences caused by loss of
income due to disability and premature death. Based on the incidence5, mortality data 6, and
the 1997 Philippine population by age and gender, assuming a duration of illness at 2.2
years, Peabody and colleagues estimated that 514,000 years of healthy life or disability
adjusted life years (DALYs) are lost, due to illness and premature death from TB each year,
affecting predominantly males and the most productive age group.7 The actual number of
DALYs may be higher due to under reporting or misreporting.
Based on treatment effects regression analysis of TB impact on daily wage rates using 1998
APIS data at prevailing prices in 2002, men with TB earn Philippine Peso (PhP) 451 less
than those without TB; and females with TB earn PhP 216 less than those without TB. This
translates to almost PhP 8 billion loss of income per year for the country. Foregone income
6
is approximately PhP 26.4 billion due to premature deaths from TB, which does not yet
include direct and indirect cost of treatment, productivity losses and income loss due to
disability from TB. 7
The prevalence of tuberculosis is highest among the poor, elderly and urban dwellers.
Multi-Drug Resistant Tuberculosis (MDR-TB)
Based on the 1997 National Prevalence Survey (NPS)8, the incidence of MDR-TB, defined
by the WHO as in vitro resistance to both isoniazid and rifampicin, is 4.3%. In the Sentinel
Surveillance Study involving 4 sites in the Philippines (the National Capital Region,
Zamboanga, Cebu, and La Union), the MDR-TB rate was 5.1%, while the Multicenter TB
Study done in 1998 covering seven regions reported 9.7%. Looking at selected areas in the
country involving 265 patients with positive AFB smears and TB cultures, the rate of
MDR-TB was 6.4% in Metro Manila, 9.6% in La Union, 4.4% in Zamboanga, and 5.2% in
Leyte.9
Tertiary hospitals in the Philippines also show alarming rates. Fifty-two percent of
culturepositive
previously treated patients progressed to become treatment failures and eventually
became MDR-TB in a study by Quelapio and colleagues.10 Investigating the susceptibility
of MDR-TB strains from 50 patients undergoing re-treatment to second line-agents,
another hospital noted high resistance rates against ofloxacin (20%), ethionamide (34%),
kanamycin (46%), and cycloserine (48%). 11
Global rates for MDR-TB vary in published literature. The first and second global report
on MDR-TB released in 1997 involving 35 countries, and 2000 involving 58 countries
respectively, showed a rate of 1.4%. In selected “hot-spot” areas, however, the rate was
noted to be as high as 54%. Areas reporting higher MDR TB rates were noted to have a
higher number of previously treated patients and a poor tuberculosis control program. 12
Tuberculosis in Special Populations
There is a paucity of local data describing the incidence of tuberculosis in special groups of
individuals.
HIV Patients. Resurgence of tuberculosis in the 1980’s has been attributed to the
discovery of the human immunodeficiency virus. Presently, estimates ranging from 2.4 to
7.5% of HIV-infected individuals in less developed countries are assumed to develop active
TB each year.13 The rate of development of active TB was noted to be similar in tuberculin
positive and tuberculin negative HIV patients – 7.1/100 person-years versus 6.7/100
person-years.14 Here in the Philippines, limited data on TB/HIV co-infection exists. HIV
prevalence in the general population is reported as less than 1% (<0.1 to <0.2%)15.
Montoya and colleagues documented 39 (48.75%) of 80 HIV infected patients having
7
Mycobacterial infection, 34 of whom had a positive AFB smear. Of the 25 patients with
positive cultures, 22 (88%) had M. tuberculosis.16 In a retrospective review involving 72
patients with HIV/AIDS, 10 (13%) were diagnosed to have tuberculosis.17 At present, the
degree of infectiousness of an HIV patient with TB remains unknown.
Health Care Workers. Risk of developing tuberculosis is higher among health workers in
the medical and tuberculosis wards (13%), compared to other areas in the hospital (3%).
This is 40 times higher than the general population.18 In a cross-sectional study of medical
and chemical engineering students in different levels of their training programs,
tuberculosis infection was determined using the tuberculin skin test (TST). Medical
students were noted to have an increasing prevalence of positive reactions to TST as they
advance (4.6%, 7.8%, 16.2%, respectively, p<0.001), while chemical engineering students
do not (4.2%, 4.3%, 4.4%, respectively, p = 0.913). The risks were greatest during the
years of clinical training, when medical students have increased contact with patients.19
Children. Tuberculosis in children has not been given much attention until 1993 when the
World Health Organization recognized the burden of tuberculosis in children. Most cases
in children are due to the spread of tuberculosis from sputum positive adults. In
industrialized countries, the frequency of tuberculosis will be less than 10 per 100,000
population, though in slum dwellers, this may rise to 60/100,000. In South Africa, and
India, the caseload from birth to 15 years is between 20 to 39%.20 In the Philippines, a
prevalence study in a rural community involving 240 children showed that 52.1% who got
exposed to sputum positive adults and only 43.1% with exposure to adults with PTB based
on positive chest x-ray findings, were positive purified protein derivative (PPD) reactors.21
Elderly. Tuberculosis in the geriatric population warrants investigation due to the
increasing longevity and waning immunity in this group. In Hong Kong, cases of
tuberculosis in individuals above 60 years old increased from 31.9% to 45.4% from 1989 to
1998. In this age group, tuberculosis is diagnosed in advanced state and is usually
accompanied by other co-morbid illnesses.22 In a home for the aged, utilizing miniature
chest radiographs, Llado and colleagues were able to determine the prevalence of
pulmonary tuberculosis at 9.4%.23
Other Immunocompromised Conditions. End-stage renal disease patients, diabetics,
individuals with connective tissue disease, i.e., systemic lupus erythematosus and receiving
chronic steroid therapy, and patients with hematologic or solid-organ tumors are another
subgroup of patients commonly afflicted with tuberculosis. The incidence of tuberculosis
in dialysis-requiring patients was 134 per 100,000 person years with more than half of the
population presenting with extrapulmonary manifestations.24 The condition is suspected in
patients with prolonged fever, commonly of an unknown origin.25 In a local review of
cases, TB, as presumptively diagnosed by radiographic abnormalities, was found to be the
most common infection, occurring in 309 (37.3%) diabetic patients.26 In diabetic patients
with confirmed tuberculosis, cavitary lesions (82%) are more predominant than noncavitary
lesions (59%).27 In systemic lupus erythematosus patients, prevalence of
tuberculosis from Philippines, Singapore and Mumbai ranged from 5 to 30%.28
8
II. The National Tuberculosis Program: Historical Perspectives and Major
Achievements
The major points in the history of tuberculosis control in the Philippines are summarized in
the Figures below.
Box 2. Historical Points in the Tuberculosis Control in the Philippines 1910-1950.
History of Tuberculosis Control in the Philippines
(1910-1950)
1910: Mortality rate due to Tuberculosis was 487 per 100,000
The Philippine Islands Anti-Tuberculosis Society (now known as the Philippine
Tuberculosis Society Inc or PTSI) was founded on July 29,1910 by Governor
Cameron Forbes. Mrs Eleanor Franklin Egan was its first President and
Honorable Sergio Osmeňa was its first Vice-President
1911: San Jan del Monte Sanitarium was opened with 14 nipa hut cottages
to admit TB cases
1918: Santol Sanitarium opened. Treatment consisted of fresh air, sunshine,
nutritious food, bed rest and isolation
Radiologic services began with fluoroscopy as initial test for case finding
1932: Mortality rate due to TB was 223.85 per 100,000
1932: TB Commission was created (Act No. 3743)
1933: Powers and duties of TB Commission transferred to Bureau of Health
1934: Sweepstakes Law (RA 4130) established the Philippine Charity
Sweepstakes Office (PCSO) to fund Society’s operations
1938: Santol Sanatorium was renamed as Quezon Institute
The name of society was changed to Philippine Tuberculosis Society Inc,
PTSI.
1944: Streptomycin (SM) was first used as part of the treatment for TB
1947: Mainstays of TB treatment were pneumotherapy, thoracoplasty and
prolonged hospitalization
1948: Quezon Institute was rehabilitated after WWII
1949: First case of pneumonectomy in a far-advanced case
9
Box 3. Historical Points of Tuberculosis Control in the Philippines 1950-1990s.
History of Tuberculosis Control in the Philippines
(1950- 1990)
1950 TB Commission became Division of Tuberculosis under the Office of
the Secretary of Health
TB Center within the DOH with the TB Ward at San Lazaro Hospital
Treatment offered: Streptomycin (SM) injection and Para-Amino Salicylate
(PAS) tablets
Extension services thru Chest Clinics, mobile radiographic (or xray) units
and educational campaigns
1951: BCG vaccination started
1954: Tuberculosis Law (R.A. 1136) which created the Division of
Tuberculosis and the National Tuberculosis Center of the Philippines at the
DOH compound
1954: Triple drug therapy with Isoniazid (INH), PAS and SM
1958: E.O. 288establsihed the Bureau of Disease Control and the Division
of TB was placed under it.
1964: Minglanilla Prevalence Survey in Cebu Province which showed the
prevalence of smear positive was 4/1000.
1968: National TB Program expanded with the creation of Rural Health
Units (RHU). Services offered: direct microscopy, domiciliary care,
selective Xray, BCG vaccination, TB registry. Treatment offered: 12 months
of INH-SM
Mid 70s with huge expansion of TB Program and active partnership
between the DOH and PTS: New thrust on 1)case finding through sputum
microscopy with more microscopes and training for microscopy at the
RHU level, 2) case holding with medicine available; 3) importance of BCG
vaccination, later became compulsory and part of the Expanded
Program for Immunization (EPI)
1973: PTS home program launched; PCCP was formed
1974: Treatment offered: 18 monthss of INH-SM-Ethambutol
1976: Establishment of National Institute of Tuberculosis (NIT) in
cooperation with the WHO and UNICEF intended for human resource
development and operational researches
1981-1983: first National TB Prevalence Survey by the NIT
1980s: the Lung Center of the Philippines opened
1984: More NIT researches led to the introduction of a new treatment
regimen called the Short-Course Chemotherapy (SCC):
o 2 months Intensive Phase of INH-Rifampicin-PZA or 2HRZ
o 4 months Continuation Phase of INH-Rifampicin or 4HR
1986 after the People Power revolution, the Ministry of Health became the
Department of Health (DOH). The TB Control Service was created.
1987: the strengthened National TB control Program was launched and
the SCC was adopted nationwide. Medicine was available in blister
packs. Manual of Procedure was revised. PTS and DOH partnership was
further strengthened, with PTS Chest clinics adopting National TB Program.
1989, 1990, 1993: Philippine College of Chest Physicians-led Tri-Chest
Organization with DOH and other agencies released consecutive parts of
the First National Consensus on Tuberculosis.
10
Box 4. Historical Points in Tuberculosis Control in the Philippines 1990- 2000s.
History of Tuberculosis Control in the Philippines
(1990s to 2000s)
1990: NTP received financial and technical support from Italian government
and World Bank improving TB control at Regions 5,8,10, other cities and
provinces.
1991: Local Government Coded devolved the DOH health services to the
local government units (LGUs) which became the implementers of the NTP.
1990s: TB efforts in Cebu was boosted by support of the Japanese
International Development Agency (JICA)
1992: the Quezon Institute was restored by the PCSO
1994: The Philippine Coalition Against TB (PhilCAT) was organized with key
professional societies involved in the fight against TB along with the DOH as
founding members57
1995: TBCS issued Revised Policies and Guidelines on the Diagnosis and
Management of TB with new thrust to improve case holding.
1995: University of Santo Tomas TB Clinic introduced use of directly observed
treatment in managing outpatient TB
1996: DOH piloted the Directly Observed Treatment Short course (DOTS)
strategy in three areas: Batangas, Antique and Iloilo City
1996 onwards: expansion of DOTS with the strategy officially adopted by the
NTP with active participation of the LGUs, various partners in TB including WHO,
World Bank, JICA, World Vision-Canadian International Development Agency,
Italian Cooperation for Development, Australian Aid and Medicos del Mundo.
1996: August 19 was proclaimed as National TB Day Proclamation
1997: The Philippine Pediatric Society (PPS) presented the Second Consensus
on Childhood Tuberculosis during PhilCAT convention
1997: the DOH subcontracted the conduct of the Second National TB
Prevalence Survey with the Tropical Disease Foundation. The prevalence of
sputum positive individuals was 3.1 per 1000 population and the annual risk of
infection was computed at 2.3%
1998: PhilCAT led the first local commemoration World TB Day on March 24
1998: TheNational TB Control Program became one of the flagships of the DOH
1999: The First Clinical Practice Guidelines on the Diagnosis, Treatment and
Control of Tuberculosis was developed spearheaded by the Philippine Society
of Microbiology and Infectious Diseases (PSMID) with the PCCP and the DOH.
1999: The TB Control Program became the No. 1 priority health program of the
LGUs. Procurement of anti-TB drugs was transferred to the Regional Health
Offices
11
Box 5. Historical Points in Tuberculosis Control in the Philippines 2000 to Present
History of Tuberculosis Control in the Philippines
(2001 to Present)
2001: the PTSI continued to flourish with 52 branches across the country. They
strengthened the implementation of DOTS. The Quezon Institute was renovated.
2001: PTSI hosted the 21st Eastern Region IUATLD Conference jointly with the PCCP.
2001: The first DOTS-Plus Project was initiated by a private agency the Tropical
Disease Foundation Inc. (TDFI). Being the first and only Green Light Committee
approved facility, TDFI expanded its DOTS services to include management of
MDR-TB cases through its DOTS-Plus initiatives.
2002: The Comprehensive and Unified Policy (CUP) on TB control was issued by
President Gloria Macapagal-Arroyo on March 2003 as Executive No. 187. This was
a joint product of many public and private organizations spearheaded mainly by
the DOH and the PhilCAT. The CUP synchronized the different TB control efforts of
the various agencies, with the NTP guidelines as the implementing framework.
2002-03: The DOTS strategy achieved nationwide coverage in the public health
sector. All public health centers, RHUs and their substations were utilizing the NTP
policies and the DOTS strategy for their local TB control efforts.
2003: The first National Drug Resistance Survey was initiated with the external
support of the WHO and JICA. The results became the basis for the policy to
address MDR-TB.
The NTP maintained the quadruple therapy but shifted its policy from use of single
drug formulations (SDF) to fixed dose combination (FDC). This is the present
treatment formulation under the NTP for all DOTS facilities.
2003: The Philippines received an international grant through the Global Drug
Facility (GDF) for additional drug support, vis-a-vis PPMD installation. The regular
drug procurement of the NTP is also coursed through this agency.
2004: the Hospital-based NTP-DOTS policies were issued to involve hospitals in the
provision of DOTS services and strengthen the inter-facility referral network.
The Lung Center of the Philippines became the government’s counterpart support
to the DOTS-plus initiative.
Since then the coverage of DOTS broadened to include all other key health
sectors. The Public-Private Mix DOTS (PPMD) strategy enhanced private sector
adherence to the NTP-DOTS. The Operational Guidelines on PPMD was developed
by the NTP in cooperation with the PhilCAT, WHO and GFATM.
What followed was the development of various models and approached to
operationalize the PPMD with strong support from partners such as the PhilCATCenters
for Disease Control (CDC)-USAID, PhilTIPS-USAID, and the GFATM.
Among the major TB projects were 1) the PhilTIPS project assisted by the USAID
which focused on improving TB services of the private sector; 2) the LEAD project
also assisted by the USAID which looked into improvement of the quality of services
of the public sector through strengthened local governance and capacity
development; and 3) several rounds of the GFATM through the PhilCAT, World
Vision and the TDFI which worked on additional PPMD units, creation of social
demand and expansion of the DOTS-plus.
In line with the Health Sector Reform Agenda (HSRA), the DOTS certification to
ensure the quality of DOTS services as delivered by all DOTS facilities and the
Philhealth TB OPD Benefit Package through the process of DOTS certification to
allow sustainability of quality services were institutionalized.
2005: The Third Revision of the Manual of Procedures (MOP) of the NTP was
released.
12
III. Assessment of Tuberculosis Control in the Philippines
Tuberculosis remains a major health problem despite laudable efforts of the National TB
Program after the implementation of DOTS in 1996. Since the introduction and
maintenance of DOTS in the public sector, and the subsequent expansion involving the
private sector, several accomplishments have been reported.
In spite of the remarkable achievements, several issues and concerns related to TB control
have been identified. Various problems linked to factors attributable to the patient, the
health care provider, and the program contributes to the persistence of tuberculosis in the
country.
Patient-related Factors
The health seeking behavior of patients with tuberculosis is highly variable as shown in the
1997 National Prevalence Survey. In this study by Tupasi 29, patients with symptoms
suggestive of TB took no action (43%), self-medicated (31.6%) or consulted a health care
provider (25.4%), which include private medical practitioners (11.8%), public health
centers (7.5%), private hospitals (4.4%) and traditional healers (1.7%). Among those
confirmed to have the disease, 32.9% did nothing.
Significant differences in the health seeking behavior were noted when symptomatic
subjects were stratified into those with and those without bacillary disease (p=0.003), by
symptoms reported (p< 0.001), or by age group (p< 0.001). Patients with chest or back
pains (Odd’s Ratio [OR] 1.33, 95% CI 1.08-1.62) were likely to take no action; conversely,
those aged 40-59 (OR 0.74, 95% CI 0.62-0.89) and 60 and over (OR 0.59, 95% CI 0.47-
0.74) were likely to consult. Self-medication was significantly less likely in those
presenting with hemoptysis (OR 0.40, 95% CI 0.26-0.62) or chest/back pain (OR 0.57,
95% CI 0.46-0.72) and in those aged 60 years and over (OR 0.74, 95% CI 0.58-0.94). 19
Determinants to utilize government health centers included bacillary disease (OR 2.21,
95% CI 1.17-4.17), presence of two or more symptoms (OR 2.23, 95% CI 1.50-3.30),
hemoptysis (OR 3.0, 95% CI 1.81-4.96) and age groups 40-59 (OR 1.76, 95% CI 1.21-
2.56) and 60 and above (OR 2.31, 95% CI 1.53-3.50). Determinants to consult private
doctors were: age group 60 and over (OR 2.67, 95% CI 1.94-3.66), residence in urban (OR
1.39, 95% CI 1.03-1.88) and urban poor areas (OR 1.72, 95% CI 1.26-2.36). Chest/back
pain was a determinant for consulting a traditional healer (OR 4.42, 95% CI 2.07-9.41),
aged 40-59 years (OR 0.43, 95% CI 0.22-0.88) and 60 and above (OR 0.08, 95% CI 0.01-
0.62) were less likely to consult traditional healer.19
A survey conducted by Portero et al30 in Metro Manila, Philippines in 2002 showed that
only the factor of no intention to seek health care among TB symptomatics correlated
significantly with average family income; those with low income (< Php 2,000 monthly)
were seven times more likely than those with medium and high incomes not to intend to
seek medical care (OR 7.10, 95% CI 8.25-6.11). Similarly, those with low income were
almost twice more likely than the rest to self-treat for TB (OR 1.74, 95% CI 2.06-1.46).30
13
Perception and belief have been reported to influence health-seeking behavior.31 The
knowledge, attitude and perceptions towards tuberculosis among Filipinos are likewise
variable. The National Demographic Health Survey (2003) among TB patients showed the
following findings32: (a) there is a high level of awareness for both men and women that
TB is curable (89%, 92%, respectively); (b) majority identified smoking as the main cause
of TB (57% in men, 47% in women) followed by alcohol drinking, fatigue and microbes or
germs or bacteria; (c) sharing of eating utensils is still the most widely accepted mode of
transmission; (d) 53% of persons delay consult despite symptom/s because TB is perceived
as harmless; and (g) awareness of DOTS strategy is less than 20%. In the same survey,
government facilities emerged as the most common source of anti-tuberculosis drugs
among individuals who took anti-TB medicines, which is less than 25%; proximity is the
main reason for the choice of health care provider, while the choice of private physicians or
clinics is based on and perceived quality of service. A similar study conducted in Malabon
reported TB to be acquired by allowing sweat to dry from body, vices and hard labor; and
delay in health seeking is due to high cost of medical care. 33
Socio-economic conditions play an influential role in the perceived knowledge of TB
patients concerning the disease’s diagnosis and treatment. Knowledge of a disease is
essential to its control. A study by Portero et al20 found level of education as the only
independent variable associated with TB knowledge. A college degree and a higher family
income were associated with a higher level of understanding of tuberculosis as a disease,
while a non-formal education was associated with the belief that tuberculosis is an inherited
disease; a majority of respondents from this category linked TB with poor living conditions
and air pollution. Although TB knowledge score was not influenced by the source, the
radio (78.6%) was the most popular medium for TB information in any socio-economic
group.20
Healthcare Provider-related Factors
In 2003, strengthened government commitment and funding led to 100% DOTS coverage
of public health units; however case detection rates did not meet global targets.34 Of those
who sought professional care, TB symptomatics preferred private practitioners and
hospitals because of perceived quality of service, guaranteed confidentiality and flexibility
of treatment, compared to health centers where microscopy services and anti-TB drugs are
free (16.2% versus 7.5%).35,36,37
The Philippines has a large number of private providers (both for-profit and non-profit),
representing a large available resource nationwide, utilized even by the lower income
groups, as yet untapped by the national TB program.38 It is estimated that 20,000 to 35,000
of sputum smear positive patients seek treatment from private physicians each year.5
Private doctors see an average of 16 TB patients a month, roughly one in ten patients, or
14% of their average patient load, mostly by pulmonologists (27%), infectious disease
specialists (12%), internists (10%), general practitioners (9%), family medicine (9%), and
non-pulmonary specialists (8%). TB suspects also comprise a large proportion of the
patient loads of radiologists (50%), surgeons (29%) and pathologists (20%). 9
14
However, recent surveys conducted since 1998 (Table I) still showed poor compliance by
the private sector to the standards set by the WHO-NTP in the diagnosis and treatment of
tuberculosis.6-9 Case finding and holding mechanisms, including reporting in the private
health sector remain variable, individualized, and generally not linked to the NTP. General
practitioners posted the lowest average vignette scores followed by those practicing in
schools, work areas, hospital outpatient (OPD) and emergency room (ER) areas compared
to specialists when asked about their knowledge on tuberculosis and DOTS.9
Table I. Summary Table of Studies on Private Physicians and their Adherence to the
WHO-NTP Standards on the Diagnosis and Treatment of Tuberculosis.
Manalo et
al
199839
Medicos
del Mundo
2001 40
PhilCAT/CDC
200241
UP Econ
Study
2004 42
No. of doctors
surveyed
214 1355 188 1535
Coverage Family
physicians,
Nationwide
Nationwide NCR-Cavite Nationwide
Average number of
new TB pts seen/mo
Not
reported
5-10 5 16
Use of x-rays as
primary diagnostic
tool
Not
quantified
87.9% 95% 45%
Use of sputum
microscopy as
primary tool
Not
quantified
17.4% 59% 12%
Treatment adherence
to NTP (%)
29% 10.7% 16% 25%
Number of treatment
regimen variations
>100 64 >80
Recording/Reporting Variable Variable Variable Variable
Private physicians referred their patients to health centers only if they cannot afford to pay
microscopy examinations done at the private laboratory and/or unable to buy branded anti-
TB medications.8 Only 20% of physicians surveyed nationwide referred to health centers;
most referrals are confined within the private sector.9 There is fear of losing patients to
health centers, mistrust in the quality of free government TB drugs, habitual drug shortage
in the past, perceived attitude problem among government workers, perceived “slow”
patient services, and lack of knowledge of the NTP and its free services.43 This manifests
the explicit lack of strategies and policies to inform the private sector about renewed
government efforts and involve them in the revised National TB Program, one of the major
findings of the WHO global assessment in 2001.44
15
National TB Program-Related Factors
TB control programs must prioritize the prevention of new infections through
the elimination of the source of transmission. At the moment the TB control program is
focusing on achieving the benchmark of 90% successful completion of therapy for all
patients with active disease.45,46 This will become possible with effective case finding and
efficient case holding. Through the adoption of DOTS under the NTP in 1996, policies and
mechanisms have been laid down to guide the country’s approach to meeting the targets of
70% detection rate and 85% cure rate set by the WHO in order to significantly decrease TB
prevalence rates.
IV. Current Activities on Tuberculosis Control
What is currently being done to address patient-related problems?
In 2002, the creation of social demand for DOTS services is one of the directions of the
Global Fund through production of broadcast and print IEC materials, focused community
organizing, and provision of innovative promotional approaches to improve the knowledge,
attitude and practices of TB clients. The World Vision Philippines, Health Promotion
Center, DOH, and the LGUs were involved to implement these projects. The impact of
such activities still remains to be seen.
What is currently being done to address provider-related problems?
Recognizing the potential and pivotal role of the private sector as the missing link to
achieve global targets in case detection and cure rates, the Philippines pioneered to adopt
officially the public-private mix (PPM) strategy in its national TB program in 2003.47,48
In 2003, PPM models supported by CDC, PhilCAT and DOH were pilot-tested in different
private clinic settings, which led to replication and creation of more PPM sites nationwide,
public- or private-initiated, as technical and financial support from the Global Fund and
Philippine Tuberculosis Initiatives in the Private Sector (PhilTIPS) poured in. Also,
PhilHealth has included adequate reimbursement for TB case management to public and
private units accredited to provide DOTS services, including DOTS referring doctors.49,50,51
Regional Centers for Health Development (CHDs) and NTP Coordinators became the
government infrastructure that implemented, consolidated and scaled up initiatives to
involve private hospitals, clinics, health maintenance organizations (HMOs) and individual
private practitioners as DOTS partners at various levels.52,53,54 In preparing the government
health sector for this public-private collaboration towards TB control, the Local
Enhancement and Development (LEAD) Project conducted governance strengthening and
technical/capacity building activities for government doctors.
16
Six professional medical societies have committed to engage its members to DOTS
implementation through its integration in the residency and fellowship training programs.
These societies were the Philippine College of Physicians (PCP), the Philippine College of
Chest Physicians (PCCP), the Philippine Academy of Family Physicians (PAFP), the
Philippine College of Occupational Medicine (PCOM), the Philippine Society for
Microbiology and Infectious Diseases (PSMID) and the Philippine Pediatric Society (PPS).
The Association of Private Medical Colleges (APMC) has likewise mandated the
integration of TB and NTP education in the medical curriculum. At least two-thirds of
medical schools have become involved in DOTS activities at various levels.
As of June 2006, there are 379 PhilCAT-certified PPMD facilities (332 public, 47 private),
of which 222 are PhilHealth-accredited. There are 2,474 private practitioners who have
been re-trained on the NTP to engage them as either DOTS referring physicians, members
of the TB Diagnostic Committee, or as PPMD providers. However, DOTS training was
limited to medical society conventions, training institutions, project and local coalition
initiatives. A sustained, regular, massive DOTS information dissemination for all private
physicians remains to be seen.
The UP Econ study9 shows that of the private doctors managing TB, 75% are aware of
DOTS, however, only 35% reported adopting it in actual practice either as referring
physician (52%), provider (26%), certifier (18%), or TBDC member (15%). About 28%
still report exclusively using chest x-ray as primary diagnostic tool. Even among those who
claimed to be DOTS-trained referring doctors and certified DOTS provider, vignette scores
of knowledge on DOTS were variable and barely met acceptable cut-offs. There are
relatively low levels of formal DOTS engagement and even lower levels of actual TB
DOTS practice. One-time information dissemination alone or financial incentives itself is
not sufficient to encourage formal adoption and actual practice of TB DOTS. Both are
needed and must be sustained.
Regression analysis in the same survey shows the following findings that may have impact
on future information dissemination efforts:
Those who are likely to be DOTS-aware are those who are PhilHealth-accredited,
with more recent TB training within one year, who are pulmonary specialists,
members of specialty societies, and who are engaged in teaching and research.
Those who are likely to adopt DOTS in private practice are those with multiple
clinics, with awareness of the PhilHealth TB outpatient benefit package, who
received DOTS training, who practice in clinics with access to sputum collecting
equipment, who are pulmonary specialists, and who practice in work-based clinics.
Those who are likely to seek certification as DOTS referring physician are those
who already are PhilHealth-accredited health professionals, who have multiple
clinics with larger patient load, who are aware of the PHIC TB out-patient benefit
package, who have received TB DOTS training, who practice in clinics with
17
sputum collecting equipment, who are pulmonary specialists, who are based in
HMO clinics, hospital OPD or emergency rooms, and more recent TB training.
Those who are likely to seek certification as DOTS providers are those who are
PhilHealth-accredited, who report awareness of the Philhealth TB out-patient
benefit package, who have received TB DOTS training, who are in clinics with
sputum collecting equipment.
Those who are likely to use sputum microscopy are those who are not accredited
with private insurance firms (including HMO accreditation), who are members of
specialty societies, who are aware of the Philhealth TB outpatient benefit package,
who are younger, and who had more recent TB training.
Those who are likely to use the NTP-recommended SCC regimen are those who are
teaching, who have more recent TB training and who have lower TB patient load.
Those who are likely to separate TB patient records are those who are not
accredited with private insurance firms (including HMO accreditation), who are
members of specialty societies, who do not own their clinics, who have greater TB
patient densities, who have been trained, and who are aware of the PHIC TB
outpatient benefit package.
Those who are likely to utilize treatment partners to monitor drug intake are those
who have multiple clinics, who are engaged in teaching and research, who have
clinics in public health facilities and who are aware of the Philhealth TB outpatient
benefit package.
These suggest the need for more intensified information campaigns both among physicians
who actually manage TB patients and those who do not for possible referral to DOTS
facilities. More information campaign activities should target (1) older physicians, (2)
physicians with less recent TB training, (3) those in freestanding clinics, (4) non-members
of specialty societies, and (5) general and family medicine practitioners, internists, and
non-pulmonary specialists.
Among existing PPMD units, cost recovery mechanisms are not in place, not many are
PhilHealth-accredited and reimbursements are operation-limited. Financial sustainability of
PPMD units is yet to be assured.
Overall, the private sector has contributed an additional 3% increase in case detection rate
through its 96 established PPMD’s (Figure 1). The figure also shows the unexpected but
pleasant marked improvement observed from the public sector in the various areas where
the PPMD site is established, from 53% to 68%!. These increases led to the breaching of
the target detection rate of 70% in late 2004. A sustained monitoring scheme for the private
sector is yet to be implemented
18
What is currently being done to address program-related problems?
The NTP, through strengthened government and non-governmental support and funding,
has created and implemented several policies and guidelines.
The DOTS strategy achieved nationwide coverage in the public health sector
between 2002-2003. All public health centers, RHUs and their substations were
utilizing the NTP policies and the DOTS strategy for their local TB control efforts.
To ensure quality assurance of the NTP’s laboratory services, the National
Tuberculosis Reference Laboratory (NTRL) was built at Research Institute for
Tropical Medicine Compound in Alabang, through the support of the DOH-JICA
partnership project.
The first National Drug Resistance Survey was initiated in 2003 with external
support from WHO and JICA. The primary implementer is the NTRL in
coordination with various Regional TB Reference Laboratories and the local
government’s microscopy centers. Plan for dissemination of results is slated this
year (2006). This is important for the NTP later, as its basis for policy formulation
to address the threat of MDR-TB.
The NTP maintained the quadruple therapy but shifted its policy from use of SDF
to FDC anti TB drugs. This policy change was disseminated to all DOTS service
providers nationwide and is the present treatment preparation under the NTP for all
DOTS facilities, including the PPMD units.
In 2003, the country got an international grant approval, through the Global Drug
Facility (GDF), for additional drug support, vis-a-vis PPMD installation. Also, the
NTP’s regular drug procurement is now channeled through this international
agency.
The Comprehensive and Unified Policy (C.U.P.) on TB Control is a joint product of
key government agencies spearheaded by the DOH and private organizations
foreran by PhilCAT. This was issued by Her Excellency on March 2003 as
Executive Order No. 187 to synchronize TB control efforts amongst these agencies,
with the NTP guidelines serving as their implementing framework.
In 2004, the Hospital-Based NTP-DOTS policies were revised to broaden the
participation of hospitals on the DOTS strategy. This was initially intended for the
government hospitals where strengthening of a facility referral network is being
promoted. This Administrative Order also provides guidelines on provision of
DOTS services for hospitals.
The coverage of DOTS, to include other key heath sectors, became inevitable to
harmonize the TB control activities in the country. Private sector engagement to the
NTP-DOTS was built on partnerships, through the PPMD strategy. The Operational
19
Guidelines on PPMD was developed by the NTP, in cooperation with PhilCAT, the
WHO and the Global Fund Against Tuberculosis and Malaria (GFATM).
From 2003 up to present, various models and approaches to operationalize PPMD
are currently being undertaken with supports coming from PhilCAT-CDC-USAID,
PhilTIPS-USAID and the GFATM.
Two USAID-assisted projects support the NTP. The PhilTIPS Project is focused on
improving the TB services of the private sector through their engagement with the
NTP while the LEAD Project enhances the quality of the public sector through
strengthened local governance and capacity development.
The GFATM Round 2, another approved international grant, embarked on the
installation of additional PPMD units, creation of social demand and, expansion of
DOTS-Plus. This is in partnership with PhilCAT, World Vision and the TDFI
respectively. Its 4th component is the 3rd National Prevalence Survey, which will be
conducted in 2007.
The Lung Center of the Philippines (LCP) represents the Government’s counterpart
support to the DOTS-Plus initiative. The DOTS unit of LCP also functions as a
satellite treatment center for MDRTB cases within its localized catchment area.
Expansion of DOTS-Plus to the LCP is through GFATM assistance.
At present, the External Quality Assurance (EQA) on direct sputum smear
microscopy is being implemented on a phased basis. This system guards the quality
of NTP laboratory services provided by the peripheral microscopy centers. The
NTRL and the respective Regional TB Reference Laboratories oversee the system
by strengthening its laboratory network.
In view of the Health Sector Reform Agenda (HSRA) adopted by the country, the
DOTS certification is developed to ensure the quality of DOTS services delivered
by all DOTS facilities, both public and private. Likewise, the PhilHealth TB
Outpatient Benefit Package, through the process of DOTS accreditation, serves as
the NTP’s health financing scheme to sustain such quality services.
The 3rd revision of the MOP was undertaken by the DOH in partnership with local
and international agencies. The 2004 edition includes the recent initiatives of the
NTP with the perspective of a stronger private involvement in the Program.
20
Figure 1. Case Detection Rates of All Private-Public Mix DOTS Centers 2001-2004
%
Case
Detection
Rates
V. Further Measures Necessary to Fully Achieve TB Control in the
Philippines
The difficulties associated with different factors related to the patient, the healthcare
provider and the national program require the following additional measures to achieve TB
control:
Patient-related Factors
1. Efforts towards promotion of awareness among people regarding tuberculosis,
through health education programs should be intensified. These activities should
specifically address a) knowledge of the disease, b) health-seeking behavior c)
attitudes towards self-medication and source of treatment, provided that:
a. Socio-economic factors should be considered in the design of TB
information campaigns specifically the level of education.
b. It is community-based.
2. Mass media can play a key role in a program based on passive case-finding and free
diagnosis and treatment to encourage people to seek medical care.
53.2 52.7 53.3
68
30
40
50
60
70
80
2001 2002 2003 2004
Public + Private Smear (+) Public Smear (+)
54
71
21
3. Policy makers should address socio-economic issues closely associated with
tuberculosis as well and these are a) poverty b) low educational attainment c) poor
living conditions.
Research Gaps on Patient-related Factors :
1. Health systems research to determine the obstacles among low-income patients to
accessing free government TB health services
2. Evaluation of the effect of current education dissemination efforts on the knowledge,
attitude and practices in the community
Healthcare Provider-related Factors
Current efforts, policies and program planning should further intensify involvement of
the private health sector to engage them in various levels of DOTS implementation.
1. Focused, organized and regular DOTS education and re-training efforts should be
prioritized among private practitioners actually managing TB patients, especially the
general practitioners and those practicing in schools, work areas, hospital outpatient
departments, and community areas to standardize case finding, and improve referral
to DOTS facilities.
2. Referral to DOTS facilities, whether private or public initiated, must be encouraged
to assure improved success rates because of access to free drugs, improved
compliance rates through supervised treatment, standardized recording, and
reporting to the national TB program. Private practitioners can retain management of
the patients while avoiding the cost of monitoring and direct observation of drug
intake. This will improve additionality by the private sector to the overall national
case detection and cure rates.
3. Efficient, prompt and strengthened PhilHealth TB outpatient package reimbursement
for referring physicians may provide add-on incentives for better referral
mechanisms between the private physician and the DOTS unit.
4. Although the positive impact of PPM initiatives on case detection has been
demonstrated in a few sites, there is a need to incorporate a careful and more
comprehensive strategy to monitor and evaluate the current scale-up of PPMD
expansion in the Philippines.
5. Financial sustainability of PPMD units should be evaluated. There may be a need to
develop cost recovery mechanisms and greater commitment of LGU’s for drug
supply.
Research Gaps on Provider-related Factors:
22
1. Evaluate the impact of integrating TB education in medical schools on the medical
practice of medical graduates in terms of case finding, holding and referral to DOTS
facilities
2. Cost-effectiveness studies to assess the efficiency and feasibility of the PPMD
programs
3. Operations studies to look into the obstacles in the PhillHealth OPD TB package
reimbursement schemes to private and public DOTS facilities, including DOTS
referring physicians
4. Evaluation of education dissemination efforts in the knowledge, attitude and practice
(KAP) of doctors on TB especially among general practitioners
C. National TB Program-Related Factors
Based on the five essential components of DOTS, i.e. sustained political commitment,
quality-assured TB sputum microscopy, standardized short-course chemotherapy,
uninterrupted supply of quality-assured anti-TB drugs and standardized recording and
reporting system, the following measures are necessary to further improve and sustain
the NTP’s achievements on TB control:
1. Sustained political commitment
Government must guarantee the continuous monitoring and improvement of the quality
of DOTS implementation through a strengthened public sector that will (a) provide
unhindered access to its services especially by the poor and marginalized, (b) ensure
adequate and regular monitoring and supervision of its program at all levels, and (c)
assure its sustainability through establishment of local, national and international
coalitions of all stakeholders. A top-level commission with members from major
stakeholders whose sole mandate is the control of TB in the country should oversee this
whole process. The PhilCAT may fit this role.
Major policies were enacted to facilitate the provision of DOTS to all divisions and
attached agencies of the DOH. The Health Sector Reform Agenda – a comprehensive
strategy to reform the public health sector – made TB control a priority. NEDA lent its
support to the NTCP by facilitating the inclusion of programs and projects supporting
TB control in the Medium Term Public Investment Plan, by monitoring the progress of
implementation of ODA-assisted TB control programs, and by assisting in the
evaluation of tax deductions applicable to private donations for TB control programs
and projects. The TB Prevention and Control Program of the Department of Education
– School Health and Nutrition Center adopted DOTS in its management of TB cases
among all primary and secondary school teachers and non-teaching personnel. The
Department of Interior and Local Government Memorandum Circular No. 98-155
23
enjoined all local government units to pass a resolution declaring TB control as the
primary public health program for 1998-2004, to adopt DOTS, and to create an anti-TB
Task Force comprised of public health personnel, representatives from local medical
schools and civic organizations, and private medical practitioners. It also encouraged
the LGUs to make every public health center or facility a DOTS unit – replete with the
requisite trained manpower, microscopy services, anti-TB drugs and reporting books to
monitor the progress of patients.
These important programs developed were mainly for the public sector. The significant
role played by the private sector was eventually recognized. The promotion of DOTS
in both national government agencies as well as the private sector was instituted
through Executive Order No. 187, series of 2003 as the Comprehensive and Unified
Policy (CUP) for TB Control. This was a landmark policy that aimed to increase private
sector participation in the NTP-DOTS program. The same order mandated the
collaboration of public and private sectors in the management of an information and
education campaign for the CUP. Private sector organizations included the Philippine
Coalition against Tuberculosis (PhilCAT), the Philippine Medical Association, and the
Association of Health Maintenance Organizations of the Philippines. The CUP
deputized PhilCAT to carry out monitoring and accreditation functions.
Strategies to stimulate patient demand for TB services through government financial
support were then put in place. The PhilHealth, in its effort to expand benefits to its
members and dependents, initiated the development of the PhilHealth TB package to
encourage doctors to refer patients to DOTS facilities. Thus, this will indirectly
intensify the demand for TB services. PhilHealth accredited only those facilities
providing DOTS as providers of the package.
Four factors can sustain political will: popular perception, scientific and medical
consensus, and the media. (3) Thus, increasing the public’s knowledge about the TB
problem through media and other fora including those in the academe, and in industry
activities may broaden popular perception and concern for the problem. In scientific
societies, consensus has been worked for so as to standardize quality of care.
The PhilCAT represents an alliance of major stakeholders on TB control in the
Philippines. Organized in 1994, PhilCAT was established with PCCP, DOH, PSMID,
PTSI, Cure-TB and ACCP-Philippine Chapter as founding members. Thirty other
organizations eventually joined and signed as members. Up to this time, PhilCAT has
been actively coordinating several government and non-government agencies, including
the academe and industrial groups, fostering understanding, cooperation and
complimentary work, and strengthening the various advocacy strategies to control TB
in our country.
2. Quality microscopy service
Since sputum exam remains to be the most cost effective means of detecting TB disease,
there must be a sufficient number of laboratories across the country able to provide
24
quality microscopy services. All regions of the country must have a reference
laboratory. All laboratories both public and private must be certified before they are
allowed to perform sputum exams. Quality assurance monitoring must be done prior to
the renewal of licenses of laboratories to ascertain quality of services. Sputum
microscopy of the highest standards must be assured in the training of future medical
technologists. The call for mass education of the public regarding the value of sputum
microscopy in TB control by a previous consensus group is reiterated.
The Research Institute for Tropical Medicine was named the reference laboratory,
tasked with ensuring the highest standards in microscopy. The training and certifying of
microscopists from across the country are its chief functions. In addition, an External
Quality Assurance (EQA) on direct sputum smear microscopy to guard the quality of
NTP laboratory services provided by the peripheral microscopy centers.
In a consensus arrived at by the Task Force on TB 2000, it was recommended that a
mass media campaign was needed “since patients themselves may not like the sputum
test and insist on certain actions not consistent with the program.”
3. Regular availability of drugs
TB drugs must be made available, accessible, and affordable. Studies on how TB drugs
are allocated, distributed and utilized are vital towards this end. TB drugs should be
included in the essential drugs list of the Philippines.
Through the concerted efforts of various agencies led by the Department of Health,
grants from the GDF and the GFATM have allowed the Philippines to have globally
procured, quality-assured TB drugs.
Free drugs from the GDF are in Fixed-Dose Combinations (FDC). These drug
preparations combine two or more first-line anti-TB drugs in one capsule. They
simplify treatment and – more importantly – prevent monotherapy, effectively reducing
emergence of resistant strains. DOH Circular No 238 series 2003 called for the shifting
from single drug formulations (SDFs) to FDCs in two phases until full nationwide
coverage is achieved.
4. Standardized records and reports
Records and reports are the source of statistics on TB that are used to guide programs.
These should be standardized and centralized in a TB center or by a TB commission.
Networking and computerization will increase efficiency of this process.
The Manual of NTP details the standard forms and records that must be kept in DOTS
facilities. The forms include the NTP Laboratory Request Form, the Laboratory
Register, the NTP Treatment Card, the NTP Identification Card, and the TB Cash
Register. Reports, on the other hand, comprise Quarterly Reports on Laboratory,
Quarterly Reports on Case Finding, and Quarterly Reports on Treatment Outcome.
25
Currently, DOTS program coordinators and workers manually tabulate these forms and
reports.
While DOTS accredited programs meticulously work on these reports, a survey done
by PhilTIPS on private practitioners showed that record keeping and monitoring is not
as rigorous or standardized.
5. Supervised treatment DOT
Strengthen human resource capabilities through continuous training of CHWs,
supervision and evaluation of their performance and more importantly provision of
appropriate incentives and recognition for their contributions.
The utilization of thousands of community health volunteers who act as treatment
partners (supervising the treatment of many TB patients) made significant strides in the
Philippine DOTS strategy.55 In addition to serving as observers of treatment, these
volunteers have helped (1) raise community awareness of TB, its treatment and the
importance of strict adherence to the regimen, (2) facilitate case detection and referral
for diagnosis, (3) address stigma during patient encounters and indirectly through group
discussions, (4) provide general support, (5) recognize drug adverse effects, (6) track
those who interrupt treatment, and (7) document progress and outcome.56
The Magna Carta for health workers in the Philippines has provisions for benefits that
should rightfully be given to those who render health services. However, in many parts
of the country, CHWs give their time and talent to serve their communities on a
voluntary basis. Although commendable, the community, through its leaders, should
also be able to do what is just for these health workers.
26
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