Country Progress Report Philippines The 9th Technical Advisory Group and National TB Program Mangers meeting for TB control in the Western Pacific Region Manila, Philippines 9-12 December 2014

Philippines Archipelago of 7,100 islands 100 million population, 17 regions High TB burden and high MDR TB burden 2012 DRS: 2% among new and 21% among retreatment cases 1996 – start of DOTS strategy implementation and in 2003 with 100% DOTS coverage in the public sector, adoption of PPMD strategy as a national strategy 1999 – Start of PMDT in the private sector and 2008 mainstreamed to NTP 2013 Mortality rate: 27/100,000 Prevalence:438/100,000 Incidence: 292/100,000 Case Detection Rate: 87, Treatment Success Rate: 88

Major Successes NTP policies and guidelines are updated to align with international policies and will be implemented nationwide in 2015 TB services are provided for free and are integrated with basic health services nationwide With 2010-2016 National TB Control Strategic plan that has been reviewed and updated With multi-sectoral involvement – private sector and other government agencies With scale-up of diagnostic and treatment services for drug resistant TB cases With strong political commitment from the government (increasing budget for the TB program) With financing package for TB (Philhealth package)

Major Challenges Still many missing TB cases due to; Lack of access to quality assured TB diagnostic services and passive casefinding, TB is not a reportable disease Limited involvement of non-NTP care providers Persisting stigma on TB Low number of detected and enrolled MDR-TB cases and with high number of default. Weak TB HIV collaboration especially at the service delivery level and limited geographic coverage Slow development and implementation of initiatives to increase access to TB services by vulnerable groups Weak health system Weak logistics and information management systems Variable capacity in TB control program management by TB teams at all levels Lack of manpower at the service delivery levels

2010-2016 Philippine Plan of Action to Control TB (PhilPACT) Objectives Strategies Reduce local variation in TB control program performance Localize implementation of TB control Monitor health system performance Scale up and sustain coverage of DOTS implementation Engage both public and private health care providers Promote and strengthen positive behaviour of the communities Address MDR-TB, TB/HIV, and needs of vulnerable population Ensure provision of quality TB services Regulate and make available quality TB diagnostic tests and drugs 7. Certify and accredit TB care providers Reduce out-of-pocket expenses related to TB care Secure adequate funding and improve allocation and efficiency of fund utilization

Outcome Targets based on PhilPACT Indicators Status as of Dec 2013 2016 Targets Susceptible patients Case Detection Rate, all forms 87% 90% Treatment Success Rate, all forms 88% MDR-TB patients Notification Rate 16% 62% Treatment Success Rate 41% 75%

Output Targets based on PhilPACT Indicator Status as of Dec 2013 2016 Targets Total no. of presumptive TB examined 2,481,418 (45%) 5.5 million Total TB cases provided with treatment 855,904 (57%) 1.5 million Total no. of children given treatment or given INH preventive therapy 102,747 (14%) 730,000 Total MDR-TB cases detected and registered 7,883 (40%) 19,500 Total TB patients who underwent provider initiated counselling and testing on HIV/AIDS 8,623 (19%) 45,000

Funding for PhilPACT Per Year 2010 - 2016

Reach the Unreached Updated Policy on intensified casefinding among close contacts, high-risk clinical groups (PLHIV, DM, etc), high risk populations (inmates, elderly, urban and rural poor) Screening of presumptive TB using DSSM, GenExpert and Chest X-ray for bacteriologically confirmed and clinically diagnosed cases Hiring of additional staff (AIDERS), deployed to hard to reach and poor areas With TB HIV collaboration – HIV counseling and testing for registered TB cases in category A and B areas and all PMDT treatment facilities. PLHIV screened for TB in HIV treatment hubs. Engagement of public (35%) and private hospitals (18%) 54% of inmates with access to DOTS services Engagement of pharmacies for referring patients With final draft policy for TB during disaster (for signature)

Laboratory Strengthening Improvement of access to diagnostic services through Introduction of LED FM in 60 intermediate and peripheral laboratories Expansion of GenExpert sites (73), culture (20) and DST centers (3) Involvement of the private sector Ensuring quality services through EQA for microscopy, monitoring of workload, Turn-Around-Time and error rates for GenExpert sites, monitoring of culture and DST laboratory performance indicator and annual proficiency testing for DST laboratories Technical assistance for system strengthening of Laboratory information system linked to ITIS Quality assurance Policy formulation (use of rapid tests and diagnostic algorithm) Monitoring and evaluation

Surveillance New case definitions are already used by all PMDT facilities and in 2015 by all DOTS facilities nationwide With Integrated TB information system (in 6/17 regions). For enhancement to include Modules for laboratory, inventory and pharmacovigilance (routine and CEM) Data are analyzed during monitoring, program implementation reviews and program evaluation

Expansion of PMDT Diagnostic and Treatment Facilities 2003- 2007 2008 2009 2011 2012 2013 2014 Regional Expansion NCR Region 7 Region 1 CAR Region 4B Region 2 ARMM Region 4A Region 6 Region 3 Region 5 Region 9 Region 8 Region 10 Region 12 Region 11 CARAGA No. of Gx Labs 16 17 24 73 New No. of Facilities 5 1 15 12 6 10 Cumulative No. of Facilities 11 26 38 44 54 CAR (1) RO 2 (1) RO 1 (2) RO 1 (1) RO 3 (1) RO 4A (6) RO 4A (1) RO 4A (2) RO 4A (5) NCR (5) NCR (12) NCR (16) NCR (14) RO 5 (1) RO 5 (2) RO 6 (5) RO 6 (3) RO 6 (2) RO 8 (1) RO 8 (3) Add expansion of Laboratory RO 4B (1) RO 7 (2) RO 7 (1) CARAGA (1) RO 10 (2) RO 10 (1) RO 9 (1) RO 9 (2) RO 12 (1) RO 12 (2) RO 12 (3) ARMM (1) RO 11 (2) RO 11 (1)

Trend of Enrollment and Treatment Outcome of Patients under PMDT

PMDT Targets and Activities Other Initiatives 9 month Treatment Regimen Use of Bedaquiline e-TAP Community PMDT Care Enhancement of Information System Enhancement of Logistics System Diagnostic Facilities: 199 GeneXpert sites 180 thru GF 19 from other sources 28 culture laboratories 7 DST Centers Treatment Facilities: TC: 20 STC: 110 iDOTS facilities Decentralize Quickly Enrollment: 2015: 4365 2016: 5177 Treatment Success Rate: 75%

Bold Policies and Supportive Systems With existing PhilHealth package for Drug Susceptible TB (90U$ per TB case) Expansion to include a package for Drug Resistant TB – situational analysis for dissemination; actuarial study in 2015; policy in 2016 TB case notification to coordinate with other DOH offices and to include in the pending bill on TB control Meeting with FDA and other stakeholders Pharmaco-vigilance system enhancement Limit commercial access of anti-TB drugs

Patient Centered care: involvement of patients and Community Patient groups are involved in NTP activities on advocacy, planning and evaluation and as treatment partner Plan Capacitate patients as counselors or peer educators Provide funds for patient activities and link patient group to other government agencies for livelihood opportunities Provide enablers through the enhance transportation allowance package (e-TAP) as well as food package Hire staff (AIDERS) to assist in detecting and following-up of TB cases Involvement of NGOs, Community Health Teams, community groups for referral of cases, providers of services and to follow-up cases

Thank you!