IPHO-Maguindanao October 2005 – September 2009

GOAL Reduce TB Morbidity and Mortality in Maguindanao STRATEGIC OBJECTIVES Increase detection rate of smear positive TB cases from 69% to 75 % by September 2009 Increase cure rate of smear positive TB cases from 72% to 85% by September 2009 Target Population: 475,056 individuals aged 15 and above living in Maguindanao province. Major Strategies: Quality Assurance Capacity Building Behavior Change Communication Advocacy and Social Mobilization

TB situation in Maguindanao Five Elements of D.O.T.SGaps/Challenges Political Commitment Shortage of staff (medical technologists) & funding for TB program from LGUs. Case detection through Quality assured bacteriology 5 functioning laboratories; 7 medtechs; 19 microscopes; insufficient training; no systematic quality control activities. Standardized treatment, with supervision and patient support (DOT) Geographic distance of patients to health centers deterrent in supervised treatment; many patients complete tx. w/o lab confirmation. An effective drug supply and management system Existing supplies insufficient to treat all cases. Monitoring & Evaluation System Data not readily available; delays in data entry & submission of reports; no cohort analyses.

Department of Health Autonomous Region in Muslim Mindanao Integrated Provincial Health Office: Program Coordinators District level: 4 Hospitals, serve as Lab Validation Centers *quality control* Municipal level: 28 RHUs Human Resources: 13 MTs, Doctors, Nurses TB Activities: Med Tech receives smearing, reads & sends report to BHS Nurse supervises RHUs. Midwives smear & stain samples, send them to MTs with Motorist Receive results, sends them to BHS, DOTS. Barangay Health Stations: Midwives provide primary health care, Including TB activities: receive sputum samples from patients, and give results to patients, DOTS Health and Nutrition Posts: Barangay Health Workers TB Activities: receive sputum samples from patients, give results to patients, DOTS Irregular supervision of RHUs & BHSs Motorist transport smeared samples and results from RHUs t Lab. Validation Center Some patients asked to come back to BHS or HNP for sampling or results 1 Med tech/ 4 municipalities not available all days/week Midwives lack smearing skills BHWs lack smearing skills

Innovation one: Improving access with BHWs role expansion Training in DOTS, and sputum collection & smearing –DOTS: 2-day –Sputum Collection & smearing: 5-day training (didactic 2 days; practicum 3 days) 116 BHWs with 2 major roles: 1. Collecting sputum & smearing –Transport slides (no MOW) –Recording 2. As treatment partner

Innovation two: Microscopists on Wheels Private transport group (mostly single motorcycle) plying at remotest area volunteered to provide services for TB control & prevention. –Free or discounted fare for TB patients & symptomatics –Free transport of slides or specimen –Promote TB awareness & free services of RHU Membership: voluntary Loose support group or formally organized Process used: –RHU recommended transport group from their area –Gen. orientation & core group provincial level –Follow-up RHU level.

Innovation three TB Club Serves as a peer-support group to ensure patient’s treatment compliance & reduce stigma. Activities: –sharing and encouragement among members to motivate adherence to treatment regimen –cured patients giving testimonies and serving as peer-educators –contact tracing –case referral Membership: voluntary Structure: flexible, formally organized or loose-group.

Table 1. Percentage Contribution of Support Groups to Case Finding in 10 Municipalities, Maguindanao,Philippines Support Groups No. of symptomatic s referred No. referred who turned positive Total No. of Smear Positives % Contribution MOW TB Clubs

Table 2. Percent Contribution of BHWS to Case Finding in __ Municipalities,Maguindanao Philippines, July-September 2007 Support Group No. of Slides Smeared No. turned positive Total no. of smear positive cases (RHUs) % contribution of BHWs BHWs

LESSONS LEARNED: INNOVATIONS Spirit of volunteerism abounds even in the poorest of communities; people just need to be given the right opportunities. Explore promising practices from other projects that can be replicated, adapted or enhanced. Develop a common framework or mechanism to implement MOWs or TBClubs across the municipalities but allow some flexibility for operationalization. Mechanisms for sustaining the enthusiasm of volunteer health workers should be part of the overall plan. Actively engage the support of the local government to provide incentives to the volunteer health workers. A good documentation of the contribution of the support groups is a must to demonstrate their effectiveness.

Operations Research on Gender Inequalities Objective: To determine the nature of disparities in the no. of cases detected for men and women; particularly, whether these disparities are related to inequalities in access to TB care services for women in Maguindanao. Methodology: Sampling: 5 randomly chosen high performing RHUs Data Collection: Clinical Observations, exit interviews, FGD and records review

Operations Research on Gender Inequalities Objective: To determine the nature of disparities in the no. of cases detected for men and women; particularly, whether these disparities are related to inequalities in access to TB care services for women in Maguindanao. Methodology: Sampling: 5 randomly chosen high performing RHUs Data Collection: Clinical Observations, exit interviews, FGD and records review

FINDINGS and Opportunities for increasing the standard of quality of care No difference between sexes regarding satisfaction with quality of care, but more female clients reported to have received complete information on TB treatment regimen Patient’s treatment card does not include sex disaggregated data to trace contacts. More women registered as symptomatics but less were asked to provide sputum samples. More female clients were asked to bring their contacts. Female clients were poorer than male clients. More female clients perceived lack of privacy during consultation. More female clients preferred face-to-face communication. More female clients came from same barangay where the RHU is located, a concern of where women seek care if they don’t live near the RHU. Few gave suggestions on how to improve the services of RHU but women recommended giving the medicines for a week supply to save time and fare while men recommended improving information.

Include sex disaggregated data on the contacts in the treatment card Increase active case finding among male patients for female contacts The first TB screening for both sexes’ clients should be done in private ward. Ensure complete examination and request of sputum samples to symptomatic male and female. Increase awareness among general population for the gratuity of the TB drugs and where they can seek TB services. Ensure all female and male clients receive their first dose of treatment. Increase awareness among all TB clients & BHWs, esp. service be negotiated with MOW for female clients living in underserve area. Increase face-to-face activities for both clients to increase access. Increase awareness among both clients about the role of the BHWs as treatment partners. Use the TB Clubs as a forum where female clients provide feedback about the TB services and recommendations to improve it. Proposed Interventions for gender-sensitive TB control