1. DOTS-Plus to DOTS Philippines Thelma E. Tupasi Tropical Disease Foundation Rosalind G. Vianzon NTP Manager, Philippines

2. Reasons for embarking on DOTS-Plus: Outcome of DOTS DOTS Clinic at the MMC, Reasons for embarking on DOTS-Plus: Outcome of DOTS DOTS Clinic at the MMC, February 1999-January 2002 Outcome New cases (126) Previously treated (65) Cure83.3%53.8% Failure0.838.5 Died6.41.5 Lost7.11.5 MDR-TB2.441 Quelapio MID et al: MDR-TB a threat to TB Control, Cohort Analysis, MMC DOTS-CLinic

3. Reasons for embarking on DOTS-Plus: Health and socioeconomic consequences of no DOTS-Plus Patients are left untreated leading to transmission Patients are managed inadequately/ inappropriately leading to amplified resistance Patients deteriorate leading to absenteeism and lack of productivity Patients die leading to lost income

4. Scarce resources and competing priorities: DOTS vs DOTS-Plus Scarce resources and competing priorities: DOTS vs DOTS-Plus Private practitioners lack of adherence to the DOTS strategy Private practitioners lack of adherence to the DOTS strategy Absorptive capacity Absorptive capacity Establishing a laboratory network to support DOTS-Plus Establishing a laboratory network to support DOTS-Plus Shifting from pilot project to policy development Shifting from pilot project to policy development Constraints and major challenges to DOTS-Plus

5. Scarce Resources: Access to treatment: 304 patients applying for treatment Scarce Resources

6. Scare Resources: Support for DOTS-Plus in first 165 patients n=165 patients

7. Scarce Resources: Global Fund for DOTS+ To utilize the GLC-approved DOTS-Plus pilot project for policy development on MDR-TB in the NTP GFATM Philippine program providing USD 0.5 M/yearly for DOTS-Plus 100-120 patients yearly for five years 100-120 patients yearly for five years 2 nd line anti-TB drugs 2 nd line anti-TB drugs Enablers: Enablers: Transport cost reimbursement Transport cost reimbursement Drugs for adverse reactions Drugs for adverse reactions

8. 1997 NTPS Role of the Private Medical Practitioners in TB Treatment Referrals for DOTS-Plus Care providers consulted

9. Private Practitioners and Fluoroquinolones in the Philippines

10. Resistance to Fluoroquinolones and Kanamycin

11. GLC technical assistance political commitment to the DOTS+ pilot project among NTP and its technical advisers uninterrupted supply of quality assured 2nd line anti-TB drugs appropriate laboratory support for the diagnosis of MDR-TB including culture and DST under supranational laboratory supervision treatment under DOT and management of adverse drug events, reporting and recording.

14. Individualized Tx. Outcome of Therapy OutcomenAll117 Patients who remain in therapy 101 Patients who complete therapy 83 Cure61%70%85.5% Failure1911.914.5 Died1517.8 Default14

15. DOTS-Plus in the Philippines is highly cost-effective Cost per DALY averted: US $ 242 vs GNI of $1,040 in the Philippines 1. Cost <per capita GNI is highly cost- effective 2. 3x per capita GNI is cost-effective as recommended by the Commission on Macroeconomics and Health. 3. COST is within the range of "attractive" investments defined by the World Bank Katherine Floyd and Raj Gupta

16. From Pilot project to Policy: Issues DOTS: Local ownership and sustainable financial commitment to support basic DOTS programme DOTS: Local ownership and sustainable financial commitment to support basic DOTS programme DOTS-Plus pilot project: Enunciation of its current and potential relevance to the National TB Control Program DOTS-Plus pilot project: Enunciation of its current and potential relevance to the National TB Control Program 2 nd line anti-TB drugs: Registration, availability and controlled distribution to prevent abuse and emergence of drug resistance 2 nd line anti-TB drugs: Registration, availability and controlled distribution to prevent abuse and emergence of drug resistance

17. Sputum culture 2-3 m AFS Neg DOTS Previously Treated: CAT II New: Cat I Neg Pos Continue Cat IContinue Cat II Cure DST: MDR-TB DOTS Plus Pos Neg 4-5m AFS Neg

18. MDR-TB in the Philippines Socioeconomic and health reasons for embarking on DOTS-Plus Socioeconomic and health reasons for embarking on DOTS-Plus Constraints and barriers Constraints and barriers Problem engendered by second-line anti-TB drug use in the country Problem engendered by second-line anti-TB drug use in the country Limited resources and absorptive capacity Limited resources and absorptive capacity Individualized treatment is effective, feasible, and cost-effective Individualized treatment is effective, feasible, and cost-effective GLC mediated technical assistance: enabled pilot project to follow 5 elements of DOTS-Plus enforced GLC mediated technical assistance: enabled pilot project to follow 5 elements of DOTS-Plus enforced Integration of DOTS-Plus within DOTS in the NTP: Clear Policy within the NTP Integration of DOTS-Plus within DOTS in the NTP: Clear Policy within the NTP

19. DOTS-PLUS EXPANSION and MAINSTREAMING PART II: ISSUES and CHALLENGES in INTEGRATING DOTS-PLUS in INTEGRATING DOTS-PLUS into the PUBLIC HEALTH DOTS

20. - Setting-up the policy environment operational feasibility - reality setting operational feasibility - reality setting 100% DOTS coverage in the public sector 100% DOTS coverage in the public sector evidence is available from the pilot project evidence is available from the pilot project that DOTS is feasible & cost effective in the that DOTS is feasible & cost effective in the country; support evidence from the DRS country; support evidence from the DRS potential impact & equity in access potential impact & equity in access economic and social productivity, (MDG) economic and social productivity, (MDG) safe and healthy environment safe and healthy environment ISSUES

21. - Readiness in integrating the system strategic implementation strategic implementation development of human resources development of human resources enhancing QA laboratory support under supranational laboratory supervision enhancing QA laboratory support under supranational laboratory supervision ensuring logistical support for second-line drugs ensuring logistical support for second-line drugs institutionalized technology institutionalized technology ISSUES

22. CHALLENGES Policy Environment: High political agendum within the NTP High political agendum within the NTP NTP point person for DOTS (+) NTP point person for DOTS (+) DOTS (+) Task Force vis-à-vis NTP-TWG DOTS (+) Task Force vis-à-vis NTP-TWG Increase advocacy for strong political commitment of all stakeholders Increase advocacy for strong political commitment of all stakeholders Support from NTP partners - Advisory Body Support from NTP partners - Advisory Body (L ocal & International advisers) (L ocal & International advisers)

23. Systems Integration: Strategic Implementation: - area analysis for an impact implementation - DRS results Human resource development: - additional Staff and/or re-tasking of existing roles and functions - intensive training with immersion in the DOTS(+) Project -multidisciplinary approach at all levels of health care CHALLENGES

24. Systems Integration: Laboratory Capacity and Proficiency: - maximize developed laboratory under the DRS Strengths: Strengths: QA center for microscopy Established lab network in place Proficient laboratory Staff Not integrated with other laboratory works CHALLENGES

25. Systems Integration: Logistical Support: - NTP budget for 2 nd line drugs plus GFATM support -unified system for drug management (1st &2nd line drugs) - regulation and control in the distribution of 2 nd line drugs - technical / financial assistance from other partners CHALLENGES

26. Institutionalized Technology: - multi-sectoral coordination of stakeholders NTP, LGUs, Private Providers, Experts / Academe, Professional societies/International Agencies/ community - community-based approach CHALLENGES

27. Strategic Area Human Resource Development Laboratory Capacity & Proficiency Logistical Support Institutionalized Technology DOTS(+) NTP within NTP Stepwise Approach to Mainstream DOTS (+) into NTP the NTP