TB-DOTS in the Philippines: impact of decentralization and health sector reform
Alberto G Romualdeza
The base paper by Enarson & Billo includes a thoughtful account of the DOTS programme’s development, from its inception following the Declaration of Amsterdam, the World Health Assembly resolution, and the workshop of National TB Programme Managers of 22 high-burden countries.
As a high-burden country, the Philippines participated in all three milestone events. The story of DOTS implementation in the country had begun five years before, when the WHO Regional Director for the Western Pacific Region and the newly appointed Philippine Secretary of Health agreed in mid-1995 to give priority attention to tuberculosis by allocating at least half of the country’s WHO funds (roughly US$ 2 million per biennium) to initiate a major TB control effort. By mid-1996, 16 out of the country’s 77 provinces were selected as pilot sites.
From the start, the NTP had to deal with the administrative difficulties introduced by a 1992 law transferring responsibility for health services to local governments. By 1995 the Department of Health had devolved control of health service units to 77 provinces and over 1600 cities and municipalities. Nevertheless, the NTP’s well-motivated, technically competent and well-managed staff was able to start up the DOTS strategy in all 16 selected sites in less than two years. Learning from the experience of other national programmes, like immunization and family planning, NTP developed mechanisms to work with local government units to implement its activities.
Results of the National TB Survey of 1997 confirmed that the Philippines, with an estimated prevalence of almost half a million cases, still had a major TB problem. This provided the impetus for nationwide implementation of the DOTS strategy, which was expanded starting in 1999. By the end of 2000, the Philippines reported 100% DOTS coverage.
Meanwhile, analysis of national health expenditures led to a health sector reform agenda that significantly streamlined DOH operations, beginning with the central office. In the ensuing central office staff reductions, NTP positions were reduced from 22 to 2 in 2001. However, a subsequent staffing review enabled the restoration of 7 posts. Additionally, NTP trained regional health office staff, who work closely with local governments.
NTP’s 2000 data showed that DOTS was implemented throughout the country, that its treatment success rate was 88% and its case detection rate was 48%. To improve case detection, NTP strengthened its links with the Philippines Coalition Against Tuberculosis (an NGO of private individuals and institutions) by developing the public–private mix (PPM) DOTS approach. The National Health Insurance Programme also included implementation of DOTS strategy in its benefits package.
DOTS thrives today, thanks to local and national political commitment, the support of WHO-WPRO, funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the introduction of the Global Drug Facility for procurement of DOTS supplies. It has met the global targets with 75% case detection and 87% success rates. Nevertheless, some concerns persist, such as whether such levels of commitment and support can be maintained for another decade. Additional concerns include the possible emergence of uncontrolled multidrug-resistant strains of TB and increases in what is now a low and slow HIV/AIDS situation in the Philippines. A final concern is whether the National Health Insurance Programme, pivotal in health-care financing reform, can expand its coverage of the DOTS strategy fast enough to cover anticipated reductions in external support beyond 2010. ■
- M-Tech Medical Hospital, 379 Sen. Gil Puyat Ave., Bel-Air Village, Makati City 1209 Metro Manila, Philippines.