The Philippines achieved full DOTS coverage in 2003, has met the global target for treatment success in each of the past four years and is coming close to the target for case detection. TB control has progressed thanks to strong government commitment and a relatively well-staffed programme, while innovative partnership arrangements are making important contributions to TB control activities and resource mobilization. The financial position is favourable, with the budget for TB control activities fully funded for 2004 and 2005. The use of barangay (small local district) health workers to treat and follow patients has been a very beneficial national policy that has helped to achieve high treatment success rates. Involving medical schools and private physicians in DOTS services is now a government priority because this will increase case detection and ensure that standard methods for diagnosis and treatment are used in the private sector. Surveillance for TB drug resistance is in progress. The Philippines is one of the few high-burden countries that has started to implement DOTS-Plus treatment for MDR-TB cases. Providing TB control and other health services to population groups in remote mountainous areas and small islands, and accessing insecure areas, present continuing challenges.
System of TB control
The NTP has recently been reorganized as part of the national health sector reform process. Following restructuring and considerable decentralization of the Department of Health, the number of staff at central level was substantially reduced. Although additional staff have subsequently been employed at central level, there are still too few to carry out regular monitoring of programme activities in the regions. This means that regional coordinators are now responsible for most coordination and technical assistance, even though they may be responsible for more than one health programme and thus have limited time for TB control activities. Fortunately, the number of staff in the provinces and in rural health units is sufficient, and most staff have adequate training in all aspects of TB control. Each of the country’s 16 regions has a centre for health development that provides technical support to the provincial health offices. Provincial TB coordinators supervise staff in the rural health units, which are the main focus of TB control in the Philippines.
The TB laboratory network is structured as follows: the NRL is responsible for developing policy, management, training of microscopists, supervision of intermediate laboratories and DRS. Regional and provincial laboratories implement the policies developed by the NRL and provide EQA to the peripheral laboratories. The primary role of the peripheral laboratories at the rural and city health units is sputum smear microscopy. Culture and drug susceptibility testing are carried out by the NRL, one private laboratory and one NGO-affiliated laboratory. Seven regional laboratories have the capacity to perform culture.
Surveillance and monitoring
The TB case notification rate was decreasing before 2001 but has increased slightly since then. In 2003, as in previous years, the highest notification rates were among adults aged 45 years and older. These observations suggest that the TB incidence rate is probably in decline in the Philippines, with this reduction obscured since 2000 by DOTS expansion and the greater effort given to case-finding. The DOTS case detection rate increased rapidly to 48% in 2000 and then more slowly to 68% in 2003. Treatment success was reported as 88% in the 2000, 2001 and 2002 DOTS cohorts, and 91% of new smear-positive cases notified in 2002 were registered for treatment in that year.
With the public sector DOTS programme nearing full implementation, greater efforts are being made to diagnose and treat patients in collaboration with the private sector. The NTP must now also consider how to evaluate the epidemiological impact of the DOTS programme. Two prevalence surveys were done in the Philippines before the implementation of DOTS that showed little reduction in culture-positive or smear-positive disease between 1981–1983 and 1997. A new national TB prevalence survey is scheduled for 2007. This will show whether or not the Philippines can meet, or has already met, the Millennium Development Goal of halving prevalence between 1990 and 2015.
Improving programme performance
The Philippines reached 100% DOTS coverage in 2003 as a result of strengthened DOTS expansion efforts, backed by government commitment and funding for TB control as a priority public health programme. As part of the health sector reform process, management capacity and programme infrastructure were upgraded, and TB control activities became the responsibility of the Infectious Diseases Office under the National Centre for Disease Control and Prevention. Following the reorganization of the Department of Health, the procedural manual for the NTP and the Comprehensive and Unified Policy for TB Control in the Philippines will be revised. This policy provides a framework for collaboration with other government agencies and with the private sector, which in turn will help to harmonize and unify TB control efforts in the Philippines.
Nationwide implementation of FDC anti-TB drugs started after successful training for health-care workers. To improve case detection, TB control initiatives focused on children were pilot tested in urban and rural areas, and TB control activities in high-risk populations begun. A TB outpatient benefit package, PhilHealth, was introduced to improve treatment success rates.
The first nationwide DRS survey started in June 2003. This will provide the first reliable estimate of the magnitude of MDR-TB in the country. In 2000, the GLC approved a DOTS-Plus project at Makati Medical Center in Manila (a private medical centre collaborating with the NTP), with an initial cohort of 200 patients. With support from the GFATM, this cohort has been expanded to 750 MDR-TB patients in 2004. As yet, no MDR-TB patients are treated in the public sector.
In addition to management of MDR-TB, diagnostic and laboratory services, TB/HIV coordination and links with other health-care providers could also be improved.
Diagnostic and laboratory services
The laboratory service at intermediate and peripheral levels is good and staff are well-trained; however, EQA for sputum smear microscopy is not in place in every laboratory and needs to be strengthened where it already exists. An updated national manual for EQA for direct sputum smear microscopy was developed and distributed in late 2004. A priority for 2005 is to establish models for EQA, to monitor and evaluate the model EQA implementation and to expand to other laboratories. Eventually, hospitals and private laboratory facilities will be included in EQA activities. Laboratory networking is to be developed at all levels of the health service; successful networking will require reinforcement of the NRL.
There are no existing data on TB/HIV coinfection in the Philippines. However, HIV prevalence in the general population, and among TB patients, remains low (<1%). Given the worsening HIV/AIDS epidemics in neighbouring countries, it is important to monitor HIV prevalence in the general population as well as among high-risk groups including TB patients.
Links with other health-care providers
With the aim of consolidating and scaling up initiatives to involve private health-care providers in DOTS, the Philippines issued guidelines on PPM DOTS in 2004, and a national committee for PPM DOTS has been established. Operational guidelines for PPM DOTS in the Philippines were published, endorsed by the Secretary of Health and distributed. PPM-DOTS units, whose role is to coordinate private sector involvement in provision of DOTS services, have been set up in over 50 sites nationwide. More than 2000 private providers have been trained, and six professional societies have introduced the DOTS strategy in their training curricula. Two thirds of medical schools have become or are in the process of becoming involved in DOTS activities. The positive impact of these initiatives on case detection has been demonstrated in a few sites, but there is a need to incorporate a careful and more comprehensive strategy for monitoring and evaluation of the current scale-up of PPM DOTS in the Philippines.
The Philippines benefits from several partnerships that strengthen the programme and support DOTS expansion. Overall external technical collaboration is coordinated by WHO. Other external technical support is provided by CDC, JICA, KNCV, Medicos del Mundo (Spain), USAID and World Vision, which has helped to maintain technical quality during the expansion phase. An important innovation led by the Department of Health is the organization of the Philippines Coalition Against TB (PhilCAT). This includes a substantial group of NGO and private sector entities that collaborate to help private sector TB control activities and to mobilize local resources. The major funding partners are CIDA, GFATM, JICA and USAID.
Budgets and expenditures
The budget specifically for TB control activities has been similar in the four years 2002–2005, at about US$ 7–8 million. However, funding gaps existed in 2002 and 2003, whereas no funding gap has been reported for 2004 or 2005. This improved funding situation is linked to an increasing level of grant funding, much of which is related to initiatives to increase case detection – in particular, USAID funds for PPM DOTS. Funding from the government has fallen, related to austerity measures that affect public spending as a whole. In contrast to most other HBCs, there is also a budget for second-line drugs in 2004 and 2005, linked to implementation of DOTS-Plus in Manila. On a per patient basis, the overall NTP budget has fallen from US$ 66 in 2002 to US$ 48 in 2005. This is mainly explained by a reduction in the cost of first-line drugs, which has fallen from US$ 26 per patient treated in 2002 to US$ 17 per patient treated in 2005. When costs beyond those reflected in the budget specifically for TB control are also included, i.e. health clinic visits for DOT and monitoring during treatment, the cost per patient has been about US$ 160–180 for the past four years, and total TB control costs have been around US$ 22–30 million per year.