Programmatic Management of MDR-TB by Private Health Sector in the Philippines

Nenet Ortega, CNS Correspondent, Philippines
Several Asian countries, including Philippines, come in the bracket of 22 high TB burden countries in the world. The Department of Health of Philippines, implements the National Tuberculosis Control Programme (NTP) through its health offices and units of 81 provinces and 1,634 municipal and city governments.  Direct services are provided mainly at the primary health centres that utilize the Directly Observed Treatment Short Course (DOTS) strategy to treat TB.

The complete drug regimen for the entire treatment duration (which usually lasts from 6 to 12 months), including expenses for diagnosis and follow up for DOTS treatment, is covered by the Philippine Health Insurance system for all poor members and their families.

However, those living in geographically isolated and depressed areas have poor access to treatment facilities. So many of those exhibiting symptoms of the disease do not address it, while those who start treatment fail to complete it and drop out midway. Mobile population who are diagnosed with TB and enrolled on treatment are sometimes lost to follow up and discontinue TB DOTS treatment. According to the local TB programme coordinator, lost to follow up and drop out patients come back only when they are already too sick.  These cases usually contribute to multi drug resistant TB (MDR-TB) incidence.

Despite the fact that diagnosis and treatment for standard TB is available in almost all of the local government health facilities, many still ignore their health and care seeking behavior. Clients usually come to facilities late when conditions are already aggravated, and they have become presumptive MDR-TB cases.  Facilities that manage presumptive and diagonosed cases of MDR-TB operate only in the metropolis which could be hundreds of miles away from where the patients live, thus making them inaccessible.

To address needs of presumptive MDR-TB cases, private facilities and willing hospitals have been engaged by the government to be part of TB diagnosis and treatment centres. Identified private partners are those operating in areas where clients and referrals can come forward for diagnosis and treatment. The Department Of Health (DOH) has mainstreamed programmatic management of MDR-TB into the country’s NTP, at the same time mobilizing the private health sector as TB treatment partners. In order to reach out to more patients who drop out of the programme and become presumptive MDR-TB patients, the DOH has decentralized the management of MDR-TB by setting up treatment centres in potential and high burden localities. This will reduce the load of patients seeking treatment in Metro Manila.

TB and presumptive MDR-TB clients in 6 provinces and one independent city of Bicol region are fortunate because the regional DOH has partnered with a private hospital to implement programmatic management of drug resistant TB (PMDT). The Sorsogon Medical Mission Group (SMMG) is one such private hospital that has been designated as an MDR-TB Treatment Center. This private PMDT treatment centre would cater to clients coming from the 6 different provinces of the region. The number of clientele seen at this cooperative hospital has increased over the years-- from 56 patients in 2009 to 428 patients as of September 2014. To avoid mortality due to the delays in accessing MDR-TB treatment by patients, SMMG has enhanced and improved its services by putting up a PMDT Culture laboratory, and at the same time uses the Gene Xpert system. The laboratory and the machine is managed by a trained Medical Technologist and technician. Gene Xpert testing  is a rapid test that detects and identifies Rifampicin resistant MDR-TB within a matter of 2 to 3 hours only,  as opposed to the old method of requiring a sputum culture test result from the National TB Reference Laboratory in Metro Manila where results can take upto 4 to 6 months to be released.

With technical assistance from the DOH Regional Office for Bicol through Dr Myrna Listanco, the Technical Programme Focal Person, further decentralization of  the services has been done to make MDR-TB services available and accessible to other provinces within the region-- an additional treatment centre has been set up at the Bicol Medical Centre, a government retained hospital. This centre is provided with MDR-TB drugs and other logistics. Specimens for immediate diagnosis are sent out to SMMG.

For now, all programme components-- non-clinical and clinical services at the PMDT Testing  Centres are funded through the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund). MDR-TB drug supplies is good  until 2016,  with available  buffer for newly diagnosed patients.  According to Dr Nancy Labarete, the Managing Physician of the centre, the current spending per MDR-TB patient for two years is roughly US$ 7,000.00. The gap in funding is provided with support by the local chief executives of the municipalities where patients come from. MDR-TB patients are required to temporarily stay in a safe place they call ‘haven’ to sustainably and continuously take their drugs everyday as administered by the health providers. When the patients are declared non contagious, they go back to their homes where they have to report daily to the local rural health centres designated as treatment satellites where they take their drugs until the 1 1Ž2 to 2 years of medication is completed. In between the treatment, scheduled reporting to the treatment centres is required to monitor prognosis, response to the drugs and further examinations to make sure that other organs are not adversely affected due to side effects of the MDR-TB drugs. Everyone of the graduating patients are given benefits and incentives which they can use to start a livelihood and regain economic abilities all over again.

A decentralized and programmatic approach in managing MDR-TB is a good practice that may also be utilized in drug sensitive TB cases and hopefully in other health programmes. The co-operation between the regional DOH as the source of technical assistance, the local private facility for providing the venue as treatment centre managed by the Global Fund paid health staff, and the local government as treatment satellites and hubs for clients to continue and complete taking their medication are complementing efforts. As the saying goes, “no one can do it alone”, thus complementation of the efforts by different players is pivotal in making this GF funded PMDT initiative doable.

As early as this time, the SMMG treatment centre, together with the national and regional DOH, and the principal recipient for TB in the Philippines should already sit down, plan and come up with mechanisms and strategies on how to replicate, expand and sustain all of these initiatives to make sure that each and every MDR-TB presumptive person is able to get the much needed  life saving MDR-TB drugs.

MDR-TB is indeed a major threat to global public health. It will be a key topic at the forthcoming 45th Union World Conference on Lung Health (organized annually by the International Union Against Tuberculosis and Lung Disease—the Union) in Barcelona, with presentations on the latest research and the release of preliminary data on new clinical trials currently taking place. The conference theme "Community-driven solutions for the next generation", reflects the need to find solutions to challenges of MDR-TB and other lung health issues by involving all stakeholders-- from health care professionals in the private and public sector and policy makers to the people and communities they serve.

Nenet Ortega, Citizen News Service - CNS
14 October 2014