Health Care Delivery System for MDR-TB Management

Below is a table that shows the similarities and differences between the DOTS strategy and MDR-TB management.

Element DOTS Strategy DOTS expanded framework as applied to MDR-TB management

Sustained political commitment 4 4

Case finding strategy quality assured direct smear microscopy (DSSM) quality assured DSSM, culture and DST

Supervised treatment

Uninterrupted supply of drugs Standardized records and reports Standardized treatment with first-line drugs under supervised treatment, with patient support

Appropriate treatment strategies using first- and second-line drugs under supervised treatment and proper case management conditions with more comprehensive patient support quality assured first-line anti-TB drugs quality assured first- and second-line anti-TB drugs

4

4 (designed for DR-TB control)

The DOTS-Plus pilot project in the country has moved to a programmatic approach through PMDT, under a privatepublic mix collaboration. The structure of the health care delivery system for MDR-TB management differs from that for the regular DOTS strategy. In the DOTS structure, the service delivery area needed is a functioning DOTS facility while for MDR-TB management in the Philippines the following types of facilities are required:

Treatment Centers Treatment Sites

In general, Treatment Centers are DOTS facilities, public or private, providing comprehensive management for more than 10 MDR-TB patients at one time. Treatment Centers are specialized referral centers which through their link with Culture and DST Centers, are able to detect and confirm MDR-TB cases. Diagnosed patients are registered in Treatment Centers where treatment is initiated with a complete package of services while these patients are sputum-positive. Once sputum-negative and stable, the patients are endorsed to community-based DOTS facilities called Treatment Sites which are nearer patients’ places of residence through a programmatic process of patient decentralization.

Treatment Sites, on the other hand, are DOTS facilities, public or private, providing a basic or limited package of services for MDR-TB management for fewer than 10 patients at one time, although the exact number depends on the capacity of each Treatment Site. These facilities provide continuing care to patients endorsed by Treatment Centers until treatment completion. However, even during this time, patients continue to visit Treatment Centers at least monthly and remain to be under their supervision and overall responsibility.

While there are differences in the scope of services available at the two service delivery areas for PMDT, there are also common functions such as supervised treatment of all doses which is a must whether at the Treatment Center or at the Treatment Site, health education and counseling, active tracing of interrupters and defaulters, etc.

The roles and functions of Treatment Centers and Treatment Sites in PMDT are described as follows:

MDR-TB Treatment Centers

Referral center for MDR-TB suspects Detection of MDR-TB cases (smear microscopy and link to Culture and DST Centers) Household contact investigation

Registration and initiation of treatment of MDRTB cases – Residence verification – Sustainability check Supervised treatment especially while sputumpositive Bacteriologic follow-up of treatment response through culture Early detection, monitoring and management of adverse drug reactions (ADRs) including serious and uncontrolled ADRs and link to specialists Active tracing of treatment interrupters and defaulters Programmatic patient decentralization for community-based TB care Drug management Supervision and monitoring Health and drug education/counselling Psychosocial services Recording and reporting

MDR-TB Treatment Sites

Referral of MDR-TB suspects to Treatment Centers Identification of MDR-TB suspects (smear microscopy)

Continuing treatment for endorsed cases

Supervised treatment when sputum-negative

Bacteriologic follow-up of treatment response through microscopy Early detection of ADRs and management of minor ADRs and referral to Treatment Centers for serious and uncontrolled ADRs Active tracing of treatment interrupters and defaulters Acceptance of patients decentralized by Treatment Centers Drug management (limited to very few patients)

Health education/counselling

Recording

The first three MDR-TB Treatment Centers in the Philippines are the TDF-MMC DOTS Clinic at the Makati Medical Center (MMC) set up in 1999, the Kabalikat sa Kalusugan (KASAKA)-Quezon Institute (QI) MDR-TB Housing Facility in 2004 and the Lung Center of the Philippines (LCP)- Public Health and Domiciliary Unit (PHDU) DOTS Center in 2005, both in Quezon City. More centers are being set-up as PMDT expands in the country.

Likewise, the Treatment Sites are increasing in number as more patients are endorsed from Treatment Centers to these DOTS facilities in the community. These are mostly the public health centers and a number of PPMD units, faith-based organizations and non-governmental organizations.

The chart on the next page illustrates how the health care delivery system for MDR-TB management is organized in the Philippines.