UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
LEVEL IV

COMPETENCY APPRAISAL II
Community Health Nursing

Analysis of the documentary “Kalusugan” through the

concepts of Communicable Disease (Tuberculosis) in the
Philippines

RLE 2.3
Balangue, Tim
Pineda, Jethro B.
Pio, Kirk Isaiah R.
Romero, Abbey Rochelle M.
Tolentino, Jyle Kristine T.
Torres, Vince Ronald E.
Uy, Sergio Miguel G.
Vergel de Dios, Jan Mitchelle D.R.
Villegas, Frances Mikaella C.
Yang, Yvonne G.
Introduction
Case Scenario
Lydia Marcos, female, with a case of Tuberculosis for more than 10 years. Sister Norma
blames the high prices of medicines for the worsening condition of Lydia. Due to their
financial incapacity, the family fails to provide the drugs needed to address the illness of
their family member. South Upi Municipal Hospital, where Lydia was admitted, also
reported lack of supplies and shortage in free TB drugs that could have been beneficial
to address the illness of Lydia.

As stated in the documentary, a person with tuberculosis has an expense of 70 php per
day (according to Department of Health). Due to the critical condition of Lydia, her
expenses per day is more than 1,000 php.

TUBERCULOSIS
-caused by a bacterium called Mycobacterium tuberculosis.
-Spread person to person
-Symptoms include cough with sputum and blood at times, chest pains,
weakness, weight loss, fever and night sweats.

> a treatable and curable disease

-Active, drug-susceptible TB disease is treated with a standard 6-month course
of 4 antimicrobial drugs that are provided with information and support to the
patient by a health worker or trained volunteer.
> “Disease of the poor” - because it is more prevalent in developing countries where
poverty and malnutrition are a problem.

> Included in SDG 3: Ensure healthy lives and promote wellbeing for all at all ages
Under paragraph 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and
neglected tropical diseases and combat hepatitis, water-borne diseases and other
communicable diseases.

Specific Strategy:
SDG END TB
Reduction in number of TB 2030 2035
deaths compared with 2015
(%)
Reduction in TB incidence 80% 90%
rate compared with 2015
(%)
TB-affected families facing 0% 0$
catastrophic costs due to
TB (%)
Statistics
❖According to the World Health Organization's (WHO) 2018 Global Tuberculosis
Report:
- Tuberculosis is one of the leading causes of death worldwide and it is the
leading cause of death from a single infectious agent
- The Philippines has a "high burden of tuberculosis" together with South Africa,
India, and Indonesia compared to other countries. The Philippines ranks 4th in
TB burdened countries. India ranks 1st.
❖In 2010, TB was the 6th leading cause of mortality in the Philippines with a rate
of 26.3 deaths for every 100,000 population and accounts for 5.1% of total
deaths. (According to DOH)
❖In 2017, there were approximately 581,000 Filipinos diagnosed with active TB
and 27,000 Filipinos have died of the disease. Worldwide, there were 1.3
million deaths recorded in the same year

WHO provides us a graphical report of the estimated number of incident TB

cases last 2000-2017:

Latest news/ updates

❖(2019) - World TB day is celebrated every March 24th. Last year’s theme was
“It’s time” (Internationally). DOH also launched a campaign locally entitled
“#EndTBNowNa!”.
❖(2018) - The Department of Health (DOH) vowed to find and treat 2.5 million
tuberculosis patients by 2022 to end the high burden of the disease in the
 country at the UN High-Level General Assembly held in New York City last
2018.
❖(2019)- DOH signed a joint pledge of support with the WHO, United States
Agency for International Development (USAID) and Global Fund "to take the
Philippines off the list of countries with the highest TB burden in the world".
“U.S. government is also investing over PHP3 billion in projects that support the
National Tuberculosis Control Program. Today, USAID is reaffirming our
commitment to strengthen the capacity of the Department of Health to
accelerate, scale up and sustain the TB response,” USAID Acting Mission
Director Patrick Wesner said.
v (2017) - Health Secretary Paulyn Ubial said President Rodrigo Duterte has
committed to sign an executive order (EO) that would allow only the DOH to
provide anti-TB drugs to patients as response to the results of the 2016 National
Tuberculosis Prevalence Survey
v (2015)- TB Caravan in Ilocos held led by the Department of Health (DOH)-Ilocos
Region and funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria
through the Philippine Business for Social Progress.
v (2014) Drug resistant TB was found in the Philippines

The National Tuberculosis Control Program (NTP)

National Tuberculosis Control Program adds the following vital components: a)

integration of guidelines for the diagnosis and treatment of adult and pediatric TB cases,
susceptible, and drug-resistant TB cases, b) introduction of intensified case finding for
vulnerable groups, c) inclusion of the new diagnostic tools in the algorithm, d) inclusion
of new chapters on TB prevention, TB DOTS referral system, and DOTS certification
and accreditation, and e) adoption of records and reports based on new international
standards.

The DOH Regional Offices (RO) through their Regional NTP teams, manage TB at
the regional level while the provincial health and city health offices, through their
provincial/city teams are responsible for TB control efforts in provinces and cities. TB
diagnostic and treatment services that are in accordance with NTP protocol are
provided by DOTS facilities which could either be the public health facilities such as the
RHUs, health centers, hospitals; other public health facilities such as school clinics,
military hospitals, prison/jail clinics; NTP-engaged private facilities such as private
clinics, private hospitals, private laboratories, drug stores and others. Community
groups such as the community health teams and barangay health workers participate in
community-level activities.
Social Determinants of Health Affecting TB

Considering that poverty has a great effect on the status of tuberculosis, living
spaces that are not large enough, those with poor ventilation, and working
environments often are a cause and are direct risk factors for the spread of
tuberculosis. An important risk factor for contracting the disease is undernutrition.
Also associated with poverty is the poor knowledge with regards to health and lack of
motivation to learn this information which then could lead to the contracting of several
diseases that may act as TB risk factors such as HIV, smoking and alcohol abuse.

The reduction of poverty decreases the risk of contracting tuberculosis as well as the
development of the disease. This may also contribute to the improvement of the
accessibility of health services and discipline to follow specific treatment related to
TB. The “health-in-all-policies” approach is the takeon health-related rights and
obligations. It improves accountability of policy makers for health impacts at all levels
of policy-making such as focusing on the implementation and evaluation of the
consequences of public policies on health systems, determinants of health, and well-
being which will be beneficial for TB care and prevention. The required social,
economic and public health policies include those that:

● Pursue overarching poverty reduction strategies and expanding social

protection
● Reduce food insecurity
● Improve living and working conditions
● Improve environment and living conditions in prisons and other congregate
settings
● Address the social, financial, and health situation of migrants
● Promote healthy diets and lifestyles, including reduction of smoking and
harmful use of alcohol and drugs

Through this, the prevention and education of the masses is prioritized although
treatment is also given benefit by having improvements to the adherence of the
people to TB treatments.

Functions of Health Service Providers

At the service delivery points, each of the different types of health workers from
physicians to barangay health workers contribute to NTP implementation and progress.
Below are the specific functions of each type of health worker.

Physician
●Organize planning and evaluation of TB control activities in DOTS facilities.
●Ensure that all staff have been trained on TB DOTS.
●Supervise staff to ensure proper implementation of NTP policies and guidelines.
●Evaluate presumptive TB based on clinical and laboratory evidence.
●Prescribe appropriate treatment.

Nurse
●Manage the process of detecting TB cases in coordination with other staff.
●Maintain and update the Presumptive TB Master list and TB register.
●Facilitate requisition and distribution of anti-TB drugs, laboratory supplies and
forms.
●Maintain records on logistics and ensure proper storage of drugs.
●Provide continuous health education to all patients.
●Conduct training of health workers and community volunteers.
●Prepare, analyse and submit the quarterly reports.

Midwife
Under the supervision of the nurse, they do the following:
●Identify presumptive TB patients and ensure proper collection and transport of
sputum specimen.
●Refer all diagnosed TB patients to physician and nurse for clinical evaluation
and initiation of treatment.
●Maintain and update NTP treatment cards.

Barangay Health Workers/Community Health Volunteers

●Identify and refer presumptive TB to DOTS facility for sputum collection.
●Collect and ensure transport of sputum specimen.
●Assist health staff in doing DOT to TB patients.
●Keep and update the NTP ID cards.
●Report and retrieve defaulters within two days.
●Attend regular consultation with the health personnel, together with patient and
treatment partners.

Policies
1. Case Finding
●Both passive and intensified case finding activities shall be implemented in
all DOTS facilities.
●Intensified case finding shall be done among close contacts, high risk clinical
groups, and high-risk populations. Priority for close contact investigation
shall be among household members. If feasible, screen other contacts of
bacteriologically-confirmed TB cases, DR-TB patients and index childhood
TB cases.
●Direct Sputum Smear Microscopy (DSSM), whether by light or fluorescence
microscopy, shall be the primary diagnostic tool in NTP case finding. All
presumptive TB who could expectorate - whether pulmonary or
extrapulmonary - shall undergo DSSM prior to treatment initiation.
However, non-compliance with DSSM should not be a deterrent to
treatment initiation among EPTB cases.
●All presumptive TB should undergo DSSM unless this is not possible due to
the following situations:
○Mentally incapacitated as decided by a specialist or medical institution
○Debilitated or bedridden
○Children unable to expectorate
○Patients unable to produce sputum despite sputum induction
●Two sputum specimens of good quality shall be collected, either as
frontloading (i.e., spot-spot one-hour apart) or spot-early morning
specimens, based on the patient’s preference. The two specimens should
be collected at most within 3 days.
●Available rapid diagnostic test (e.g., Xpert MTB/RIF) shall be used for TB
diagnosis among presumptive DR-TB, PLHIV with signs and symptoms of
TB, smear-negative adults with CXR findings suggestive of TB smear-
negative children and EPTB.
●If Xpert MTB/RIF is inaccessible, smear-negative patients shall be evaluated
by the DOTS physician who shall decide using clinical criteria and best
clinical judgment. If in doubt, the case may be referred to a
clinician/specialist within the area or to a TB Diagnostic Committee (TBDC)
as long as the recommendation could be made within two (2) weeks.
●Tuberculin skin test (TST) shall not be used as the sole basis for TB
diagnosis. It shall be used as a screening tool for children. A 10mm
induration is considered a positive TST reaction. Only trained health
workers shall do the testing and reading.
●All DOTS facilities, whether public or private are encouraged to establish
their own in-house microscopy unit. However, in cases where this is not
 possible, access to an officially linked NTP-accredited microscopy unit
would be acceptable.
●All municipalities and cities shall ensure access to quality-assured
microscopy services. One microscopy center shall cater to, at most,
100,000 population. In difficult to access areas, remote smearing stations
(RSS) manned by trained volunteers could be established.
●All laboratories providing DSSM services or other TB diagnostic tests,
whether public or private, shall participate in the External Quality
Assessment (EQA) system of the NTP.
●All presumptive DR-TB shall be referred to the nearest DOTS facility with
PMDT services for screening or an Xpert MTB/RIF site for testing.
●All PLHIV shall be screened for TB co-infection.

2. Case Holding
●All diagnosed TB cases shall be provided with adequate and appropriate
anti-TB treatment regimen promptly.
●Anti-TB treatment shall be done through a patient-centered, directly observed
treatment (DOT) to foster adherence. DOT should be carried out in settings
that are most accessible and acceptable to the patient. Exert all efforts to
decentralize DR-TB patients as soon as possible to a treatment facility
most accessible to the patient.
●Anti-TB treatment regimen shall be based on anatomical site, and
bacteriologic status including drug resistance and history of prior treatment.
Except in cases of adverse drug reactions and special circumstances
requiring treatment modifications
●The national and local government units (LGUs) shall ensure provision of
drugs to all TB cases. LGUs should allocate funds for drugs and supplies in
the event of unforeseen supply interruptions to ensure the continuity of
treatment within their areas of jurisdiction.
●A TB patient diagnosed during confinement in a hospital may start treatment
using NTP drug supply upon the approval of the hospital TB team. Once
discharged, the patient shall be referred by the hospital TB team to a
DOTS facility for registration and continuation of the assigned standard
treatment regimen.
●Treatment response of PTB patients shall be monitored through follow-up
DSSM and clinical signs and symptoms. All adverse drug reactions
(ADRs), whether minor or major, shall be reported using the official
reporting form of the FDA.
 ●Tracking mechanisms for patients lost to follow-up shall be put in place to
ensure that patients who fail to follow-up as scheduled are immediately
traced.
●Appropriate infection control measures shall be observed at all times based
on “Guidelines on Infection Control for TB and Other Airborne Infectious
Diseases.”
●All registered TB patients in Category A and B sites, shall be offered PICT.
●All confirmed drug-resistant TB cases shall be offered PICT.

3. Prevention of TB
●All DOTS facilities and TB laboratories should implement TB IC interventions,
following in order of hierarchy: administrative, environmental and
respiratory controls.
●Managerial activities shall ensure that the above interventions are
implemented.
●Use of respirators shall be limited to identified high-risk areas. Only
respirators that meet international standards (e.g., NIOSH-certified N95 or
CE-certified FFP2) shall be used. Proper training and “fi t test” shall be
undertaken for identified health care workers who will use respirators. Fit
testing shall be done every year if the same respirator type will be used or
every time before a new respirator type will be distributed.
●DOTS facility staff shall ensure that TB patients are informed about TB IC
measures for their households, workplace and community.
●All infants should be given a single dose of BCG except those who are
known to be HIV positive, those whose HIV status is unknown but who are
born to HIV-positive mothers and those whose symptoms are suggestive of
HIV.
●Isoniazid Preventive Therapy for six (6) months shall be given to all eligible
child household contacts and PLHIV once TB disease has been ruled out.
●In the absence of PPD, symptomatic screening could be used alone to
screen household contacts and identify children who will benefit from
Isoniazid Preventive Therapy. The unavailability of PPD shall not deter the
provision of IPT to 0-4 year old children who are household contacts of
bacteriologically-confirmed index cases.
●IPT should not be given to child contacts of drug-resistant TB.

4. Recording and Reporting

●Recording and reporting for NTP shall be implemented in all DOTS facilities
whether public or private. All NTP records should be kept for at least seven
(7) years before properly being discarded.
 ●Recording and reporting shall include all cases of TB, classified according to
internationally accepted case definitions. Quarterly reports should reflect
the sex, age, registration group and source of cases reported from various
units in the province/city/ municipality.
●Confidentiality of patient records shall be observed at all times.
●Recording and reporting for NTP shall use the FHSIS network for routine
reporting and feedback.
●The Integrated TB Information System (I-TIS) shall be the official electronic
TB information system.
●All quarterly reports should be sent to the DOH through channels (DOTS
facility to PHO/ CHO to RO to DPCB-DOH) based on agreed timeline.
●Records and reports shall allow for the calculation of the main indicators for
program evaluation.
●The NTP shall release official data annually based on the key program
indicators. Request for other data shall be coursed through a formal letter
to the NTP stating the intended use of the data.

5. Management of Anti - TB Drugs and Diagnostic Supplies

●The overall management of all TB drug supplies and diagnostic supplies, and
the development and dissemination of corresponding policies and
guidelines shall be the responsibility of the NTP with the support of the
MMD, the NTRL/RITM, ROs and the LGUs.
●The local government units shall ensure that NTP policies and guidelines for
NTP supplies management are implemented properly at their level. They
shall also actively participate in the monitoring and evaluation of the
implementation of these policies and guidelines.
●NTP shall ensure that drugs selected for the use of the program are in
accordance with international guidelines (e.g., WHO), are indicated in the
national standard guidelines (i.e., NTP-MOP), registered with the
Philippines FDA and included in the national formulary. Standardized fixed
dose combination (FDC) of anti-TB drugs shall be used under the NTP
whenever appropriate. The NTP, with the support of NTRL and FDA, shall
ensure the quality of anti-TB drugs and laboratory supplies used in the
program.
●Quantification and ordering shall be based on utilization rate, projected
increase of cases due to strengthened case finding and provision of buffer
stocks. Buffer stocks equivalent to 100% annual requirement should be
maintained.
●Procurement of TB drugs and diagnostic supplies at the national and local
government level shall follow the “Government Procurement Reform Act”
 or RA 9184 and the DOH policies, guidelines, and standards for the
procurement of TB drugs and laboratory supplies.
●Medicines and supplies shall be stored under appropriate conditions and
accounted for through proper recording and reporting. Stock status should
be reflected in the National Online Stock Inventory Reporting System
(NOSIRS).
●The ROs, PHOs and CHOs shall ensure that drugs and diagnostic supplies
are promptly distributed to the next level. The DOH central office shall
deliver the NTP commodities to the ROs. ROs shall deliver the NTP
commodities to the PHOs/CHOs. PHOs and CHOs shall ensure the prompt
delivery of the NTP commodities to RHUs/HCs and all other DOTS
facilities. Drugs for DOH retained hospitals within NCR will come from
MMD, while for those outside of NCR, drugs will come from the ROs.
●The use of medicines shall be guided by the presence of appropriate
indications for treatment based on the NTP standards for diagnosis of TB,
and the absence of contraindications to their use.
●Disposal of expired and damaged drugs and diagnostic supplies shall follow
the government rules and regulations.
●LGUs shall be responsible for the reproduction of all official NTP forms to
ensure availability and adequacy in all RHUs/DOTS facilities including jails
and prisons.
●LGUs shall set aside funds for the emergency procurement of sufficient
quantities of TB drugs and diagnostic supplies in times of impending
shortage to ensure continuous availability of NTP commodities at their
service delivery points.

6. TB-DOTS Referral System

●Patients shall have the right to know the reason/s for referral and to
participate in the choice of facilities where s/he will be referred.
●Health care providers have the responsibility of ensuring prompt and
appropriate response to patient’s health needs by immediate referral for
services that can be provided by other health providers/facilities.
●A two-way functional referral must be observed by ensuring that a receiving
facility provides feedback to the referring facility.
●It is a shared responsibility of the referring and receiving facilities to exert all
efforts of ensuring that a referred patient is not lost during the referral
process.
●All referring facilities / providers must use the standard NTP referral form
(Form 7. NTP Referral Form).
●All hospitals shall maintain a hospital TB referral logbook.
 ●Patients who were not referred in accordance to NTP policies and
procedures shall be accommodated and evaluated accordingly.

7. Advocacy, Communication and Social Mobilization

●The Local Health Board of all LGUs shall include ACSM activities in their
provincial, city or municipal health plan.
●The DOTS facility staff and stakeholders shall advocate with local political
leaders to increase funding for TB programs and institute policy changes to
support the implementation environment.
●The DOTS facility health staff shall ensure the provision of accurate, reliable
and up to-date information to all clients and patients that will motivate them
to seek care and complete treatment.
●ACSM activities must be customized according to specific needs of a
community but communication messages delivered must be consistent
with the messages developed by the National TB Control Program and
National Center for Health Promotion of the DOH.
●The DOTS facility health staff shall involve the community in TB program
implementation through social mobilization activities, mainly organizing and
sustaining existing community-based organizations or groups.
●All BHWs, CHTs and CBOs must refer presumptive TB identified in the
community and ensure that these patients go to the DOTS facility

8. DOTS Certification and PhilHealth Accreditation

●Policies on DOTS Certification
1.The DOH, through the RCC-NTP, shall be the lead agency in the TB-
DOTS certification process. The RCC-NTP shall be responsible
for certifying TB-DOTS centers/facilities in both public and
private sectors.
2.A health facility that provides TB DOTS services and assumes ownership
and transparency for its operations is eligible for certification.
3.A DOTS facility shall be awarded certification if it meets the following set
of core standards prescribed by NTP:

A.The TB DOTS center is easily located and patients have convenient

and safe access to the center.
B.The TB DOTS center provides for the privacy and comfort of its
patients and staff.
C.The TB DOTS center provides for the safety of its patients and staff.
D.All patients undergo a comprehensive assessment to facilitate the
planning and delivery of treatment.
 E.All patients have continuous access to accurate and reliable TB
diagnostic tests.
F.A care plan is developed and followed for all patients
G.Patients have continuous access to safe and effective anti-TB
medications throughout the duration of their treatment.
H.Policies and procedures for providing care to patients are developed,
disseminated, implemented and monitored for effectiveness
I.Policies and procedures for managing patient information are
developed, disseminated, implemented and monitored for
effectiveness and
J.The TB DOTS center has an adequate number of qualified personnel
skilled in providing DOTS services.

4.The length of certification award has an effectivity of 3 years.

●Policies on PhilHealth Accreditation

1.DOTS facilities which are eligible for accreditation include, but are not
limited to, the following: LGU health units, hospital-based clinics, HMO,
factory clinics, church based clinics and school-based clinics.
2.TB DOTS package providers duly certified by DOH are qualified for
automatic accreditation (PhilHealth Circular 54 s. 2012). TB DOTS
clinics that are not certified shall undergo pre-accreditation survey to
ensure that they comply with the standards.
3.PhilHealth shall provide the benefit package for qualified adult and child
TB patients from any accredited DOTS facility. The package shall
include the following:follow up sputum smear examination/s,
consultation services and anti-TB drugs for the entire treatment cycle.
4.The health care provider shall determine the PhilHealth’s member
eligibility and compliance with the requirements for availment as
prescribed by PhilHealth.
5.The DOH recommends the following allocation scheme for the TB DOTS
benefit package: 25% for consultation services of the referring physician
during the treatment course, 35% for the health facility staff including the
treatment partner who had a role in the delivery of services to the
patient, 40% for operational costs involved in providing quality care for
TB patients. When applicable, payment for TB Diagnostic Committee
and quality assurance for sputum microscopy, expenses for training of
staff, cost of additional laboratory supplies and drugs will be included in
the operational costs. In cases when there is no referring physician, the
25% shall be allocated for operational cost.
 6.Accredited TB DOTS facilities may continuously participate as provider
until such participation is withdrawn or terminated based on the rules set
by PhilHealth. However, they are required to submit the following
requirements on or before January 31 of every year:

A.Updated DOH Certificate

B.Performance Commitment
C.Latest Audited Financial Statement (for private facilities only)
D.Proof of payment of the participation fee, and
E.Updated business permit (for private facilities only)

7.Failure to submit the above requirements by the end of February shall

cause denial of claims starting March 1 (based on treatment start date).
If the requirements are submitted after February, the health care
institution shall apply for re-accreditation.
8.If the certificate of the TB DOTS provider expires within the year, the
facility is given 60 days within which to submit the updated certificate.
Failure to submit within 60 days shall cause denial of claims beginning
on the 61st day and onwards (based on treatment start date) until it
submits the certificate.

9. Monitoring, Supervision and Evaluation

●The RO NTP coordinators shall serve as technical assistance providers for

the PHO/CHO NTP coordinators. The provincial or city NTP coordinators
shall serve as NTP supervisors for all DOTS facilities. The DOTS facility
physicians shall serve as NTP supervisors for the health staff of the facility
while the Public Health Nurse serves as supervisors for midwives.
Midwives shall supervise community volunteers.
●Monitoring, supervision and evaluation activities should be integrated in the
annual work plans of the health facility and should contain the list of
areas/facilities to be visited, objectives of the visit, timelines, expected
outputs and feedback mechanisms.
●Conduct of monitoring and supervisory visits should be done on a quarterly
basis. Areas may be prioritized for monitoring based on TB program
performance and other needs. Whenever feasible, NTP monitoring in
DOTS facilities shall be integrated with monitoring of other health
programs.
 ●Qualitative and quantitative data from routine NTP reports shall be analyzed
and used to identify and address problems in program implementation.
●Key program indicators will be used to monitor and evaluate TB program
performance at all levels.
●Local Government Units shall support monitoring, supervision and evaluation
activities.

Specific measures are provided in the “Guidelines on Infection Control for TB and
Other Airborne Infectious Diseases” issued by the DOH.

Environmental control includes technologies for the removal or inactivation of

airborne infectious droplet nuclei. It is considered as the second line of defense for
preventing the spread of TB and, in combination with the right administrative controls,
will reduce the risk of infection. Cost-effective environmental control measures that
could be used at the DOTS facilities are natural ventilation and mixed mode mechanical
ventilation (i.e., use of fans together with natural ventilation).

For DOTS facilities, the following are practical and simple measures that could be
adopted:
1. Open windows and doors to improve natural ventilation;
2. Evaluate and document direction of airflow daily in high-risk areas within the
DOTS facility. Use smoke test (incense sticks or mosquito coil) to visualize air
movement;
3. Place or re-arrange furniture and seating such that staff-patient interaction occur
with airflow passing from health worker to patient or between health worker and
patient, rather than from patient to health worker (i.e., airflow from “clean to
dirty”);
4. Ensure that fans are clean and working properly

The 5 A’s of Primary Health Care:

OPPORTUNITIES
PROBLEM/S TO ADDRESS IMPLEMENTATION
THE PROBLEM
Accessibility The PHC in some One solution for this The RO NTP
areas of problem would be coordinators shall
Maguindanao is not the coordination and serve as technical
accessible. The cooperation of other assistance providers
nearest hospital to government services for the PHO/CHO
the community will namely the DPWH in NTP coordinators.
take a long way as providing roads and The provincial or city
well as healthcare pathways to get to NTP coordinators
facility, estimating a the people. Another shall serve as NTP
travel time of 5 solution would be supervisors for all
hours. As the WHO organized DOTS facilities. The
guidelines states, in dispatching of DOTS facility
order to consider a midwives to physicians shall serve
health facility to be communities as NTP supervisors
accessible it should regularly in order to for the health staff of
be within 30 complete the the facility while the
minutes from the treatment regimen Public Health Nurse
community. for TB. serves as supervisors
for midwives.
Midwives shall
supervise community
volunteers. This can
then be an effective
way to transfer the
information needed by
the patient for his/her
treatment even if the
patient is far from
health centers.
 Affordability TB drugs represent The anti-TB drugs are With the use of the
a major out-of- given in the national policy of the program,
pocket expense for and local government the overall
a patient and the health centers free-of- management of all TB
family. The high charge. Proper drug supplies and
cost of anti-TB management of TB diagnostic supplies,
drugs for the poor is drugs and diagnostic and the development
a major barrier that supplies particularly and dissemination of
limits access to at the peripheral level corresponding policies
treatment and cure. is done. DOTS facility and guidelines shall
Taking into staff are trained on be the responsibility of
consideration the how to best ensure the NTP with the
capacity of the an uninterrupted support of the MMD,
people in supply of drugs and the NTRL/RITM, ROs
community to pay diagnostic supplies and the LGUs.
for these, they are through better supply
not capable of such management
expenditures practices. Some
knowing that they supplies of healthcare
themselves are facilities should also
already struggling in be shouldered by the
providing their basic government for the
needs. benefit of the poor.

Acceptability Since there is a Providing Health The implementation

lack of health care Teaching to these for this case is that
facilities, indigenous people would be the tracking mechanisms
people of remote best way to for patients lost to
areas in overcome this follow-up will be put in
Maguindanao tend problem. Telling place to ensure that
to rely on their them the DOTS patients who failed to
natural behavior to Strategy of the WHO follow-up as
solve their diseases will help them scheduled are
which is using comply with the immediately traced.
herbal medicines or treatment of TB and This is to ensure that
seeking eliminate their they are not revising
consultation to mindset of their treatment by
“albularyos” expensive medicines doing other things that
for TB. It would also they believe and to
erase their culture of ensure that they will
 believing that only focus on DOTS
seeking “albularyos” treatment.
can be the best way
of dealing with their
diseases.

Availability Being in the remote Coordination and With the advocacy

areas, most of the cooperation with and social
people’s basic various companies mobilization of the
necessities like (especially program, the DOTS
food, water, pharmaceuticals). facility staff and
medicine and Furthermore, the stakeholders shall
government government should advocate with local
services are not encourage other political leaders to
being met due to private stakeholders increase funding for
being too far, hard to invest and TB programs and
to reach and develop the areas institute policy
sometimes areas by providing them changes to support
that have been tax exemption, the implementation
forgotten or being affordable land environment.
unknown. resources, and
advertisement of the
government to the
area as a place of
destination.
 Appropriatenes It was mentioned in Distribution of DOTS The initiative of the
s the film that major facilities should be program to this issue
barangays in the well established in is to make use of the
Philippines lack the Philippines policy regarding
their own health especially the PhilHealth
centers. Even the remote areas which Accreditation on
only hospital in need it the most. DOTS facilities which
South Upi, The DOH should are eligible and
Maguindanao lacks also observe the includes, but are not
its own medicines areas which heavily limited to, the
and supplies for TB. need them. following: LGU health
Coordination to units, hospital- based
people should also clinics, HMO, factory
be maintained for clinics, church-based
them to know where clinics and school-
they should really go based clinics.
for their current
This can help to increase the
illnesses. number of DOTS facilities
which specifically holds the
medicines and supplies
needed for TB.

Four Cornerstones/Pillars:

Community participation. The 17 Regional Offices (ROs) through its regional

NTP teams manages TB at the regional level while the Provincial Health Offices (PHOs)
and city health offices (CHOs), through its provincial/city teams are responsible for the
TB control efforts in the provinces and cities. TB diagnostic and treatment services are
part of the basic integrated health services which are provided by DOTS (Directly
Observed Treatment, Short Course, current means of delivery of treatment Services)
facilities which could either be the public health facilities, such as the RHUs, health
centers, hospitals; other public health facilities, such as school clinics, military hospitals,
prison/jail clinics; NTP-engaged private facilities, such as the private clinics, private
hospitals, private laboratories, drugstores and others. Community groups, such as the
community health teams and barangay health workers participate in community-level
activities.

Intra and inter sectoral linkages.Various developmental partners and their

projects provide technical and financial support to NTP, such as the World Health
Organization (WHO), United States Agency for International Development (USAID),
Global Fund Against AIDS, TB and Malaria (Global Fund), Research Institute of
TB/Japan Anti-TB Association (RIT/JATA), Korean Foundation for International Health
(KOFIH) and Korean International Cooperation Agency (KOICA) and KNCV
Tuberculosis Foundation. New USAID projects bring the total U.S. government
contribution in support of DOH’s National Tuberculosis Control Program to over Php 6.5
billion.

Appropriate Technology. For clinic visits, the patient’s Form 5. NTP ID Card is
checked. Form 4. TB Treatment/IPT Card is used to record all treatments.

Support Mechanism Made Available. The NTP closely works with various
offices of the DOH, such as the National Center for Health Promotion (NCHP) for
advocacy, communication, and social mobilization; the Epidemiology Bureau (EB), and
the Knowledge and Management Information and Technology Services (KMITS) for
data management; Health Policy Development and Planning Bureau (HPDPB) for policy
and strategic plan formulation; Material Management Division (MMD), Central Office
Bids and Awards Committee (COBAC) and Food and Drug Administration (FDA) for
drug and supplies management; the National TB Reference Laboratory of the Research
Institute for Tropical Medicine (NTRL-RITM) for laboratory network management; Lung
Center of the Philippines (LCP) for PMDT-related researches and training activities and
the 17 regional offices (ROs) for technical support to the provincial health offices (PHO)
and implementing units; and the Philippine Health Insurance Corporation(PhilHealth) for
the TB-DOTS accreditation and utilization of the TB-DOTS outpatient benefit package.

Programmatic Management of Drug-Resistant Tuberculosis

The PMDT treatment facilities and laboratories are currently being managed by the
National TB Control Program through the different DOH – regional offices and the
National TB Reference Laboratory respectively. The implementation of the PMDT
program is being funded mainly by the Global Fund grant. The treatment facilities
screen all presumptive DR-TB patients and send specimens to laboratories for
confirmation. These treatment facilities maybe a treatment center
(TC), a satellite treatment center (STC), or a treatment site (TS). The Treatment Center
(TC) does the screening of the patients and sending of the sputum specimen to the
PMDT laboratories. The TC also initiates patient treatment until the patient finishes the
treatment. The Satellite Treatment Center (STC) will perform the same tasks as TC only
on a smaller scale. The Treatment Sites (TS) also screen and send specimens to
accredited laboratories but will only manage patient’s treatment during the continuation
phase. The TC is usually a provincial/city hospital that covers the province with a
population of around 1 million, the STC is in most of the cases located at a district
hospital serving a cluster of municipalities with population of around 200,000 and the
so-called TS are selected DOTS health centers/RHUs serving a municipality with a
population of around 50,000.

Policies

1. On Case Finding

1. All MDR-TB suspects seen at the DOTS facilities, both public and private should be
screened through sputum microscopy, culture and drug sensitivity test (DST).
2. Culture procedures shall be quality assured by the NTRL or a laboratory that is duly
recognized by a supranational reference laboratory.

3. Rapid indirect rifampicin DST shall be applied whenever available and feasible, for a
rapid
and timely diagnosis of MDRTB.

2. On Case holding and Treatment

1. All confirmed MDRTB patients shall be assessed only by the trained physician of the
PMDT Treatment Center for proper case management.
2. Treatment regimens shall consist of at least four core drugs with certain or almost
certain,
effectiveness. The drug dosage shall be determined by body weight. A suggested
weight-
based dosing scheme shall be developed and included in the PMDT Training
Modules.

3. All drugs shall be administered through supervised treatment for at least six days a
week.
Each drug and each dose shall be given by strict Direct Observed Treatment
(DOT) all
throughout the treatment duration.

4. Treatment shall be for a minimum duration of 18 months after sputum

conversion.
Extension of treatment shall be decided upon by the consilium.

5. Treatment Sites shall only manage MDR-TB cases decentralized by the respective
 Treatment Center. As such, these cases are confirmed negative sputum cultures
and are no longer receiving injectable drugs.

6. Only trained staff of the identified Treatment Site, as well as trained community
members
shall implement the case holding of MDRTB cases at their level.
7. Confirmed MDR-TB cases residing outside identified expansion areas, e.g., Metro
Manila,
shall be advised to relocate to an area near a Treatment Center. Those with no
capability to
relocate shall be prioritized to stay in the PMDT Housing Facility during the time
of sputum
or culture positivity.

8. The PMDT Staff shall enjoin patients on focus group discussions, training skills for
livelihood projects and other socialization activities to continuously motivate
them and
provide them with the much-needed encouragement.

3. On Recording and Reporting

1. Recording and reporting for PMDT shall be as similar as possible to the NTP-DOTS
information system. The NTP, in partnership with the PMDT team of TDF, shall
develop necessary forms for PMDT implementation, in consonance with the current
NTP-DOTS policies and guidelines, as well as with these PMDT Guidelines. Existing
forms from the previous PMDT Projects shall also be modified accordingly.

2. Records and reports to be used shall focus on the basic indicators needed. These
forms shall contain indicators that can be routinely collected as scheduled.

3. Submission of PMDT reports shall be from the Treatment Centers to the CHD
concerned, courtesy copied to the City Health Offices, where the patients of the
respective Treatment Center comes from. The CHDs shall consolidate all Treatment
Center reports, jointly verified with TDF and submit to the NTP as scheduled.

4. Logistics and Drug Management

1. Procurement of SLDs shall be made in accordance to GLC standards and

guidelines.At the initial stage of PMDT, the NTP shall coordinate with TDF, being the
only GLC-approved agency in the country, to expedite the acquisition/procurement of
these drugs.

2. Bulk/Main storage of First Line Drugs (FLDs) and Second Line Drugs (SLDs) shall be
at the warehouse of the CHD upon compliance with the general warehousing
requirements.

3. Quarterly requisitions of drugs to the CHO by the Treatment Sites shall be done for
consolidation and submission to the Treatment Center. The Treatment Center shall in
turn submit all consolidated requests to TDF, for forecasting purposes and preparation
of an allocation list.

4. Based on the drug allocation list, the CHD shall distribute drugs to Treatment Centers
on a quarterly basis or as needed. The CHO in turn, shall distribute these to the
corresponding Treatment Sites.

5. Upon decentralization of the MDRTB case, the Treatment Site shall be responsible
for the storage of the drugs requiring low temperature; including cold chain
management for PASER. Cold chain management shall follow the EPI standards and
guidelines.

6. Safekeeping measures and appropriate storage condition shall be strictly observed

and monitored at each level.

7. In the event that unforeseen situations occur, the concerned PMDT facility shall
exercise appropriate drug retrieval mechanisms.

5. On Supervision, Monitoring and Evaluation

1. Monitoring of the various PMDT facilities shall be conducted by the NTP in

partnership with key stakeholders including the NTRL, CHDs, LGUs and TDF.

2. There shall be a designated PMDT staff at each type of PMDT facility who shall
supervise and monitor the implementation of PMDT activities.

3. Routine monitoring visits shall be done monthly for the first six months and quarterly
thereafter.
4. A monitoring tool shall be used by the monitoring team to facilitate the monitoring
process.

5. Evaluation of policy implementation shall be regularly conducted. Internal

assessment shall be integrated with the regular schedules of NTP's national
consultative workshops while external evaluations shall be conducted every 1-2 years,
jointly with the Green Light Committee and WHO.

6. On Training

1. The CHDs in coordination with the TDF shall spearhead the conduct of various
training activities for the peripheral levels. For laboratory, the NTRL and the CHD TB
Reference Laboratories shall conduct the skills development/enhancement of the
concerned laboratory staff.

2. Training modules shall serve as tools during the actual conduct of training sessions to
guide the trainers, facilitators, trainees and the other technical experts involved.

3. A post-training evaluation shall be done, as part of supervision, to assess the

capacities and identify the areas that need enhancement.

4. Training of Treatment Center Staff shall be as follows:

a. Newly hired staff of Treatment Centers shall undergo modular training on PMDT
followed by an immersion or hands-on competency-based training at the TDF
Treatment Center and/or its satellites.

b. Once the staff has fulfilled the necessary competencies and is assessed to have
satisfactory performance, the staff shall be deployed to the Treatment Center where
he/she shall be assigned.

c. A post-training evaluation shall be done while at the Treatment Center or at the

training site. An evaluation tool shall be developed for this purpose.

The Four Pillars of Primary Health Care

●Active Participation - An interactive workshop wherein the participants will go

through a multitude of activities such as case discussions, exercises, role
play, and self-assessment such as the one conducted by the Centers for
 Disease Control (CDC), Atlanta and WHO (HQ and WPRO) in Manila,
Philippines from May 30th to June 7th of 2013, could be done as a form of
training for the respective barangay health leaders of the community. Those
who are involved in the said program can also give feedback on every module
in the workshop and also an overall evaluation on the said course. This is to
create a number of trainers who would then be able to further train other
health staff with regards to PMDT.

●Intra and intersectoral linkages - This program is facilitated and is being

improved upon by the Philippine Plan of Action to Control TB (PhilPACT) in
conjunction with the National TB Program (NTP) and other stakeholders and
partners. Activities such as advocacy, facility and laboratory expansion,
managing, as well as drugs and supplies management are being facilitated by
the DOH’s Regional Offices (ROs) through the NTP coordinators in the
different regions. The management of all research related to PMDT is
managed in coordination of the Lung Center of the Philippines (LCP). The TB
laboratory network as well as the expansion of the culture and Drug
Susceptibility Testing (DST) laboratories is the responsibility of the the
National TB Management Division (MMD).

●Use of technology - Treatment facilities screen all patients who are presumed
to have DR-TB in which these specimens they collected would be sent to
laboratories such as a Treatment Center, Satellite Treatment Center, or
Treatment Site for confirmation.

●Support mechanisms - The DOH Regional Offices manage the PMDT

treatment facilities. Also, the Infectious Disease Office (IDO) of the DOH was
empowered to manage PMDT within its framework. Under the DOH’s
Knowledge Management and Information Technology is the Integrated TB
Information System (ITIS) which utilizes a web-based system for the data
collection, processing, reporting, and use of information necessary for
improving TB control effectiveness and efficiency.

5A’s of Primary Health Care

Problem/s Opportunities to Implementation

address the
problem

Accessibility Since there is a Through the

Despite having lots need for a more program, PMDT
 of health centers accessible health shall be available to
here in our country, care facilities, all health centers as
it still doesn’t reach enough budget well as to different
the standard of 1 should be allocated hospitals.
barangay = 1 health to create more Decentralization of
center. We have health centers & PMDT should be
41939 barangay yet hospitals especially implemented for a
15436 only have in areas far from more effective
health centers. the city. Proper measure to solve
Therefore, other knowledge such as the problem of
barangays have to first aid, and access to treatment
travel far to reach a common illness and decrease the
health facility. It management loss to follow up.
was shown in the should also be
video an example imparted to our
of reality that others people especially to
even have to walk those living far from
for hours — in their health facilities..
case, about 4 hrs to
reach a health
center, and about
12 hours walk to
reach the nearest
hospital. There are
times, patients don’t
have time to go to
hospitals especially
for emergency
cases causing them
to die without
seeing a doctor.

Affordability We all know how

much it cost when Laws regarding The implementation
one gets cheap medications of the PMDT
hospitalized. should also be program is being
Despite having lots implemented funded mainly by
of discounts or accordingly for it to the Global Fund
government be affordable for all. grant. Outside
assistance, there’s Also, as mentioned treatment of MDR-
still a need for out- from the video, for TB could cost
of-pocket savings long-term solution, 200,000 pesos,
for medications & there is a need to whereas PMDT
other needs. TB create a national treatment is free,
medications cost a drug industry which and could even
 lot, and as is self-reliant, come with financial
mentioned from the supported by assistance
video, it’s about 70 government and (example:
pesos/day, good for produces transportation
6 months way back. appropriate and allowance)
Other people enough especially for
doesn’t even have medications patients from far-
enough money to depending on the flung areas.
supply the basic needs of the people
needs of their
family such as food.
Worse case
scenarios are
having
complications or
being drug resistant
such as in TB
medications..

Acceptability Decentralization of
People who haven’t Respect and honor PMDT should be
seen doctors has to of the norms and implemented for a
have alternatives to values must be more effective
somehow cope up demonstrated at all measure to solve
with illnesses and times. Also, rapport the problem of
these kind of should also be access to treatment
situations. Others established to gain and decrease the
rely on herbal the trust of the loss to follow up.
medicines and patients. This will cause
quack doctors, or them to seek more
sometimes due to advise to health
the fact that it is care professionals
common in the & not just rely on
community, they do their instincts in
not see it as a managing their
problem which illnesses.
requires immediate
attention, causing
low salience of the
problems.

Availability As noted from the Proper budget must

There are so much video presented, be allocated to
cases of there is a need for a provide the needs
unavailability budget increase of the health
mentioned in the when it comes to facilities to be able
video. First are the health. A standard to cater all patients.
health facilities of 5% of the total Through the
itself. We do not national budget program, the
have enough health must be met in diagnostic capacity
centers to order to supply the should be
accommodate all need of the facilities continuously
our people. we have. There is boosted by the
Second, even if we also a need to Xpert MTB/RIF
have hospitals & support the health implementation.
health centers, centers for it to be Trained personnel
without enough able to provide the should always be
budget, it’ll be very needs of people available even in
difficult to manage. which illness can some lower level
Third, are the easily be cured or treatment sites and
personnels. Due to prevented from no recent stock
the fact that, heath having outs or gaps in
care professionals complications. SLDs procurement
are overworked and Enough income, should be reported.
underpaid, they are just workload&
leaving for abroad programs should be
to sustain the implemented to
needs of their attract health care
families as well. professionals to
This causes stay and serve our
hospitals to close, people.
and patients to
receive not enough
medical attention.
Fourth, the
supplies, and
equipments are not
enough. There is
overpopulation in
the health facilities,
ventilation
problems, not
enough beds to
accommodate
patients
comfortably, and
even wheelchairs.
This compromises
the services
provided for the
patients. Lastly,
 medications are
sometimes not
available, or out-of-
stock in health
centers. In the
video, in one of the
health centers in
Mindanao which
was supposed to
cater 1542 people,
only have
paracetamol &
vitamins good for
10 people. In one of
the hospitals shown
in the clip, some
medications were
already expired.

Appropriateness Despite the fact that

In the video, we can Facilities should be the program has
see how in accordance to been monitored for
inappropriate things the needs of the its effectivity and its
were. Despite patients who are risks since the
having cases of TB, near the area. beginning, it should
anemia, and other Health care still be monitored at
illnesses, the health resources should all times especially
center nearest to be appropriate and when it expands its
the area where the adequate to supply scope. Trained
people lived has different age health professional
medications groups. shall be the one to
(paracetamol & monitor, handle,
vitamins) but are no and see to it that
help for their appropriate people
illnesses. It doesn’t receives
meet most appropriate
constraint, treatment.
preference, and
needs of the
patients.

The End TB Strategy

The End TB Strategy, developed in the context of the UN SDGs, is a logical evolution
and a paradigm shift from past global TB strategies. The DOTS strategy of 1994 helped
revitalize NTPs and equivalent entities by putting in place the essential basics to
address the TB epidemic. The Stop TB Strategy of 2006 broadened the response by
addressing the emerging challenges of HIV-associated TB and MDR-TB. It aimed to
improve access to quality TB care by engaging all public and private care providers, civil
society organizations and communities. The Stop TB Strategy also encouraged
investment in research for better tools and approaches.

In the year 2010, tuberculosis ranks 6th place in the leading cause of mortality with a
rate of 26.3 deaths for every 100,000 population and accounts for 5.1% of total deaths.
It is about 28.6 deaths per 100,000 population. In the latest statistics in the year 2019,
about one million Filipinos have had active TB disease. This is recorded as the third
highest prevalence rate in the world.

Tuberculosis is easily treated. Yet, in our country it is the number one killer among all
infectious diseases. Every day more than 70 people lose their lives due to this.
One and big problem is income. About 100,000-150,000 people with TB suffer from
extreme costs while seeking treatment in the public sector every year. The main
reasons for that are low income, transport costs, and the drugs needed to cure TB itself.
Some instances could be when a patient develops drug resistant tuberculosis due to
failure of following the program for the reason stated a while ago, which are more
expensive and difficult to treat. Therefore, adding to the increasing problem of TB.

In the Philippines, patients with confirmed TB cases may enroll in the TB-DOTS
program. PhilHealth pays P4,000.00 for the entire six-month treatment which includes
diagnostic work-up, consultation services and drugs provided when enrolled into the
DOTS.

The TB-DOTS program is only applicable for new cases of pulmonary and extra-
pulmonary TB in children and adults. What this program lacks is it does not cover cases
of patients who returned for treatment after interruption for two or more months which
could cause a bigger problem increasing the number of Filipinos with tuberculosis. I
think it is important to have a back-up plan and not include those patients who failed to
return in treatment or incase some patients failed to follow the schedule. Knowing that
most Filipinos have a hard time going back and forth to the health services and not
everyone has the luxury of time.

Active Participation
 There should be a strong coalition with civil society organizations and
communities. The affected communities must also be a prominent part of the proposed
solutions. Community representatives and civil society must be enabled to engage more
actively in programme planning and design, service delivery, and monitoring, as well as
in information education, support to patients and their families, research advocacy.
A strong coalition that includes all stakeholders needs to be built. Such a
coalition of partners can assist people in both accessing high-quality care and in
demand in high-quality services. A national coalition can also help drive greater action
on the determinants of the tuberculosis epidemic.
To have active participation and to roll-out the End TB Strategy, countries will
need to have an advocacy, baseline preparedness, and collaboration. As a country we
should advocate for and achieve: High level political commitment-which we have heard
in the documentary that the government doesn’t support much on funding for rural
hospitals or health care centers and lately there has been a 16.6 billion peso budget cut
for the DOH. And that there should be a high level national mechanism to direct the
adaptation and implementation of the End-tb Strategy. Baseline Preparedness wherein
there is to assess the TB situation, knowing how and why one person who has
tuberculosis had it. People should also be aware of the policy and the environment they
are living in. In the documentary it was shown that the woman with tb, only went after
health services when her condition got worse. Lastly, there should be collaboration
across different departments, with patients and affected communities, private sector and
national/international supporters and partners. With more health education for the
people, they would be more aware of the disease and know ways to prevent
tuberculosis.

Intra/Inter Sectoral linkages

-USAID, DOH, DSWD

The Department of Health and Department of the Social Welfare and

Development also launched the integration of the TB module into the DSWD Family
Development Sessions. These sessions will include health education classes on TB
prevention, control, care, and treatment for recipients of the PantawidPamilyang Pilipino
Program, the Philippine government’s conditional cash transfer program.

Use of technology
The DOH is committed to three ‘business-not-as-usual’ strategies for our all-out-
war against TB: (1) high-level commitment, (2) massive screening, testing, and
treatment, and (3) mandatory notifications by the private sector
 The first strategy aims to address the social determinants of TB to prevent
catastrophic costs to patients and their families due to loss of income during their
sickness due to TB. It will involve the participation of the Department of Social Welfare
and Development.

The second strategy aims to provide faster and better access to the latest
technologies to screen, test, and treat people with TB. This will be through the proper
allocation of budget required by the Philippine Strategic Elimination Plan to deploy
adequate resources and health workers on the ground. It will involve the participation of
legislators and the Department of Budget and Management.

The third strategy aims to enforce the Comprehensive Tuberculosis Elimination

Plan Act of 2016 (RA 10767) for mandatory notifications by all public and private
providers. It will require all care providers, private as well as public, to notify the
Department of Health of every person with TB that they diagnose.

Genexpert

-Xpert can detect drug resistance much faster less than a day compared to the average
75 days of the phenotypic DST. Xpert can only detect rifampicin-resistance the use of
phenotypic DST cannot be totally removed from the diagnostic pathway: the DST is still
required to establish the treatment regimen.

-The use of Xpert accelerates the initiation of treatment for Rifampicin-resistant patients.

-The WHO recommended concessionary price for the module is USD 17,500 [PHP
909,572] and USD 9.98 [PHP 518.71] - price accepted for public procurement only.

-Prices in private sector Philippines seem to range between USD128–183 [PHP 6653
9512] per test applied to patient

-In 2016, the total number of Xpert and culture laboratories in the public sector of the
country is 180. All of the regions have at least one Xpert laboratory with the majority
located in NCR (30).

-Private healthcare facilities in the country offering Xpert MTB/Rif services are not yet
fully accounted for. A Lancet article from 2016, indicates the existence of at least 11
Xpert modules in the private sector.
TB-LAMP

-(Loop-mediated isothermal amplification), requires minimal laboratory infrastructure

and has been evaluated as an alternative to sputum smear microscopy, still the most
widespread test in use in resource-limited settings.

-TB-LAMP is a unique temperature-independent way of amplifying DNA from TB

organisms. It is a manual assay that takes less than one hour and results can be read
with the naked eye under ultraviolet light.

-The test does not detect drug resistance and is therefore only suitable for testing of
patients at low risk of multidrug-resistant TB (MDR-TB).

-TB-LAMP provides better results than sputum smear microscopy, detecting 15% more
patients with pulmonary TB if done in all persons presenting with signs and symptoms
of TB

Support- what resources are used?

New USAID projects bring the total U.S. government contribution in support of
DOH’s National Tuberculosis Control Program to over Php6.5 billion. As a result of the
U.S.-Philippine partnership, the number of TB patients diagnosed and treated in the
Philippines has more than doubled since 2006.

5A’s of Primary Health Care

PROBLEM/S OPPORTUNITIES TO IMPLEMENTATIO

ADDRESS THE N
PROBLEM
Accessibility As seen in the video, To address the With the help of the
there is a problem, one solution program, a strong
transportation barrier is to have the DOH coalition with social
from the community collaborate with organizations and
to the health care DPWH in making communities can be
facility which disables roads accessible to a great help in
the people who have the community. achieving an
regular check-ups expanding access
and only rely on to full range of high-
home visits. quality services and
expanding access
to services for all in
need, especially
vulnerable groups
faced with the most
barriers and worst
outcomes.

Affordability As stated in the In order to address With the help of the

video, the expenses this problem, there is program, universal
of a person with a need to provide health coverage is
tuberculosis costs barangay health achieved through
around 70 pesos per centers in remote expanding
day which cost areas in which it can coverage, including
around 12,600 pesos reduce their stay and costs of
for 6 months. Due to additional fees in the consultations and
the high cost of hospital thus having testing, medicines,
medicine in the DOTS which are free follow-up tests and
Philippines, people of service in health all expenditures
cannot afford centers. associated with
treatment. staying in complete
curative or
preventive
treatment.
Acceptability Since there are no To address the With the help of the
health care facilities problem, health program, pursuing
available in remote teaching should be a “health-in-all-
areas, the indigenous done such as proper policies” approach
people have no orientation on taking will immensely
choice but to rely on prescribed benefit tuberculosis
herbal medicines. medications for care and prevention
Poverty is also tuberculosis by a such as addressing
associated with poor physician. the health issues of
general health migrants and
knowledge and a lack strengthening
of empowerment to cross-border
act on health collaboration and
knowledge, which preventing direct
leads to risk of risk factors for
exposure to several tuberculosis,
tuberculosis risk including smoking
factors. and harmful use of
alcohol and drugs,
and promoting
healthy diets, as
well as proper
clinical care for
medical conditions
that increase the
risk of tuberculosis,
such as diabetes.
Availability Since there is a lack There should be a With the help of the
of drug manufacturers collaboration of the program, a national
in the Philippines, the DOH and the strategic plan
government imports government. A should be
resources from other national drug industry developed. Taking
countries which should be created into consideration
makes our local and supported by the of incorporating five
medicines expensive. government to make distinct sub-plans: a
Additionally, use of our own core plan, a budget
medicines will not be resources. plan, a monitoring
available in remote and evaluation
areas in which they plan, an operational
would rely on DOH. plan and a technical
assistance plan.

Appropriatenes In the video, there There should be an With the help of the
s are inappropriate improvement in social national strategic
situations where services so that plan, an adequate
medications are implementation of funding should be
inaccessible in health programs secured to be able
hospitals and requires would be successful. to make
patients to be referred medications
to rhu’s and health accessible.
centers.

Duterte Health Agenda

Three Guarantees

Guarantee 1: All life stages and triple burden of disease

Which attains Health related SDG targets: Financial Risk Protection, Better Health
Outcomes, Responsiveness

Communicable diseases such as tuberculosis are highly evident and manifested by the
vulnerable citizens in Maguindanao. Due to lack of necessary healthcare services
including medications, medical supplies, proper health teachings, and medical and
nursing interventions, these problems are still being unsolved and continuously worsen;
hence, affects more people in the community. With the implementation of Duterte’s
Health Agenda 2016-2022 “All of Health and Health for All”, these issues may be
address by applying the guarantee with regards to all life stages and triple burden of
disease that covers sexual and reproductive health, immunization, adolescent health,
geriatric health, health screening, promotion & information as well as communicable
diseases. Through providing advance quality, health promotion and primary care by
conducting annual health visits for all poor families and special populations like these
areas, people in this community will become knowledgeable thus may increase their
awareness about health and illnesses. Furthermore, valuing all clients and patients,
especially the poor, marginalized, and vulnerable should also be observed through
prioritizing the poorest 20 million Filipinos in all health programs and support them in
non-direct health expenditures may also be given concern especially in this community
in order to prevent the continuous growing of communicable diseases to these
communities.

Guarantee 2:Service delivery network

One problem encountered was lack of Barangay health Center in the area. People do
not have a chance to see a doctor to seek for consultation about their condition. Readily
ambulance was also not available to transfer patients to the nearest hospital. To
address the issue, The Philippine Health Agenda 2016-2022 which is “All for Health
towards Health for all” should be widely implemented. Guarantee 2 of the Health
Agenda which is the Service delivery seeks to provides functional network of Health
Facilities. Services are delivered by networks that are Fully Functional, Compliant with
Clinical Practice Guidelines, Available 24/7 & even during disasters, Practicing
Gatekeeping, Located close to the people and Enhanced by Telemedicine. Easy access
to health facilities can ensure optimum health.

Guarantee 3:Universal health insurance

According to Philippine Health Agenda 2016-2022, every year 1.5 million families are
pushed to poverty due to prohibitive and unpredictable user fees or co-payments of
health care expenditures that leads them to forego or delay care. To address this issue
one of the guarantees of the Philippine Health Agenda 2016-2022, namely “All for
Health towards Health for All”, is universal health insurance. This guarantee seeks to
provide financial freedom, using PhilHealth, when accessing services that may help
these people from remote areas achieve optimum health. It will be easier for the people
to pay for services in the hospital for PhilHealth will provide free and affordable care.
The community health nurse should educate the people on how PhilHealth works and
its benefits. One of the benefits of having PhilHealth are it cover preventive services,
outpatient diagnostics, medicines, blood and blood products. The community health
nurse should also inform the client the steps on how to avail PhilHealth, its rules and
regulations. The downside in this guarantee, most of the clients have not registered
their names to the National Statistics Office. Thus, their names are not listed to the
qualified indigent members. As a community health nurse, we must also secure
essential papers, like birth certificate, marriage contracts etc., for these clients because
they are not recognized by the government since they live in remote areas. It would be
difficult for them to avail the program right away because their names must be listed and
must be qualified as an indigent member of the society. Once they are registered and
are qualified indigent members, they are automatically enrolled and covered under the
program. They won't pay for anything since the NGO, LGU’s, corporations etc. pays for
each enrolled indigent family.

Sustainable Development Goals

The United Nations Sustainable Development Goals (SDGs) include ending the TB
epidemic by 2030 under Goal 3. The Strategy: Provides a unified response to ending
TB deaths, disease, and suffering.
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical
diseases and combat hepatitis, water-borne diseases and other communicable
diseases.
Progress of Goal 3 in 2019
●Tuberculosis remains a leading cause of ill health and death. In 2017, an
estimated 10 million people fell ill with tuberculosis. The burden is falling
globally: incidence of tuberculosis has continued to decline from 170 new and
relapse cases per 100,000 people in 2000 to 140 in 2015, and 134 in 2017;
and the tuberculosis mortality rate among HIV-negative people fell by 42 per
cent between 2000 and 2017. However, large gaps in detection and treatment
persist and the current pace of progress is not fast enough to meet the
Sustainable Development Goal target, with drug-resistant tuberculosis
remaining a continuing threat.
Health systems and funding
●Official development assistance (ODA) for basic health from all donors
increased by 61 per cent in real terms since 2010 and reached $10.7 billion in
2017. In 2017, some $2.0 billion was spent on malaria control, $1.0 billion on
tuberculosis control and $2.3 billion on other infectious diseases, excluding
HIV/AIDS. UHC Which addresses the problem

Universal Health Care Law

Sec. 2 of the Universal Health Care Law stated that it s the policy of the state to protect and
promote the right to health of all Filipinos and instill health consciousness among them. Towards
this end, the State shall adopt:
a.) An integrated and comprehensive approach to ensure that all Filipinos are health
literate, provided with healthy living conditions, and protected from hazards and risks that could
affect their health.
b.) A health care model that provides all Filipinos access to a comprehensive set of quality
and cost-effective, promotive, preventive, curative, rehabilitative and palliative health services
without causing financial hardship, and prioritizes the needs of the population who cannot afford
such service.

In the situation of Lydia Marcos, it was said in the documentary that the medications that she
needed for her condition was around 70 pesos each day. Even though this law could help
minimize the burden in her condition during her time. She only went to the hospital when her
condition got worse where her daily expense reached up to 1000 pesos per day. Although this
law would benefit a lot of people, the problem that we may face in the future is the compliance
and how the Filipino people would take the responsibility to seek for the needed treatment or
prevention in the right time. Some problems led into critical problems especially in Lydia’s
situation because she may have not followed the treatment regimen and went to health care
professionals when there were signs and symptoms that’s already worse enough that sadly led
into her death.

REFERENCES:

Department of Health (2014). Manual of Procedures of the National Tuberculosis

Control Program 5th Edition. Manila, Philippines: DOH, 2014. Retrieved February 16,
2020, from https://www.doh.gov.ph/sites/default/files/publications/MOP_Final_a.pdf

Smith, D. S., Cruz, V., & Webb, K. (2008, May 23). Using New Diagnostic Technologies
to Find Prevalence of Latent and Multiple Drug Resistant Tuberculosis in Metro Manila,
Philippines. Retrieved February 16, 2020, from
https://web.stanford.edu/group/parasites/ParaSites2008/Victor Cruz_Kevin Webb/LTBI
and MDR prevalence in Philippines.htm