Thursday, December 08, 2005

Editorial – December 8, 2005

Public-Private Mix DOTS {PPMD} in Aklan
By: Megs S. Lunn
In many countries, private health care providers are the gateway to health services for people with symptoms of tuberculosis. The types of private providers and their roles in TB management, however, vary greatly among and within countries.
The National Tuberculosis Prevalence Survey done in 1997 (1997 NPS) revealed that the magnitude of TBS in the Philippines hardly declined between 1982 and 1997. In 1996, the National TB Control Program (NTP) adopted the directly observed treatment short-course (DOTS) strategy. By the end of 2001, more than 90 percent of the population have access to it. Cohort analysis revealed good treatment outcomes. Public-private sector collaboration in TB control was strengthened since the Philippine Coalition Against TB (PhilCAT) was organized in 1994. There are four areas of collaboration, namely, policy development, advocacy and information dissemination, training and research and service delivery. Four models of public-private mix (PPM) DOTS in service delivery were developed. The private DOTS clinics provide the space, staff and operational funds while the Department of Health (DOH) provided technical assistance, anti-TB drugs, laboratory supplies and forms. Evaluation showed that PPM in TB control is feasible with good results. The major challenge is to replicate and institutionalize the PPM DOTS.
Hence, the municipality of Kalibo, thru the Municipal Health Office is privileged to be chosen as one of the expansion sites of PPMD. To make global health initiatives on communicable diseases with big emphasis on TB, the Municipality of Kalibo held a Public-Private Mix DOTS {PPMD} Symposium for Non-Medical Participants last December 6, 2005 at the CAP Bldg, Kalibo, Aklan. The symposium started with the warm welcome of Municipal Mayor Raymar A. Rebaldo. Dr. Jocelyn T. Garcia, Rural Health Physician and PPMD Unit Head introduced the guest speaker – Dr. Edith G. Caloyloy of DOH 6, Regional NTP Coordinator and Vice-Chair, CICAT.
A very lively and productive open forum followed her presentation. Mayor Raymar A. Rebaldo, assisted by Dr. Jocelyn T. Garcia and Dr. Agrelita D. Fernandez awarded the Certificate of Appreciation to the guest speaker. Vice Mayor Nilda B. Tambong gave the closing message. Ms. Marjo Verushka M. Morales was the program host.
Dr. Caloyloy discussed The Growing Burden of Tuberculosis in the Philippines. According to her, “Tuberculosis is one of the most common causes of morbidity and the most common cause of death in HIV-positive adults living in less-developed countries, yet it is a preventable and treatable disease.”
Since the quality of treatment influences the duration of illness and the case fatality rate, WHO developed a strategy for TB control comprising of five {5}s elements: political commitment, diagnosis by direct smear microscopy, a mechanism to secure drug supplies, standardized recording and reporting, and use of standardized short-course chemotherapy with direct observation of treatment.
Tuberculosis deaths include those of patients who died without ever being treated or while receiving treatment, as well as late deaths from relapse or posttuberculous complications.
DOTS strategy calls for sustained political commitment by national governments and mobilization of additional resources – human and financial – from within and outside endemic countries to help implement a comprehensive and expanded DOTS programme. The DOTS programme should be made an integral health system activity with nation-wide coverage that anchors TB activities throughout the health system at all levels, including peripheral health facilities and the community. ssBeing a public good with large benefits to society, adequate resources should be made available to achieve the goal of TB control worldwide.
Particular efforts are needed to foster local, national and international partnerships for TB programmes taking into account technical and financial requirements at all levels like improving the balance between disease-specific and sectorwide programs, between treatment and prevention, and among the roles of public, private, and community organizations and substantially enhancing monitoring and evaluation, research, and data gathering capacity at both the global and the country level.
Dr. Caloyloy stressed that, “Social mobilization is needed to tackle TB within high-prevalence countries. This is essential to further sustain the political will necessary for effective implementation of a comprehensive DOTS strategy. Governments can facilitate social mobilization by fostering communication among all health care providers, patients and public at large especially with the help from the media for information dissemination and public awareness,” Dr. Caloyloy further srecommended a method of case detection like the sputum smear microscopy among symptomatic persons rather than the use of x-ray results to avoid wrong diagnosis of the patients. Patients seeking care at health care facilities should be given more importance and for them not to be ashamed, rather to be proud of the treatment. In return, health care services must be available and accessible services to the whole population sof the community. Adequate investments in the health system are essential to provide access to a sputum microscopy network with built-in quality control.
Likewise, HIV infection remains the single most important factor that increases the risk of developing TB. For this purpose, TB control programmes should be linked closely with HIV/AIDS prevention and control programmes. Strategies for patient care must be be developed.
As resources increase, additional diagnostic tools such as chest X-ray, mycobacterial culture and drug susceptibility testing may be added to supplement sputum smear microscopy in a systematic manner. Standardized short-course chemotherapy to all cases of TB under proper case-management conditions including direct observation of treatment; proper case management conditions imply technically sound and socially supportive treatment of services must be made available. To ensure the accountability of TB services, help TB patients to adhere to treatment and avoid emergence of drug-resistant forms, direct observation of treatment is recommended.
Harnessing community contribution to TB care will increase access to effective TB care. To enable them to adhere to treatment, TB patients need support and care sensitive to their needs. It means providing a treatment partner or supporter acceptable to patients to reinforce their motivation to continue treatment and counter the tendency of some to interrupt treatment. TB control programmes must explore the use of locally appropriate and acceptable ways of community-based or work place-based direct observation of treatment. Quality-assured sputum microscopy must be accessible to monitor the treatment progress, assess treatment outcomes and certify cure among patients of pulmonary tuberculosis.
According to Dr. Caloyloy, “these Anti-TB drugs are made available free of charge to all TB patients since curing TB patients is beneficial to society at large. Their proper utilization in practice should be strictly monitored. People who are suspected with TB must go to their respective Rural Health Center and seek the treatment as soon as possible to avoid the spreading of the disease.”
Dr. Jocelyn T. Garcia pointed out, “Convenient and accessible TB treatment and care are essential. The challenge is to do this in ways that contribute to community development that are effective, acceptable and affordable”
Dr. Agrelita D. Fernandez added that, “Community participation in primary health care (PHC) is not a new idea where community health workers play important role with adequate support, motivation and incentives. It is better to work through existing community organizations than to create new ones./MPmailto:april_73uk@yahoo.co.uk

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