Using Patient Pathway Analysis to Design Patient-centered Referral Networks for Diagnosis and Treatment of Tuberculosis: The Case of the Philippines.

Background: Tuberculosis (TB) is the 8th leading cause of death in the Philippines. A recent prevalence survey found that there were nearly 70% more cases of tuberculosis than previously estimated. Given these new data, the National TB Program (NTP), operating through a decentralized health system, identified about 58% of the estimated new drug-sensitive (DS) TB patients in 2016. However, the NTP only identified and commenced treatment for around 17% of estimated new drug-resistant patients. In order to reach the remaining 42% of drug-sensitive patients and 83% of drug-resistant patients, it is necessary to develop a better understanding of where patients seek care. Methods: National and regional patient pathway analyses (PPAs) were undertaken using existing national survey and NTP data. The PPA assessed the alignment between patient care seeking and the availability of TB diagnostic and treatment services. Results: Systemic referral networks from the community-level Barangay Health Stations (BHSs) to diagnostic facilities have enabled more efficient detection of drug-sensitive tuberculosis in the public sector. Approximately 36% of patients initiated care in the private sector, where there is limited coverage of appropriate diagnostic technologies. Important differences in the alignment between care seeking patterns and diagnostic and treatment availability were found between regions. Conclusions: The PPA identified opportunities for strengthening access to care for all forms of tuberculosis and for accelerating the time to diagnosis by aligning services to where patients initiate care. Geographic variations in care seeking may guide prioritization of some regions for intensified engagement with the private sector.

Factors Associated with Loss to Follow-up during Treatment for Multidrug-Resistant Tuberculosis, the Philippines, 2012-2014.

To identify factors associated with loss to follow-up during treatment for multidrug-resistant (MDR) tuberculosis (TB) in the Philippines, we conducted a case-control study of adult patients who began receiving treatment for rifampin-resistant TB during July 1-December 31, 2012. Among 91 case-patients (those lost to follow-up) and 182 control-patients (those who adhered to treatment), independent factors associated with loss to follow-up included patients' higher self-rating of the severity of vomiting as an adverse drug reaction and alcohol abuse. Protective factors included receiving any type of assistance from the TB program, better TB knowledge, and higher levels of trust in and support from physicians and nurses. These results provide insights for designing interventions aimed at reducing patient loss to follow-up during treatment for MDR TB.

Public-private mix DOTS in the Philippines.

The National Tuberculosis Prevalence Survey done in 1997 (1997 NPS) revealed that the magnitude of tuberculosis 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% of the population have access to it. Cohort analysis revealed good treatment outcomes. Despite this improvement in the public sector, there is a concern that the epidemiological impact of DOTS will be limited due to the non-participation of the private practitioners, a major stakeholder. 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.