Country Profile

Philippines
case notification rates continue to increase in the Philippines as PPM initiatives are expanded and community task forces become involved in case-finding. The quality of treatment continues to improve; the success rate for new smear-positive cases has been above target for the past 7 years. eQa has been extended to all diagnostic facilities, and culture is becoming more widely available. Management of MDr-Tb is expanding, much of it with Glc approval. The diagnosis and treatment of Tb in children was an important focus for the nTP in 2006; at least one city in each region was equipped in 2006 to manage paediatric Tb. a national prevalence survey was completed in 2007, the results of which will help inform estimates of the burden of Tb in the Philippines. The introduction of an electronic Tb register may result in improvements in the quality of routine data, which can then be better used to monitor programme performance and impact. However, the nTP has no specific plans to perform special analyses of routinely collected data.
SURVEILLANCE AND EPIDEMIOLOGY, 2006 Population (thousands)a Estimates of epidemiological burden1 incidence (all cases/100 000 pop/yr) Trend in incidence rate (%/yr, 20052006)2 incidence (ss+/100 000 pop/yr) Prevalence (all cases/100 000 pop)2 Mortality (deaths/100 000 pop/yr)2 of new Tb cases, % HiV+b of new Tb cases, % MDr-Tb (2004)c of previously treated Tb cases, % MDr-Tb (2004)c Surveillance and DOTS implementation notification rate (new and relapse/100 000 pop/yr) notification rate (new ss+/100 000 pop/yr) DoTs case detection rate (new ss+, %) DoTs treatment success (new ss+, 2005 cohort, %) of new pulmonary cases notified under DoTs, % ss+ of new cases notified under DoTs, % extrapulmonary of new ss+ cases notified under DoTs, % in women of sub-national reports expected, % received at next reporting leveld Laboratory services 3 number of laboratories performing smear microscopy number of laboratories performing culture number of laboratories performing DsT of laboratories performing smear microscopy, % covered by eQa Management of MDR-TB of new cases notified, % receiving DsT at start of treatment of new cases receiving DsT at start of treatment, % MDr-Tb of re-treatment cases notified, % receiving DsT of re-treatment cases receiving DsT, % MDr-Tb Collaborative TB/HIV activities national policy of counselling and testing Tb patients for HiV? national surveillance system for HiV-infection in Tb patients? of Tb patients (new and re-treatment) notified, % tested for HiV of Tb patients tested for HiV, % HiV+ of HiV+ Tb patients detected, % receiving cPT of HiV+ Tb patients detected, % receiving arT 86 264 WHO Western Pacific Region (WPR)
rank based on estimated number of incident cases (all forms) in 2006

287 -1.0 129 432 45 0.1 4.0 21

Philippines rank 9 Other HBCs in WPR Other countries in WPR

171 99 77 89 61 1 31 94

Case notifications
notification rate (DoTs and non-DoTs cases per 100 000 pop)

notifications, particularly ss, fell dramatically in the late 1990s, but are now fairly stable; proportion of new pulmonary cases that are ss+ has risen to about 60% 400 300 200 100 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 relapse new extrapulmonary new ss/unk new ss+

2 374 3 3 100

0.0 58 8.4 91

re-treatment

Unfavourable treatment outcomes, DOTS

30
20

outcomes not evaluated for all patients in last two years, but treatment success remains above 85% target
% of cohort (new ss+ cases)

no policy no

18

17

15

16

13

12

12

12

12

13

11

Data not available

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 not evaluated Transferred Defaulted Failed Died Target <15%

DOTS expansion and enhancement DoTs coverage (%) DoTs notification rate (new and relapse/100 000 pop) DoTs notification rate (new ss+/100 000 pop) DoTs case detection rate (all new cases, %) DoTs case detection rate (new ss+, %) case detection rate within DoTs areas (new ss+, %) e DoTs treatment success (new ss+, %) DoTs re-treatment success (ss+, %)

1995 4.3 1.4 0.6 0.4 0.4 9.7

1996 2.0 2.5 0.7 0.8 0.5 23 82 66

1997 15 10 4.5 3.2 3.2 21 83 26

1998 17 25 14 7.7 10 60 84 83

1999 43 43 27 13 20 46 87

2000 90 118 66 39 48 53 88

2001 95 138 76 43 56 59 88

2002 98 149 82 48 61 62 88

2003 100 164 90 54 67 67 88 76

2004 100 158 94 52 72 72 87 53

2005 100 162 97 54 74 74 89

2006 100 171 99 58 77 77

Global Tuberculosis conTrol | WHO REPORT 2008 | 137

PhiliPPiNes
IMPLEMENTING THE STOP TB STRATEGY1 DOTS ExPANSION AND ENHANCEMENT

Political commitment, standardized treatment, and monitoring and evaluation system Achievements Planned activities l introduced management of paediatric Tb in one city in each region; l continue training health personnel at all levels on 4th edition of nTP trained nTP coordinators who in turn trained health-care staff; manual Department of Health provided paediatric anti-Tb drugs, PPD l regularly monitor and evaluate nTP initiatives at regional and local reagents and syringes levels through nTP coordinators and partners l revised nTP manual (4th edition) to include new initiatives; l Pilot test electronic Tb register conducted orientation and training of doctors and nurses at all levels on 4th edition of manual l contracted external consultant to conduct evaluation of national monitoring and evaluation and information systems for Tb, malaria and HiV l Produced annual report of nTP activities Quality-assured bacteriology Achievements l completed nationwide expansion of eQa (including capacity building and logistics); results of eQa not available

Planned activities
l conduct regular monitoring of laboratory activities l build capacity for culture needed for programmatic management of

MDr-Tb
l strengthen culture capacities of public laboratories identified to

collaborate with nTP Drug supply and management system Achievements l ensured uninterrupted supply of first-line anti-Tb drugs to regional and peripheral levels

Planned activities
l integrate management of second-line anti-Tb drugs with Department

of Healths drug distribution system to avoid stocks-outs of second-line drugs as experienced in 2006 l Monitor drug supply and distribution at regional level

TB/HIV, MDR-TB AND OTHER CHALLENGES

Collaborative TB/HIV activities Achievements l set up Tb/HiV coordination committee with formal endorsement of secretary of Health; held meetings to discuss roles and function of committee (nTP managers, naP managers, nGos and partners of both nTP and naP invited) Diagnosis and treatment of multidrug-resistant TB Achievements l expanded management of MDr-Tb services to lung centre of the Philippines (public facility) l Decentralized treatment of MDr-Tb to health centres l Glc evaluated management of MDr-Tb at lung centre of the Philippines and at Makati Medical center

Planned activities
l Formulate policies on collaborative Tb/HiV activities l implement provider-initiated HiV counselling and testing for Tb

patients in selected areas in Metro Manila after training relevant health staff Planned activities
l Train health personnel and develop modules to standardize and

mainstream implementation of programmatic management of MDr-Tb l Formulate policy for programmatic management of MDr-Tb and incorporate management of MDr-Tb fully into routine activities of nTP l Prepare those public health facilities that will be participating in management of MDr-Tb; train staff and equip additional laboratories for culture and DsT Planned activities
l explore possibility of introducing management of MDr-Tb in prisons

High-risk groups and special situations Achievements l Worked with medical staff of national bilibid and Womens correctional prisons, and with bureau of corrections l coordinated with faith-based nGos and other government organizations to implement Tb control in selected urban areas with poor populations

unless otherwise specified, achievements are for financial year 2006; planned activities are for financial year 2007.

138 | WHO REPORT 2008 | Global Tuberculosis conTrol

PhiliPPines
HealtH system strengtHening, including Human resource development

Achievements l involved broad range of partners from health and other sectors in planning for Tb control l aligned nTP plan and budget with national plan for health development, poverty reduction strategy paper, medium-term framework for health and sWap l completed planning of comprehensive and unified policy on Tb control (cuP) for other government bodies (including departments of education and of labour)
engaging all care providers

Planned activities
l Hire additional staff for central office of nTP through Global Fund

Achievements l increased number of formal PPM projects from 48 in 2005 to 149 in 2006, in coordination with Philippine coalition against Tuberculosis (PhilcaT) and with support from Global Fund l initiated sustainability planning of project-supported PPM sites through PhilcaT l conducted DoTs training for staff of non-nTP health facilities participating in PPM activities
empowering people witH tB, and communities

Planned activities
l establish additional PPM initiatives with support from Global Fund l conduct central and regional planning for sustainability of PPM

projects
l conduct joint monitoring and evaluation activities at regional level l support certification of nTP and non-nTP facilities providing Tb

diagnosis and treatment by regional certifier team in all regions

advocacy, communication and social mobilization Achievements l commemorated World Tb Day and national lung Month l conducted acsM training for selected nTP coordinators and partners l completed evaluation of social mobilization strategies in World Vision implementation sites community participation in tB care Achievements l organized community task forces in 268 municipalities (those supported by World Vision); trained task forces in Tb control; included contribution of task forces to case-finding in evaluation of task forces patients charter Achievements The Patients Charter was published in 2006 and was therefore not available for use in countries until then.
researcH, including special surveys and impact measurement

Planned activities
l Develop and finalize nTP acsM handbook l Formulate national and regional acsM plans

Planned activities
l involve communities in the observance of World Tb Day and national

lung Month events

l organize additional community task forces l conduct refresher courses for community task forces

Planned activities
l incorporate Patients charter in DoTs training for health workers l Promote Patients charter through advocacy events such as national

lung Month Achievements l completed preliminary planning and preparation for 2007 national Tb prevalence survey

Planned activities
l conduct national Tb prevalence survey l conduct operational research on supply chain of anti-Tb drugs l conduct Tb KaP survey of communities, patients and health workers

in collaboration with World Vision and university of the Philippines

l conduct operational research on identification of clinical,

radiographic and socio-demographic characteristics of smearnegative X-ray-positive Tb

Global Tuberculosis conTrol | WHO REPORT 2008 | 139

PhiliPPines
Financing tHe stop tB strategy ntp budget by source of funding
20
16 20 15 16 17

substantial increase in funding from the Global Fund 20072008; stable funding needs since 2002
19 18

ntp budget by line item, 2008

operational research/ surveys 2% acsM/cTbc 12% PPM 11% Tb/HiV 1%

largest components of budget are DoTs (49%) and MDr-Tb (24%) other 1% First-line drugs 20%

15
us$ millions

10 5 0

Gap Global Fund Grants (excluding Global Fund) loans Government (excluding loans)

nTP staff 27% MDr-Tb 24% 2002 2003 2004 2005 2006 2007 2008 lab supplies & equipment 2% Programme management & supervision 0.3%

ntp budget by line item

20
16

increased funding needs for MDr-Tb and acsM; nTP expects to treat 340 MDr-Tb patients in 2008 (double the number treated in 2007)
20 15 16 17 19 18

ntp funding gap by line item

5 4
us$ millions

Persistent funding gaps for management of MDr-Tb since 2005; funding gap for DoTs mainly for dedicated nTP staff
4.4 3.9

15
us$ millions

10 5 0

other operational research/surveys PPM/Pal/acsM/ cTbc Tb/HiV MDr-Tb DoTsf

3 2 1
0.3

2.7 2.1 2.0

other operational research/surveys PPM/Pal/acsM/ cTbc Tb/HiV MDr-Tb DoTs

2002

2003

2004

2005

2006

2007

2008

2002

2003

2004

2005

2006

2007

2008

total tB control costs by line item 4

35 30
us$ millions

cost of clinic visits based on 120 visits per new ss+ patient during treatment and 24 visits per new ss/extrapulmonary patient
30 22 21 23 23 23

per patient costs, budgets and expenditures 5

250 200 150 100 50
46 50 37 40 29

increasing costs and budget per patient; lowest expenditure per patient in 2006 Total Tb control costs nTP budget nTP available funding nTP expenditure First-line drugs budget
31

28

clinic visits Hospitalization nTP budget

25 20 15 10 5 0

us$

25

2002

2003

2004

2005

2006

2007

2008

2002

2003

2004

2005

2006

2007

2008

comparison of country report and global plan:g total Tb control costs, 20072008

ntp budget and funding gap by stop tB strategy component

(us$ millions) DoTs expansion and enhancement Tb/HiV, MDr-Tb and other challenges Health system strengthening engage all care providers People with Tb, and communities research other 2007 2008 buDGeT GaP buDGeT GaP 10 2.1 0 3.8 1.2 1.6 0.2 0.9 0.8 0 0 0.1 0.3 0.1 9.0 4.6 0 2.1 2.1 0.3 0.2 0.9 0.6 0 0 0.1 0.3 0.1

country report for DoTs and PPM/Pal/acsM/cTbc ahead of Global Plan; nTP plan for MDr-Tb was well-aligned with Global Plan before revision of Global Plan in mid-2007, but targets included in Global MDr/XDr response Plan are more ambitious 45 40 35 30 25 20 15 10 5 0
39 31 30 28

General health services other operational research/surveys acsM/cTbc PPM/Pal Tb/HiVh MDr-Tb DoTs

us$ millions

Financial indicators for tB

Government contribution to nTP budget (including loans) Government contribution to total cost Tb control (including loans) nTP budget funded Per capita health financial indicators (US$) nTP budget per capita Total costs for Tb control per capita Funding gap per capita Government health expenditure per capita (2004) Total health expenditure per capita (2004)

43% 64% 89% 0.2 0.3 0.002 14 36

45% 64% 89% 0.2 0.3 0.002

Global Plan country report Global Plan country report 2007 2008

sources, metHods and aBBreviations

ah 1

Please see footnotes page 169. incidence, prevalence and mortality estimates include patients infected with HiV. estimates of Tb burden based on 1997 prevalence survey. incidence assumed to be declining at 1% per year as in other countries in WPr. 2 MDG and sTb Partnership indicators shown in bold. Targets are 70% case detection of smear-positive cases under DoTs, 85% treatment success, to ensure that the incidence rate is falling by 2015, and to reduce incidence rates and halve 1990 prevalence and mortality rates by 2015. estimates for 1990 are prevalence 819/100 000 pop and mortality 80/100 000 pop/yr. 3 For routine diagnosis, there should be at least one laboratory providing smear microscopy per 100 000 population. To provide culture for diagnosis of paediatric, extrapulmonary and ss-/HiV+ Tb, as well as DsT for re-treatment and failure cases, there should ideally be at least one culture facility and one DsT facility in each province. 4 Total Tb control costs for 20022006 are based on expenditure, whereas those for 20072008 are based on budgets. estimates of the costs of clinic visits and hospitalization are WHo estimates based on data provided by the nTP and from other sources. see Methods for further details. 5 nTP available funding for 20042006 is based on the amount of funding actually received, using retrospective data; available funding for 20022003 and 20072008 is based on prospectively reported budget data, and estimated as the total budget minus any reported funding gap. indicates not available; pop, population; ss+, sputum smear-positive; ss, sputum smear-negative pulmonary; unk, pulmonary sputum smear not done or result unknown; yr, year.

140 | WHO REPORT 2008 | Global Tuberculosis conTrol