SUSTAINING DOTS AND MOVING FORWARD WITH THE STOP TB STRATEGY

1. SUSTAINING DOTS AND MOVING FORWARD WITH THE STOP TB STRATEGY César Bonilla MD.

2. 300 250 200 150 100 50 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 198.6 202.3 256.1 248.6 227.9 208.7 198.1 193.1 186.4 165.4 155.6 146.7 140.3 123.8 MORBIDITY 183.3 192.0 243.2 233.5 215.7 196.7 161.5 158.2 156.6 141.4 133.6 126.8 121.2 107.7 TB INCIDENCE 116.1 109.2 148.7 161.1 150.5 139.3 111.9 112.8 111.7 97.1 87.9 83.1 77.4 68.8 BK+INCIDENC MORBIDITY AND INCIDENCE RATE OF TUBERCULOSIS PERU 1990-2003 DOTS DOTS Expansion and Sustainability Start of reform and loss of leadership Source: National Health Strategy for TB Prevention and Control (ESN-PCT)

3. 133 140 120 100 Months 80 60 40 13 12 8 2 20 0 DR. PG DR. R. DR. E DR. R DR. D. SUAREZ ACCINELLI TICONA CANALES ZAVALA PERIOD OF ADMINISTRATION (IN MONTHS) AT THE NATIONAL TB CONTROL PROGRAM 1991-2004

4. BKs DX Años 1,060,000 BK were not performed 2 BK per SR are performed 530,000 SR were not tested SR Tested BK + 2,4 % per every 42 SR 1 case BK + DIAGNOSIS GAP OF SMEAR POSITIVE PULMONARY TB (SP PTB) 12,500 cases of SP-PTB went undiagnosed

5. MAGNITUDE OF THE MDR-TB PROBLEM IN PERU CHILDREN < 18 YEARS OLD WITH MDR-TB WITH ACCESS TO STAND. AND INDIV. RETREATM, AND • The presence of MDR-TB is the result of numerous failures by the healthcare system over time: • Use of ineffective treatment regimes for MDR-TB during the 80s and 90s which amplified the resistance. • Persistent MDR-TB cases in the community without timely access to adequate treatments which increased sources of infection with MDR bacilli among contacts. • Poorly defined therapeutic policies in relation to new MDR-TB cases among contacts of documented MDR-TB cases. • Underestimation of the magnitude of MDR-TB which prevented adequate diagnosis and treatment interventions. THREE-YEAR TREND LINE PERU 1996-2004 300 250 y = 26,8x - 53,778 2 R = 0,9352 213 200 173 Nº of children with MDR-TB 150 124 100 92 < 18 years Linear (< 18 y) 56 50 32 26 5 1 0 96 97 98 99 00 01 02 03 04

6. NEW PARADIGMS • Human dignity, bioethics, human rights within a health citizen context, for the control of TB and MDR-TB. • Comprehensive and integrated healthcare to enhance TB and MDR-TB control actions. • Intersectoriality, interinstitutionality and development of strategic partnerships for TB and MDR-TB control, for the advocacy and design of public policies. • Multidisciplinary teams made up by the healthcare team, civil society representatives and associations of people living with TB, for organizing and providing care to people with TB and MDR-TB. • Strategic communication.

7. Strategic Management Public Health and Epidemiology Technical Specialization Criteria STOP TB Committee Peru National Health Strategy for TB Prevention and Control National Multisectorial Health Coordinator • Coordination, Conducting, • Communication, Cooperation. • Shared management, leadership and accountability. TB/HIV Co-Infection Committee Group of Experts Scientific Associations Civil Society Comité Técnico Permanente TECHNICAL STANDING COMMITTEE ADVISORY COMMITTEE NGOs Universities MINSA Representatives Departments EsSALUD Dep. of Health Technical Criteria Strategies and Programs Criteria, Strategies, Plans and Commitments

8. POLICY GUIDELINES OF THE HEALTH SECTOR AND NATIONAL HEALTH STRATEGY FOR TB PREVENTION AND CONTROL DOTS Supply and Rational Use of Drugs DOTS PLUS Sector Management Health Prevention and Promotion HR Funding MINSA Comprehensive Care Technologic. Developm. Democratization Technical Efficiency Continuos Quality Improvement Decentralization Modernization Institutional Culture Comprehensive Insurance Local Governments HIV/TB PAL Others Strategic Partnerships PPM Accreditation HRTAs Service Advocacy Social Mobilization AMSC Training Research Biosafety HRTA: High Risk of Transmission Areas Evaluation Supervision Monitoring Multidisciplinary, Multifunctional, Intersectorial and Interinstitutional Team

9. Public Stakeholders (Citizenship) Citizen Watch National Health Strategy for TB Prevention and Control MINSA Institutional and Intersectorial Articulation Comprehensive Care Institutional Stakeholders AND Intersectorial Stakeholders

10. STRATEGIC PLAN 2004-2010 Ministry Decision 721-2005 Vision To consolidate and maintain by 2010 higher levels of efficiency and effectiveness by ensuring the progressive and sustained decrease of tuberculosis incidence in Peru. Mission To ensure early detection and diagnosis, as well as timely, supervised and free-of-cost treatment of people affected by TB, MDR-TB and the TB/HIV co-infection in all healthcare services in Peru, in order to reduce the TB morbidity and mortality rate as well as its social and economic implications.

11. STRATEGIC PLAN 2004-2010 RM 721-2005 • General Objective • To progressively and sustainably decrease TB incidence through timely, supervised and free-of-cost detection, diagnosis and treatment of people with TB in all healthcare services in the country by providing comprehensive quality care in order to reduce the morbidity and mortality rate and its social and economic implications. • Impact Goal • To decrease the incidence rate of smear positive pulmonary TB from 66.39/100,000 inhabitants (Annual Report ESN-PCT 2004) to 53/100,000 inhabitants by the end of 2010.

12. TECHNICAL HEALTH STANDARDS (TS) AND PUBLICATIONS TS – TUBERCULOSIS TS MDR-TB Tuberculosis Training Module Biosafety Training Module Evaluation Report ESN-PCT 2004 Building Strategic Partnerships

13. PERU STOP TB PARTNERSHIP CEREMONY FOR SETTING-UP THE COMMITTEE

14. 1.4 2.5 1.2 2 1 1.5 0.8 Millions Millions 0.6 1 S.R. Ex. 0.4 Bk Diag Total 0.5 0.2 0 0 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 IDENTIFICATION OF SYMPTOMATIC RESPIRATORY PATIENTS PERU 1990-2005 16 % Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

15. 120 100 90 100 80 70 80 60 60 50 40 40 30 20 20 10 0 0 2000 2001 2002 2003 2004 2005 % Detection Reported SP PTB Estimated SP PTB % CASE DETECTION, ESTIMATED RATE AND REPORTED RATE OF SP-PTB PERU 2000-2005 96 % Rate of SP PTB x 100,000 inhabitants % Case Detection WHO GOAL CASE DETECTION: 70 % Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA and Global Tuberculosis Control WHO Report 2006

16. 300 300 250 250 200 200 150 150 100 100 50 50 0 0 1990 1990 1991 1991 1992 1992 1993 1993 1994 1994 1995 1995 1996 1996 1997 1997 1998 1998 1999 1999 2000 2000 2001 2001 2002 2002 2003 2003 2004 2004 2005 2005 198,6 198,6 202,3 202,3 256,1 256,1 248,6 248,6 227,9 227,9 208,7 208,7 198,1 198,1 193,1 193,1 186,4 186,4 165,4 165,4 155,6 155,6 146,7 146,7 140,3 140,3 123,8 123,8 124,4 124,4 129,0 129,0 MORBILIDAD MORBIDITY 183,3 183,3 192 192 243,2 243,2 233,5 233,5 215,7 215,7 196,7 196,7 161,5 161,5 158,2 158,2 156,6 156,6 141,4 141,4 133,6 133,6 126,8 126,8 121,2 121,2 107,7 107,7 107,7 107,7 109,7 109,7 INCID. TBC TB INCID. 116,1 116,1 109,2 109,2 148,7 148,7 161,1 161,1 150,5 150,5 139,3 139,3 111,9 111,9 112,8 112,8 111,7 111,7 97,1 97,1 87,9 87,9 83,1 83,1 77,4 77,4 68,8 68,8 66,4 66,4 67,1 67,1 INCID. BK+ BK+ INCID. MORBIDITY AND INCIDENCE RATE OF TB IN PERU 1990-2005 Epidemiological Pico Start of Reform Inicio de Reforma Management Gesti ó n y Peak Epidemiol ó gico DOTS DOTS DOTS Expansion and Sustainability Expansi ó n y Sostenibilidad DOTS and Loss of y Perdida de Recuperaci and Recovery ó n Leadership Liderazgo of Leadership de liderazgo Epidemiological Pico Epidemiol ó gico Peak Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

17. COHORT STUDIES OF NEW SP-PTB CASES 2001-2005* Outcomes 2001 2001 2002 2002 2003 2003 2004 2004 2005* 2005* 2001 2001 - - 2005* 2005* WHO GOALS ** % % % % % % % % % % % % % % Cured 92 92 91,5 91,5 89,3 89,3 89,6 89,6 89,5 89,5 90,3 90,3 85 85 Failures 2 2 2,2 2,2 3 3 3 3 3,3 3,3 2,7 2,7 3 3 Deaths 2,2 2,2 2,2 2,2 2,4 2,4 2,2 2,2 2,1 2,1 2,2 2,2 5 5 Defaults 3 3 3,2 3,2 4,3 4,3 4,2 4,2 4,3 4,3 3,8 3,8 4 4 Referrals 0,8 0,8 0,9 0,9 1,9 1,9 1,1 1,1 0,8 0,8 1,1 1,1 3 3 * First Semester ** Compendium of indicators for monitoring and evaluating national tuberculosis programs WHO/HTM/TB/2004.344 Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

18. CASES ENROLLED IN MDR-TB TREATMENT AND % OF DEATHS PERU 1997 – 2005 14.7 % 2,641 % MDR-TB Deaths Nº of MDR-TB cases enrolled in Retreatment 68 3 % Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

19. BACTERIOLOGICAL CONVERSION AT SIXTH MONTH OF MDR-TB RETREATMENT PERU 1997 – 2006 Implementation of MDR-TB Technical Standard, New Standardized Regime and Strengthening of MDRTB-Technical Unit Changes in Inclusion Criteria for Former Standardized Regime (Recommended for failures to primary and secondary regime) % Negative Culture in MDR-TB Retreatment Cases Implementation of Former Standardized Regime (To access this treatment patients had to go through various first-line drug treatments) Months of Re-Treatment Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

20. Average Annual Budget 1991- 2005: $ 3 000,000 USD BUDGET OF NATIONAL HEALTH STRATEGY FOR TB PREVENTION AND CONTROL PERU 1991-2006 Millions $ USD 9 780,000 $ USD DOTS STRATEGY: POLITICAL COMMITMENT Source: National Health Strategy for TB Prevention and Control-DGSP/MINSA

21. THE FUTURE OF THE COUNTRY IS SHAPED HAVING THEIR NEEDS IN MIND Tuberculosis can be cured Discrimination too Let us show our support and understanding towards this cause

22. LESSONS LEARNED • Health Sector Reform: • Decentralization, and the new concepts of quality care, equity, participation of civil society and information transparency, represent the most relevant aspects of the reform and an opportunity for National TB Control Programs. • Without technical and regulatory support and commitment to national goals, decentralization is the main enemy of any National TB Control Program, since it dismantled all processes aimed at achieving success. • Reform should be applied gradually.

23. LESSONS LEARNED • Management in the National Health Strategy for TB Prevention and Control : • DOTS is not only measured by its ability to provide diagnosis and treatment but also for promoting values, managerial capacity and commitment. • Healthcare services must articulate supply and demand so they can be adapted to the actual health needs. • An opportunity must be identified in the multifunctionality and turnover of staff.

24. LESSONS LEARNED • Strategic Partnerships: • TB control must incorporate new stakeholders since we have shifted from a biomedical approach to a community and participatory approach. • TB is a public health issue that concerns us all. • The concept of citizen rights and responsibilities must be included in the new management of the ESN-PCT. • The integration of the State with the civil society allows an • increase in collective health awareness.

25. LESSONS LEARNED • Strategic Partnerships: • The updating of the Technical Standard legitimized by the participation of civil society and organizations of people living with TB strengthens the governing role of MINSA. • The participation of community health promoters enhances the DOTS strategy. • The participation of organizations of people living with TB gives a human face to the social mobilization efforts aimed at controlling the disease.

26. NEXT STEPS • Within the framework of the Millennium Development Goals and the prioritized public health objectives of the Americas, policies must be established to subsidize those affected by TB, starting with the mother and child component. • Strategic multidisciplinary partnerships must be set up to monitor the extent and impact of the intervention in the poverty, exclusion and tuberculosis component. • Respect for human dignity, bioethics and human rights must be promoted at all management levels in order to eradicate stigmatization and discrimination against people living with TB.

27. NEXT STEPS • As part of the TB Control Strengthening in Peru, the following actions must be taken : • Maintain current indicators and propose others to be used at a management level such as: • Social participation in citizen watch actions, • Incorporation of tuberculosis as a socioeconomic development indicator. • Subsidy coverage in health and nutrition (access to diagnosis, treatment and rehabilitation of complications and aftereffects).

28. NEXT STEPS • As part of the TB Control Strengthening in Peru, the following actions must be taken: • Improve the managerial capacity of the intermediate multidisciplinary working teams. • Consider High Vulnerability Areas with High Risk of Transmission (urban-marginal areas, borderline communities, indigenous populations, people deprived of their liberty and others). • Promote decentralization of care to people co-infected with TB/HIV. • Continue to improve comprehensive household care (personalized care) of people co-infected with MDR-TB/HIV in accordance with the particular needs of each patient. • Address the problem of incurable MDR-TB.

29. THANK YOU