Placing Diagnostic Devices for Impact: Experience of the

50th Union World Conference October 30, 2019

Eddie V. Sistoso Jr., MPH, RN Research Institute for Tropical Medicine National Tuberculosis Reference Laboratory

2 Call from the Secretary of Health:

“We should do business unusual to eliminate TB” Francisco T. Duque III, MD

United Nations High Level Meeting on TB, New York, September 2018 3 PHILSTEP 1 LNSP  Provide integrated  Improve Access to patient centered Quality Assured TB TB care and and DRTB prevention services Diagnostic in all DOTS Services facilities

4 Optimizing TB diagnostic networks to improve patient access to quality TB diagnosis and treatment

5

Current Status

. Low Xpert Utilization . Limited Access to Dx Services Diagnostic Network Optimization . Sample Referral Lacking . How to improve access with current network footprint? – relocation, PhilSTEP1 2017-2022 longer working hours, etc.? . Can future testing demand be met Diagnostic Network is optimized to without the need for capital outlay? better respond to the testing demands . How to build an efficient sample to reach the Philippine Strategic TB referral network to improve patient Elimination Plan: Phase1 targets access to services? . Are more instruments needed and if so, where to place them?

6 Objectives in Philippines in 2018:

 Map TB burden and current demand for TB diagnostic services;

 Map current TB diagnostic network structure;

Identify the extent and distribution of gaps in existing services according to burden of disease;

Develop a set of diagnostic network designs defined by NTP and partners that better and more efficiently reach “missing” TB cases (unmet demand) using existing infrastructure; and

Model a set of new network paradigms defined by NTP and partners, including new product and/or services investment, to advise government strategic planning and budgeting processes.

7 Preliminary Meetings April 2018

INPUT

On-site visit to an Xpert Site in Manila With the staff of Tunasan Health Center

8 Facility Map Demand Data . Public Health Facility (locations) . Population – catchment area of health

facilities . Estimated number of cases for each HF . No. of patients seeking care, screened, and tested at a particular TB Diagnostic HF Network Mapping Data Facility Map Requirements Cost . Referral Pattern . Fixed Cost . List of Facilities with Diagnostic . Per Test Cost Equipment – eg., Xpert Machine . Site Opening Cost . Xpert Site Capacity . Transport Cost

9 Assumptions Influencing Projections

2017 . Actual Baseline Data provided; 2019 number of tests in Big 3 Regions and number of tests across entire . Assumed completed rollout of 2022 country Xpert first test across all of Big 3 regions . Assumed completed rollout of Xpert first test across entire country . Assumed adherence to algorithm and well-functioning demand . Assumed adherence to algorithm and well- generation, especially in the Big 3 functioning demand generation across the regions entire country

. Assumed well-functioning . Assumed well-functioning sample sample transport to bring samples transport to bring samples from TB treatment from TB treatment HFs to Xpert HFs to Xpert testing locations testing locations

10 Stakeholders Meeting

April 2018 October 2018 February 2019 July 2019 Preliminary Meeting

Presentation of preliminary results With the NTP Point Persons Presentation of Final Results

11 Demand for Xpert Tests Over Time Future Projected Demand is aligned with PhilSTEP

Actual and Projected Demand (Number of Xpert tests) over time – Big 3 and Entire Country

3000 2908 Entire Country Big 3 regions

2500

tests

2000 Xpert 1500

907

(in 1000s of tests) of 1000s (in 1000 1102 Number of of Number

500 479 286 623 215 123 0 2017 2018 2019 2022

12 Utilization of Xpert Testing Sites, 2017

Key: <25% Between 25% and 50% Between 50% and 80% >80% Utilized over 3000 tests per year

Baseline Model Allocated

13 Utilization of Xpert Testing Sites with additional 136 new instruments, 2018-2019

Key: <25% Between 25% and 50% Between 50% and 80% >80% Utilized over 3000 tests per year

2018 2019

2019 14 Key Changes

Entire Country Big 3 Regions . Impose a constraint for a maximum service . 950 new private sector HFs added to distance of 20km from referring HF to facility list (from FHI360 data) Xpert site . Addition of private sector HFs to support . Sample transport frequency is 4 time per ongoing planning of private sector week from every HF. In previous engagement initiatives optimization runs it was 2 time per week. . Demand reallocated using PPA care- . Only public sector HFs (TB treatment seeking percentages to split demand across sites) are candidate locations for placement HFs at City/Municipality level. of Xpert machines. Private sector HFs are not considered as candidate locations for placement of Xpert machines

15 Previous optimization runs without 20km max distance restriction

2017 2019 2022 demand demand demand levels levels levels Map Legend Customer flows Customers Sites

16 Demand Levels with 20 km Distance Restrictions

2017 522 Xpert Sites 2019 796 Xpert Sites 2022 889 Xpert Sites Key: <25% Between 25% and 50% Between 50% and 80% >80% Utilized over 3000 tests per year

17 The addition of sites is driven by the 20km distance restriction

2019 projected 2022 projected demand levels demand levels

Total Xpert sites recommended by new 796 889 model, with all conditions applied

Total Xpert sites recommended by new model, with 20km distance restriction only 784 859 (and new private HFs) Very clear from this that the addition of sites is driven by the Total Xpert sites recommended by new 20km distance model, with 4x per week transport frequency 410 747 restriction from HF to only (and new private HFs) Xpert site

Old optimization recommendation – with no 497 747 (because we set this number - ran a distance restriction and 2x per week scenario with 320 machines plus 180 planned for purchase, plus an transport frequency additional 200 after that)

18 Output

Current input for updating of Philippine Strategic TB Elimination Plan 1 (PhilSTEP), Laboratory Network Strategic Plan (LNSP), and concept note development for Global Fund;

Model output will be used as a guide by National TB Control Program (NTP) and Philippine Business for Social Progress – Global Fund (PBSP-GF) in procuring and allocating Xpert machines on 2020-2022; 2 . Presented in National Consultative Meeting last Sept 2019 . Private sector facilities in Big 3 regions integrated into service delivery models as referral sites . CHD Coordinators to validate the placement of the proposed list.

19 Allocation of Xpert Machine based from FIND’s Model

Region Province Municipality Rapid TB Diagnostic No. of existing No, of tests at Proposed Proposed no. Remarks Agree? If disagree, replacement site Laboratory machines in 2022 demand type of GX of machines (YES or NO) with justification or reason (Xpert) 2019 levels by 2022 by 2022 for recommendation

BANGUED PROVINCIAL CAR ABRA CALABA 1 2455 GX4 1 Complete (Capital) HOSPITAL

BUCLOC RURAL CAR ABRA LAMAO (POB.) 445 GX1 1 HEALTH UNIT

DELORES RURAL CAR ABRA DELORES 1810 GX2 1 HEALTH UNIT

POBLACION LACUB RURAL CAR ABRA LACUB 455 GX1 1 (TALAMPAC) HEALTH UNIT

BARIT BARANGAY CAR ABRA LUBA BARIT 1310 GX2 1 HEALTH STATION

CALANASAN CALANASAN RURAL CAR POBLACION 280 GX1 1 (BAYAG( HEALTH UNIT

CAGLAYAN CONNOR RURAL CAR APAYAO CONNER 455 GX1 1 (NEW POB.) HEALTH UNIT

Proposed GX1 AMMA JADSAC CAR APAYAO PUDTOL POBLACION 1 470 GX1 1 but was given DISTRICT HOSPITAL GX4: complete

PUDTOL RURAL CAR APAYAO PUDTOL POBLACION 1400 GX2 1 HEALTH UNIT

Example: Cordillera Administrative Region 20 Output

Databases of health facilities and laboratories with longitudes and latitudes coordinates were used by FHI 360 in planning and designing of 3 specimen referral and transportation system, including Sputum Transport Rider (STRider).

21 Acknowledgements

Kekeletso Kao Sidharth Rupani Dr. Celina Dr. Ma. Cecilia Dr. Rajendra and Team and Team Garfin, Donna Ama, Dr. Ramon Yadav Mae Gaviola, Dr. Basilio, Ma. Allan Fabella Cecilia Serrano and Team and Team

22