Executive Summary - Davao

7/28/2019 Executive Summary - Davao

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Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 1

SEMINAR-WORKSHOP ON IMPROVING THE REFERRALSYSTEMBETWEEN ARMM AND NON-ARMM AREAS

Waterfront Insular Hotel, Davao CityNovember 14-15, 2012

EXECUTIVE REPORT

Executive Summary

Introduction

Background

Methodology ..

Proceedings .... Day 1

Orientation and Overview of the activity DOH-ARMM Epeiences in implementing the life saving interventions Presentation of Referral sites by region (REGION IX, REGION X and REGION XII) Workhop 1 gaps identified including referral

Day 2

Technical input on ICV (Informed Choice and Voluntarism) Teaching ICV checklist for FP patients and Service Delivery Clients Workshop 2 Action Plans

Evaluation

AnnexesAnnex A Initial AgreementAnnex B Standard Referral Form

Annex C Identified Gaps

Annex D - Action PlansAnnex E PicturesAnnex F - Attendance


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EXECUTIVE SUMMARY

Reversing the non-moving trends of Millennium development Goals (MDGs) 4 and 5requires commitments and obligations from partners, organizations and leadership of national and local government units. The initiatives of Hellen Keller International

through the Sustainable Health Improvements through Empowerment and LocalDevelopment (SHIELD) project made horizontal and vertical sustainable improvementson this set of goals and targets.

The initiative moves requires sustainability for long-term and future consumption of services. It is not limited only to training personnel, funding the project but the need toensure the mechanism of strategic flow of local health network and moved betweenvarious components of that network. The development o strong referral system that linkor mobilize patient to the needed service will serve as holding power to make smoothflow of services.

The need to revise and update the referral system between ARMM and NON-ARMMtoday is widely recognized by the DOH ARMM in partnership wit Hellen KellerInternational - SHIELD project and Center of Health and Development towardsenhancing quality health care and relevance. This two-day workshop aims to gather thekey sectors and players of the Philippine Healthcare System of Region IX, X and XII tolook at and discuss the current status of activities undertaken, problems encountered,action taken, existing gaps and future steps of the assisted facilities in relation to theimplementation of the life-saving interventions and how they will continue/sustain theireffort after the SHIELD project.

The seminar-workshop had among its participants of the regions as mentioned above,namely the Secretary of DOH ARMM Dr. Kadil Sinolinding, Assistant Secretary of DOH-ARMM- Dr. Adiong, CHDS, CHOs, MNCHN Coordinators and CHED-10.

The current status of the implementation was identified by each of the assisted facilitiesby PowerPoint presentations before the beginning of the workshop activities. Thepresentations ignited discussion on different topics that highlighted the challenges andthe approaches to overcome those challenges. During the presentations, the peculiarityof the implementations needs a serious consideration and good timing. For instance, theZamboanga Peninsula emphasized the constraints in geographical locations, the ARMM

amidst the clan wars and socio-cultural and political boundaries must be considered asserious gaps. The seminar finds wide variations, existing gaps and key indicatorsbetween leading and lagging the healthcare system performance.

MAJOR CONCLUSIONS


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There was significant variation in the Referral processes conducted at each of thehospitals and community health centers thus causing the confusion and delayedhealthcare interventions to patients. The most significant findings from the seminar areprovided below. It includes:

1. Inadequate policies and guidelines on the referral system

Variation in referral forms Variation in processes (like recording of the died patient) Variation in the level of assistance and quality of care to the patient Variation in whether the hospital collects and holds the record and supporting

documentation Variation in tracking mechanisms, logs or databases for tracking the status of

referrals from ARMM to NON-ARMM or vice versa.

2. There are no regular follow-ups between the trained hospital staff and public healthand community health center referral coordinators (RCs)

3. There are weak existing orientation mechanisms to inform and teach other healthpersonnel.

4. Poor accessibility due to geographical locations

5. Inadequate logistics and technical support

6. Poor knowledge, attitudes and skills among health providers

Success at the local level will ultimately depend on communities and providers aidedby strong leadership and collaboration setting goals and taking action to achieve them.

At the end of the process, participants were made to draw up their action plan /strategy to sustain the program in their own political will.

RECOMMENDATIONS

The following recommendations address the major conclusions described above and arepresented by timeframe: immediate action for each hospital in terms of training otherstaffs, collaborative short-term action within this year of DOH ARMM and NON-ARMM,collaborative monitoring and system improvement of accepting and recording referrals..For ongoing monitoring and improvement of these processes, it is recommended thatthe DOH ARMM must create a group or someone to become the referral systemmonitoring person/group.


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INTRODUCTION

Despite the concerted effort of the Government and HKI-SHIELD in initiating theintegration of life-saving interventions to some assisted healthcare facilities, it seemsthat problems in the implementation and sustainability are big issues/obstacles that liesbehind, hindering the progress that must be address first to have a smoothimplementation of life-saving interventions.

This two-day workshop is to consider the final milestone of HKI-SHIELD in the process of promoting life-saving interventions among residents of ARMM and other nearby referral

sites. After 5 years of implementing these interventions, ARMM is seeing improvementsin health indices for mothers and newborn, which are also reflected in the FHS 2011.

In order to expand the network of facilities providing the life saving interventions, theDOH-ARMM in partnership with the SHIELD project has conducted a series of dissemination forum and trainings on AMTSL, EINC, LAPM-BTL and PPIUD in areas nearARMM, specifically in Zamboanga Peninsula, SOCCSARGEN, and Northern Mindanao. Asa result, health service providers and the academe in these regions were encouraged toadopt or scale up these life saving interventions to contribute in the attainment of MDG4 and 5.

The process of the seminar-workshop employed the services of SHIELD staff and DOH-ARMM officers namely: Dr. Orly de Ocampo, Dr. Dyna, Dr. Kadil Sinolinding (DOH-ARMMSecretary) and Dr. Linang (DOH-ARMM Assistant Secretary) who made the seminarinteresting, interactive, educative and participatory.

Background/Rationale:


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DOH-ARMM in partnership with the SHIELD project has conducted a series of dissemination forum and trainings in AMTSL, EINC, LAPM-BTL and PPIUD in areas nearARMM specifically in Zamboanga Peninsula, SOCCSARGEN, and Northern Mindanao. Thepurpose is to ensure that clients from ARMM seeking MCH consultations or are referred

to the health facilities in the said areas are provided with evidence based, high impactinterventions. This process was seen to help extend/expand the network of facilitiesproviding the life saving interventions thus contributing in the attainment of MDG 4 and5.

Several hospitals, service providers, institutions, and medical associations weretrained/oriented in the high impact evidence based interventions in Isabela City,Zamboanga City, CDO, Iligan City, Cotabato and Sultan Kudarat. Some facilities andregions have roll out the training in their respective facilities and catchment areas. Theacademe for their part particularly in Region 10 has also done their share by enhancingthe MCH curriculum to include EINC procedures and PPIUD in the nursing andmidwifery schools of Higher Education Institutions in the region. This was followed byEINC training of clinical instructors of the said schools.

Given this development, the SHIELD project in partnership with the DOH-ARMM and theCHDs in the above mentioned regions wanted to know the current status of activitiesbeing undertaken by the assisted facilities in relation to the life saving interventions andhow they will continue/sustain their effort after the SHIELD project. Assisted facilitieswill be provided with the opportunity to share the activities they have undertaken,problems encountered, action taken and existing gaps and next steps. Technical inputson Informed Choice and Voluntarism (ICV) will also be provided.

Objective of the workshop are the following: Share DOH-ARMM first hand experience in implementing the evidence based

high impact interventions, Determine the status of implementation/activities on the life saving procedures

in the assisted facilities Initiate steps/agreement in addressing referrals bet ARMM and Non ARMM

area, and Develop action steps/plan on how to continue/sustain efforts in improving

maternal and newborn health situation in their area.


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to adopt and scale-up these best practices to help contribute in attaining theMillennium Development Goals 4 and 5," Dr. Sinolinding said.

He indicates that the ARMM, home to 3.3 million Filipinos and growing at a rate of almost 4 percent, has some of the poorest health and development indicators among

the countrys 17 regions. The following were health challenges he mentioned: Poorest region in the Philippines both in the state of economy and health The region suffers from a fragmented and under-financed health system, low coverage of health program interventions and services,

o CPR 16%o ANC 60%o SBA - 52%o Facility based delivery 5% o FIC 69% o VAS 87%

logistically challenging geography, and ongoing clan wars/conflicts in some areas,security concerns, poor communication means, and lack of regulartransportation to health facilities limit access to and coverage of services

low number of health workers and facilities - inadequate to cover the entirepopulation, Health workers are dedicated but overloaded

o Centralized DOH-ARMM o Hospitals 24o Field Health Units

- 92 RHUs (113 municipalities) - 358 BHSs ( 2,504 barangays)

o Health Human Resources MDs 76 Nurses 106 Midwives 461

poor health status high maternal and child mortality ratios as evidenced by2006 study shows

o MMR estimated at 245/100,000 livebirths (Yabut and Bautista, NSO,2006; 162 Phil 2006 FPS)

o IMR 56/1000 livebirths (2003 NDHS; Philippines = 25) o UFMR 94/1000 livebirths (2003 NDHS; Philippines = 34)

Peoples lack of confidence and health seeking behavior Weak governance and accountability of LGUs to support social services Health-related data is considered inaccurate


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All of which created major challenges to health service delivery. Most affected by theseadverse conditions are the women and children, especially among the poor.

Dr. Sinolinding said that the DOH-ARMM mandated as lead government agency forhealth in ARMM centralized different levels integrated field and hospital services.

However, ARMM always ranked last in the state of health and economy. In response,DOH-ARMM opted to make a radical change in the system by the help of NGOs. It was in2004 and 2006 when new evidences were published in the Lancet Series. When USAID-SHIELD started in the late 2006,all these new evidences were already introduced in thedesign. CMNC (Caring for mothers and newborn n community) is a package of interventions to address maternal and newborn DOH-ARMM with USAID SHIELD Projecttechnical assistance and based on existing DOH guidelines and training curricula. Hebelieves that this can be implemented even in the weak system of LGU. The cost of interventions can be further reduced and coverage can be increased if these are

packaged together and delivered through existing health system approach . Training of frontline field health workers was also supported by the USAID SHIELD Project startingYear 2008.He said the SHIELD project and that the Hellen Keller International (HKI) is only aninstrument in introducing the programs in the ARMM.

In the face of current legal restriction on the practice of midwives, particularly on whena midwife may inject a uterotonic drug (by law, oxytocin can only be administered bythe midwife only after the placenta has been expelled. This is in direct contrast to thefirst component of AMTSL where oxytocin should be administered very soon (within 1minute) after delivery of the baby/fetus. ), the DOH-ARMM has come up with policyissuances by the policy orders: Dept. Circular No. 000384 s. 2010 Policies and Guidelines on the Active Management of the Third Stage of Labor as a proven effectiveintervention against post partum hemorrhage and Department Order No. 2010 001010 Guidelines in the Application of the Active Management of the Third Stage of Labor by Skilled Birth Attendants in the Course of Attending to Deliveries Whether at Home or in a Facility to support the performance of AMTSL and spelled out theguidelines by the trained midwives.

In the process of capacity building, they trained 12 CMNC Trainers from the regional,provincial and district levels at the year 2010 and prioritized Rural Health Midwivesfor training on CMNC with 653 field midwives and resulted to (95%) trained health

personnel which is a good indicator of wider coverage . It was sustained by a post-training follow up program in which t rained midwives reported minimal bleeding post partum and mothers were up and about a day after delivery, no reported post partumhemorrhage. Nine out of every 10 trained midwives from the field health service

practiced immediate essential newborn care.


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The process of monitoring and supervision were also considered to make sure thecorrect recording and referral. In response to the DOH- ARMMs ARMM -wideInvestment Plan for Health - 123 the health supervisors from the regional, provincial,district and municipal levels were trained. The trained supervisors took on a moresupportive role as mentors/coaches to the CMNC trained midwives to improve

performance. They provide also data collection and assessment tools with specificinstructions on how to use in the community. Some of which are Scoring guide andsheets for health program accomplishments, Interview questionnaires for serviceproviders and clients, Observation checklists to assess service provision.

The support of DOH-ARMM was made evident by findings ways and means in therealization of health goals. Such as

Purchased and distributed oxytocin to the provinces by DOH-ARMM Midwives bought oxytocin for reimbursement at cost Some partner NGOs, development agencies such as UNFPA and LGUs donated

oxytocin for use by the trained midwives TBA-midwife dialogues to agree on their roles in providing maternal care Organized community groups CHATs master list pregnant women and

refer/accompany them to trained midwifes Some LGUs supported establishment of birthing facilities

Despite the difficulty of providing health services in ARMM, the DOH-ARMM asverbalized by Dr. Kadil Sinolinding is proud of having best practices in some areas of theARMM. What is needed now is to ensure that these services are being providedaccording to accepted standards (are of high quality) and cover more people/clientswho need these services. Thus, the DOH-ARMM has embarked on a QualityImprovement initiative for its health services. It adopted the Improvement Collaborativeor IC, an approach to improve quality of health services and to scale up best practices.The adoption of the IC is a DOH-ARMM action in line with the MNCHN strategy of theDOH-ARMM and which is geared towards helping ensure the achievement of theMillennium Development Goal (MDGs 4 and 5, basically) of the country.

In November 2011, the life-saving interventions (EINC, AMTSL, PPIUD and BTL) wereintroduced and made known with pragmatic and realistic objective to complete the

service delivery network for AMTSL and ENC, namely:7 demonstration sites4 district hospitals2 provincial hospitals1 birthing facility


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QIC teams at the region and provincial levels are becoming more familiar with theprocesses and procedures of quality improvement for maternal and child health careservices. It created more opportunities for interaction between regional, provincial anddemonstration sites staff.

Today, by taking the lead they are riding now on the success of this life savinginterventions and made a gradual rise up in building a more reliable healthcare provider.Noting the changes presented by Dr. Sinolinding, the Family Health Survey of 2011attested to the improved state of health in ARMM. They have recorded the highestnumber of mother delivered with 3 steps of AMTSL (1,488) and number of newbornsreceived 4 steps of ENC (1510) with zero (0) maternal death and three (3) Neonataldeaths. Beyond statiscal figures were the learning of capability building andimplementation huge efforts are possible even under unique socio-cultural and politicalstressors in ARMM.

In Summary DOH ARMM developed the Standards, passed the policies, trained healthstaff, developed the supervision tools and ensured quality standards are followed.However, it will not end by just merely saving mothers but saving all lives from a rippleto waves. In expanding the network, they facilitate trainings and series of disseminationforum in nearby referral sites of Region IX, X and XII.

The sharing of experiences lifted the morale and level of maturity of relevant people insame work and place. In so doing, Dr. Kadil Sinolinding who is the icon of strong politicalwill and good governance enlivens the hopes of ARMM and also the participantsattended. It was well applauded and appreciated by the participants.

PRESENTATION OF REFERRAL SITES, IDENTIFIED GAPS, ACTION PLAN

According to Dr. Orly, in order to sustain the program they need to make a tangiblesteps that are specific, measurable, attainable, realistic and time bounded. In so doing,when the WHY is big enough then HOW is easy.

Moreover, the referral sites considered finances a major quandary that hinders theprogress of the on-going and to do plans. Dr. Orly asserted that the problems in fund-

raising will probably best addressed by a combined effort of agencies involved and thesubstantial local and national funding resources in CHDs, LGUs and DOH must beeffectively channeled through sound technical support with the consideration that theseinterventions are evidenced based practiced that gave a high impact on maternal andneonatal death problem in the country.

Zamboanga City Medical Center (ZCMC)


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As the program ensued, the presentation of Referral sites then followed to share andrelate the action undertaken and gaps identified. Dr. Jefrey Masilungan aNeonatologist by profession initiated the part of the program. He then presented theiractions undertaken in the pursuit of implementing these high-impact life saving

interventions:

The ZCMC-EINC Working group was officially recognized by the hospitaladministration on June 6, 2012

Reviewed Hospital policies ER/DR (5-31); Birthing Clinic and Ward 1 (6-1);NICU (6-4); OR (6-6); ER (6-14); OB ward (6-28)

Presentation of Revised Policies to Executive Committee and stakeholders(7-8)

Trained hospital personnel and dissemination of revised policies 9-24, 9-25, 9-26, 11-30

Fully implemented EINC in all areas October 2012 Currently doing monitoring every two weeks. o MWF postpartum BTL of in patients o Wed mass ligation of referrals from barangayso PP-IUD everyday at birthing clinic .o Free service and medications for ligation

Problems: low accomplishment because of renovation, pipein oxygen, NICU cleaning occupy, disinfection of OR for BTL

Discussions

As a result, in 2012 Cesarean Section with BTL surged to = 173 clients. Theseimplementations caused a wide gap of figures among mothers delivered and received

AMTSL and newborns who received 4 steps of EINC. This is a living testimony of a positive response.Without regard to, they encountered problems like expulsion in two patients but thenreinserted.

The following are gaps identified by ZCMC:Identified Gaps - ZCMC o The need for a more training program of other health service providers by

the assistance of HKI, LGU and CHD-9o Insufficient supplies/allocated funds for some equipment to use.o Limited advocacy on life-saving interventions Provision of IEC materials

Tri-media campaigno Unrevised FHSIS recording system (include AMTSL, EINC, PPIUD and BTL)o No standard forms of referral


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During the discussion, Dr. Bernadette Lleno of CHED-10 was interested on how did they implement the radical change in the hospital policy in adopting life-saving interventionsand the stumbling blocks encountered in the transition of the implementation becausechanging hospital policy must be paralleled with the system of curriculum in theacademe were the life experiences of students developed. Dr. Masilungan made a

humorous response that by the power vested upon him and as one of policy maker they oriented the staff on how will the babies be delivered from OR to NICU and DR to ward.

As part of advocacy, they initially conducted training workshops to 3 areas namely Basilan, Bacolod and Pagadian respectively. In which created a good response because it is more easy and efficient interventions.

While Dr. Orly asked also the common referral cases encountered in their own site and Dr. Masilungan answered that is limited only to isolated cases such as premature and

perforated anus but mostly were manageable and tractable.

Action Plan

In order to establish overall mechanisms to narrow these identified gaps, an actionplan was made known to all during the second plenary session. The lists of tangiblesteps are the following with specific, measurable, attainable, realistic and time-bounded objectives had identified. The ZCMC would need additional trainingseminars for AMTSL-EINC, BTL, ICV and preceptorship of PPIUD by tapping the helpof HKI and CHD 9. Dr. Orly suggested that sustainability must be practiced within thegroup, in which allowing the trained staff to pass the skill to all concerned healthpersonnel by offering re-echo or training program parallel with the skills needed .Other sustainable plans to be complied by the first quarter of 2013 are the ff:

Enhancement of local government social services population outreach workersfor recruitment of patients for BTL

Enhancement of family planning counseling services for prenatal mothers(mothers class and distribution o f IEC materials)

Enhancement of family planning counseling services for post partum mothers inOB ward and birthing clinic

ICV Compliance Monitoring of the Family Planning Clinic Creation of Electronic Database for referral system with DOH-ARMM Draft protocol for referrals

They believed that the addition of personal computer set is necessary to create asophisticated electronic database for referral system for more reliable statistical figures.That means the pilot logbook software will support fast referral and recording system.Dr. Jeffrey of ZCMC expected that DOH-ARMM will respond positively on this request.However, Dr. Linang Adiong did not give a strong commitment in the realization of thisrequest but promised to resurface in the meetings with DOH-ARMM for possible grant.


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Zamboanga City Health Office

Zamboanga CHO shared common gaps with other referral sites in terms of limitations in

staff education and training and lack of trained personnel involvement.

The targets have been reached, but continuous efforts are in progress to maintain andfurther lower cases of maternal and neonatal deaths as evidenced by:

Reduced maternity mortality rate from 30% in 2008 to 31% in 2011 Reduced infant mortality rate from 16.13% in 2008 to 13% in 2011 Conducted Training on Community based maternal Newborn care (35 PHM) Conducted Capacity Enhancement on Maternal and newborn health (POGS) 18

PHM

Oriented Private clinic medical assistants of OB-GYN practitioners on FHSIS Assured adequate Medical supplies for OB cases in all 16 lying-in clinic Trained 16 teams on Basic Emergency Obstetric Newborn Care (BEmONC) Trained 32 Nurses and 45 Midwives on EINC

Identified gaps ( no copy)

Action Plan Conduct training on AMTSL/EINC to all service providers and PPIUD to selected

service providers(MO/Nurses) Lobby for budget allocation for augmentation of supplies and materials, equipment

and drugs for the use of the program Request prototype IEC materials for reproduction and distribution Masterlisting and consolidation of all AMTSL/EINC/PPIUD clients and segregate

referred clients for proper endorsement of data to DOH-ARMM on a quarterly basis CHO to submit monthly report to CHD Institutionalization and sustainability of the program budget allocation Monitoring and evaluation- AMTSL/ EINC/PPIUD and ICV compliance Full implementation of life-saving interventions in all birthing facilities of Zambo City

Discussion

Dr. Orly strongly asserted that he cannot send anyone for training as of the moment dueto some necessary module revisions. It was said that the help of MNCHN especially inbudget and monitoring will make a quantum leap in the realization of all these plans.The head of CHD-9 Dr. Dionio affirmed commitment, support and engagement for these

plans.


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****

Isabela City Health Office Dr. Rafael Cabug

The presentation of Dr. Cabug made known by centering the point on primary level of

health thus minimizing the problems encountered.

Actions undertaken HFEP with Rationalization Plan Enrolled clients in PHIC ^monitoring, surveillance, case finding and recording Intensified health education information dissemination Involved TBAs in service deliveries.

Gaps Identified

Lack of facilities to conduct deliveries Prefer home deliveries due to financial constraints. Cultural, Ethnic, religious, traditional beliefs and misconceptions. Families in hard to reach, critical areas preferred hilots because of distance and

security reasons. Poor health seeking behavior lack of trained personnel Lack of transportation Lack of funds Insufficient LGU counterpart

Poor IEC, surveillance, monitoring GIDA and peace and order issues Poor data gathering, recording and reporting GIDA and peace and order issues Poor referral system within the city and ARRM health facilities

Action Plan (no copy)

Discussion

The utilization of trained personnel PPIUD insertion will help to create a pool of trained capacitated health personnel as Dr. Orly suggested. In so doing, almost all referral siteswill be capable enough in handling cases. He also wanted to collect referral slips/forms

for proper recording and monitoring of dislocated clients. However, Dr. Cabug made toknown that this is not feasible step because in the community most clients will not returnon the next appointment. The only way is to duplicate the copy of their referral slip and must be pile for monitoring.


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To enhance understanding on a possible range of options to address various gaps, theIsabela City - CHO followed a guiding principle that traditionally, socially and culturally we are part and parcel of one nation and that the call to serve is strong enough toaccommodate even dislocated referrals. The golden rule of Dr.Cabug is to develop a

strong influence to health in the primary level. In so doing, this will change the landscapeof health status thus speeding the MDGs 4 and 5.

Center on Health and Development Region 9

Dr. Cynthia Dionio presented the regional status of Zamboanga Peninsula in terms of Family Planning Achievements of where they are now. Some of the necessary activitieswere done and others are to be performed.

Family Planning CBT Level 2 Training conducted on Natural Family Planning onMarch 6-8, 2012 for 3 provinces and 2 cities ( private and public mix) with (40health personnel)

Conducted CBT 2 (IUD Insertion)Training - For 3 provinces with (55 healthpersonnel )

Conducted the Orientation l ICV (Informed Choice and Volunteerism) andOrganized the Provincial /Municipal ICV Team - 3 provinces and 5 cities(190 health personnel)

Conducted Data Quality Check Training - For Non-Health Gov Areas, ZamboangaCity and Isabela City (50pax)

Planning to conduct NOSIRS (National Stock Inventory Reporting System)/SMS(Supply Management System)Training -

Conducted CBT 1 (2 batches) and CBT 2 IUD (3batches) for NFP (2 batches) Act as Resource Person on FP CBT level I in different provinces/city Conducted Monitoring and Evaluation of FP/MNCHN Program and CBT 2 (IUD

Insertion) Post Training Procurement and distribution of FP Commodities, IUD Instruments Participated in the BTL Mission together with the ZCMC Itinerant Team -

Zamboanga Sur - 36 clients ligated (Ipil , Zamboanga Sibugay-51 clients ligatedlast Oct 1-9, 2012 )

Conducted Training on AMTSL/EINC 3 Batches conducted at Zamboanga city,Isabela city, Zambo. Sur, Zambo. norte

**Status of New Acceptors and Current Users year accomplishment 2011 &2012 1st and 2nd quarter data is 35.39%.

Discussion


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Problem of low counseling and increase demand of permanent method were noted that hinders the progress of those interventions. In response, they hired two (2) OB toconduct programs.

The HKI promised for trainings to expand more the network of trained personnel.

But accordingly, Dr, Dionio will include the plans gradually because the committeelocked-up already the timeline for 2013 before the seminar. The MNCHN grant will be

fully use for these plans. According to Dr. Adiong, the DOH-ARMM cannot give full commitment in terms of financial support in all the planned program. Dr.Orly suggested consolidating the referral slips coming from different places of ARMM to identify thenumber of patients from ARMM and the procedures done.

After which, Region X represented a strong network and system as they represented 3key areas involved in the implementation of life-saving interventions, namely: academe,City Health Office and Hospitals. They tried to work hand in hand as evidenced by thefirst trainers t raining of Clinical Instructors in all colleges & universities of Region X andthe Enhancement of Curriculum by integrating the life-saving intervention into theacademic system because the beginning skills of future frontline health workers areessential for future benefits and for long-term implementation.

Iligan City Hospital GTLMHThese are the following action steps made by Iligan City Hospital under the leadershipand new flagship of Dr. Anita Saloma.

Actions taken Conducted orientation of staff on the units involved( 7/2012), thus increasing gthe health personnels awareness

Implementation of the practices on life-saving interventions protocols andresulted to satisfactory feedback from clients

FP counselling @ OPD OB-Gyn Clinic


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Dr. Saloma of GTLMH mentioned the need for revision of PARTOGRAPH standard format used because it lack details and hastily concluded that it is more laboriousundertaking like stages of labor must be clearly define and stated. However, Dr. Orly responded that it was made for the purpose of simplifying and comprehensibleamong TBAs and BHWs.

The attachment of partograph used with the referral slips must be complied also by the referral sites to provide instant information during trying times or emergency cases as Dr. Dyna commented.

The hospitals policy on receiving referrals initiates the use of logbook that ca rry theinformations on where the referral came from and going to. Dr. Saloma ratified themonitoring system by making a memorandum order to follow. But the problem lieson the dislocated referrals coming over because they are eating much of theresources of the hospital which are not even enough to satisfy the needs of local clients.

Gaps Identified and action plan No trained PPIUD service provider

o Request for training from HKI Lack of equipment (delivery table)

o Request for training Lack of space (DR/LR)

o CEMONC Building under construction Lack of supplies and meds

o Request additional budget from LGU Lack of IEC on EINC, AMSTL, BTL

o Create task force to implement Regular recording/reporting for monitoring purposes

o Task force in charge for monitoring Incomplete referral from the referring unit

o Establish standard referral forms communicated to referring units, tobe filled up properly prior to referral

Lack of commitment of trained staff on PPIUD, BTL o Meet the trained staff with CHO on how to provide services to other

health facility

No EINC Training conducted on midwiveso Coordinate with CHO, NGO for financial assistance

Lack of supplies (oxytocin and dexamethasone)o Coordinate with CHO and MNCHN program

Lack in the advocacy on EINCo Training on midwives in order to fully understand and adopt EINC


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Poor reporting and ff-up regarding PPIUDo Consolidate data as to the census, outcomes and complications

encountered

These are the tangible steps behind the identified gaps towards fulfilling this campaign.

Dr. Saloma is committed to change the landscape of health status in her own workingcommunity. But shes hoping that the concern on the utilization of resources fromdislocated referrals must be heard by the DOH-ARMM to give a counter support be it

financial or services.

Northern Mindanao Medical Center The following are major strategies done and monitored by NMMC represented by Dr.Caroline Orimaco and Ms. Amelia Paas that took forward in the realization of thiscampaign.

Actions taken CONSULTATIVE WORKSHOP ON REDUCING UNMET NEED FOR MODERN FAMILY

PLANNING Performed daily voluntary surgical sterilization among clients who desires

permanent method after thorough counselling. Conducted an outreach activity on identified municipalities of Region X Conducted ward rounds and do counselling on BTL and other methods esp to

high risk mothers Incorporation of family planning lecture in the prenatal counselling at OB-OPD Train OB -Gyn Resident Physicians on the techniques of permanent sterilization

(BTL) Distribution of different contraceptive methods flyers to women of reproductive

age group in the clinic and in the ward Networking with Rural Health units through the Provincial Health Office in order

to encourage more BTL Missions among the nearby towns and provinces. Participation in the yearly Surgical Mission conducted by specialty

organization(POGS) Allocation of budget by the hospital for supplies, instruments and other

materials needed for daily in house BTL and surgical missions. Issues and Concerns

o 1. Attitude problemso 2. NMMC is not yet a training ground for BTL to other health providers.o Patients are too dependent on their husbands decisionso More counselling to be done on informed choice to couple and more

training to be done to health personnel on counselling


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Gaps identified The 90 minute skin to skin contact cannot be complied due to the high number

of deliveries Not all health personnel are knowledgeable about EINC, PPIUD insertion and

AMSTL

Lacking no. of OB staff trained in BTL ***No problem in financing as they can afford to provide free services for the

poor -All meds and other supplies for BTL are provided free as well as hospitalbill

Referral note with incompleteo Making of uniform referral form properly filled up with data and legibly

signed by the referring doctor with his contact no.o Attach partograph in obstructed labor referralso Must issuance of discharge summary form to the patients upon discharge

Discussion

According to Dr. Orimaco , the implementation of PPIUD were not smoothly accepted by the mothers because they are technically too dependent on their husband. In which Dr Orly would like encourage the use of ICV (Informed choice and volunteerism) to provideCORRECT informations and myths about Family Planning (i.e. PPIUD).

They are motivated to reach the target of 50% MDGs 4 and 5 by 2013 by filling theexisting gaps, use organizational assets in financing the trainings. They envisioned alsomaking their hospital as site for PRACTICUM in life-saving interventions and eventually making this an IGP (Income generating Project) activit and Dr. Orly commended the planand spoke highly to encourage other sites to follow. e also suggested to select consultants who have timeslot specific for client in the hospital in finding services.

Dr. Orimaco identified hidden barriers encountered in which the Physician trained to perform FP program hadmany personal priorities than clients in public hospital. Dr. Orly responded to avoid sending participants for training because of non-compliance.

Iligan City Health Office

Actions taken Orientation to health service providers (Midwives, Nurses) in preparation for theplanned training - Aug. 9 and 17, 2012

Facilitated EINC Orientation Workshop in coordination with USAIDS privatesector mobilization for family phase 2 (PRISM2) on private Academes andmidwives of LGU to adopt and embrace the safe quality care for our birthingmothers and their newborn August 16, 2012


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Conduct training on EINC to Public and private health providers (Academe) September 4-5, 2012

Performed IUD insertion among postpartum mothers July to October 2012

Discussion

The weak interests and political will of the Iligan City Health Office, according to Dr.Verdida and Dr. Canada is one of the downside of the organizational culture. As anadvocate of good leadership and management they planned to make structural reformsin their policies addressing the trained personnel to re-orient and pass the skill to all health personnel in which at present weak or lack of interest. In so doing, massiveimplementation maybe done and will be sustained.

Dr. Verdida and Dr. Canada were committed to make a major breakthrough in theimplementation of their plans.

CHED 10- Dr. Bernadette Lleno

The CHED-10 represented by the dynamic Education Supervisor Dr. Bernadette Lleno.She believed that integrating it into the curriculum system will create a bigger leapsomeday. The Technical Working Group, an ad hoc organization that will sustain theprojects had plans to encourage students in making a research studies about the impactof life-saving interventions and the common problem encountered. In so doing, themore evidence-based result, the higher the acceptance and adaptions of theseinterventions.

Accomplishment as of Aug November 2012 Organization of the TWG Conduct of orientation/consultation with CHED Director Formulation of Proposal to Undertake the Project MOA Signing Between HKI, DOH & CHED 10 Issuance of CMO for the Conduct of training for faculty of the BSN & Midwifery

Programs Conduct of Training Among Deans and Level Coordinators on the Enhancement

of the syllabi Conduct of Training for faculty Members and critiquing of the enhanced syllabi Finalization of the enhanced curricula/syllabi

Problems encountered Definition of Terms (curriculum against syllabus) Identification of actual number of hours allotted for each intervention in per

subject/syllabus Limited number of faculty trained


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Minimal budget to do actual integration per HEI and conduct of monitoring forthe implementation

Inadequate coordination between stakeholders New CHED directives for accreditation of affiliation for BSN and Midwifery

Interns

Gaps Identified Limited numbers of faculty members trained in the life-saving interventions

towards attainment of MDGs 4 and 5o Conduct of re-echo and echo training to be handled by trained faculty

members.

o Seek assistance from the partners agencies who are trained with the life-saving interventions

Lack of Logistic for monitoring of the implementation of the enhanced

curriculum/syllabuso Utilize the project funds for monitoring from HKI

o Seek logistical support from HEIs Limited Logistic for the module formulation of syllabi/ evaluation tools

(competency evaluation tools) Weak interest on the curricular/syllabi enhancement

o Conduct forum, conferences on the enhance curriculum/syllabi (Deans,Faculty , Students

Inadequate coordination between stakeholders New CHED directives for accreditation of affiliation for BSN and Midwifery

Interns

Action Plan Creation of the task force on Curricula/Syllabi Enhancement Monitoring of HEIs on the implementation of the enhanced curriculum/syllabi; Issuance of the CMO for the implementation of the enhanced curriculum/syllabi Annual review of the output of the implementation

DiscussionOur action plan is limited only to service delivery among students and clinical instructor as verbalized by Dr. Lleno of CHED X. She planned to tap local trained officers todisseminate and pass the skills to other academic centers. She will conduct forums of Deans, Faculty and students . In so doing, this way will maintain its vitality and realize the

purpose of students as catalyst for change in the future.


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Amai Pakpak Medical Center APMC is located in Marawi City but under the supervisory domain of Region X. The following are actions taken by the hospital:

A Creation of APMC AMTSL, EINC , PPIUD,BTL Team (The APMC Team) Policies submitted to the Chief of Hospital thru the Chief of Clinics for theImplementation.

o Revised policies distinguishing essential and non essential practices.o Created an enabling labor room, antenatal care, and delivery room

environment.o Revised of forms and records to document how EINC is done as

mandated by the new PhilHealth Circular.

Conducted Orientation and Training on EINC at Mamitua Saber Research and

Technology Center, Mindanao State Univ.,Marawi City. Coordinated with Mrs.Veronica F. Jumuad, - Spetember 12-13, 2012 Conducted training on Private Sector Mobilization (PRISM2) Local Market Area

Manager ARMM - 21 participants from private Hospitals and Clinics Conducted Scientific lectures/orientations on EINC during Medicine Week

sponsored by PMA Lanao del Sur Medical Society.o Rural Health Physiciano APMC Residents and Specialistso Private Hospitalso Private Practitioners

Created a Memorandum of Agreement between APMC and Marawi City HealthOffice

o APMC will be the venue for all BTL sponsored by the City Health-ARMMo APMC will share the expenses for the free medical missions by the City

Health office - ARMM

Gaps Identified Lack Prenatal check-up Limited supplies for prenatal patient

Lack of trained personnel of life-saving interventions (PPIUD, BTL, AMTSL andEINC)

FP Counseling Lack of participation of stakeholders on Mortality Death Review (MDR)


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PPIUD- Aug. 5-11, 2012 Lectures to OBGYNE consultants and Residents of CRMC Introduced to Nursing Service monthly Conference- Nov. 5, 2012

Sultan Kudarat PHTSL leaderDr.Orly reminded the group that they have trained 5 birthing clinic in LambayongDistrict Hospital. In line with this, they must coordinate by this

Dr. ADiong then responded that MOA maybe a milestone in the realization of plans

The challenge now is to narrow the gaps that hinders the progress of this high-impactlife-saving interventions. At the end of the process, participants were made to draw uptheir action plan / strategies for sustainability. The SHIELD project key strategy is tomake the facility and personnel SELF-RELIANT by means of partnership andempowerment.

Day 2:

The second day of the seminar began with a continuation of workshop 1 in identifyinggaps and followed by a technical input on ICV (Informed Choice and Volunteerism) of Dr.Orly de Ocampo. In order to better understand the ways and means in developing agood FP counseling and learn more about the clients perception of the family planningservices they will be receiving.

According to Dr. Orly de Ocampo as he gave a technical input on ICV that the FamilyPlanning Program is special in a sense because, unlike the other health programs thatrefer to their so- called customers as patients, FP customers are called clients NOTpatients. Because they are NOT sick to begin with, it is very important in FP programimplementation and in the provision of its services that due diligence is given toensuring that Quality of Care is provided or observed.

In the Philippines, the constitution and DOH have placed provisions and policies in orderto ensure quality of care in FP programs.

He started by dissecting the content or meaning that lies behind informed choice andvolunteerism in which this is a freedom of client to express and make their owndecisions base on accurate and complete information on a broad range available. In sodoing, the informed choice is an access to information on a wide range of family


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planning and to counseling, services and supplies needed to help individual obtain andfollow up on a referral or simply to consider the matter further.

The integration of ICV to maintain quality family planning care took a lot of doing in theARMM. Despite the difficulty of providing health services in ARMM, the DOH-ARMM can

be proud of having best practices in some areas of the ARMM. What is needed now is toensure that these services are being provided according to accepted standards (are of high quality) and cover more people/clients who need these services. Thus, the DOH-ARMM has embarked on an initiative to enhance the Quality Assurance System for itshealth services. It thus adopted the Improvement Collaborative or IC, an approach toimprove quality of health services and to scale up best practices. The adoption of the ICis a DOH-ARMM action in line with the MNCHN strategy of the DOH-ARMM and which isgeared towards helping ensure the achievement of the Millennium Development Goal(MDGs 4 and 5, basically) of the country.

To enliven the session, Dr. Orly asked the members of the audience on the meaning of about quality of care in Family Planning and the response was in unison that quality willbe achieved by holding on the rights of the patients.

These issues can be summarized into two: meeting clients rights and providers needs.When we say that we are approaching meeting clients rights and making sure thatproviders have what they need to provide good care, then we are approaching deliveryof quality services as Dr. Orly specified.

Specifically, focus on clients rights to information, access and choice and contextualizethese in terms of providing quality FP services. These three clients rights can be

summed up into their right to informed and voluntary decision making regarding theirreproductive intentions. In FP, significant emphasis is placed on the ensuring that allclients are provided opportunities for informed and voluntary decision-making based onadequate information and making those choices accessible to the clients.

He made known to all that this is very important because better method use and clientcompliance leads to reduction in unplanned pregnancies and improved health.Continued method use results from clients getting the method they want and beingprepared for side effects as he added.

The satisfaction are high as Dr. Orly confidently emphasized with their methods becausethey get to choose the method that is appropriate for them and are well prepared tohandle possible side effects that may or may not come with the use of the method.These satisfied clients will be the best promoters of the use of family planning.Informingclients about what to expect, and what is normal, reduces fear and dissatisfaction, andeases adjustment to proper method use and client satisfaction.


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Some series of questions that were thrown to the members of the audience are thefollowing:

What are the provisions in the Philippine constitution that are relevant to thePhilippine Family Planning Program? Also, what policies have been put in place

by the DOH to ensure quality of care in the provision of FP ?

In the 1987 Constution Article 11 section 12. Family Planning supports this provision of the constitution in that by protecting the health and welfare of the mother and child, FPin fact saves their lives and strengthens the family as a basic unit of society.

The last statement of this article refers to ABORTION as being illegal in the country. FPhas always been consistent with this article abortion was never a method of FP in thecountry.

He by then briefly discussed each of the 7 policy statements as described in AO 50-A.2001 that embodies the DOH FP program policy, emphasizing the overall improvementof general health of mothers, children, and communities leading to improved quality of life for individuals and societies.

In the memorandum to all regional directors of all the regional health offices or Centersfor Health Development nationwide issued June 29, 2006, the DOH reiterated theimportance of complying with these four pillars or guiding principles in theimplementation of the FP program in the country and providing further explanations byrestating the four pillars as follows:

1. RESPONSIBLE PARENTHOOD2. RESPECT FO LIFE3. BIRTH SPACING4. INFORMED AND VOLUNTARY CHOICE

These are guiding principles in the management of quality family planning progam.It should be noted that targets and quotas for FP programs per se is actually ALLOWEDfor as long as these targets are NOT PASSED on as targets or quotas ASSIGNED to orREQUIRED of INDIVIDUAL FP SERVICE PROVIDERS. Targets for programming andbudgeting purposes are actually allowed but these numbers should not be passed on toindividual health workers or referral agents as assigned or required target numbers orquotas.

Clients choosing a particular FP method must be provided all pertinent informationregarding the method they have chosen in a language that they can understand thisinformation includes what the method is, how it works, advantages, disadvantage,possible side-effects, how to use the method, where to get it, what warning signs towatch out for and what to do if these occur and other information.


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One of the ways that service providers can at least demonstrate efforts to ensureinformed choice in FP is by making available conspicuously displayed wall chartscontaining the different FP methods.There are available poster presented by Dr. Orly and encouraged everyone to prominently display the posters in all clinics that provideFP services . There are version in Tagalog and Cebuano dialects to better ensure easy

undestanding of the IEC material.

The second provision under the freedom or choice and voluntary decision-making is theprohibition of providing incentives to FP clients or to service providers. Incentives,bribes, gratuities, or financial reward are defined to require the transfer of an item of value in order to influence a specific behavior (e.g. acceptance of a family planningmethod, or recruiting clients to achieve targets). The policy requirements prohibit thepayment of incentives to individuals for becoming acceptors. In order to qualify as anincentive, such payments must be a material or significant factor in the clientsdecision to become an FP acceptor. Reasonable reimbursement for medicine, food,medical supplies, or transportation expenses paid by the client are not considered incentives.

FP projects shall not deny any right or benefit, including the right of access to participatein any program of general welfare or the right of access to health care, as aconsequence of any individual's decision not to accept family planning services

FP Policy requirements prohibits the tying of rights or benefits, including legal privilegesand powers, to the decision to accept a method of family planning, or not. Examples of violations would include denying access to health care, access of food programs, oremployment to those people who do not accept family planning.

The service delivery site project is usually considered as the actor in this denial of benefits. An example of a violation is a threat of the denial of free health services to aclient unless she agreed to be sterilized. Also, the service delivery programs may expressstrong preferences for fieldworkers who are currently using contraception or have smallfamilies. Such conditions can be encouraged in job applicants, but they cannot berequired .

This guideline states that: service providers or referral agents in the project shall notimplement or be subject to quotas, or other numerical targets, of total number of

births, number of family planning acceptors, or acceptors of a particular method of family planning (this provision shall not be construed to include the use of quantitativeestimates or indicators for budg eting and planning purposes)

Target is a word that is often loosely used in family planning and other public healthprograms.


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Targets that are not allowed under this provision are those that are:(1) predetermined;

(2) assigned to a specific health worker and(3) enforced, or of consequence.

For example, if a fieldworker develops monthly targets for herself based on door to doorsurveys in which she asks about womens desire to have more children and she is notrequired to meet those targets, th ese are not targets that are prohibited.

On the other hand, production targets -- defined in terms of predetermined numbersof birth or family planning acceptors, which are assigned to a fieldworker and which thefieldworker is required to achieve -- are prohibited.

Assigning of targets to a mid-level health program manager or supervisor would also beconsidered problematic or a possible source of vulnerability because these supervisorsare quite likely to pass on their targets to the individual field workers.

Developing targets for planning purposes, e.g. to influence resource allocation, is not aproblem. However, provider-level targets, which are assigned and required, areprohibited.

The ultimate responsibility of securing documentation of the informed consent meaning, getting the Voluntary Sterilization (VS) clients to sign the informed consentforms falls on the shoulders of the FP counselor or operating room nurse assisting inthe procedure at the VS site or venue. However, all trained FP counselors and serviceproviders are expected to explain the contents of the informed consent forms to allpotential VS clients before the actual day of the VS procedures. This is part of a normalFP counseling session for client who chooses VS.

Included in the informed consent form is the assurance that the VS clients were madeaware of and were provided easy access to temporary methods that they can choosefrom either through direct provision or by referrals.

Again, VS clients must not be subjected to incentive payments that will influence theirdecision to accept VS as their FP method. With respect to program personnel, a

violation occurs only if the clinic makes a payment or reward to an individual worker forachieving a numerical quota or targe t, expressed as a predetermined number of FPacceptors, acceptors of a particular method of FP, or total number of births.

The following would be permitted:

Fee for service payments to family planning providers


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Non-financial, small-value items that are provided across the board toproject personnel or to individuals to acknowledge general good performance Distribution of promotional items, e.g. social marketing materials

If your NGO or the LGU or other stakeholders are receiving funds from the U.S.government, aside from the above prohibitions, you are also NOT allowed to use USGovernment monies to LOBBY either FOR or AGAINST abortion.

This last provision is not stated in this slide because funds from any other source (otherthan US Government) may be used for whatever purposes those funds recipients maywant to use them.

HOWEVER, the management or treatment of women with injuries or illnesses resultingfrom abortion whether induced or spontaneous is allowed. There should be nodiscrimination or preferential treatment of women with spontaneous abortion as

against those who had their abortions intentionally carried out.These are the policies to ensure quality of care for our FP and MCH clients and patients

the bottomline really is

Indeed, using ICV is a significant step towards attaining this quality of care is by complying with these policies and thereby ensure . According to Dr. Orly, our goal is that all clients make voluntary and informed decisions regarding their reproductive plans.

It was well applauded and appreciated, and the lunch commence for 45 minutes. After which due to time constraint, the need to practice the use of ICV Dr. Dyna taught religiously the use of service delivery clients form in order to collect pertinent informations from the patients and learn more about the perception of clients on the

family planning services they will receive.

Subsequently, Dr. Linang Adiong gave instructions on the right way to use Family ClientsForm in order to assess the impressions of clients in FP in general thus giving LGU thewhole picture of the status quo and identify the areas to be strengthened or improved.

After series of planning activities with the addition of ICV forms the necessity to come upwith initial agreement is paramount to define the purpose of the seminar. Thus, Dr. Orly

formatted a new Referral forms and was agreed upon to use it as standard tool inreferring patients to other sites. It was projected in the monitor and made known to all

for final revisions. With good judgment, the group came up a standard tool withconsensual validation of all the representatives from the 3 regions.

The initial agreement on standard forms with the necessary informations was recognized provided that each referral sites must assigned somebody to secure a duplicate copy of


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the slips for proper recoding and monitoring of dislocated cases. Other agreed itemsare as follows: DOH- ARMM will provide complete list of referring hosp/facilitiesincluding contact personnel and CP nos. & Email address, List of all referred clientsclients will be emailed to ARMM FHSIS point person, should be filed and recorded atthe receiving hospital provided that return slips will be given to the patient.

Although there are major concerns that solution may not happen overnight but theinitial agreement will give a domino effect to some areas of concerns. They signed theagreement expecting to improve the referral system between ARMM and NON-ARMMhealth facilities.

EVALUATION

Leave taking is always the sad part of the story, but goodbyes must happen in order to

meet again as the emcee formally close the formal session. The program wasculminated by asking feedback from the participants. For the record, the following arethe positive feedback from the participants:

Dr. Dionio- Indeed we are called to serve, thats why we are here to plan for long -termbenefits. Ang Health for All must be our priority.

Mam SusanPagdating naming ditto sabi ko nakakatakot ung ibang participant kasi nakakumbong but later on Fiendly man diay ang mga muslim (laugh)

Dr.CabugIm out -grown with this kind of activity in my 22 years in service, I am into the butdespite my hearing problems and not a computer savy in which I should bring my staff, but I came here to help and for some mutual benefits. Thank you Dr. Orly and HKIbecause you pull me back to my younger years, you awake my enthusiasm.

Dr. ManalansaMy boss gave an ambushed notice that I will attend this seminar, thats why I came late but I tried because I want to hear and bring good news to my working place. Thank youHKI, especially to Dr. Orly for the laud efforts of organizing this seminar. Without this

initiative, we will not create initial agreement with consensual validation from thereferral sites. With that, thank you.

The challenge now is to maintain its capacity to survive or continue the purpose evenout of the shadows of NGOs like Hellen Keller International. By then, the sessionformally closed by a prayer and let our plans be in accordance to his will.


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ANNEX A

AGREEMENT ON THE REFFERAL SYSTEM BETWEEN ARMM AND REFERRAL SITES

ITEMS AGREEMENT REMARKS1. Referral forms Standardize Referral form Agreed referral forms to be

reproduced and to bedisseminated to ARMMprovinces.

2. Necessary

information in theReferral form

All pertinent information in

the referral form should becompleted

3. List of referringhospitals/healthfacility in ARMM

ARMM will providecomplete list of referringhosp/facilities includingcontact personnel and CPno. & Email address

For BASULTA andLAMARMA Areas

- c/o DOH-ARMM


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4. Use of Email List of all referred clientsclients will be emailed toARMM FHSIS point person

If with Internet andcomputer

5. Referral Form(duplicate form)

should be filed andrecorded at the receiving

hospital

Agreed date of collection:Quarterly every first

week of succeeding quarter

6. Return slips Will be given to thepatient.

All items below were discussed and agreed upon by the group. Affixed are thesignatures of the Hospital/Health people/ARMM staff involved:

____________________________________ _________________

____________________________________ _________________

____________________________________ _________________

ANNEX BREFERRAL FORM ARMM

Date: ___________________________________Referral to (Name of Facility): _____________________________________________ Address:

____________________Referral From: _________________________ Referred by: _______________CP#_________________Name of Client: ________________________ Age: ___________________ Address:

_____________Reason for referral: ___________________________

Medical History:

Pertinent Physical Findings:

Lab Exam Done and results:


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Initial diagnosis: __________________________________________________________Meds given:

___________________________________________Attending Physician (Name & Signature)

Hospital/Health Unit contact #: _________

Note: Please attached partograph (If applicable)---------------------------------------------------------------------------------------------------------------------------------

RETURN SLIP

Name of Referred Client: __________________________ Address: _______________________________Findings:

Work-up/procedure done:

Final diagnosis: ______________________________________________Medicine given:

Instruction to referring Unit:

Attending Physician: _________________________________ CP: _________________________Hosp/Health facility: _____________________________________

_______________________________Attending Physician (Name & Signature)

Health Unit contact #: _____________

Documents

Executive Summary - Davao