Midwife Licensure Exam Community & Public Health — Philippine Health Care Delivery System & DOH ProgramsDetailed Explanation

Structure of the Philippine Health Care Delivery System

The Philippine health care delivery system is divided into two broad sectors: the PUBLIC (government) sector and the PRIVATE sector. The PUBLIC sector is financed through taxation and social insurance (PhilHealth). It is the dominant provider for most Filipinos, especially the poor. Public facilities include Barangay Health Stations (BHS), Rural Health Units (RHUs), district hospitals, provincial hospitals, regional hospitals, and DOH-retained specialty hospitals. The PRIVATE sector includes for-profit hospitals and clinics, non-profit organizations (NGOs), and faith-based health institutions. It is financed mainly through out-of-pocket payments, PhilHealth, and private Health Maintenance Organizations (HMOs). A critically important concept is DEVOLUTION. Under the Local Government Code of 1991 (RA 7160), the delivery of basic health services was transferred from the DOH to Local Government Units (LGUs). This means: - PROVINCES operate and manage provincial and district hospitals (secondary and tertiary care). - MUNICIPALITIES and CITIES operate Rural Health Units (RHUs), health centers, and Barangay Health Stations (BHS) — the primary care level. - The DOH SHIFTED its role from direct service provider to a POLICY-MAKING, TECHNICAL, and REGULATORY body. Remember: After devolution, the community health nurse most often works under the LGU (municipal or city government), NOT directly under the DOH. The DOH now supports LGUs through standards, technical assistance, and financing — but the LGU is the direct employer and operator of the RHU and BHS. The three levels of health facilities are: 1. PRIMARY LEVEL — BHS, RHUs, health centers, private clinics. First contact, preventive, promotive, and treatment of common conditions. 2. SECONDARY LEVEL — District, emergency, and provincial hospitals. General medicine, surgery, OB-GYN, pediatrics. First referral level. 3. TERTIARY LEVEL — Regional and national hospitals, DOH specialty centers (e.g., Philippine General Hospital). Highly specialized care.

The Department of Health (DOH) — Roles, Structure, and Programs

The DOH is the LEAD NATIONAL AGENCY in health. After devolution, its three major roles are: 1. LEADERSHIP IN HEALTH — Setting national health policy, direction, standards, and priorities. 2. ENABLER AND CAPACITY-BUILDER — Providing technical and financial support to LGUs, NGOs, and other health stakeholders to improve their capacity to deliver services. 3. ADMINISTRATOR OF SPECIFIC SERVICES — Directly running DOH-retained hospitals, managing national emergency and disaster responses, and administering national health programs. DOH ORGANIZATIONAL STRUCTURE: - CENTRAL OFFICE — Secretary of Health, Undersecretaries, and Technical Bureaus. Key bureaus include: • Disease Prevention and Control Bureau (DPCB) • Epidemiology Bureau (EB) • Health Promotion Bureau (HPB) • Health Facility and Development Bureau (HFDB) • Health Human Resource Development Bureau (HHRDB) - CENTERS FOR HEALTH DEVELOPMENT (CHDs) — The 17 regional offices of the DOH. They coordinate DOH policies with LGUs at the regional level. Think of CHDs as the 'bridge' between the DOH Central Office and local health systems. - DOH-RETAINED HOSPITALS — Specialty centers like the Philippine General Hospital (PGH), Lung Center of the Philippines, Heart Center, Philippine Orthopedic Center, National Kidney and Transplant Institute, and other national/regional hospitals. - ATTACHED AGENCIES — These are semi-autonomous agencies that function under DOH supervision: • PhilHealth (Philippine Health Insurance Corporation / PHIC) — the social health insurer. • Food and Drug Administration (FDA) — regulates food, drugs, cosmetics, and medical devices. • Philippine Institute of Traditional and Alternative Health Care (PITAHC) — promotes traditional medicine. • Population Commission (POPCOM) — population management. • National Nutrition Council (NNC) — coordinates nutrition programs. SENTRONG SIGLA MOVEMENT: The Sentrong Sigla (SS) Movement is the DOH's quality assurance and certification program for health facilities. It awards a 'seal of quality' or certification to RHUs and health centers that meet set quality standards. Certified facilities receive recognition, grants, and technical assistance. The goal is to improve the quality of primary health care at the local level. An RHU that earns Sentrong Sigla certification is recognized as a quality primary care facility. Remember the DOH's current position: it does NOT primarily deliver day-to-day basic health services — that is the LGU's job. The DOH sets the rules, provides technical help, and runs specialty services that LGUs cannot.

Primary Health Care (PHC)

Primary Health Care (PHC) is the CORNERSTONE of community health nursing and the entire Philippine health system. Here is everything you need to know: GLOBAL ORIGINS: - PHC was declared at the INTERNATIONAL CONFERENCE ON PRIMARY HEALTH CARE held in ALMA-ATA (now Almaty), KAZAKHSTAN (formerly part of the USSR) in 1978. - The landmark document is the DECLARATION OF ALMA-ATA. - The global goal was 'HEALTH FOR ALL BY THE YEAR 2000.' - It was a joint initiative of the WHO and UNICEF. PHILIPPINE ADOPTION: - The Philippines officially adopted PHC through LETTER OF INSTRUCTION (LOI) 949, signed in 1979 by then-President Ferdinand Marcos. - The underlying theme and CORNERSTONE of Philippine PHC is COMMUNITY PARTICIPATION (people are active partners, not just passive recipients of care). DEFINITION OF PHC: Primary health care is ESSENTIAL HEALTH CARE made universally accessible to individuals and families in the community, at a cost the community and country can afford, through their full participation and in the spirit of self-reliance and self-determination. KEY PRINCIPLES OF PHC (the '4 As and Cornerstones'): 1. ACCESSIBILITY — Services must be physically reachable by all. 2. AVAILABILITY — Services must be present when needed. 3. AFFORDABILITY — Services must be within financial reach. 4. ACCEPTABILITY — Services must be culturally and socially appropriate. FOUR CORNERSTONES OF PHC: 1. COMMUNITY PARTICIPATION — People are active partners in health. 2. INTERSECTORAL COORDINATION — Health requires collaboration across sectors (education, agriculture, water, housing). 3. APPROPRIATE TECHNOLOGY — Technology suited to local conditions and resources. 4. SUPPORT MECHANISMS — Made available to sustain the system. ESSENTIAL ELEMENTS OF PHC (Mnemonic: ELEMENTS): - E — Education for health - L — Locally endemic disease control - E — Expanded Program on Immunization (EPI) - M — Maternal and child health (including family planning) - E — Essential drugs - N — Nutrition (and food supply) - T — Treatment of communicable and non-communicable diseases - S — Safe water and sanitation LEVELS OF PHC WORKERS: 1. VILLAGE/BARANGAY LEVEL — Barangay Health Workers (BHWs) are trained community volunteers. They are the FIRST LINE of the PHC system and the backbone of community health. 2. INTERMEDIATE LEVEL — Midwives, nurses, and physicians at the RHU. Traditional healers (hilot, herbolario) are also recognized as part of the community resource base in the Philippine context. PHC IS NOT THE SAME AS PRIMARY CARE: - PHC is a philosophy and approach to health. - Primary care is the first level of facility-based health services.

Universal Health Care Act — RA 11223

The UNIVERSAL HEALTH CARE ACT (Republic Act No. 11223) was signed into law in 2019. It is the most significant health reform in the Philippines in recent decades. Every Filipino nurse must know this law thoroughly. CENTRAL AIM: Every Filipino is guaranteed EQUITABLE ACCESS to QUALITY and AFFORDABLE health care goods and services, protected against FINANCIAL RISK AND HARDSHIP. KEY PROVISIONS: 1. AUTOMATIC PHILHEALTH MEMBERSHIP: - ALL Filipino citizens are AUTOMATICALLY enrolled in the National Health Insurance Program (PhilHealth). - Membership is NO LONGER voluntary or contingent on employment. - This is perhaps the most tested provision of RA 11223 on the NLE. 2. TWO MEMBERSHIP CATEGORIES: - DIRECT CONTRIBUTORS — Those who pay PhilHealth premiums themselves: employed workers, self-earning individuals, Overseas Filipino Workers (OFWs), and those with capacity to pay. - INDIRECT CONTRIBUTORS — Those whose premiums are SUBSIDIZED by the national government: indigents/poor (Listahanan), senior citizens, persons with disability (PWDs), and other sponsored members. 3. POPULATION-BASED vs INDIVIDUAL-BASED SERVICES: - POPULATION-BASED SERVICES (PBS) — Health services delivered to groups or the entire population: health promotion campaigns, disease surveillance, vector control, sanitation. Financed by NATIONAL or LOCAL GOVERNMENT. - INDIVIDUAL-BASED SERVICES (IBS) — Services delivered to specific individuals: consultations, laboratory tests, medicines, hospitalization. Financed primarily through PHILHEALTH. 4. PROVINCE-WIDE AND CITY-WIDE HEALTH SYSTEMS: - Health services are integrated into PROVINCE-WIDE HEALTH SYSTEMS (PWHS) and CITY-WIDE HEALTH SYSTEMS (CWHS). - The RHU/health center serves as the client's PRIMARY CARE PROVIDER and GATEWAY to higher levels of care. - Every Filipino should be registered with a primary care provider. 5. HEALTH TECHNOLOGY ASSESSMENT (HTA): - A systematic mechanism to evaluate evidence and guide which health services, medicines, and technologies PhilHealth will fund. - Ensures that PhilHealth benefits are based on evidence of effectiveness and value. PHILHEALTH (RA 7875): - PhilHealth was created under RA 7875 (National Health Insurance Act of 1995). - RA 11223 STRENGTHENED and EXPANDED PhilHealth coverage. - Key benefit packages: Inpatient care, Outpatient benefits, Z-benefits (for catastrophic conditions: certain cancers, end-stage renal disease), Konsulta Package (primary care), and Maternity Care Package. - The KONSULTA PACKAGE provides primary care consultation, basic diagnostics, and medicines at accredited primary care facilities — aligned with PHC principles. UHC reinforces a PRIMARY CARE-LED, REFERRAL-BASED SYSTEM. This means the nurse at the RHU is more important than ever — they are the frontline of UHC implementation.

The Two-Way Referral System

The TWO-WAY REFERRAL SYSTEM is the mechanism that links the levels of health care so clients receive the right care at the right place and return to the community for follow-up. It ensures continuity of care and prevents fragmentation. TWO DIRECTIONS: 1. UPWARD REFERRAL (FORWARD REFERRAL) — A client whose health needs EXCEED the capacity of the current facility is referred to a higher-level facility. - Example: A patient at the BHS with suspected appendicitis is referred to the municipal/district hospital (secondary level). - The nurse must prepare a REFERRAL FORM/SLIP containing: client demographics, clinical findings, interventions already done, and reason for referral. - The referral form ensures the receiving facility has complete information. 2. DOWNWARD REFERRAL (BACK-REFERRAL) — After specialist care at a higher-level facility, the client is referred BACK to the primary facility for continuing care and follow-up. - Example: A patient discharged from the provincial hospital after a stroke is referred back to the RHU nurse for home visits, rehabilitation support, and monitoring. - Back-referral promotes continuity of care and prevents hospital readmission. KEY REQUIREMENTS FOR EFFECTIVE REFERRAL: - ACCURATE DOCUMENTATION — The referral form must be complete and legible. - COMMUNICATION — The referring facility should communicate with the receiving facility (phone, referral letter). - FOLLOW-THROUGH — The community nurse must track referred clients and receive back-referral information. - PATIENT STABILITY — Ensure the patient is stable enough for transport before referring upward. WHY THE REFERRAL SYSTEM MATTERS FOR NLE: - It demonstrates the nurse's role as COORDINATOR and COLLABORATOR. - It connects the BHS/RHU nurse to the entire health system. - RA 11223 reinforces this system through province-wide health systems where all levels are integrated. - Under RA 9173, the nurse's scope of practice includes referring clients to appropriate services. COMMON MISTAKE IN REFERRALS: - Sending an unstable patient without stabilization first. - Incomplete referral documentation. - No back-referral or follow-up after hospital discharge.

Field Health Services Information System (FHSIS)

The FIELD HEALTH SERVICES INFORMATION SYSTEM (FHSIS) is the DOH's OFFICIAL recording and reporting system for health services at the local (primary care) level. It is the system that generates local, regional, and national health statistics used for planning, monitoring, and program management. WHY FHSIS MATTERS: The FHSIS is the nurse's primary tool for managing community health data. Accurate FHSIS recording ensures that program decisions (e.g., where to deploy vaccines, which barangay needs more TB treatment) are based on real data. Under RA 9173, documentation is a core nursing responsibility. KEY TOOLS OF FHSIS: 1. INDIVIDUAL TREATMENT RECORD (ITR) — The BASIC BUILDING BLOCK of the FHSIS. Every client visit at the BHS or RHU results in an ITR entry. It records the client's demographics, presenting complaint, diagnosis, treatment given, and follow-up plan. Think of it as the community version of the patient's chart. 2. TARGET CLIENT LISTS (TCLs) — These are registers that TRACK clients belonging to specific program groups so that NO CLIENT IS MISSED. There is a TCL for each major program: - Under-1 (EPI) list - Prenatal/Maternal care list - Family planning list - TB-DOTS list - Hypertension/Diabetes management list (newer programs) The TCL ensures the nurse follows up with every registered client, especially those who missed appointments. 3. SUMMARY / MONTHLY CONSOLIDATION TABLE — Consolidates data from ITRs and TCLs at the RHU level every month. Provides a monthly picture of the health situation. 4. QUARTERLY AND ANNUAL REPORTS — Data is aggregated from the monthly reports and submitted to the municipality/city, then to the CHD (DOH regional office), and eventually to the DOH Central Office. These reports feed into national health statistics. NURSE'S ROLE IN FHSIS: - The community health nurse is responsible for accurate, timely recording and reporting in the FHSIS. - FHSIS data is used to: monitor program performance, identify underserved populations, plan health interventions, and allocate resources. - The nurse uses TCLs to identify defaulters (e.g., a pregnant woman who missed her 3rd prenatal visit) and conduct home visits. FHSIS IN THE NLE: NLE questions on FHSIS typically ask about which form is the basic unit, what TCLs are for, and the sequence of reporting. Remember: ITR → TCL → Monthly Consolidation → Quarterly/Annual Report → Municipal → CHD → DOH.

Roles of the Community Health Nurse

The community health nurse functions within the Philippine health delivery system in multiple roles. Under RA 9173 (Philippine Nursing Act of 2002), the nurse's scope of practice in community and public health settings includes these key functions: 1. CARE PROVIDER — Delivers direct nursing care at the clinic (RHU/BHS), during home visits, and in community settings. This includes health assessment, nursing care planning, and implementing nursing interventions. 2. HEALTH EDUCATOR — Teaching individuals, families, and communities about health promotion, disease prevention, and self-care. This is the CORE PHC function of the community nurse. Health education is embedded in every client encounter. 3. MANAGER / SUPERVISOR — Manages the nursing service at the RHU. Supervises BHWs (Barangay Health Workers) and midwives. Plans, organizes, directs, and evaluates health programs. 4. COORDINATOR / COLLABORATOR — Links clients, families, referral facilities, and other sectors (e.g., schools, social welfare). Coordinates care through the referral system. Works with the interdisciplinary health team. 5. RECORDER / REPORTER — Maintains FHSIS records (ITRs, TCLs, monthly reports). Provides accurate health data for program planning and evaluation. This is a legal responsibility under RA 9173. 6. ADVOCATE — Advocates for clients' rights to health services, especially for marginalized and vulnerable populations. Ensures clients are aware of and can access PhilHealth benefits. 7. COMMUNITY ORGANIZER — Mobilizes community participation in health programs. Facilitates community diagnosis and community action. Empowers communities to identify and solve their own health problems — consistent with PHC's principle of community participation. 8. RESEARCHER — Identifies health problems through community health assessment and nursing research. Uses evidence to improve community health nursing practice. RELATIONSHIP TO PHC: - The community nurse's role is directly aligned with PHC principles: promoting community participation, using appropriate technology, and coordinating intersectoral action. - BHW supervision is a management function — the nurse trains, guides, and evaluates BHWs. RA 9173 CONTEXT: - RA 9173 defines the nursing scope of practice, including independent and collaborative nursing functions. - Community nurses must practice within this defined scope, referring beyond their scope to physicians and specialists as appropriate.

Providing technical assistance to an LGU to improve its capacity is the DOH's role as enabler and capacity-builder. This role was established post-devolution when the DOH shifted from direct service delivery to supporting LGUs.

Under RA 11223, ALL Filipino citizens are automatically enrolled in PhilHealth. An indigent (poor) informal settler who cannot pay premiums is classified as an INDIRECT CONTRIBUTOR — his premiums are subsidized by the national government.

Target Client Lists track all registered program clients (including prenatal clients) to ensure no one is missed. When a client does not return for a scheduled visit, the TCL identifies them as a defaulter. The nurse's next step is a home visit to follow up and bring them back into care.

The Philippines formally adopted Primary Health Care through Letter of Instruction (LOI) 949 signed in 1979. RA 7160 is the Local Government Code (devolution), RA 7875 created PhilHealth, and RA 11223 is the UHC Act.

The patient's transfer from RHU (primary) to provincial hospital (secondary) is an UPWARD REFERRAL because the patient's needs exceed the RHU's capacity. After hospital discharge, the return of care responsibility to the RHU is a BACK-REFERRAL (downward referral). This is the two-way referral system in action.

Community members identifying their own health problems and creating an action plan = COMMUNITY PARTICIPATION (the cornerstone of PHC). Collaborating with the agricultural officer to address malnutrition = INTERSECTORAL COORDINATION (health requires action beyond the health sector). These are two of the four cornerstones of PHC.

The ELEMENTS mnemonic: E=Education for health, L=Locally endemic disease control, E=Expanded Program on Immunization (EPI), M=Maternal and child health/family planning, E=Essential drugs, N=Nutrition, T=Treatment of diseases, S=Safe water and sanitation. The SECOND 'E' (third position) is EPI. The FIRST 'E' is Education; the THIRD 'E' (fifth position) is Essential drugs.

Vector control is a service aimed at the ENTIRE POPULATION (not an individual patient), making it a POPULATION-BASED SERVICE. Under RA 11223, population-based services are financed by the national or local government, not by PhilHealth. PhilHealth funds INDIVIDUAL-BASED services like consultations and hospitalizations.