SEMINAR-WORKSHOP ON IMPROVING THE REFERRALSYSTEM BETWEEN ARMM AND NON-ARMM AREAS

Waterfront Insular Hotel, Davao City November 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 Annexes Annex A Initial Agreement Annex B Standard Referral Form Annex C Identified Gaps Annex D - Action Plans Annex E Pictures Annex F - Attendance

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

EXECUTIVE SUMMARY Reversing the non-moving trends of Millennium development Goals (MDGs) 4 and 5 requires 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 Local Development (SHIELD) project made horizontal and vertical sustainable improvements on 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 to ensure the mechanism of strategic flow of local health network and moved between various components of that network. The development o strong referral system that link or mobilize patient to the needed service will serve as holding power to make smooth flow of services. The need to revise and update the referral system between ARMM and NON-ARMM today is widely recognized by the DOH ARMM in partnership wit Hellen Keller International - SHIELD project and Center of Health and Development towards enhancing quality health care and relevance. This two-day workshop aims to gather the key sectors and players of the Philippine Healthcare System of Region IX, X and XII to look 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 the implementation of the life-saving interventions and how they will continue/sustain their effort 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 DOHARMM- Dr. Adiong, CHDS, CHOs, MNCHN Coordinators and CHED-10. The current status of the implementation was identified by each of the assisted facilities by PowerPoint presentations before the beginning of the workshop activities. The presentations ignited discussion on different topics that highlighted the challenges and the approaches to overcome those challenges. During the presentations, the peculiarity of the implementations needs a serious consideration and good timing. For instance, the Zamboanga Peninsula emphasized the constraints in geographical locations, the ARMM amidst the clan wars and socio-cultural and political boundaries must be considered as serious gaps. The seminar finds wide variations, existing gaps and key indicators between leading and lagging the healthcare system performance.

MAJOR CONCLUSIONS Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 2

There was significant variation in the Referral processes conducted at each of the hospitals and community health centers thus causing the confusion and delayed healthcare interventions to patients. The most significant findings from the seminar are provided 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 health and community health center referral coordinators (RCs) 3. There are weak existing orientation mechanisms to inform and teach other health personnel. 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 aided by strong leadership and collaborationsetting 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 are presented by timeframe: immediate action for each hospital in terms of training other staffs, 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 that the DOH ARMM must create a group or someone to become the referral system monitoring person/group. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 3

INTRODUCTION Despite the concerted effort of the Government and HKI-SHIELD in initiating the integration of life-saving interventions to some assisted healthcare facilities, it seems that problems in the implementation and sustainability are big issues/obstacles that lies behind, hindering the progress that must be address first to have a smooth implementation 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 improvements in 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, the DOH-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 near ARMM, specifically in Zamboanga Peninsula, SOCCSARGEN, and Northern Mindanao. As a result, health service providers and the academe in these regions were encouraged to adopt or scale up these life saving interventions to contribute in the attainment of MDG 4 and 5. The process of the seminar-workshop employed the services of SHIELD staff and DOHARMM officers namely: Dr. Orly de Ocampo, Dr. Dyna, Dr. Kadil Sinolinding (DOH-ARMM Secretary) and Dr. Linang (DOH-ARMM Assistant Secretary) who made the seminar interesting, interactive, educative and participatory.

Background/Rationale: Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 4

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 near ARMM specifically in Zamboanga Peninsula, SOCCSARGEN, and Northern Mindanao. The purpose 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 impact interventions. This process was seen to help extend/expand the network of facilities providing the life saving interventions thus contributing in the attainment of MDG 4 and 5. Several hospitals, service providers, institutions, and medical associations were trained/oriented in the high impact evidence based interventions in Isabela City, Zamboanga City, CDO, Iligan City, Cotabato and Sultan Kudarat. Some facilities and regions have roll out the training in their respective facilities and catchment areas. The academe for their part particularly in Region 10 has also done their share by enhancing the MCH curriculum to include EINC procedures and PPIUD in the nursing and midwifery schools of Higher Education Institutions in the region. This was followed by EINC training of clinical instructors of the said schools. Given this development, the SHIELD project in partnership with the DOH-ARMM and the CHDs in the above mentioned regions wanted to know the current status of activities being undertaken by the assisted facilities in relation to the life saving interventions and how they will continue/sustain their effort after the SHIELD project. Assisted facilities will be provided with the opportunity to share the activities they have undertaken, problems encountered, action taken and existing gaps and next steps. Technical inputs on 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.

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 5

Expected output: Action steps on how to continue/sustain the life saving interventions in their facility/city/province/region Accomplishment reports of the assisted sites/facilities. Agreement/steps in improving between ARMM and NON-ARMM Methodology: The seminar-workshop was enriched by a PowerPoint presentation per area on the said identified gaps and existing activities on the implementation of life-saving interventions. The discussion was captured also in the form of a matrix to drive specific actions of the assisted facilities in moving forward and for sustainability. The participants: Twenty-eight expected delegates came over to converge, talk and listen because none of them is as smart as all of them to know of what is exactly the real score between ARMM and Non-ARRM assisted facilities in terms of the implementation of life-saving interventions.

PROCEEDINGS DAY ONE: November 14, 2012 Objective: Opening prayer: A canned ecumenical prayer was recited by Elizalde Bana, MSU-IIT Nursing Faculty and emcee of the said seminar workshop. Many were called but few came and some were late due to geographical constraints as some travelled long distance to reach the place. The process of opening the seminar should be made by Dr. Kadil and so the plenary session started late at 9:30 am because he arrived late for some very good reason such as overlapping of activities granted that he is busy enough as the head of the DOH-ARMM.

On the first day, 16 participants from different places wrapped with socio-cultural boundaries gathered together to participate by all means of their effort of coming over, namely from Zamboanga Peninsula (Region IX) represented by Dr. Cynthia Dionio as Regional MNCH Coordinator, Dr. Rafael Cabug of Isabela City City Health Office (CHO), Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 6

Dr. Jeffrey Masilungan a Neonatologist by profession of Zamboanga City Medical Center and Mrs. Susan Mendoza the Family Planning Coordinator of Zamboanga City Medical Center.

Northern Mindanao (Region X) was expected to present good number of delegates. However, due to time constraints and overlapping series of activities in their own locality it was represented only y Dr. Caroline Orimaco and Ms. Amelia Paas of Northern Mindanao Medical Center (NMMC), Dr. Anita Saloma Chief of Iligan City Hospital, Dr. Sheila Verdida and Dr. Karen Canada of Iligan City Health Office and including the adopted hospital of Region X located in Marawi City is Amai Pakpak Medical Center was represented by Dr. Latiph as Head of OB-GGYNE and Ms. Rasmia Abbas as DR Nurse. The SOCSARGEN region some expected participants unfortunately did not came for some very good reasons as they have also important community service events at the same time. Later part of the seminar, Dr, __________ from Sultan Kudarat made a grand entrance as she travelled early to represent Region XII in her presence. Dr. ________ and Ms. ___________ represented the Cotabato Regional Hospital. Dr. Orly de Ocampo who made a dramatic growth in the implementation of this project sets in to welcome the participants and let them feel the sense of belongingness that they are very important players in the pursuit of changing the landscape of health status in ARMM and to their own community. The friendly atmosphere was established well and for the sake of knowing what will happen during the session, Dr. Orly emphasized to all participants to make a good space of cooperation in the realization of the seminar objectives. The driven motivation of this seminar aims to (1) Improve referral system between DOH-ARMM and referral partners, (2) Build/strengthen the capacity of service providers in the referral facilities in Life Saving, evidence-based interventions, (3) Build/Generate community support /participation thru the CHT in selected sites. It was expected to be that way, and its good that expectations exist as benchmark to satisfy and meet the needs while working with this high profile participants professionally. These expectations to meet the objectives are well recognized by Dr. Kadil Sinolinding while he offered a warm welcome to the participants and shared its experiences and successes in the implementation of these life-saving interventions in the plenary session. Riding on the success of life-saving interventions made a bigger step in reaching the goals of the country. Best practices from the community, the local government units, and hospitals were shared to inspire and at the same time encourage local stakeholders Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 7

to adopt and scale-up these best practices to help contribute in attaining the Millennium 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 regular transportation to health facilities limit access to and coverage of services low number of health workers and facilities - inadequate to cover the entire population, Health workers are dedicated but overloaded o Centralized DOH-ARMM o Hospitals 24 o 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 by 2006 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

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 8

All of which created major challenges to health service delivery. Most affected by these adverse conditions are the women and children, especially among the poor. Dr. Sinolinding said that the DOH-ARMM mandated as lead government agency for health 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 in 2004 and 2006 when new evidences were published in the Lancet Series. When USAIDSHIELD started in the late 2006,all these new evidences were already introduced in the design. CMNC (Caring for mothers and newborn n community) is a package of interventions to address maternal and newborn DOH-ARMM with USAID SHIELD Project technical assistance and based on existing DOH guidelines and training curricula. He believes 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 starting Year 2008. He said the SHIELD project and that the Hellen Keller International (HKI) is only an instrument in introducing the programs in the ARMM. In the face of current legal restriction on the practice of midwives, particularly on when a midwife may inject a uterotonic drug (by law, oxytocin can only be administered by the midwife only after the placenta has been expelled. This is in direct contrast to the first component of AMTSL where oxytocin should be administered very soon (within 1 minute) after delivery of the baby/fetus. ), the DOH-ARMM has come up with policy issuances 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 effective intervention 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 the guidelines 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 Midwives for 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 posttraining follow up program in which trained midwives reported minimal bleeding post partum and mothers were up and about a day after delivery, no reported post partum hemorrhage. Nine out of every 10 trained midwives from the field health service practiced immediate essential newborn care.

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 9

The process of monitoring and supervision were also considered to make sure the correct recording and referral. In response to the DOH-ARMMs ARMM-wide Investment Plan for Health - 123 the health supervisors from the regional, provincial, district and municipal levels were trained. The trained supervisors took on a more supportive role as mentors/coaches to the CMNC trained midwives to improve performance. They provide also data collection and assessment tools with specific instructions on how to use in the community. Some of which are Scoring guide and sheets for health program accomplishments, Interview questionnaires for service providers and clients, Observation checklists to assess service provision. The support of DOH-ARMM was made evident by findings ways and means in the realization 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 as verbalized by Dr. Kadil Sinolinding is proud of having best practices in some areas of the ARMM. What is needed now is to ensure 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 a Quality Improvement initiative for its health services. It adopted the Improvement Collaborative or 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 the DOH-ARMM and which is geared towards helping ensure the achievement of the Millennium Development Goal (MDGs 4 and 5, basically) of the country.

In November 2011, the life-saving interventions (EINC, AMTSL, PPIUD and BTL) were introduced and made known with pragmatic and realistic objective to complete the service delivery network for AMTSL and ENC, namely: 7 demonstration sites 4 district hospitals 2 provincial hospitals 1 birthing facility

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 10

QIC teams at the region and provincial levels are becoming more familiar with the processes and procedures of quality improvement for maternal and child health care services. It created more opportunities for interaction between regional, provincial and demonstration sites staff. Today, by taking the lead they are riding now on the success of this life saving interventions 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 2011 attested to the improved state of health in ARMM. They have recorded the highest number of mother delivered with 3 steps of AMTSL (1,488) and number of newborns received 4 steps of ENC (1510) with zero (0) maternal death and three (3) Neonatal deaths. Beyond statiscal figures were the learning of capability building and implementation huge efforts are possible even under unique socio-cultural and political stressors in ARMM. In Summary DOH ARMM developed the Standards, passed the policies, trained health staff, 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 ripple to waves. In expanding the network, they facilitate trainings and series of dissemination forum in nearby referral sites of Region IX, X and XII.

The sharing of experiences lifted the morale and level of maturity of relevant people in same work and place. In so doing, Dr. Kadil Sinolinding who is the icon of strong political will and good governance enlivens the hopes of ARMM and also the participants attended. 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 tangible steps 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 the progress of the on-going and to do plans. Dr. Orly asserted that the problems in fundraising will probably best addressed by a combined effort of agencies involved and the substantial local and national funding resources in CHDs, LGUs and DOH must be effectively channeled through sound technical support with the consideration that these interventions are evidenced based practiced that gave a high impact on maternal and neonatal death problem in the country. Zamboanga City Medical Center (ZCMC) Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 11

As the program ensued, the presentation of Referral sites then followed to share and relate the action undertaken and gaps identified. Dr. Jefrey Masilungan a Neonatologist by profession initiated the part of the program. He then presented their actions undertaken in the pursuit of implementing these high-impact life saving interventions: The ZCMC-EINC Working group was officially recognized by the hospital administration 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, 925, 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 barangays o PP-IUD everyday at birthing clinic. o Free service and medications for ligation Problems: low accomplishment because of renovation, pipe in oxygen, NICU cleaning occupy, disinfection of OR for BTL Discussions As a result, in 2012 Cesarean Section with BTL surged to = 173 clients. These implementations 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 then reinserted. 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-9 o Insufficient supplies/allocated funds for some equipment to use. o Limited advocacy on life-saving interventions Provision of IEC materials Tri-media campaign o Unrevised FHSIS recording system (include AMTSL, EINC, PPIUD and BTL) o No standard forms of referral

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 12

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 interventions and the stumbling blocks encountered in the transition of the implementation because changing hospital policy must be paralleled with the system of curriculum in the academe 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 action plan was made known to all during the second plenary session. The lists of tangible steps are the following with specific, measurable, attainable, realistic and timebounded objectives had identified. The ZCMC would need additional training seminars for AMTSL-EINC, BTL, ICV and preceptorship of PPIUD by tapping the help of HKI and CHD 9. Dr. Orly suggested that sustainability must be practiced within the group, in which allowing the trained staff to pass the skill to all concerned health personnel 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 workers for recruitment of patients for BTL Enhancement of family planning counseling services for prenatal mothers (mothers class and distribution of IEC materials) Enhancement of family planning counseling services for post partum mothers in OB 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 a sophisticated 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 this request but promised to resurface in the meetings with DOH-ARMM for possible grant. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 13

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 and further 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 due to some necessary module revisions. It was said that the help of MNCHN especially in budget 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. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 14

**** 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 sites will 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 to known that this is not feasible step because in the community most clients will not return on the next appointment. The only way is to duplicate the copy of their referral slip and must be pile for monitoring. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 15

To enhance understanding on a possible range of options to address various gaps, the Isabela 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 to accommodate 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 landscape of 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 activities were done and others are to be performed. Family Planning CBT Level 2 Training conducted on Natural Family Planning on March 6-8, 2012 for 3 provinces and 2 cities ( private and public mix) with (40 health personnel) Conducted CBT 2 (IUD Insertion)Training - For 3 provinces with (55 health personnel ) Conducted the Orientation l ICV (Informed Choice and Volunteerism) and Organized the Provincial /Municipal ICV Team - 3 provinces and 5 cities (190 health personnel) Conducted Data Quality Check Training - For Non-Health Gov Areas, Zamboanga City 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 ligated last 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 Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 16

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 to conduct 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 committee locked-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 the number of patients from ARMM and the procedures done.

After which, Region X represented a strong network and system as they represented 3 key 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 the first trainers training of Clinical Instructors in all colleges & universities of Region X and the Enhancement of Curriculum by integrating the life-saving intervention into the academic system because the beginning skills of future frontline health workers are essential for future benefits and for long-term implementation.

Iligan City Hospital GTLMH These are the following action steps made by Iligan City Hospital under the leadership and new flagship of Dr. Anita Saloma.

Actions taken Conducted orientation of staff on the units involved( 7/2012), thus increasing g the health personnels awareness Implementation of the practices on life-saving interventions protocols and resulted to satisfactory feedback from clients FP counselling @ OPD OB-Gyn Clinic Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 17

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 laborious undertaking like stages of labor must be clearly define and stated. However, Dr. Orly responded that it was made for the purpose of simplifying and comprehensible among 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 carry the informations on where the referral came from and going to. Dr. Saloma ratified the monitoring system by making a memorandum order to follow. But the problem lies on the dislocated referrals coming over because they are eating much of the resources 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, to be 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 midwives o 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 EINC o Training on midwives in order to fully understand and adopt EINC Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 18

Poor reporting and ff-up regarding PPIUD o 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 working community. But shes hoping that the concern on the utilization of resources from dislocated 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 this campaign. 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 problems o 2. NMMC is not yet a training ground for BTL to other health providers. o Patients are too dependent on their husbands decisions o More counselling to be done on informed choice to couple and more training to be done to health personnel on counselling

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 19

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 hospital bill Referral note with incomplete o 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 referrals o 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 provide CORRECT 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 the existing gaps, use organizational assets in financing the trainings. They envisioned also making 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 plan and 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 the planned training - Aug. 9 and 17, 2012 Facilitated EINC Orientation Workshop in coordination with USAIDS private sector mobilization for family phase 2 (PRISM2) on private Academes and midwives of LGU to adopt and embrace the safe quality care for our birthing mothers and their newborn August 16, 2012 Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 20

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 an advocate of good leadership and management they planned to make structural reforms in 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, massive implementation maybe done and will be sustained. Dr. Verdida and Dr. Canada were committed to make a major breakthrough in the implementation 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 leap someday. The Technical Working Group, an ad hoc organization that will sustain the projects had plans to encourage students in making a research studies about the impact of life-saving interventions and the common problem encountered. In so doing, the more evidence-based result, the higher the acceptance and adaptions of these interventions. 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 Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 21

Minimal budget to do actual integration per HEI and conduct of monitoring for the 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 5 o 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 lifesaving interventions Lack of Logistic for monitoring of the implementation of the enhanced curriculum/syllabus o 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 Discussion Our 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 to disseminate 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. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 22

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 the Implementation. 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 Physician o APMC Residents and Specialists o Private Hospitals o Private Practitioners Created a Memorandum of Agreement between APMC and Marawi City Health Office o APMC will be the venue for all BTL sponsored by the City Health-ARMM o 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 and EINC) FP Counseling Lack of participation of stakeholders on Mortality Death Review (MDR)

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 23

Action Plan Continuous training/orientation in AMTSL ENC EINC BTL PPIUD FP Counseling Implementation of FP by DR concerned Continuous implementation with roper, complete recording & documentation of the Life Saving Interventions Monitoring of the involve staff in the implementation of the life saving interventions Proper/regular coordination between referring units & APMC Blood letting Discourage TBAs in handling home deliveries instead partner them with midwives, utilize them to assist & accompany patient to health facilities

Discussion APMC through Dr. Latiph believes that continuous orientation and trainings must be maintained since employees are transient in their working areas and look for a better and secured job. The good thing is they have created adhoc group to make the program sustainable in terms of monitoring and continuous training to other personnel. In response, Dr. Adiong will provide IEC materials from IPHO be it posters, brochures and leaflets, she also suggested to make standardized logbook same like with Twai Twai RHU recording system. The bloodletting project must be coordinated with LGU. She also discouraged home deliveries by TBAs, however at times of unstable peace and order in the area most of which the TBAs will attend the birth provided that they are trained with the life-saving interventions and must be paired with midwives. Dr. Latiph unlocked the secrets that lie behind the peculiarity of implementation of lifesaving interventions in the culturally bound areas. One must consider: clan wars, religious beliefs and conservative culture differences. Despite the summon to engage in this kind of situation they still continue to advocate and rise up against the gravity. A very wise move was made known by giving orienting the IMAM or head of the church to transcribe this in religious teaching. In so doing, the rate of application and reliability for commoners are high enough. Cotabato Medical Center Action undertaken EINC started- February 2011 Twice a month meeting ( pedia,OB, nurses) Unang Yakap- April 2011

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 24

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 leader Dr.Orly reminded the group that they have trained 5 birthing clinic in Lambayong District 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-impact life-saving interventions. At the end of the process, participants were made to draw up their action plan / strategies for sustainability. The SHIELD project key strategy is to make the facility and personnel SELF-RELIANT by means of partnership and empowerment. Day 2: The second day of the seminar began with a continuation of workshop 1 in identifying gaps 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 a good FP counseling and learn more about the clients perception of the family planning services they will be receiving. According to Dr. Orly de Ocampo as he gave a technical input on ICV that the Family Planning Program is special in a sense because, unlike the other health programs that refer to their so-called customers as patients, FP customers are called clients NOT patients. Because they are NOT sick to begin with, it is very important in FP program implementation and in the provision of its services that due diligence is given to ensuring that Quality of Care is provided or observed. In the Philippines, the constitution and DOH have placed provisions and policies in order to ensure quality of care in FP programs. He started by dissecting the content or meaning that lies behind informed choice and volunteerism in which this is a freedom of client to express and make their own decisions base on accurate and complete information on a broad range available. In so doing, the informed choice is an access to information on a wide range of family Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 25

planning and to counseling, services and supplies needed to help individual obtain and follow 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 the ARMM. 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 to ensure 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 DOHARMM has embarked on an initiative to enhance the Quality Assurance System for its health services. It thus adopted the Improvement Collaborative or 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 the DOH-ARMM and which is geared 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 will be 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 that providers have what they need to provide good care, then we are approaching delivery of quality services as Dr. Orly specified. Specifically, focus on clients rights to information, access and choice and contextualize these 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 their reproductive intentions. In FP, significant emphasis is placed on the ensuring that all clients are provided opportunities for informed and voluntary decision-making based on adequate information and making those choices accessible to the clients.

He made known to all that this is very important because better method use and client compliance leads to reduction in unplanned pregnancies and improved health. Continued method use results from clients getting the method they want and being prepared for side effects as he added. The satisfaction are high as Dr. Orly confidently emphasized with their methods because they get to choose the method that is appropriate for them and are well prepared to handle 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.Informing clients about what to expect, and what is normal, reduces fear and dissatisfaction, and eases adjustment to proper method use and client satisfaction. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 26

Some series of questions that were thrown to the members of the audience are the following: What are the provisions in the Philippine constitution that are relevant to the Philippine 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, FP in 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. FP has always been consistent with this article abortion was never a method of FP in the country. 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 improvement of 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 Centers for Health Development nationwide issued June 29, 2006, the DOH reiterated the importance of complying with these four pillars or guiding principles in the implementation of the FP program in the country and providing further explanations by restating the four pillars as follows: 1. RESPONSIBLE PARENTHOOD 2. RESPECT FO LIFE 3. BIRTH SPACING 4. 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 ALLOWED for as long as these targets are NOT PASSED on as targets or quotas ASSIGNED to or REQUIRED of INDIVIDUAL FP SERVICE PROVIDERS. Targets for programming and budgeting purposes are actually allowed but these numbers should not be passed on to individual health workers or referral agents as assigned or required target numbers or quotas. Clients choosing a particular FP method must be provided all pertinent information regarding the method they have chosen in a language that they can understand this information 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 to watch out for and what to do if these occur and other information. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 27

One of the ways that service providers can at least demonstrate efforts to ensure informed choice in FP is by making available conspicuously displayed wall charts containing the different FP methods.There are available poster presented by Dr. Orly and encouraged everyone to prominently display the posters in all clinics that provide FP 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 the prohibition 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 planning method, or recruiting clients to achieve targets). The policy requirements prohibit the payment of incentives to individuals for becoming acceptors. In order to qualify as an incentive, such payments must be a material or significant factor in the clients decision 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 participate in any program of general welfare or the right of access to health care, as a consequence of any individual's decision not to accept family planning services FP Policy requirements prohibits the tying of rights or benefits, including legal privileges and 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, or employment 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 a client unless she agreed to be sterilized. Also, the service delivery programs may express strong preferences for fieldworkers who are currently using contraception or have small families. Such conditions can be encouraged in job applicants, but they cannot be required. This guideline states that: service providers or referral agents in the project shall not implement 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 quantitative estimates or indicators for budgeting and planning purposes) Target is a word that is often loosely used in family planning and other public health programs. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 28

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 door surveys in which she asks about womens desire to have more children and she is not required to meet those targets, these are not targets that are prohibited. On the other hand, production targets -- defined in terms of predetermined numbers of birth or family planning acceptors, which are assigned to a fieldworker and which the fieldworker is required to achieve -- are prohibited. Assigning of targets to a mid-level health program manager or supervisor would also be considered problematic or a possible source of vulnerability because these supervisors are 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 a problem. However, provider-level targets, which are assigned and required, are prohibited. The ultimate responsibility of securing documentation of the informed consent meaning, getting the Voluntary Sterilization (VS) clients to sign the informed consent forms falls on the shoulders of the FP counselor or operating room nurse assisting in the procedure at the VS site or venue. However, all trained FP counselors and service providers are expected to explain the contents of the informed consent forms to all potential VS clients before the actual day of the VS procedures. This is part of a normal FP counseling session for client who chooses VS. Included in the informed consent form is the assurance that the VS clients were made aware of and were provided easy access to temporary methods that they can choose from either through direct provision or by referrals. Again, VS clients must not be subjected to incentive payments that will influence their decision 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 for achieving a numerical quota or target, expressed as a predetermined number of FP acceptors, 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

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 29

Non-financial, small-value items that are provided across the board

to project 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 US Government monies to LOBBY either FOR or AGAINST abortion. This last provision is not stated in this slide because funds from any other source (other than US Government) may be used for whatever purposes those funds recipients may want to use them. HOWEVER, the management or treatment of women with injuries or illnesses resulting from abortion whether induced or spontaneous is allowed. There should be no discrimination 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 Clients Form in order to assess the impressions of clients in FP in general thus giving LGU the whole 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 up with 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 in referring 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 with consensual 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 Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 30

the slips for proper recoding and monitoring of dislocated cases. Other agreed items are as follows: DOH-ARMM will provide complete list of referring hosp/facilities including contact personnel and CP nos. & Email address, List of all referred clients clients will be emailed to ARMM FHSIS point person, should be filed and recorded at the receiving hospital provided that return slips will be given to the patient. Although there are major concerns that solution may not happen overnight but the initial agreement will give a domino effect to some areas of concerns. They signed the agreement expecting to improve the referral system between ARMM and NON-ARMM health 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 was culminated by asking feedback from the participants. For the record, the following are the positive feedback from the participants: Dr. Dionio- Indeed we are called to serve, thats why we are here to plan for long -term benefits. Ang Health for All must be our priority. Mam Susan Pagdating naming ditto sabi ko nakakatakot ung ibang participant kasi naka kumbong but later on Fiendly man diay ang mga muslim (laugh) Dr.Cabug Im out-grown with this kind of activity in my 22 years in service, I am into the but despite 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 HKI because you pull me back to my younger years, you awake my enthusiasm. Dr. Manalansa My 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 you HKI, 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 the referral sites. With that, thank you. The challenge now is to maintain its capacity to survive or continue the purpose even out of the shadows of NGOs like Hellen Keller International. By then, the session formally closed by a prayer and let our plans be in accordance to his will. Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 31

ANNEX A AGREEMENT ON THE REFFERAL SYSTEM BETWEEN ARMM AND REFERRAL SITES ITEMS 1. Referral forms AGREEMENT Standardize Referral form REMARKS Agreed referral forms to be reproduced and to be disseminated to ARMM provinces.

2. Necessary information in the Referral form 3. List of referring hospitals/health facility in ARMM

All pertinent information in the referral form should be completed ARMM will provide complete list of referring hosp/facilities including contact personnel and CP no. & Email address

For BASULTA and LAMARMA Areas - c/o DOH-ARMM

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 32

4. Use of Email

5. Referral Form (duplicate form)

List of all referred clients clients will be emailed to ARMM FHSIS point person should be filed and recorded at the receiving hospital Will be given to the patient.

If with Internet and computer Agreed date of collection: Quarterly every first week of succeeding quarter

6. Return slips

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

ANNEX B

REFERRAL 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:

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 33

Initial diagnosis: __________________________________________________________ Meds given: ___________________________________________ Attending Physician (Name & Signature) Hospital/Health Unit contact #: _________ Note: Please attached partograph (If applicable) ---------------------------------------------------------------------------------------------------------------------------------

RETURN SLIP
Name of Referred Client: __________________________ _______________________________ 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 #: _____________ Address:

Executive Report: Seminar-workshops on improving Referral System between ARMM and Non-ARMM Page 34