* aa zane courouno RUALAVENUS ora.cnoz aata, pruenes ON TRLNS T8000 31 October 1991 “ADMINISTRATIVE ORDER . No. 11 “s. 1991 TO : Regional Health Directors, _ Regional Program focrdinators, Provincial Health officers. Provincial Program Coordinators, District Health Officers, City Health Officers; Municipal Health Officers, “Public Health Nurses, Rural Health Midwives, Barangay Health Workers SUBJECT: Revised/Added Roles and Functions of the Municipal Health Officer, the Public Health Nurse ang the Rural Health Midwife : of the Rural Health Midwife in the community including care of the individual, health education and dieenes control. There is now a need to update the job description of three main health service providere at the delivery point - the Municipal Health Officer (MHO), the Public Health Nusce (PHN) and the Rural Health Midwife (RHM), not so much to change their roles as to incorporate roles which they are actually performing already. These revisions are also neceseary to provide working conditions and relationships which are conducive bo integrating the services Roneree frontlines towards. the needs of the clients and beneficiaries, especially the mothers’ acd children. ~ Recent thrusts and changes in planning, budgetting and other aspects of management also need to be incorporated. in this administrative order, the Rural Health Unit (RHU) includes the Main Health Center and its Barangay Health Stations (BES). Zhe following ‘shall be the revised roles and functions of the MHO, PHN and RHM:ee gga RURAL HEALTH MIDWIFE (RAM) °° 7 ~ The RHM is the most peripheral first level health worker in the Department. of Health (DOH). She translates health programs and plans into’ direct:services to clients. o ent: In planning, budgeting and logistics management, So thé ‘RHM shall: 4:1 Prepare an annual health plan for her barangays following the “area-based program planning” methodology, as much ac possible involving local barangay officials and other Community members. . This. includes collection of all necessary barangay level information needed in the plan: {dentification of problems and its causes: formulation of goals and measures: and identification of activities and Tesources required to accomplish these activities. 4.2 In consultation with her immediate cupervisor, submit jist of her training needs based on the standard list of basic training, knowledge and skills requirements for the RHM, Annex A. 1:3 Properly use equipment, drugs and other supplies according to standard treatment and management guidelines fesued by the DOH. This function shall include proper recording and accounting of, equipment, supplies and materials received, disbursed and utilized/distributed; and maintenance and referral for repair of equipment. 1.4 Properly maintain the health facilities and surroundings in her catchment area. 2. Health Care: In order to provide the best possible quality of service from a wide range of health services for the individual patients, the RHM shall: 2.1 Learn all the basic knowledge.and skills required of _ the RHM according to the standard requirements for RHMs through attendance in courses, in-service trainings and other learning opportunities. 2.2 Make a thorough assessment of the totel health needs of her cliente and their families, as much as possible during the firet contact with the patient. 2.3 Provide the range of basic Maternal and Child Health (NCH) services listed in Annex B according to her assessment of the needs of her clients and their families. These services should be provided in a _eontinuing and comprehensive manner and with particular attention to high risk individuals and families. aContinuation’ fof “healtii care includes, amang others. * completion:.of primary immunization doses so that all children::.:are.,fullyimmunized before they reach one year old;::completion of. tetanus toxoid (TT) doses of pregnant women sbeforeithey. deliver;. promotion and monitoring of scerouth from/birth untilsthe,age of five years; feeding of Mthe (eslanderweight\.; child, until” “he/she "is" fully eh | SATEESS End Soguier pronsta, neal ana roatpertum 'eare including family planning services. 2.4 Based on a family health care plan, provide all other basic DOH health consultation and referral services. 2.8 Conduct clinics in every barangay in her catchinent area: at least, once a week if the barangay is accessible within 2 hours by regular routes; at least once a month if the barangay can be reached only after 2 hours using ‘the regular routes. 2.6 Record all-health services rendered, maintain a recording and filing system and keep a supervisory record book for her supervisors” comments and recommendations. 3. Epidemiology ‘and Statistics: 3.1 In disease surveillance and outbreak investigations, the RHM shall: 3.1.1 Report disease incidence using the standard . case definitions, Annex C. 3.1.2 Monitor a selected number of diseases, Annex D, by charting or graphing them on a weekly basis as they occur in her barangay/s. 3.1.3 Immediately alert the MHO of any unusual increase in the disease incidence of any of the selected diseases. For some diseases, Annex D, reports are needed within 24 hours after seeing the patient. 3.2 In the registration of births, deaths and other cases, the RHM shall report births and deaths according to standard routine reporting formats. 3.3 In. program accomplishment feedback, regularly and accurately report service performance using the field health services information system. She shall also use information from this system in her routine management and health care functions. 4. Community Health and Organization: To promote community participation in health care, the RHM shall: 4.1 Identify community leaders and health volunteers and other GOs and NGOs.4.2 As much as possible in coordination with other GOs and : NGOs, enhance the area-based barangay health plan with community level ihformation and diagnosis and prepare end implement a community health plan which includes: » 4.2.4/«iCommunity meetings and assemblies 4.2.2 Health education sessions such as mothercraft and mothers’ classes, hilot classes, barangay health workers trainings, and others 4.2.3 Community health. promotion projects such as environmental sanitation and other health activities. . Organize and monitor Barangay Primary Health Care committees and actively participate in existing community health organizations in the barangay/s. Regularly follow-up and extend technical support to barangay health workers, hilots and other health volunteers within her catchment areas. PUBLIC HEALTH NURSE (PHN) The PHN works closely with the MHO.. She is a very important health care provider. Together with the MHO, she supervises the RHMe and acte as the immediate assistant to”the MHO. If, for some reason, the MHO is not available or is not able to execute his/her functions, the PHN performs the WHO’s functions as appropriate. to her capabilities. Her perspective is essential in streamlining the activities of the Ris ‘she supervises, most especially the community health activities. 1. Management: The PHN assists the MHO in all of the management functions. To do this, the PHN shall: 1.1 Provide technical assistance to RHMc in preparing their barangay-based health plans. 1.2 As much as possible in coordination with local government, officials, other GOs and NGOs, countercheck the barangay health plans and consolidate these for the RHU. Assist the MHO in drafting a Municipal Support Health Plan incorporating the RHU activities and resources needed to make sure the barangay-based health plans are accomplished - Assist the MHO in identifying needs in staffing and task assignments for RHU/BHS staff. Recommend special strategies for organizing manpower such as mobile teams or “bayanihan” teans.1.6 Regularly assess. the technical, management and 5 communication skiils of, the Rilis. fi 1.7: Draft: a:d-year ‘training plan for all RHU staff, incorporating™. the training needs as discussed with the RHMs: "and taking into..consideration the training, skills and knowledge requirements for RHMs. The training plan shall include the skills desired: title of specific courses available; the methodology required, for 2 instance, on. the job practicum; and the preferred : schedule ‘and venue for training of each staff, ireluding herself. The 3-year plan shall be updated yearly. 1.8 Conduct’ a post-training assessment of RHMs. 4.9 Attend supervigory skills development courses. 1.10 Conduct at least once a month supervisory visits of each ee RHM in their barangays according to the RHM’s capability a and performance. Thie shall include preparation of be supervisory visit schedules; development or adaptation of ee supervisory checklists, indicators and tools; and be reporting. of visit findings and problems. Difficulties oy and major or recurrent problems hall be referred to the E MEO: 4 1.11 Enter into the supervisory book kept by RHMs all her fs monitoring findings and recommendations and the date of the next vielt. This will serve as a guide for the RNM’s F j appropriate action and reference for the next monitoring visit. E 1.12 Act as the overall property custodian of the RHU. This bs includes requisition, allocation. distribution and proper be use of equipment, supplies and materials; training of a other RHU staff on the proper use of these materials; ad proper recording, reporting and accountings and timely be | referral for repair of nonfunctioning equipment. She may fe be assisted by other RMU staff as designated by the MHO. S| 1.18 Asdist the MHO in developing or adapting tools for be evaluating the RHU and its programs and in implementing fi evaluation ‘activities. | Thie ehall— include kK recommendations on reward and discipline schemes as appropriate at the RHU level. 2. Health Care: ‘The PHN shall recognize the special midwifery | skills of the RHMs and must provide, in general, the technical guidance to RHMs on the nursing aspects of the care’ of the i individual patient. To do this, the PHN shall: 2.1 Aside’. from the nursing knowledge and skills, learn all the basic knowledge and skills required of RHMs, Annex A. be2.2 Review the management by the FHM of @ selected number of hali"focus on: correctness of assesment’ of aithfulnese:to procedures according to ‘guidelines’ and protocols :ony. proper . treatment ‘/-and management. such as,’ among others,” proper. ‘management “ofsca'\ohild with diarrhea or cough, or when and how to insert an intrauterine device (IUD); and appropriateness and adequacy of medications given, taking | into consideration ‘DOH policies such as the national drug policy, and the policy not to use anti-diarrheals and cough medicines on children, the standard regimen of the DOH, among others. It shall, therefore, be the responsibility of the PHN -to know these relevant policies and communicate these to the RHMs. 2.3 Develop and adapt tools that will assist RHMs in systematically delivering services in a client-based manner. Such tools can include, among others, poster size treatment and management charts end flow charts pasted on walls; or desk-top checklists or other materials. 2.4 Propose. clinic flow and management systems that will facilitate the smooth: flow.of patients; easy retrieval of patient charts and records; and streamline health education activities and services. 2.5 Attend to referred cases within her capability. 2.6 Assist the MHO in minor surgical cases treated at the RHU. : Epidemiology and Statistics: The PHN has an active role in disease surveillance and, epidemiology of diseases in the community. She/he shall: 3.1 Propose and prepare tools (e.g. graphs, tables and charts of selected summative health indicators and special activities) for better analysis of service delivery and performance results. 3.2 Teach RHMs the standard case definition, Annex C, and use these in disease reporting. 3.3 Graph weekly disease incidence cases in the municipality and display these conspicuously. 3.4 Immediately alert the MHO of any unusual increase in Ancidence of diseases. taking into consideration selected diseases that need to be reported within 24 hours after the case is seen.Resist ‘the MHO vin! outbreak investigations. following Ineexby collating preliminary reports and gation forms, among others. Jlanning and ‘implementing. disease, control mase*- -immunizations,, community and health’ education classes during © an Plan and secure necessary resources needed for disease control measures.. This includes identification and calculation of resources required such as vaccines, needles and syringes and other materials, . 3.8 Supervise the RHM in accurate recording and timely Peporting and proper utilization of health information, 4. Community. Health and Organization: The PHN has an important and active role in community health activities. She/he provides the perspective and overall direction to these community activities. ‘The PHN shall: 4.1 Provide technical guidance to RHMS on "proper identification of commmity health problems and strategies to solve these. She shall promote appropriate attitudes and concepts by making sure that the objectives of community participation and organization are clear to everyone and that effective methodologies to inform and mobilize communities are used. 4.2 Oversee monitoring of PHC committees, BHW training, hilot training, mothercraft and mothers’ classes and other community activities. 4.3. Review the curricula for BHWs, hilots, mothers and other curricula or syllabi used in health education activities. She shall make euggestions for improvement as appropriate. : 4.4 Propose a municipal’ level health communication’ plan targetted at the general public or specific sectors of the community. MUNICIPAL HEALTH OFFICER (MHO) ‘The MHO is the overall responsible officer of the Rural Health Unit. She/he. is’ the overall manager, supervisor, trainor, epidemiologist, medical and legal officer of the unit. She/he is ultimately responsible for all office and program activities. ‘The MHO performe the whole range of management 1. Managemen’ from planning to evaluation. She/he shall: functionsed 1.2 13 15 1.7 1.8 | 1.9 oe CUproblems'are held; and that "% soe Make sure that thé Area-based program planning methodology is correctly followed by the RMU staff. this means. that,..among.others, she/he shall make sure that the Necessary data-ars available and are used properly; that appropriate, joint meetings and adequate discussions of s the priorities for the ty are in proper perspective. ~ Municip Reviews “analyze, and formally approve the consolidated annual RHU-based health plan. -He shall also formally submit the plan to the District Health Office. the District-aoproved plan shall be submitted and. presented to the local municipal officials and/or the local “iealen Board, if required. . He shall make sure that this approved plan is reviewed and approved by the Municipal Development Council and included in the Municipal Development Plan. Negotiate for the RHU resource requiremehts from appropriate bodies such as the District Health Office or the, local government Health Board. Call end chair regular monthly staff planning, consultation, operations and review meetings. - Determine manpower needs and decide task assignments of RHU staff. As much as possible. in collaboration with local government officials,other GOs .and NGOs, plan Special strategies to provide more efficient services. Negotiate for staffing concerns such as additional stat items; detail, or deployment of staff. Assessment of needs and requests for additional manpower shall “take inte consideration the hard-to-reach areas. Recruit, assess. and recommend new staff for hiring. Assess technical, managerial and communication skills of all. RMU staff, especially the supervisory skills of | the PHN. Review .and approve the proposed training plan for RMU Staff, incorporating her/his own training needs. 1.10 Provide on-the-job training for specific needs to all RMU i corel staff in all aspects at all possible contacts. Organize in-house courses for gpecial topics as appropriate based on identified weaknesses and problems. 1,42 Develop, plan and implement an appropriate system of staff . assessment, motivation and reward such as. for instance, performance contracts.4.14 1.15 1.16 1.47 2.4 2.2 a Periodically. visit, at’ least once every 2 months and as ‘often as the need arises, staff at the BHS level to countercheck — supervisory findings and to resolve problems. - Focus must be given to problematic" areas prought:to her/his attention by the PHN. Provide feedback to the higher level management regarding useful ‘innovations developed or problems encountered at ‘tthe |RHU ‘level. SU) » Review and approve tools, indicators and schedules for supervision and evaluation. . Develop .and enforce a system for proper management of logistics such as memorandum receipts, proper requisition and issue vouchers, stock records, at least twice a year ocular inventories, and other auditing and accounting procedures. This includes use of practical guides and cut-off for “buffer stocks to decide when to reorder supplies and decision for proper disposal of non— functioning equipment through proper’ condemnation procedures. This also includes reallocation of equipment to other BHS, when necessary. identify and tap community resources to augment government resources. 2. Health Care: As the medical officer, the MHO is the technical expert in individual. care of the patient. As such she/he shall: Make sure that all RHU staff acquire the basic knowledge and skills required for the RHM and PHN. This will involve follow-through after formal courses, in-service training and continuing review of the clinical and patient care skills of the RHU staff, if possible at every contact with the staff. Countercheck the organization of the delivery of services, including flow of patients, proper management and referral of cases, and adherence to guidelines and standard treatment; management and referral protocols Trenelate the integration thrusts of the DOH - particularly those in maternal and child care - into practical steps to deliver services from the point of view of the clients, not the programs. This includes motivation of staff and testing of innovative schemes. Attend to cases referred by the RHM and PHN in addition to new patients needing his/her care. Conduct barangay level clinics in each barangay in the municipality at least once every 3 months and as often as the need arises.i 3. Epidemiology and Statistics: As the epidemiologist of the RHU, the HO shall: 3.1 Learn and practice all epidemiological skills necessary to do disease surveillance and outbreak investigations. 3.2 Teach the RHU’ staff on the use of standard case definitions and assess staff capability to recognize the selected diseases, Annex D. 3.3 Analyze weekly disease surveillance reports and immediately report outbreaks to proper authorities using standard formats. 3.4 Teach RHU staff how to properly analyze and interpret: surveillance information. 3.5 Conduct epidemiological irivestigations on all reported outbreaks as much as possible. This includes checking the presence of signs and symptoms according to the standard case definitions and doing clinical confirmation and, if available, laboratory teats of cases. In. a confirmed outbreak, institute appropriate disease control measures such as mass imnunization; environmental control; or mass treatment of cases, among others. Determine the cause of death of persons dying without medical attendance and issue the necessary death certificate. Promote the registration of vital events such as births and deaths. Supervise all-the recording and reporting according to standard recording and reporting formats as well as the use of these information in the management of the RHU and its activities. . Legal and. Medico-legal: As such, the MHO shall exercise general supervision over the hygienic and sanitery | conditions of the municipality, including public and private premises. He shall. be the expert. witnees in court cases. In this connection, he shall: 4.1 Enforce all sanitary laws and regulations appliceble to his. municipality and shall cause ary violation to be duly prosecuted. Abate nuisance endangering public health. Identify the cause of any special disease or mortality; institute measures to eliminate these causes; and immediately report these cases to higher authorities. 10y ‘Enforce any internal quarantine regulations applicable to his municipality> 4.5 Draft. and recommend to the municipal council suitable ordinances or regulations for carrying into effect the powera. conferred by law upon such body in respect to matters of sanitation. 4.6 Conduct “ autopsies. and. other medico-legal clinical assessments and appear in court as the medical expert, when necessary. - 5. Community Health and Organization: As the head of the RHU, he/she shall formally represent the DOH in gatherings and activities’ in’ the community: He/she shall be the guiding force and inspiration for commmity projects. He/she shall: 5.1 Respond to requests for guidance, review and approval, and attendance to community gatherings and projects. 5.2 Suggest’ community projects and activities and actively support these to make sure the objectives are attained. Thie shall include identification and allocation of resources if necessary. 6. District.eupport: When asked by the District Health Officer, the MHO. ghall- perform District support’ functions .such ac coordination and monitoring of activities and programs of the other RHUs within the District. For your, compliance. Au R.A.f BENGZON, M.D. Seorétary of HealthANNEX A Basic Training Requirements for All Expected Competency Knowledge of RHMs roles and functions Knowledge of general components of DOH programs and services Knowledge of government procedures and requirements KAS on prenatal, natal and post- natal care including use of HBMR and partogram KAS on basic family planning services KAS on UFC EPI activities and procedures Detection and home treatment of early pneumonia Proper management of diarrhea and dehydration using ORESOL KAS on detection and rehabilitation of underweight, anemic, and vitamin A deficient children and mothers How to motivate mothers to breast- feed; how to help mothers with breastfeeding problems How to give effective health education; how to make good visual aids Rural Health Midwives Title of Course Basic Orientation Course for RHMs Basic Maternal Care Training Course Basic FP Course Comprehensive Skills including ICS Basic UFC Training Course Basic EPI Course for RHMs and Nurses Pneumonia Case Manage ment Course for RHMs Diarrhea Case Manage- ment Course for RHMs Basic Nutrition Course Breastfeeding Counsel- ling Course Skills Training on Health Education and Communication (Other training competencies such as ability to detect and treat goiter, KAS ‘on emergency obstetrics, etc., are for selected RHMs only, eg. those in endemic areas or far flung communities only.)* | ANNEX B Basic MCH Services I..Services for Mothers: A. “Services for the Reproductive Health ‘of Mothers: 1. Reproductive health and family planning counselling 2. Regular health, nutritional and dental assessment, advice and treatment 3. Family planning services according to couple“s choice 4. "Safe sex": prevention and management of sexually transmitted diseases particularly AIDS 5. Breastfeeding advise and training 6. Nutrition counselling, micro-nutrient and food supplementation 7. Health education on reproductive health, responsible parenthood, safe motherhood and mothercraft B. Pre-natal Services: 1. Assessment of pregnancy 2. Identification of high risk pregnancies 3. Tetanus toxoid immunization 4. Management of health problems 5. Education on proper nutrition, dental care, tetanus toxoid immunization, preparation for delivery, breastfeeding and birth spacing C. Postnatal Services: 1. Monitoring of progress of labor and assistance .in delivery . 2. Post-partum care 3. Education on post-partum health including family planning and child care especially breastfeeding, immunization and nutrition 4. Family planning services 5. Aeaiatance on breastfeeding problems 6. Nutritional supplementation Il. Services for Children: A. Care of Infants Under One Year Old: 1. Neonatal services (within the first week) 1.1 Immediate newborn care -2 Complete assessment, breastfeeding including giving of colostrum and rooming-in 3 Immunization (BCG and hepatitis B) 4 Protection from risk of infection and referral 5 1. 1. 1.5 Birth regietration2. Eight days to one year old: 2.1 Growth monitoring : 2.2 Immunization: BCG, DPT, OPV, measles and hepatitis B 2.3 Exclusive breastfeeding first 4-6 months and up to 2 years old : 2.4 Counselling on proper weaning and nutrition supplementation 2.5 Early detection and treatment of infections and illnesses Care of Children Under Five Years Old 1. Promotion of proper home enviroment through education and counselling 2. Promotion of supportive community environment 3. Continuation of growth monitoring 4. Management of common problems especially diarrhea, pneumonia and nutritional deficiencies 5. Nutritional advice and supplementationANNEX Cc. 2 Standard Case Definition The following aré clinical signs’ and symptoms which together in combination can be used to suspect particular diseases. PROBABLE MEASLES - History of a generalized blotchy rash lasting 3 or more days AND - History of fever (38 degree centigrade or more, if measured) AND - History of any one of the following: * cough; * runny nose (coryza); * red eyes (conjunctivitis). AND - Any one of the following: : * typical findings on physical examination by a qualified health worker; fever 38 degree centigrade or more (if measured), cough, runny nose (coryza), red eyes (conjuctivities), blotchy (maculopapular) rash; * exposure to a suspect case of measles in the previous 3 weeks (incubation period 1-2 weeks); * epidemic of measles in the are: SUSPECT PERTUSSIS - History of severe cough AND - History of any one of the following: * cough persisting 2 or more weeks: x fits of coughing; * cough followed by vomiting. SUSPECT POLIOMYELITIS . ~ Acute onset of flaccid paralysis of the leg(s), and/or arm(s), and/or trunk (including any child less than 15 yeare old diagnosed to have Guillain Barre syndrome) for which no other cause can be identified. SUSPECT DIPHTHERIA ~ Acute pharyngitis, nasopharyngitis or laryngitis with a AND - Any one of the following: * typical findings on physical examination by a qualified health worker; airway obstruction; exposure to a case of diphtheria in the previous 2 weeks; epidemic of diphtheria currently in the area; death. wR EX‘ tne ' tS . / . ° PROBABLE TUBERCULOSIS IN CHILDREN e - An ill child with a history of contect confirmed case of pulmonary tuberculosis; - Any child * who does not return to normal health after, measles or whooping cough; x with loss of weight, cough and wheeze who does not respond to antibiotic therapy for acute respiratory disease; x with abdominal ewelling with a hard painless. mass and free fluid; * with painless firm or soft swelling in a group of superficial lymph nodes; x with any bone or joint lesion of slow onset; * with signs suggesting meningitis or disease in the central nervous system; with a suspect or Note: Complaints which should also arouse suspicion include: * Failure to gain or slight loss of weight, loss of energy over 2-3 months. Sometimes intermittent fever. NEONATAL TETANUS” ~ History of normal suck and cry for the first 2 days of life AND - History of onset of illness between 3 and 28 days of age AND - History of inability to suck followed by stiffness and/or “convulsions” AND ~ Typical findings on physical examination by a qualified health worker: inability to suck (triemus), and/or atiffnese (generalized muscle rigidity), and/or . “convulsions” (muscle spasms). ACUTE SEVERE DIARRHEA ~ Diarrhea within 14 days duration from onset of present illness AND - If the child has at least one of the following: * lethargy or unconsciousness; * inability to drink; * dry skin (i.e. skin goes back very slowly when pinched). AND - Any of the following: x very sunken and dry eyes; * absent teara; * very dry mouth and tongue.mse Ph bor aa PNEUMONIA . - Cough or difficult breathing AND - Any or all of the following: * there is fast breathing if a child: P less than 2 months old has respiratory rate (RK) of 60 per minute or more . . 2 months - 12 months old has RR of 50 per minute or more 1 year - under 5 years old has RR of 40 per minute or more * chest indrawing; * inability to feed or drink. AIDS a. AIDS in adult - Presence of at least two of the following major signs in the absence of a known cause for immunodeficiencf, such as cancer or severe malnutrition: x weight loss of 10% or more body weight; * chronic diarrhea ‘for more than 1 mont! * intermittent or constant fever for more than 1 month. + AND - At least one of the following minor signs: persistent cough for more than 1 month; generalized pruritic dermatitis; recurrent herpes zozter; oropharyngeal candidiasis; chronic progressive and disseminated herpes simplex infection; generalized lymphadenpathy. AND - Presence of generalized Kaposi’s sarcoma or cryptococcal meningitis. KKK KKK b. Pediatric AIDS - Presence of at least two of the following major signs in the absence of other known causes for immunosuppression: x weight loss or abnormally slow growth; x chronic diarrhea for more than 1 month; * prolonged or intermittent fever for more than 1 month. AND - At least two of the following minor signs: generalized lymph node enlargement; oropharyngeal candidiasis (thrush in the mouth); recurrent common infectione; persistent cough; generalized dermatitis; confirmed maternal HIV infection. RRR KER