Zamboanga del Sur SDN Referral Guideline

I. Introduction

The Local Government Code of 1992 mandated the Provincial, City and Municipal
government units to assume ownership and management of local health systems,
including the provision of both preventive and curative services. The National
Government through the Department of Health (DOH) retained the duty in providing
strategic directions, regulating services and providing assistance to Local Government
Units (LGUs) in managing the devolved health services. However, these post devolution
management arrangements created some operational challenges in coordinating LGU
inter-jurisdictional arrangements in providing health care services. This is particularly
observed in managing patients or clients under a fragmented referral system involving
local health providers and facilities owned by autonomous LGUs, and DOH-retained
hospitals for higher level of care.

The devolved set up became more challenging as the direct delivery of health care
became the primary responsibility of the LGUs while the DOH government assumes
leadership in providing both financial and technical support to health programs
management implemented at the local level. Several strategies have been established
by both the DOH and LGUs aiming to resolve bottlenecks in providing access to a
continuity of health care offered by the network of facilities and providers from District
Health System, Inter-Local Health Zone to Service Delivery Network based on the
MNCHN strategy specifying an organized network of public and private health care
facilities. Further, Implementing Rules and Regulations (IRR) of the Responsible
Parenthood and Reproductive Health Act of 2012 mandated the implementation of
health service delivery network (SDN) as one of the core strategies to implement the
law. The DOH later reiterated SDN implementation through the issuance of “Adoption
of the Guideline in Establishing Service Delivery Network” specifying basic steps to
establish an SDN. Under the Duterte administration, the Philippine Health Agenda
(PHA) of the DOH also specified Service Delivery Network (SDN) as one of the three
basic guarantees under the country’s health system, emphasizing the need to link
facilities and providers at different levels

Taking off from these relevant policies and guidelines, the Provincial Government of
Zamboanga del Sur, through the Provincial Health Office (PHO), partners with the
National Government in establishing the District 1 – Josefina, Mahayag, Dumingag,
Molave, Tambulig, Sominot, Midsalip, Aurora, Ramon Magsaysay, Tukuran, Labangan
and Pagadian City Service Delivery Network and District 2 – Dumalinao, San Pablo,
Guipos, Tigbao, Lakewood, Kumalarang, Bayog, San Miguel, Dinas, Dimataling, Pitogo,
Tabina, Lapuyan, Vicenzo Sagun and Margosatubig Service Delivery Network.

The Service Delivery Network is a critical component of the health system as this
completes the full functionality of health service delivery. SDN as defined is a system for

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creating demand of identified priority population groups or clients with unmet need along
a continuum of health services, fully served by an organized network of health service
facilities and health care professionals, resulting in significant health outcome
improvements (USAID SDN Compendium). A province that has a functioning SDN is
significantly superior in terms of improving maternal and neonatal health outcomes and
other relevant health outcomes compared with one that operates health facilities on an
independent basis. A province with an organized SDN draws in the capacities of health
service organizations (HSO) in its catchment area and manages them as a unified
delivery system. In this way, regardless of the point of entry of the patient/client in the
system, he/she will be treated in the appropriate health facility.

An SDN also solves health service delivery concerns commonly experienced by the
HSOs in their locality which are best tackled at the system level rather than by individual
institutions. Engaging health care providers, both public and private, are given
importance and that they are fully informed on the demands of the target clients for
quality health services. The scope of facility referral extends beyond the existing two-
way referral system by also adopts cross border and cross sector referral arrangements
depending on the availability and type of health care needed by priority target clients.
The patient referral for FP-MNCHN services is an example of a system level concern.
As such, HSOs that participate in the network must accept the FP-MNCHN patients as
clients of the network rather than individual HSOs. Therefore, services to these clients
extend beyond the walls of the HSO. It is incumbent upon the HSOs in the network to
follow certain guidelines as they jointly operate the SDN. These guidelines serve to
standardize the referral practices in the network and bring order in the operations in the
network.

The guidelines are grounded on the following policy issuances:

1. Implementing Rules and Regulations of Republic Act Number 10354 (The

Responsible Parenthood and Reproductive Health Act of 2012):

Rule 3, Section 3.01 – Definition of terms,– Service Delivery Network (SDN)

Rule 4: Service Delivery Standards
Rule 5 – Service Delivery Network – Describes the SDN operations and
procedures
Rule 14 – Conduct of Maternal Death Review and Fetal and Infant Death Review
2. Administrative Order Number 2014-0046: Defining the Service Delivery Networks
(SDN) for Universal Health Care or Kalusugan Pangkalahatan.

3. Department Memorandum 2014-0313: Adoption of the Guidelines in Establishing

Service Delivery Networks

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4. Philippine Health Agenda 2016-2022: All for Health towards Health for All. SDN is
one of the three guarantees that the government is committed to provide quality care for
all life stages and address the triple burden diseases financed through universal health
coverage for all Filipinos.

The health service providers and facilities of DISTRICT 1 AND 2 SDN, have taken the
initiative to engage relevant partners to operationalize the SDN that would respond to
the urgent need of improving, strengthening and sustaining the delivery of health services for
its population, especially the poor and marginalized;

For, and in consideration of the foregoing principles, the service providers of DISTRICT 1 AND
2 SDN through the support of the Zamboanga del Sur PHO and DOH RO IX along with the
public and private health facilities and stakeholders, decided to pursue the following guidelines
and agreement.

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The members of the said DISTRICT 1 AND 2 SDN shall be composed of the following:

Table 1: Directory of SDN Facilities

Name of Health Contact Numbers/ email
CONTACT Person SERVICES OFFER
Facility address
Provincial Health Dr. Ramon O. Blancia Jr. 0930 6865 332 /
Office [email protected]
Rosebud Bana 0905 2388 520
Ma. Theresa Acenas 0923 5988 952
Red Cross-Pagadian
Chapter Administrator Teodora Ortiz 0917 7019 961
Quality Assurance [email protected]
Officer Sharyll L. Gonzales 0917 5460 415
DSWD Provincial Link Yvonnie N. Suico 0918 7387 847
4ps Joefel G. Daquioag 0917 7294 560
Provincial PopCom Anatalia Sayade 0910 9056 855
Public / DOH Retained Hospitals

Kapatagan Provincial
Hospital
Margosatubig Regional Dr. Richard Sison 062 211 5634 1. Diagnostic -Level 1
Hospital Gibson Gonzales - ER Hospital 0947 0353 849 • X-ray (C-Arm in the OR)
Number
Mona Galvez [email protected] 2. Laboratory- Level 2
Reggie Guevarra 0910 8907 711 - Blood Collecting Unit - Hematology
- Microscopy - Blood Chemistry
- Immunology& Serology - Gene Xpert

3. Services
• BEMONC/ CEMONC/ Gynecology/
Perinatology
• Teratology
• Orthopedic/ Spine Surgery ;Tue- Thursday
• Anesthesia
• Psychiatry- Tuesday on call
• Pediatrics
• Pulmonary Medicine ; Tuesday- Thursday
• Adult Nephrology ; Tuesday- Thursday
• Endocrinology ; Tuesday- Thursday
 • Internal Medicine
• Transport Service
• NICU
• SCU
• HIV Testing Center
• AYHS
• TB DOTS
• Animal Bite
• Smoking Cessation
• High Risk Pregnancy
Mayor Hilario A. Ramiro Maam Lorna Limyu 0917 7005 336 Ø Major Services:
Sr. Medical Center ER Hospital Number 0920 5330 875 - Internal Medicine - OB- Gynecology
(MHARS MC) [email protected] - Family Medicine - Pediatrics
- Surgery

Ø Sub- Specialty:
- Orthopedic - Psychiatry
- Pediatric Pulmonology - Anesthesiology
- Nephrology - Pediatric
- Cardiology - Neurology
- Diabetology - Urology
- Ophthalmology - Oncology
- Cancer Surgery - Neuro- Surgery
- Adult Pulmonology

Ø Hospital Services:
- Public Health Unit - Cashier
- Blood Banking - Dental Services
- Supply Services - Pharmacy
- Out- Patient Department - Admitting Services
- Philhealth Services - CT Scan
- Delivery Room Service - Laboratory
- Human Resource Service - Medical Records
- Budgeting Services - Billing Services
- Laundry/ Linen/ Sanitorial
- Accounting Services - Security Services
- Emergency Room Services
- Women & Child Protectors Unit
- Medical Social Work Services
- Procurement Services
- Maintenance & Transport Services

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 - Information Technology Services

Ø Special Units:
- NICU (Neonatal Intensive care Unit
- PACU (Post Anesthetic Care Unit
- HDU (Hemodialysis Unit)
- ICU (Intensive Care Unit
- ASU ( Acute Stroke Unit)

Ø OPD Clinic:
- ABTC - TB DOTS
- Mental Health Clinic - DM Clinic
- Oncology Clinic - HIV Clinic
Zamboanga del Sur Dr. Maria Rovel A. Blancia 0908 8942 372 1. CLINICAL SERVICE:
Medical Center ER Hospital Number 0949 4843 340 1.1 General Clinical Care:
[email protected] • Medicine
• Pediatrics
Denise A. Romanillos 0933 8692 539 • Obstetrics and Gynecology
0920 6377 522 • Surgery and Anesthesia
1.2 Emergency Service
Zefanie Siyluy 0915 9990 379 1.3 Out- Patient Service
• General Consultation and Treatment
Teresa Fedelis Lumacad 0909 2482 452 • Family Planning and Reproductive and
Women’s Health Clinic
• Eye Care Clinic
• Immunization Clinic
• Epilepsy Mangers Clinic
• Animal Bite Treatment Center
• Dental Cliic
• Electro Encephalogram Unit
• Cardio-Vascular Unit:
Ø ECG
Ø 2d Echo
Ø Stress Test
Ø Pedia Echo/ Fetal Echo
Ø Duplex Scan
Ø Holter Monitoring

2. NURSING SERVICE
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 2.1. Clinical Care
2.2. Special Care:
• OR/ PACU
• DR/ NICU
• High Risk Pregnancy Unit
• Intensive Care Unit
• Hemodialysis Unit
2.3. Health Education and Counseling
2.4. Newborn Screening
2.5. Lactation Management

3. ANCILLARY SERVICE:
3.1 Tertiary Clinical Laboratory:
• Hematology
• Clinical Chemistry
• Clinical Microscopy
• Microbiology
• Serology- Immunology
• Parasitology
• Blood Station
3.2 Diagnostic S-Ray Service:
• Computerized Radiography
• Digital Radiography & Fluoroscopic X-Ray
• Mobile X-Ray
• CT Scan (2& 16 slices)
• Ultrasound
3.3 Pharmacy
3.4 Physical Therapy
Private Hospitals

Aisah Medical Hospital Landline 215 4413 • ER/ OPD Services- 24hours ROD
ER Hospital Number # 0955 8217 759 • Laboratory Services 24hours
SMU CP # 0917 6236 204 • Radiology Department
2D Echo CP # 0908 8981 525 Ø X-Ray (Mon-Sun until 11pm)
2nd Station # 0955 3095 170 Ø Ultrasound (Mon-Fri; 8am-5pm)
3rd Station # 0946 6474 353 Ø 2D Echo (Adult, Pedia & Neonate;
4th Station # 0955 8922 109 Mon- Fri; 8am-5pm)
• Minor & Major Operation
• Delivery Services
• Newborn Hearing Test
• Newborn Screening Test
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• NICU
• SMU

Doctor Specialist
Ø Pedia Cardio- Dr. Lozada
Ø Pedia:
- Dr. Merlin - Dr. Canalija
- Dr. Maño - Dr. Mondarte
- Dr. Garde - Dr. Aguisanda
- Dr. Ronald Farrales - Dr. Santos
- Dr. A. Farrales - Dr. Poloyapoy
Ø OB- Gyne
- Dr. Cruz - Dr. Pasay
- Dr. Castro - Dr. Borbon
- Dr. Salvador - Dr.Vista
- Dr. silao
Ø Orthopedic Surgeon
- Dr. Tan - Dr. Caliso
- Dr. Punsalan - Dr. Luy
Ø Neurosurgeon
- Dr. Lecciones
Ø Neurologist
- Dr. Marianito
Ø Nephrologist
- Dr. Mondarte
- Dr. Racuya
Ø Pulmonologist
- Dr. Bancorro
- Dr. Capatoy
Ø Cardiologist
- Dr. Frankie Ligas - Dr. Poloyapoy
- Dr. Kathy Ligas
Ø Internist
- Dr. Nasiad - Dr. Navarro
- Dr. Mondarte - Dr. Tago
- Sr. Gallardo - Dr. Edding
- Dr. Ortiz
Ø Surgeon
- Dr. Espaniola - Dr. Lucero
- Dr. Ampong - Dr. Paciencia
- Dr. Carbonell - Dr. Salvador
- Dr. Florendo
Ø Anesthesiologist
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 - Dr. Ybañez - Dr. Buenaobra
- Dr. Vista
Ø Oncologist
- Dr. Hidalgo
Aurora Community and Alicia Sabado 0919 2853 268
Emergency Hospital [email protected]
Incorporated, Aurora,
ZDS
Blancia Hospital, Via M. Blancia 062 225 2302
Molave ZDS [email protected]

Borbon General Patrick Melbert Borbon 0921 7725 035

Hospital Inc. [email protected]
Chavez Hospital, Dinas Felecito Chavez [email protected]
ZDS
Jamelarin Hospital Dr. Angela Jamelarin Española 0917 7144 904 (Record Section) Emergency Room
Medicalrecord_jamelarinhospital Operating Room
@yahoo.com.ph Delivery Room
Annalisa Porquez 0998 3711 341 Laparoscopic Surgery
Roxane B. Ediang 0955 1007 032 Tertiary Clinical Laboratory
ECG
X-Ray
Transport Services
OPD Specialty Clinic
Ø General Cancer
Ø Trauma Surgery
Ø General and Neuro Pediatrics
Ø Obstetrics and Gynecology
Ø Orthopedic Surgery
Ø Internal and Family Medicine
Ø Psychiatry
J. Cabahug General Dr. Liz Corazon Parangan 0932 2960 924 v Laboratory
Hospital Inc. v X-ray (24 hrs)
0920 9380 193 v Operating Room
v Delivery Room
v Minor Operations
Happy Valley Hospital, Sheila Marie Madrid 0908 2949 258
Tambulig ZDS [email protected]

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Hofileña Hospital Dr. Jose F. Hofileña III 0925 6757 770 1. Hemodialysis Unit
- Dr. Maritess D. Racuya
Vanile S. Macutay 0912 1797 070 - Dr. Emerson Mondarte
2. Portable X-Ray/ X-ray
ER Hospital Number 0933 8610 623 - Dr. A. Hofileña
3. 2D Echo- Cardiologist
- Dr. Jasmine H. Ampong
4. CT-Scan (Sent to Davao via E-mail)
5. OR/ DR
- OB cases
- Ortho cases
- Surgical cases
6. CCU –ongoing repair
7. Ultrasound – Dr. A. Hofileña
8. NICU (1bed capacity)
9. Laboratory
Lorenzo Tan Multi- Marilou Encallado 0936 5259 415
Purpose Cooperative [email protected]
Hospital, Mahayag
Metro Pagadian Dr. Rosalind Te-Pasay 0917 7722 070
Specialist Hospital Leah May C. Ceno 0927 7075 436
Pagadian City Medical Harlyn Busadre- Obedencia [email protected] v Anesthesiologist
Center v Orthopedic Surgeon
ER Hospital Number 0923 5088 831 v Neurosurgeon
v Neurologist
Shahanie Bravo 0929 2271 605 v Oncologist
v Endocrinologist
v Opthammologist
v General Surgeon
v Cardiologist
v Pediatrician
v Internist
v Nephrologist
v Pulmonologist
v Obstetrician- Gynecologist
v General/ Cancer Surgery
v General Dentistry
v Dermatologist

Ø 24hours Pharmacy
Ø 24hours Radiologist
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 - X-Ray
- CT Scan
Ø Ultrasound
- Mon, Tue, Thu, Fri;10am-12pm,3pm-5pm
- Wed; 8am-10am, 1pm-3pm
- Sat; 9am-12pm (Every other Saturday)
Ø 24 hour Laboatory Services
Ø 2D Echo (8am-5pm)
Ø Stress Test & Treadmill (8am-5pm)
Ø Dialysis Center
Ø Delivery Rom
Ø Emergency Room
Ø NICU
Ø ICU
Ø Animal Bite Center
Ø NBS
Ø Operating Room/ Recovery Room
Pagadian Doctor Dr. Genelene Sy 214 3943 v SERVICES:
Hospital 0932 8866 885 Ø Laboratory (Level II)
Ø 2D Echo : (Monday - Saturday)
Ø Operating Room (Surgery)
Ø Delivery Room
Ø Dental : (Tue, Thu, Sat)
Ø X- Ray
Ø Ultrasound : (In- Patient only)
v CLINICS:
Ø Internist
1. Dr. Alan Sy : (Monday - Saturday)
2. Dr. Genelene Sy : (Monday - Saturday)
3. Dr. Reynaldo Ortiz : (Monday - Saturday)
Ø EENT
- Dr. Edgar Legaspi : (Monday - Saturday)
Ø OB/Gynae
- Dr. Lorelie Cruz : (Mon, Wed, Fri)
Ø Pulmonologist
- Dr. Gino Bancoro : (Mon, Wed, Fri, Sat)
Ø Endocrinoloist
- Dr. Caprice Yang : (Mon, Wed, Fri, Sat)
Ø Pedia
- Dr. Deviglem Alo : (Mon, Wed, Fri, Sat)
Ø Dentist
- Dr. Jessel Eneola : (Mon, Thu, Sat)

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 Ø Cardiologist
- Dr. Frank Ligas : (Monday - Friday)
Salug Valley Medical Dr. Rolynn S. Igano 0918 9422 326 v Clinical Services
Center, Molave, ZDS [email protected] Ø Out Patient Department
ER Hospital Number 0930 0888 689 Ø General Surgery
Leizel A. Pam-ot 0928 4051 154 Ø Orthopedic Surgery
Ø Internal Medicine
Ø Pulmonologist
Ø Pediatrics
Ø OB-Gynecology
Ø Dental
Ø ICU
v Ancilllary Services
Ø Radiology
Ø X-Ray
- Ultrasound
Ø Laboratory
- Blood Chemistry
- Microbiology
- Heamatology
- Serology and Immunology
- Clinical Microscopy
Ø Pharmacy (24hours)
v Faclities and Amenities
Ø Fully-ewuipped Emergency Room
Ø 2 Bed ICU
Ø Spacious Private Rooms
Ø 24hours Ambulance Services
Ø Philhealth Wards
Ø Charity Wards
Ø OR-DR Complex
SS Lumapas Hospital, Dra. Ma. Corazon Ariosa 0920 7937 452
Molave ZDS [email protected]

Public Birthing facilities

Blessed Mother Birthing Erlinda Sabate 0910 5417 117
Home, Sto. 0907 712 829
Nino,Pagadian City Blessedmotherbirthinghome@gm
ail.com
Prima C. Daliposon 0921 4035 804

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CHO Lying-in Clinic 24 Hours Hotline 214 1966
Dr. Arnel Lerias 0920 9380 190
Magdalena Janolino 0920 6019 375
Mahayag Municipal Esterlita Teogangco 0909 4031 994
Hospital
Midsalip Infirmary Dr. Ciriaco S. Lagare 0946 1573 542
Hospital Melody R. Reyes 0917 6539 904
Alberto R. Jatico, Jr. 0908 8119 366
Sta. Lucia Birthing Dr. Arnel Lerias 0920 9380 190
Home, Pagadian City Anelia Cabarellas 215 3643
Private Birthing facilities
Mom's Lying-in Clinic, Agnes Nazareno 0917 7173 204
San Pedro, Pagadian
City

Mother and Baby Care,

San Francisco,
Pagadian City

St. Margaret Birthing Marilou Calunia 0930 7848 186

Home, Tuburan
Pagadian City

Saint Mary’s Lying In Marilyn Saysip 0910 8228 651

Clinic, Balangasan, [email protected]
Pagadian City Roslina F. Castillo 0919 2666 473
Hotline 24 Hours 062 925 0499

Well Family Birthing

Clinic, Sto. Nino,
Pagadian City

Rural Health Units

RHU - Aurora Dr. Silyne A. Cabahug 0917 7093 115 Philhealth Accredited
RHU Hotline 062 331 2079 - Primary Care
[email protected] - Maternal Care
Veronica C. Lecciones 0910 7574 357 - Newborn Care
Arleen Verdad 0947 9671 277 - TB-DOTS

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RHU – Bayog Dr. Gretchen A. Dubrico 0917 3259 863 Philhealth Accredited
[email protected] - Primary Care
Betty Jane L. Liguan 0917 2067 588 - Maternal Care
- Newborn Care
- TB-DOTS
RHU – Dimataling Dr. April Suzette Exile 0917 8120 468 Philhealth Accredited
[email protected] - Primary Care
Flordeliza Ortega 0916 2958 751 - Maternal Care
- Newborn Care
- TB-DOTS
RHU – Dinas Dr. Nurdaya Abubakar [email protected] Philhealth Accredited
[email protected] - Primary Care
RHU Hotline 0912 5906 828 - Maternal Care
Naty V. Tumatal, N-III 0999 9534 160 - Newborn Care
Mila A. Mansing, RHM 0907 6172 547 - TB-DOTS
- Family Planning
- Malaria Out-Patient Treatment
RHU - Dumalinao Dr. Patrick Kean Toledo 0948 4072 220 Philhealth Accredited
[email protected] - Primary Care
Cyril Gay B. Mabuyo 0998 5526 690 - Maternal Care
- Newborn Care
- TB-DOTS
RHU – Dumingag Dr. Ju Kanra Panugao 0917 7051 099 Philhealth Accredited
[email protected] - Primary Care
Elena S. Perigo, PHN 0998 8523 654 - Maternal Care
- Newborn Care
- TB-DOTS
RHU – Guipos Dr. Kristyn Lipayon 0916 7928 188 Philhealth Accredited
[email protected] - Primary Care
Efara P. Moradas 0909 2166 337 - Maternal Care
Francita Petiluna 0950 7688 295 - Newborn Care
- TB-DOTS
RHU - Josefina Dr. Rhoel Elumbaring 0908 8622 047 Philhealth Accredited
[email protected] - Primary Care
[email protected] - Maternal Care
Elma Genciano 0910 1747 853 - Newborn Care
- TB-DOTS

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RHU – Kumalarang Dr. Wilric Asuncion 0917 6326 222 Philhealth Accredited
RHU Hotline 0917 3145 388 - Primary Care
[email protected] - Maternal Care
Soraida D. Claveria 0975 3969 267 - Newborn Care
- TB-DOTS
- Animal Bite Treatment Center
RHU - Labangan Dr. Mailyn O. Manupac [email protected] Philhealth Accredited
RHU Hotline 0915 1190 934 - Primary Care
Umaya S. Damada 0955 7629 299 - Maternal Care
Lydia Labio 0906 7168 024 - Newborn Care
- TB-DOTS
RHU – Lakewood Dr. Saylen K. Asuncion 0917 7298 937 Philhealth Accredited
[email protected] - Primary Care
Nelida Seniedo 0917 9594 549 - Maternal Care
Ruby Ceno 0917 7100 370 - Newborn Care
- TB-DOTS
RHU – Lapuyan Dr. Herbert W.S. Saavedra [email protected] Philhealth Accredited
RHU Hotline 0949 1585 433 - Primary Care
Czarmecris Lee T. Lumosbog, 0998 9736 008 - Maternal Care
RN - Newborn Care
- TB-DOTS
- Malaria Out-Patient Treatment
BHS Bulawan Lying-in, Charry Fe E. Garciano, RM 0910 2832 015 Philhealth Accredited
Lapuyan - Maternal Care
- Newborn Care
BHS Maruing Lying-in, Juvelyn O. Bugao, RM 0908 9058 939 Philhealth Accredited
Lapuyan - Maternal Care
- Newborn Care
BHS Tiguha Lying-in, Honey Bee Paragas, RM 0910 5063 861 Philhealth Accredited
Lapuyan - Maternal Care
- Newborn Care
RHU – Mahayag Dr. Wilson G. Lumapas ruralhealthunit_mahayag@yahoo. Philhealth Accredited
com - Primary Care
RHU Hotline 0939 9269 086 - Maternal Care
Joy Cavan 0909 2535 889 - Newborn Care
- TB-DOTS

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RHU - Margosatubig Dr. Dulce Ann Albarico 0918 9574 269 Philhealth Accredited
[email protected] - Primary Care
Ms. Rosalie A. Ang, PHNII 0946 1637 064 - Maternal Care
Margarita S. Sarvida, RHM 0909 4239 108 - Newborn Care
- TB-DOTS
RHU – Midsalip Carla C. Indanao 0907 2821 836 Philhealth Accredited
- Primary Care
- Maternal Care
- Newborn Care
- TB-DOTS
RHU – Molave Dr. Prisco S. Pabatao, Jr. 0998 2413 372 Philhealth Accredited
[email protected] - Primary Care
Anastacio T. Fortaleza 0927 5053 614 - Maternal Care
- Newborn Care
- TB-DOTS
BHS- Simata, Ester Magallanes 0939 8002 413
Molave
CHO – Pagadian City Dr. Noel E. Ceniza 215 4132 / 21 4420 Philhealth Accredited
0917 7761 019 - Primary Care
0946 1534 879 - Maternal Care
[email protected] - Newborn Care
Magdalena Janolino 0920 6019 375 - TB-DOTS
Balangasan Main Jay Ann Villanueva 214 2176
Health Center, Fely A. Bontilao 0998 5616 762
Pagadian City
San Jose Main Dra. Gemma Liberty D. Santos 214 4522
Health Center, Eva Aranua 0907 5338 399
Pagadian City
San Pedro Main Dr. Noel E. Ceniza 214 4680
Health Center, Ma. Flordeluna Millanar 0946 3045 018
Pagadian City
Sta. Lucia Main Dr. Ariel Lerias 215 3643
Health Center, 0920 9780 190
Pagadian City Sarah Maria Duran 0943 2813 922

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RHU – Pitogo Dr. Erickson Padunan 0933 8617 184 Philhealth Accredited
[email protected] - Primary Care
Erna B. Patayon, PHN 0921 7553 437 - Maternal Care
Pedrelyn Abigay 0946 6588 483 - Newborn Care
Amie Gran, PHN II 0930 6871 068 - TB-DOTS
RHU – Ramon Dr. Leah Yu 0920 9880 910 Philhealth Accredited
Magsaysay [email protected] - Primary Care
Airene R. De Castro [email protected] - Maternal Care
BellaV. Sabuero 0950 2194 495 - Newborn Care
- TB-DOTS
RHU – San Miguel Dr. Francis Louis Alcachupas 0938 1163 330 Philhealth Accredited
RHU Hotline 0926 2304 876 - Primary Care
[email protected] - Maternal Care
Grace G. Manda 0930 5445 878 - Newborn Care
- TB-DOTS
RHU – San Pablo Dr. Hermeraldo Catubig Jr. [email protected] Philhealth Accredited
RHU Hotline 0908 8138 573 - Primary Care
0998 9772 376 - Maternal Care
Juliet A. Paler, RN 0930 0618 462 - Newborn Screening
- TB-DOTS
RHU – Sominot BEMONC Facility 0950 5683 039 Philhealth Accredited
[email protected] - Primary Care
Dr. Pesabel Z. Apostol 0919 9996 514 - Maternal Care
Apolinaria Onez 0919 7894 253 - Newborn Care
Leni Andale 0927 9038 400 - TB-DOTS
RHU – Tabina Dr. Roberto Pastoriza 0939 9245 537 Philhealth Accredited
RHU Hotline 0907 1797 424 - Primary Care
Abella Delizo 0950 8033 868 - Maternal Care
[email protected] - Newborn Care
Amy Joy C. Abaday 0930 4855 938 - TB-DOTS
RHU - Tambulig Dr. Janet A. Hernando 0932 8747 440 Philhealth Accredited
[email protected] - Primary Care
Anne Kathrine C. Maisog 0910 7816 616 - Maternal Care
Cheilo P. Tahadlangit 0999 7140 032 - Newborn Care
- TB-DOTS
Aliyah BHS and Juliet A. Ocariza, RHM 0926 3868 932 Philhealth Accredited
Birthing Home, - Maternal Care
Lower Liason, - Newborn Care

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 Tambulig, ZDS

Balugo Health Judith B. Talip, RHM 0946 8394 982 Philhealth Accredited
Station and Birthing 0936 2962 497 - Maternal Care
Center, Balugo, - Newborn Care
Tambulig ZDS

Highland Cluster B Nida F. Bagolor, RHM 0912 2906 500 Philhealth Accredited
Health station and - Maternal Care
Birthing Clinic,Tulu- - Newborn Care
an, Tambulig, ZDS
Lower Usogan Rosalina L. Pates, RHM 0950 5659 867 Philhealth Accredited
Barangay Health - Maternal Care
Station and Birthing - Newborn Care
Clinic, Lower sugan,
Tambulig, ZDS
Sumalig Birthing Estrella A. Pansa, RHM 0909 5388 227 Philhealth Accredited
Center, Sumalig - Maternal Care
Tambulig ZDS - Newborn Care
RHU – Tigbao Dr. Grayvimin S. Figueras [email protected] Philhealth Accredited
RHU Hotline 0938 6811 301 - Primary Care
Araceli S. Dilao, RHM 0938 9221 684 - Maternal Care
- Newborn Care
- TB-DOTS
RHU – Tukuran Dr. Kizmar Arani Pueblos [email protected] Philhealth Accredited
RHU Hotline 0947 8418 121 - Primary Care
Herzy Quinones 0938 6855 209 - Maternal Care
Mary Jane Cadutdut 0907 7397 769 - Newborn Care
- TB-DOTS
RHU – Vincenzo Dr. Grace F. Sabellano 0999 9906 941 Philhealth Accredited
Sagun [email protected] - Primary Care
Annabelle O. Gutierrez 0946 5758 545 - Maternal Care
Juliet G. Elago 0948 2499 420 - Newborn Care
Aleli E. Tablo 0938 1710 398 - TB-DOTS

14
II. Vision and Mission

Vision:
A Service Delivery Network in which all constituents have access to quality, responsive and
appropriate health services at all times and as needed rendered by competent and people-
centered health providers regardless of culture, religion, economic standing and geographic
location.

Mission:
1. To create policies and agreements in strengthening health services through a
dynamic and responsive SDN management.
2. To engage different stakeholders in promoting maternal and child health through
comprehensive and integrated MNCHN-FP initiatives at all levels.
3. To implement local health initiatives through collaborative planning, community
action and policy advocacy at all levels.
4. To establish a progressive, responsive, and acceptable system for public and private
partnership for health delivery.

III. Purpose

The overall objective for the operationalization of DISTRICT 1 AND 2 SDN is to contribute to the
reduction of maternal, neonatal and child mortalities and other diseases by improving the
provision of core package of services and its referral system to benefit the public, more so, the
priority population groups and areas in DISTRICT 1 AND 2 SDN.

The following have been decided upon to be the functions and agreements for the
operationalization of the DISTRICT 1 AND 2 SDN in Zamboanga del Sur.
General Functions

1. Empower community volunteers such as CHVs, BHWs, BSPOs for demand generation
activities ( FDS, FP/ANC-EPI Integration, USAPAN)

2. Strengthen public health programs in all hospitals.

3. Organize, coordinate, and manage multi-level and two-way referral mechanism for all
health services, not limited to MNCHN and Family Planning, such as; a) Basic FP
services (Pills, DMPA, Condom, NFP); b) Long-Acting Reversible Contraceptives
(Interval IUD insertion and removal ); c) Long-Acting Reversible Contraceptives (Post-
Partum FP/PPIUD); Long Acting Permanent Method(LAPM)

4. Strengthen competencies of SDN HSPs on FP/MNCHN/AY and other health programs

through the provision of trainings on the following courses, among others; a) Family
Planning Competency Based Training 1(FPCBT1) ; b) Family Planning Competency
Based Training 2(FPCBT2) Interval and Post-Partum IUD insertion and removal ; c)
Basic Life Support; d) Lactation Management Training ; e) BEmONC; f) IPC/C for
Midwives g) IPC for BHWs; h) USAPAN
 5. Establish appropriate management arrangements for recording and reporting
performances of both public and private FP service delivery points to conform with the
government mandated databases.

6. Establish referral guidelines to standardize the referral practices in the network and bring
order in the operations in the network.

IV. SDN Guiding Principles and Values

➢ People-centered health care – putting people at the center of health care where
individuals, families and communities are served by and are able to participate in trusted
health systems that respond to their needs in humane and holistic ways.
➢ Culture of care and communication- clients and patients are informed and involved in
decision-making and having choices, and where health service providers show respect
for their privacy and dignity and respond to their needs in a holistic manner.
➢ Responsible, responsive and accountable services and health care institutions, where
affordable, accessible, safe, ethical, effective, evidence-based and holistic health care
are provided.
➢ Supportive health care environments, it is putting in place appropriate policies and
interventions, positive care and work environments, strong primary care workforce, and
mechanisms for stakeholders’ involvement in health services planning, policy
development and feedback for quality improvement.

V. Service Delivery Network Framework

The conceptual definition of SDN is that it is a system for creating demand of identified
priority population groups or clients with unmet need along a continuum of health services,
fully served by an organized network of health service facilities and health care
professionals, resulting in significant health outcome improvements. SDN as a health
system solution is premised on the need to address fragmentation of health service delivery
system, which disproportionately affects the health status of vulnerable population groups
with inadequate means and limited capacity to avail of the services they need.

1
 Figure 1: SDN Framework

This view of SDN highlights three critical requirements or conditions: (1) mechanism for
creating demand of priority population groups and identify need for specific health services,
e.g., FP/MMCHN, TB, and HIV/AIDS program services; (2) health care delivery system
through an organized and functional network of health facilities and providers; and (3) the
clients availing health services have satisfied their unmet need for health care service/s,
which leads to improvement of health outcome. The three SDN conditions are invariably
supported by governance mechanisms to manage and sustain operations, and monitor
health outcome improvement given varying context and political landscape.

➢ Creating demand of priority population groups (poor NHTS and 4Ps or CCT
beneficiaries, disadvantaged groups, GIDA population, Senior Citizen, PWDs)
through outreach, counseling, health screening, Usapan Sessions, FDS, etc.

➢ Health care delivery system through an organized network of health facilities and
providers makes up the backbone of the referral mechanism of the network of
facilities and providers. It refers to health systems inputs such as facilities,
equipment, skills type and number of providers, transportation and communication
support infrastructure.

➢ Governance mechanism. It refers to the support mechanism / enabling environment

established to sustain the operations of the entire network of providers and monitor
its functionality and effectiveness. It includes the management structure,
arrangement and other technical inputs to maintain facilities and providers as a
network, such as service capacity and quality, accreditation and licensing, capacity
development and incentives for providers, financing, policy support and providing
mandate, and a functional feedback mechanism through M&E.

➢ Health status improvement - pertains to the effect of the interaction of the “users”
with the network of health service providers. The results are articulated as health
outcomes, e.g. service utilization indicators or change in morbidity and mortality,
including some inputs and process indicators. It requires a sound M&E system to
capture change in health status and document health outcome improvement.

2
 Table 2: The 10 Elements of a Functional Service Delivery Network
ELEMENTS INDICATORS
Organized, trained, and deployed.

Providing health information including PhilHealth and basic MNCHN-FP and other
1. Community Health health programs/ services to families
Volunteers (CHVs)/ Assuming designated roles and responsibilities
BHWs are Functional.
Provided with basic information/ guidelines on:
- Access to providers and facilities providing MNCHN-FP and other health
programs/ services

Facility-based health services – list of services, schedules, cost of services and

use of electronic masterlisting and tracking tool
2. RHUs/ BHS, health
centers, and private Outreach/ mobile services – regular services to GIDAs, special “response”
clinics are providing (emergency/ disaster/ outbreaks) to areas with poor access to specific MNCHN-
MNCHN-FP services FP services such as the LAPM and LARC and other health programs/ services.
and other health
programs/ services Facility-based and outreach/ mobile MNCHN-FP and other health programs/
services are planned and implemented collaboratively by public and private
sectors

3. Functional Organized transport and communication system.

Community-based
Guidelines on the use of transport and communications facilities.
transport and
communication Name/s and contact information of authorized/ responsible persons for transport
systems. and communication services (approving person/s, driver, etc.)

Certified/ Licensed BEmONC capable facility by DOH-RO.

4. BEmONC-capable
facilities have Basic MNCHN-FP and other health programs/ services are implemented regularly
transport and in accordance with the approved clinic/ technical guidelines.
communication
system. Provide appropriate in-referrals and out-referrals of MNCHN-FP and other health
programs/ services clients.

Regular implementation of comprehensive MNCHN-FP and other health

programs/ services in accordance with approved clinical/ technical guidelines.
5. CEmONC-capable
facilities have Initiate collaboration among health providers by providing feedback, conducting
transport and maternal death reviews and PIR, discussion on clinical standards and elevate
communication results to LHBs/ LCEs and health managers for proper action.
system.
Provide appropriate in-referrals and out-referrals of MNCHN-FP and other health
programs/ services to clients.

Covered by a partnership agreement/ memorandum of understanding.

6. Public and private Private and public sector facilities and practitioners/ providers affiliated with the
sectors actively SDN
participating.
Private and public sector facilities regularly providing FHSIS and other reports.

3
 Private and public sectors represented in all levels of management/ technical
structure.
Written guidelines on the referral mechanism (adapted)

7. Referral mechanism Referral services documented by both the referring and referral facilities through
initiated/ established referral logbook/registry with assigned Referral coordinator/ liaison officer.
for each SDN.
Plan for strengthening SDN-MNCHN-FP and other health programs/ services
referral available

The Local Blood Council is organized to plan, promote and implement voluntary
blood donation in accordance to DOH guidelines
Partner agencies (PNP, DepEd, LGU, religious group, etc.) are identified as
8. Blood services members
available and
accessible. Availability of Blood Collection Units (BCUs) with regular mobile blood donation
activities within the network

Memorandum of Agreement is executed between blood service facility and

network of facilities/hospitals
Written MOU/ MOAs among network members (across borders, across sectors,
etc.)
9. Organized MNCHN/ Private sector membership/ representation
FP SDN and other
health programs/ MNCHN-FP SDN and other health programs/ services implementation plan
services Management
structure and Regular meetings of key stakeholders duly documented
guidelines
M and E system installed
Presence of community-feedback mechanism

Clinical practice guidelines are available in all facilities

Presence of local policies on the SDN and core package of services

NHIP accreditation of health facilities and providers

DOH national policies adapted into local policies such as promotion of FBD, EBF,
immunization, micronutrient supplementation, and CSR policies and guidelines.
10. Functional health
systems instruments Implementation of the RA 7600 (Rooming-in and Breastfeeding Act) and EO 51
for SDN (Milk Code) in all birthing facilities.
Institutionalized local policies supportive of MNCHN-FP and other health
programs/ services implementation.

Institutionalized data quality check, functional logistics management and

procurement system, and conduct of maternal, neonatal and infant death audit
and review, and other programs implementation reviews.

4
VI. The Referral System

1) Definition- Referral is a process in which a health worker at a one level of the health
system with insufficient resources (drugs, equipment, skills) to manage a clinical
condition, seeks the assistance of a better resourced facility at higher level to assist
in, or take over the management of, the client’s case.

An effective referral system ensures a close relationship among all levels in the
health system and helps ensure that clients receive the best possible care closest to
home. It assists in making cost-effective use of hospitals and primary health care
services and helps build the capacity of health centers and enhance access to better
quality care.

2) Reasons and Purpose of Referral. The key reasons for referral either an
emergency or routine case include:

➢ to seek expert opinion about the client

➢ to seek additional or different services for the client beyond the facility’s
capability
➢ to seek admission and management for the best interest of the client
➢ to seek the use of diagnostic and therapeutic tools (technical examination or
intervention)

3) The Referral Loop is consist mainly of the following:

➢ Referring or initiating health care provider or health facility, who prepares

an outward referral to communicate the client’s/ patient’s condition, status
and pre-referral interventions provided, and the reason/s for the referral; and
➢ Receiving health care provider or health facility who accepts the referred
case, provides the needed care, and prepares the back referral at the end of
their health care involvement, to let the initiating facility know what has been
done. This generally completes the referral loop between the two (2) facilities
from two levels of care.

5
The SDN Referral is a two-way process to ensure the continuum of care is covered. The
process involves the public, private, community-based health care providers and
health care facilities, which can take the form of a vertical, horizontal, or diagonal
relationship/s as shown below.

Figure 2: SDN Referral System

Inside Border Cross Border

Private Public Public/Private

Tertiary Regional Tertiary

Hospital Hospital Hospital

Private Private Hospital

Hospital
Provincial
Hospital

Private Clinic/ RHU/ Birthing Private Clinic/

Private Facilities Private Provider
Provider

BHS/ Community

The concept of SDN referral may include cross-border network relationships such as
crossing service sectors (public-private) and crossing borders (geographic and political
boundaries) in delivering health services.

4) Referral Information System

6
 All facilities, both public and private, within the DISTRICT 1 AND 2 SDN are obliged
to maintain a good Referral Registry. This means, complete, accurate, timely and
accessible to concerned providers and staff.
➢ A referral register is a means of maintaining a list of all incoming referral
(Annex E) and outgoing referrals (Annex F) for one facility or service
provider. Information registered will include, among others:

o client referred,
o where referred,
o when and why referred,
o whether the referral case is closed or continuing (the returning
referral/back-referral form has been received with any necessary
rehabilitation or follow-up), and
o whether it was an appropriate referral or if there were any issues

➢ Directory of Services that records all facilities, organizations and individual

providers providing specialty care for MNCHN-FP and other health programs/
services and contact information, i.e. landline and mobile numbers, preferably
devoted for the purpose for easy and timely access (See Table 1).

➢ Referral Slip and Back Referral Form. The referral slip will be
accomplished fully by the referring facility with all relevant information
required. The back referral slip will be accomplished by the receiving facility
with vital information such as discharge diagnosis, clinical summary, services
provided, and follow-up care to be done by the provider at Referring Facility
(See Annex B).

5) General Roles and Responsibilities

Generally, the roles and responsibilities of the units involved in a referral system will
include the following:

a) Community
➢ CHWs/BSPOs/BHWs are designated to provide the following navigational
and basic service delivery functions:
o Informing families of their health risks
o Assisting families in health risks and needs assessment
o Assisting families develop health use plans such as birthing plans and
facilitating access by families to critical health services
o Advocating for birth spacing and counseling on family planning services
o Tracking and master listing of pregnant women, women of reproductive
age, children below 1 year of age
o Early detection and referral of high-risk pregnancies
o Reporting maternal and neonatal deaths
o Facilitate availability of communication and transportation system 24/7

7
 ➢ Barangay Officials shall ensure mechanism of blood donation per year &
identification of blood donors is in place based on voluntary blood donation,
safety requirements and utilization such as:
o Secure copy of blood donors’ profile to include RH negative blood type
and other rare blood types
o Mobilizes volunteers for regular Mass Blood Donation to reach 1% of
total population
o Coordinate & participate with respective RHU for blood donation
agreements with blood service facility

➢ Barangay Officials shall ensure prompt issuance of necessary documents

o for financial support on top of PHIC in situation identified by LGU social
workers
o for Philhealth requirements such as Birth certificate, barangay
certification, Indigent certificate, marriage certificate, etc.
o for indigence certification as necessary

➢ Barangay Officials shall ensure availability of communication and

transportation at all times

b) Referring Facility
➢ ensures staff awareness of the referral guidelines;
➢ ensures continuous supply of referral forms;
➢ keeps directory of health facilities;
➢ ensures recording of referral activities;
➢ devises mechanisms to track referral;
➢ provides transport to emergency cases;
➢ assigns referral coordinator/liaison officer;
➢ ensures staff at point of entry understand referral process;
➢ ensures referred patients are seen by appropriate professional;
➢ considers attached investigations;
➢ ensures prescheduled referrals are seen without delay, and
➢ devises follow-up plans as part of the back-referral responsibility

c) Receiving Facility
➢ assigns referral coordinator;
➢ ensures staff at point of entry understand referral process;
➢ ensures referred patients are seen by appropriate professional;
➢ considers attached investigations;
➢ ensures prescheduled referrals are seen without delay; and,
➢ devises follow-up plans for home care

8
The Referral Coordinator or Liaison Officer will be responsible for both the incoming
and outgoing referrals, specifically:

➢ facilitates scheduling by using applicable communication;

➢ ensures availability of service at receiving end;
➢ facilitates transportation for emergency cases; and,
➢ keeps referral registry

At the municipal level, this is a designated function of the PHN or Supervising Midwife
based at the main health center.

d) Referral Coordinator Liaison Officer

➢ Complies with data sharing, maintains open communication with facilities and
observes the two-way referral mechanism including cross-sector and cross-
border
➢ Logs-in all referred patients and submits FHSIS validated data to M/C/PHO in
the area
➢ Maintains the referral registry and fills out the incoming and outgoing referral
logbooks properly.

6) Blood Referral Mechanism (per PRC-ZDS guideline)

➢ For FP/MNCHN Program: The referring RHU facility will coordinate with the
PRC- ZDS Blood Center thru text or call for the availability of a standby blood
unit/ units.

➢ When blood transfusion is needed, blood request from the hospital must be
presented to the blood center by the referring facility or patient’s relative.

➢ Blood request form must be signed by the attending physician and must contain
complete information of the patient, patient’s blood type (ABO/ Rh), component
and number of units needed, diagnosis including latest laboratory results on
hemoglobin and platelet count. Urgency of the need must also be indicated.

➢ Blood processing fee will be collected by the blood center for the cost recovery of
expenses incurred during the examination/ processing of blood, blood bag, blood
typing, reagents and other disposable supplies used during collection and
screening.

Fees collected under DOH AO No. 0045 series of 2015 are as follows:
Fresh Whole Blood - Php 1,800.00 / unit
Packed Red Blood Cell - Php 1,500.00 / unit
Fresh Frozen Plasma - Php 1,000.00 / unit
Platelet Concentrate - Php 1,000.00 / unit

9
 ➢ Blood processing fee maybe charged to the indigence fund allocation from the
LGU, PCSO or other source provided, referral slip and complete required
documents will be submitted to the blood facility. (PCSO – maternal cases with
complication only)

PCSO requirements: IMAP application form

o Medical abstract
o Blood request
o Valid ID (patient and representative)
o 2 x 2 ID picture (patient and representative)
o Police report/ incident report

Additional requirements: (to be provided by PRC)

o Promissory Note
o Statement of Account

➢ Blood donor card will be presented to the blood facility to show record of
donation. In the absence, patient’s relative will have to bring family members to
donate blood at the blood center to ensure availability of blood supply for the next
patient.
➢ Return unused blood units (FWB & PRBC) within 24 hours from time of release
from the blood center. For Platelet Concentrate and Fresh Frozen Plasma –
unused units are not accepted.

7) SDN Referral Protocols and Discipline

➢ Pre-referral stage – this is the stage from the time the client/patient is seen to
the point where a referral decision is made.
a. The appropriate health provider (HP) evaluates the client’s condition.

b. If needed, the HP orders laboratory tests to confirm assessment.

c. If a condition is beyond the HP’s expertise or the service needed is not

available in the health facility, the HP will determine the
category/subcategory (Annex A) of the condition and a referral decision is
made.

d. If the condition is not listed in the referral category list, this condition is
noted as unclassified in the referral form and is noted for consideration in
the next meeting of the SDN management/referral committee.

➢ Preparation for referral stage – From the time the referral decision is made to
completion of all the preparations and requirements for referral are done
e. The HP accomplishes completely and accurately the referral form

10
f. The HP explains the reason for referral to the client.

g. Fills up the referral form (Annex B) completely and has the client sign the
consent statement.

h. Review the referral slip and accompany the client/ patient to the receiving
facilities (Gives instructions to the
client/patient or his relatives concerning the referral slip, the name of the
receiving facility, the directions to the receiving facility’s location, name of
specific area to go to in the receiving facility, the name and designation of
the contact person or health provider to go to.)

i. For non-emergency conditions:

i. The HP informs the client of the schedule or availability of the

service or specialist in the receiving facility.

ii. The referring facility does the coordination with receiving facility

iii. Instructs the client on any preparations needed before going to the
receiving facility

j. For emergency and urgent conditions:

i. The referring facility does the coordination with receiving facility.

ii. Obtains the acceptance of the primary receiving facility.

iii. If unable to get acceptance from the primary receiving facility for
valid reasons, refer to available facility.

iv. If still unable to get acceptance from the secondary receiving facility,
calls the primary receiving facility for assistance in resolving the
referral.

v. Makes arrangements for transportation.

vi. Provides all necessary stabilization measures to keep patient’s vital

signs within acceptable range during transport.

vii. Packs medicines, IV fluids, and all things necessary for the safe
transport of the patient.

viii. Informs the client of any charges or fees covering for the materials
and supplies used in the initial management or transportation cost
and have them settle this if patient has the capacity to pay.

k. Fills the outgoing referral logbook (Annex C)

11
➢ Transfer stage – From the time the preparations for referral are completed to the
arrival of the client/patient to the receiving facility.
l. For non-emergency and non-urgent conditions

i. The patient/client proceeds to the receiving facility

ii. Presents the referral slip to the receiving facility

m. For emergency and urgent conditions:

i. The Health Provider (HP) accompanies the patient during transport

ii. Monitors vital signs while on travel and institutes appropriate

measures as needed

iii. Continues recording management and medications given including

a record of the patient’s condition.

iv. Endorses the patient to the receiving facility

➢ Receiving stage – From the time the referring facility informed the receiving
facility of the referral to the arrival by the patient and acceptance of the referral
and provision of initial treatment/management.
n. For emergency and urgent conditions:

i. Upon receipt of the call of an incoming referral, the contact person:

o Informs the appropriate ER staff on duty of the incoming referral,
the patient’s diagnosis and condition and its designated referral
category. The ER staff on duty informs the specialist of the
incoming referral and its details.
o Informs the admitting section of the incoming referral and
possible admission. The admitting section subsequently looks
for a free bed in the designated ward.
o Informs the OR/DR complex of an arrival of the incoming referral
and possible emergency procedure.
o Informs the blood center of the blood type of the incoming
referral.
o Informs the security unit of the incoming referral and to facilitate
the entry.
ii. Upon arrival of the referral

12
 o The patient is immediately transferred to the ER.
o The ER staff receives the referral slip from the referring HP.
o The ER staff makes an initial assessment and makes the
admitting orders.
o The ER staff accomplish acknowledge slip and provide to
referring HP The ER staff attaches the referral slip to the
patient’s chart
o The ER staff fills the incoming referral logbook (Annex D)

➢ Post referral stage – From the completion of service to the discharge of the
client/patient from the receiving facility.
o. For non-admitted patients: (diagnostic and consultation referral)
i. The receiving health provider gives the service and advices the
patient to return to the referring health service provider.
ii. Gives the diagnostic test results to the client (for diagnostic
referrals).
iii. Fills the return slip and instructs the client to give back to the
referring health provider.
p. For admitted patients:
i. The attending health provider orders the discharge of the patient.
ii. Accomplishes the discharge summary and provides to client.
Instructs client to return to referring facility for continuity of service/s
(Post-partum/EPI/FP services).

8) Referral Guideline on Modern Family Planning Services

➢ Demand Generation
o LGUs with the assistance of DOH RO IX, PHO, and POPCOM as core
facilitators shall capacitate community volunteers such as CHTs, BHWs,
BSPOs, BPVs for demand generation activities FDS (Family Development
Session), FP/ANC-EPI Integration, Usapan and monitor and report its
implementation.
o DISTRICT 1 AND 2 SDN TWG shall collaboratively analyze the data
gathered from the demand generation activities and evaluate the impact of
each activity in the improvement of Contraceptive Prevalence Rate (CPR) in
the LGUs.

13
 o Client generation activity such as Usapan and other similar activities shall be
conducted prior to FP service outreaches or missions and ensure observance
of ICV (Informed Choice and Voluntarism) principles.

➢ Family Planning Services

The table below shows the modern family planning services offered by the
receiving facilities.

FP Services Health Facilities

Health Center/RHU/BHS/Lying-in Hospitals
Basic FP Services All Health Center, RHU, BHS, and All Hospital, except J.
(Pills, DMPA, Lying In Cabahug Hospital
Condom)

NFP All RHUs Referrals

Interval IUD Insertion All Health Center, RHU, BHS, and Ø Midsalip Infirmary
Lying In Hospital
Ø ZDSMC

PPFP/ Post-Partum All Health Center, RHU, BHS- ZDSMC

IUD Maruing, Lapuyan, and Lying In,
except CHO- Pagadian City

BTL-MLLA Ø AMH
Ø Hofileña Hospital
Ø Jamelarin Hospital
None Ø MHARS MC
Ø MRH
Ø PCMC
Ø ZDSMC
NSV Ø Hofileña Hospital
Ø MHARS MC
None
Ø PCMC
Ø ZDSMC
Subdermal Implant All Health Center, RHU and Lying Ø AMH
Inn, Except CHO- Pagadian City Ø Hofileña Hospital
Ø Jamelarin Hospital
Ø MHARS MC
Ø MRH
Ø PCMC
Ø ZDSMC

14
➢ FP Itinerant services

o For the DOH IX Itinerant Team to perform, the MLGUs shall, in accordance
to the protocols being followed, set the date/s for the conduct of the BTL
outreach missions. MLGUs shall formally send letters of request to the DOH
for the participation of the DOH-RO IX Itinerant Team and provision of
supplies and drugs; and C/PHO to facilitate the use of resources in the PLGU
Hospitals
o Appropriate Usapan sessions and/or similar client generation activities shall
be done at least one week prior to the conduct of BTL Outreach activities thru
Popcom.
o The standard DISTRICT 1 AND 2 SDN Referral Form shall be used in
referring informed/ counselled clients for FP service Provision.
o The referring/ initiating facility shall provide assistance for the transportation
of FP Clients referred from community to facility or from facility to another
facility.

➢ Capacity Building

o The C/PHO shall be designated as the Coordinator for trainings. The Point
Persons for FP, MNCHN and other programs/services shall maintain a list of
all health service providers with the corresponding trainings attended and
trainings needed.
o The list of health service providers for each type of training shall then be
submitted by the C/PHO to the Training Provider (DOH-RO IX, line agencies,
NGOs, CSOs, etc.) for inclusion during the conduct of the capacity building
activities.
o All invitations for training shall be addressed to the C/PHO. The C/PHO shall
likewise invite the trainees/ participants from the MLGUs and private facilities
and ensure the attendance of the same to the said training/s.
o All health facilities, particularly hospitals and private birthing facilities shall be
oriented and trained on the FP recording and reporting systems (Annex C)
and funds for capacity building shall come from LGU, PhilHealth Funds,
DOH RO IX, GAD and others.

➢ Recording of FP Services in Hospitals

o All hospitals shall comply with the recording and reporting of FP services as
mandated by the Department of Health through DOH DM # 2014-0312 and
FHSIS 2012 or latest updated version:
✓ Hospital FP Registry
✓ FP client card
✓ Hospital FP Client Record (HFPCR)

15
 ✓ FP Monthly Report Form 1 (M1)
✓ FP Annual Report Form 1 (A1)

HOSPITAL Recording and Reporting Forms

Form Date of Submission Submitted to

Every 10th of the Hospital FP Coordinator/ Point

Hospital FP Registry
following month Person

Hospital FP Client Record Hospital FP Coordinator/ Point

(HFPCR) Person

FP Monthly Report Form 1 LGU Hospitals: PHO

(M1) ZDSMC: DOH-RO IX

LGU Hospitals: PHO

FP Annual Report Form 1 (A1)
ZDSMC: DOH-RO IX

o All heath facilities to comply with the accomplishment and maintenance of

records for FP Logistics Management through Stock Management and
Recording System by using the following, but not limited to:
✓ Hospital Daily Stock Record for FP commodities/supplies
✓ Hospital Daily Dispensing Record Book

➢ Reporting of FP Services
o MRH (DOH-retained) shall submit its monthly, quarterly and annual FP
reports to the DOH-Regional Office IX. The reports submitted shall be
classified as accomplishments from MRH.
o ZDSMC, Midsalip Infirmary, Mahayag Municipal Hospital, and other LGU
Hospitals to submit the FP monthly and annual reports to the PHO for
consolidation. The reports submitted by the hospitals shall be classified as
accomplishments from HOSPITALS.
o The PDOHO–Zamboanga del Sur shall collect from MHARS Medical Center
their monthly and annual FP reports for consolidation. The reports acquired
shall be classified as accomplishments from MHARS MC.
o The PHO-Zamboanga del Sur shall collect monthly and annual FP reports
from KAPATAGAN PROVINCIAL HOSPITAL for consolidation. The reports
acquired shall be classified as accomplishments from HOSPITALS.
o Private Birthing Facilities shall submit FP/MNCHN monthly and annual
reports to the respective C/MHO for consolidation. They shall likewise
maintain the FP/MNCHN Client Registry and FP/MNCHN Client Record for
validation purposes. The FP Client Card shall also be accomplished
accordingly. Reports submitted shall be classified as accomplishments by the
private birthing facilities.

16
 o All Rural Health Units shall submit the required FP/MNCHN and other
programs/services reports to the PHO following the set schedule on the
submission of monthly, quarterly and annual reports.
o All health facilities oriented and trained on FHSIS shall comply with the
reporting requirements set by FHSIS version 2012 or latest version.
o Inform, through call or SMS, concerned LGUs/RHUs of all respective clients
for follow up.
o All Health Facilities trained and oriented on MNCHN recording and reporting
shall maintain and submit the necessary/ required reports as agreed upon.
o C/PHO to integrate reports from the different RHUs, LGU Hospitals and
Private Birthing Clinics and submit the consolidated provincial report to the
DOH-Regional Office.

VII. Referral Monitoring and Evaluation

➢ Monitoring and evaluation stage– The activities to determine the functionality,

performance, and areas for improvement of the referral system
q. The Provincial/City Health Office organizes the SDN TWG
r. The SDN TWG is also designated to monitor and evaluate referral activities.
s. The SDN TWG shall hold regular quarterly meetings to discuss:

✓ Outgoing Referrals Sent in the SDN and by Facility:

o Total number of referrals sent in the SDN ( x = total count of all outgoing
referrals in the SDN)
o Number and percent of referrals sent by facilities within the SDN (y =
count of all outgoing referrals per facility, percentage = y/x times 100)

✓ Incoming Referrals Received in the SDN and by Facility:

o Total number of referrals received in the SDN (m = count of all incoming

referrals)

o Number and percent of referrals received by the facility (n = Count of all

incoming referrals received by facility, percentage = n/m times 100)

✓ Unqualified Referrals
o Number and percent of unqualified referrals (p = count of all unqualified
referrals. Unqualified referrals are cases that do not need to be referred
or cases referred to the wrong facility, percentage = p/x times 100
o Unqualified referrals are cases that do not need to be referred or cases
referred to the wrong facility, percentage = p/x times 100

17
✓ Non-Accepted Referrals
o Number and percent of non-accepted referrals (q = count referrals that
were not received either through phone or on-site rejection, percentage =
q/x times 100)

✓ Unclassified Referrals
o Conditions not listed in Annex __: Referral Categories ( Code as
U=unclassified)

✓ Adolescent and Youth Referral

o Number of Adolescent and Youth referrals (referrals within the age range
of 10-24 y.o)

✓ FP Referral Services
o Number of referrals for FP services

d. For the purpose of organizing the aggregated quarterly referral report, all facilities
in the SDN shall submit the following data to the P/CHO. These data is preferably
sent in excel file for easier handling by the P/CHO staff one week after the end of
each quarter.
Ø count of all outgoing referrals
Ø count of all incoming referrals
Ø count of all unqualified referrals
Ø count of all unclassified referrals
Ø count referrals that were not accepted by the designated receiving facility
Ø count of Adolescent and Youth referrals (referrals within the age range of 10 to
19 y/o)

Ø count of referrals for FP services ( BTL MLLA; PPFP/PPIUD/ Interval IUD,

others)

Ø Total number of referrals sent in the SDN ( x = total count of all outgoing
referrals in the SDN)

Ø Number and percent of referrals sent by facilities within the SDN (y =

count of all outgoing referrals per facility, percentage = y/x times 100)
Ø Total number of referrals received in the SDN (m = count of all incoming
referrals)

Ø Number and percent of referrals received by the facility (n = Count of all

incoming referrals received by facility, percentage = n/m times 100)

18
 Ø Number and percent of unqualified referrals (p = count of all inappropriate
referrals (cases that do not need to be referred or referred to the wrong facility),
percentage = p/x times 100
Ø Number and percent of referrals not accepted (q = count referrals that
were not received, percentage =q/x times 100)
Ø Unclassified referrals – conditions not listed in Annex A ( Code as
U=unclassified)
Ø Number of Adolescent and Youth referrals (referrals within the age range
of 10 to 24.
e. Report quarterly to the DOH regional office/PHO on the outcomes and decisions
of the referral committee meetings.

19
 SERVICE PROVIDERS’ AGREEMENT

ON PROVIDING FOR FP-MNCHN AND OTHER HEALTH PROGRAMS/ SERVICES WITHIN

THE SERVICE DELIVERY NETWORK OF ZAMBOANGA DEL SUR

By and Between

The Facility Name with address at _____________, represented by _____________,

POSITION, the Provincial Health Office, represented by _______________, Provincial Health
Officer, Facility Name with address at Address of facility represented by Name of
Representative; the Facility Name with address at Facility Address, represented by Facility
Representative; the ____________________ with address at _______________, represented
by _____________; the _______________ represented by ________________, Municipal
Health Officer; the _________ RHU represented by _______________, Municipal Health
Officer; the ____________RHU represented by ___________________, Municipal Health
Officer; the _____________ RHU represented by ______________________, Municipal Health
Officer; the _____________ RHU represented by ___________________, Municipal Health
Officer; the _____________ RHU represented by ______________________, Municipal Health
Officer; the _____________ RHU represented by __________________, Municapal Health
Officer and the _______________ City Health Office represented by
______________________, City Health Officer, herein referred to as the parties,

RECOGNIZING the need to improve maternal and neonatal health outcomes and the ability to
address this effectively is through the provision of comprehensive maternal and newborn and
reproductive health services;

INTERNALIZING that no individual health facility can possibly provide all the FP-MNCHN and
other health Programs/ services and that organizing into a unified health delivery system
through a service delivery network is the most efficient way to carry out the goals of the health
care system;

ACKNOWLEDGING the potential benefit of an organized referral system composed of all health
facilities that provide FP-MNCHN and other health programs/ services;

DESIRING to ensure the accessibility of services to maternal and newborn clients/patients and
maximize the use of their PhilHealth benefits;

COMMITTED to decrease the maternal mortality rate, neonatal and infant mortality rates, and
under five mortality rate;

Operating under this Service Level Agreement, the parties hereto agree as follows:

Part I

20
The Parties hereby establish a working partnership in providing accessible FP-MNCHN and
other health programs/ services to women, newborn and children in the SERVICE DELIVERY
NETWORK OF DISTRICT 1 AND 2 OF ZAMBOANGA DEL SUR

Part II

1. The Parties agree to undertake this partnership based on the FP-MNCHN and other health
programs/ services Referral Guidelines which shall form part and parcel of this agreement;

2. The Parties appoint the SDN Technical Management Committee as the care taker of the FP-
MNCHN and other health programs SDN and as such will be the convener of the regular and
special meetings. Hosting of these meetings can be shared by the different member facilities;

3. Each of the service providers to this Agreement hereby commits to perform the following
roles and responsibilities:

Provincial Health Office:

a. Designate the composition of the SDN for the delivery of the care
packages of FP/MNCHN and other health programs services at
Zamboanga del Sur (District 1);

b. Take the lead in assessing and building the capacity of health providers
for both public and private;

c. Take the lead in pursuing public-private partnerships (PPP) on

FP/MNCHN and other health programs/ services to support the SDN in
terms of financing and functionality;

d. Take the lead in mobilizing funds and other resources for training,
subsidies for clients, and demand generation and outreach activities.

Rural Health Units:

e. Take the lead in preparing, enhancing and upgrading public sector
facilities and providers to be designated as BEmONC capable facilities
and providers.

f. Comply to the existing referral mechanism within the SDN

g. Take the lead in the provision of BEmONC services and accept or provide
referrals from and to allied facilities and providers within the SDN.

Private Health Facilities

h. Comply to the existing referral mechanism within the SDN

i. Continue to enhance and upgrade health facilities, capacitate health staff

on new technologies and clinical practice guidelines

21
 j. Comply with the DOH standards, regulations, and established clinical
practice guidelines

k. Submit to MHO or C/PHO regularly agreed health service indicator or

FHSIS reports in line with SDN’s unified reporting system

3. The Parties understand that the FP-MNCHN and other health programs/ services referral
system is only an initial component to the full development of their SDN. As such, when
additional SDN lines are added (i.e. systems planning, quality assurance, information system,
technology transfer/sharing, diagnostic resource pooling, bulk procurement, health human
resources planning and placement, other vertical health programs), corresponding guidelines
will be developed;

4. The Parties shall follow the technical guidelines issued by the Department of Health, the
World Health Organization and other authorities recognized and agreed upon by consensus of
its members. Examples of these technical guidelines are the MNCHN MOP, EINC
Implementation Manual, and Family Planning clinical Standards Manual;

5. The Parties commit to undertake more formal and binding agreements upon successful
implementation of this service level agreement;

6. The SDN Technical Management Team is hereby organized with the following officers and
members;

Chairperson : Hon. Edilberto Adlaon, M.D.

Vice Chair : Ramon O. Blancia Jr, M.D.
Secretariat : 1. Bernadette Amantillo
2. Doreen Ann Arambala

Members :
Provincial Population Office : Evelyn Panuncialman
City Population Office : Rodetta Casenas
CHO : Noel E. Ceniza, M.D.
PSWD : Miriam Acosta
DSWD : Yvonnie Suico
Red Cross : Teodora Ortiz
AMHOP : Herbert Wee Sit Saavedra, M.D.
ZDSMC : Maria Rovel A. Blancia, M.D.
MRH : Richard Sison, M.D.
President Private
Hospital Association : Genalene Sy, M.D
ZDS Medical Society : Liz Corazon Parangan, M.D.
PDOHO : Agnes E. Fernando, R.N., Ed.D.
PHILHEALTH : Ms. Estrella Manantan
IMAP : Mary Jane Cadutdut
PLGPMI : Concepcion Pedrosa
DOH-RO : Gilbert Natividad
DOH-RO : Nerissa Guitterez
PDRRMO : Engr. Francisco Maca Jr.

22
The SDN Technical Working Group for District 1

Chairperson : Mailyn Manupac, M.D.

Vice Chairperson : Pesabeth Apostol, M.D.
Members:
All MHOs from District 1
Private Sector Representative : IMAP President, ZDS Chapter
DMOs assigned in District 1
PHO – Program Coordinators assigned in District 1
Population Program Officer
DSWD MAT for each Municipality

Point Persons:
Midsalip : Carla Indanao
Melody Reyes

Sominot : Apolinaria Onez

Lenie Andale

Ramon Magsaysay : Bella Sabuero

Irene de Castro

Aurora : Arleen Verdad

Lailane Estrera

Tukuran : Mary Jane Cadutdut

Kimberly Digan

Labangan : Umaya Damada

Lydia Labio

The SDN Technical Working Group for District 2

Chairperson : Herbert W.S. Saavedra, M.D.

Vice Chairperson : Gretchen Dubrico, M.D.

Members:
All MHOs form District 2
Private Sector Representative: IMAP President, ZDS Chapter
DMOs assigned in District 2
PHO : Program Coordinators assigned in District 2
Population Program Officer
DSWD MAT for each Municipality

Point Persons:
Bayog : Betty Jane Liguan, R.M.

Lakewood : Nelida Seniedo, R.N.

23
 Kumalarang : Soraida D. Claveria, R.M.

Tigbao : Araceli Dilao

Dumalinao : Cyril Gay Mabuyo

Guipos : Efara Moradas, R.M.

San Pablo : Juliet Paler, R.N.

San Miguel : Grace G. Manda

Dinas : Vernie Joros

Dimataling :

Pitogo : Erna Patayon, R.N.

Tabina : Amy Joy Abaday, R.N.

Lapuyan : Czarmecris Lee T. Lumosbog, R.N., M.A.N.

Vincenzo Sagun : Juliet Elago, R.N.

Margosatubig : Margarita Sarvida, R.M.

ZDSMC : Zefanie Siyluy. R.N.

MRH : Reggie Guevarra, R.N.

7. The SDN Provincial TWG shall have the following functions:

1. Convenes the members of the SDN regularly;

2. Conduct and update the resource map/ service delivery capacities of each of the
stakeholders in the network ;

3. Develop plans for resource mobilization and secure commitments between and
among SDN members;

4. Provide communication and liaison support to the SDN;

5. Monitors the implementation and functionality of the SDN FP/MNCHN and other
program/ services referral mechanism.

24
The SDN Technical Management Committee

The SDN TMC is responsible for promoting achievement of positive outcomes in establishing
the SDN through the following key activities:
1. Provide regular forum for discussion of issues and coordination of SDN technical
activities, particularly during the initial phase of implementation.
2. Ensure that the SDN MNCHN-FP and other program/ services project is guided by
effective policies, procedures, best practices, and standards within the DOH
administrative issuances.
3. Build collaboration, commitment and support within the SDN levels and in relating to
the DOH-RO level and to the broader community in the region.
4. Liaise with development partners and other working groups at the SDN level on
matters of common interest related to MNCHN-FP and other programs/ service
delivery.
5. Identify “SDN best practices” and recommend to the TAG for positive action and
dissemination with other SDNs.
6. Monitor and evaluate progress through use of agreed indicators (indicators for MDG,
input, process and output interventions), and regular reporting on targets and
benchmarks;
7. Review results on pilot initiatives in service delivery, financing, management and
quality improvement and ensure that lessons learned are used in policy
development.
8. Facilitate the implementation of selected technical recommendations generated from
SDN conferences and meetings.
9. Ensure that the SDN project has effective policies, procedures, best practices, and
standards to guide technical aspects within the DOH administrative issuances.
10. Provide assistance to the SDNs clusters regarding proposed changes in service
delivery and tools that will help accelerate and scale-up MNCHN-FP and other
programs/ services to the community.

Part III

The Service Provider Agreement may be amended upon mutual agreement of the parties.

Part IV

This Service Level Provider Agreement shall take effect upon signature and shall remain
in force until terminated in writing by the parties. It shall be reviewed 6 months after the
commencement of the implementation.

Part V
The parties mutually agree to the following referring and receiving referral arrangements

25
 Facilities that will attend Facilities that will Facilities that will
to C Referrals attend to B attend to A Referrals
(Health Center & Private Referrals ( Hospital)
Birthing Home/Lying-In Clinic/ (Hospital)
Infirmaries )
RURAL HEALTH UNIT
RHU – Aurora Ø ZDSMC Ø ZDSMC
Ø Kapatagan Ø Kapatagan Provincial
Provincial Hospital Hospital
Ø MHARS MC Ø MHARS MC
RHU – Bayog Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Dimataling Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Dinas Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Dumalinao Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Dumingag Ø MHARS MC Ø MHARS MC
Ø ZDSMC
RHU – Guipos Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Josefina Ø MHARS MC Ø MHARS MC
RHU – Kumalarang Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Labangan Ø ZDSMC
Ø ZDSMC
Ø MHARS MC
Ø MRH
Ø Kapatagan Provincial
Ø MHARS MC
Hospital
RHU – Lakewood Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Lapuyan Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Mahayag Ø MHARS MC Ø MHARS MC
RHU – Margosatubig Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Midsalip Ø ZDSMC Ø ZDSMC
Ø MHARS MC Ø MHARS MC

26
RHU – Molave Ø MHARS MC Ø MHARS MC
Ø ZDSMC Ø ZDSMC
Simata, BHS, Molave Ø MHARS MC Ø MHARS MC
Ø ZDSMC Ø ZDSMC
CHO- Pagadian City Ø ZDSMC Ø ZDSMC

Balangasan Main Health

Ø ZDSMC Ø ZDSMC
Center, Pagadian City
San Jose Main Health Center,
Ø ZDSMC Ø ZDSMC
Pagadian City
San Pedro Main Health Center,
Ø ZDSMC Ø ZDSMC
Pagadian City
Sta. Lucia Main Health Center,
Ø ZDSMC Ø ZDSMC
Pagadian City
RHU – Pitogo Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Ramon Magsaysay Ø MHARS MC
Ø ZDSMC
Ø ZDSMC
RHU – San Miguel Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – San Pablo Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU – Sominot Ø ZDSMC Ø ZDSMC
Ø MHARS MC Ø MHARS MC
RHU – Tabina Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU - Tambulig Ø MHARS MC Ø MHARS MC
Ø ZDSMC Ø ZDSMC
Aliyah BHS and Birthing Home, Ø MHARS MC Ø MHARS MC
Lower Liason, Tambulig, ZDS Ø ZDSMC Ø ZDSMC
Balugo Health Station and
Ø MHARS MC Ø MHARS MC
Birthing Center, Balugo, Tambulig
Ø ZDSMC Ø ZDSMC
ZDS
Highland Cluster B Health
Ø MHARS MC Ø MHARS MC
station and Birthing Clinic,Tuluan,
Ø ZDSMC Ø ZDSMC
Tambulig, ZDS
Lower Usogan Barangay
Ø MHARS MC Ø MHARS MC
Health Station and Birthing Clinic,
Ø ZDSMC Ø ZDSMC
Lower sugan, Tambulig, ZDS

27
RHU – Tigbao Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
RHU- Tukuran Ø ZDSMC Ø ZDSMC
Ø MHARS Ø MHARS
Ø PCMC Ø PCMC
Ø Hofileña Hospital Ø Hofileña Hospital
Ø Kapatagan Ø Kapatagan Provincial
Provincial Hospital Hospital
RHU – Vincenzo Sagun Ø ZDSMC Ø ZDSMC
Ø MRH Ø MRH
Ø PUBLIC/ PRIVATE HOSPITALS
Blessed Mother Birthing Home Ø ZDSMC Ø ZDSMC
Ø Hofileña Hospital Ø Hofileña Hospital
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital
Family Care Birthing Home, Ø ZDSMC Ø ZDSMC
Tukuran Ø PCMC Ø PCMC
Ø Hofileña Hospital Ø Hofileña Hospital
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital
Lumantas Lying-in Clinic, Aurora Ø ZDSMC Ø ZDSMC
Ø Hofileña Hospital Ø Hofileña Hospital
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital
Midsalip Infirmary Hospital Ø ZDSMC Ø ZDSMC
Ø Jamelarin Hospital Ø Jamelarin Hospital
Ø PCMC Ø PCMC
Ø MHARS MC Ø MHARS MC
Mother and Baby Care Ø Hofileña Hospital Ø Hofileña Hospital
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital
Mom’s Lying-in Clinic Ø Hofileña Hospital Ø Hofileña Hospital
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital
Saint Margaret Lying in Clinic Ø Hofileña Hospital Ø Hofileña Hospital
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital
Saint Marys Lying In Clinic Ø ZDSMC Ø ZDSMC
Ø Hofileña Hospital Ø Hofileña Hospital
Ø PCMC Ø PCMC
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital

28
 Well Family Birthing Clinic Ø Jamelarin Hospital Ø Jamelarin Hospital
Ø Hofileña Hospital Ø Hofileña Hospital
Ø Pagadian Metro Ø Pagadian Metro
Hospital Hospital

This Service Providers’ Agreement shall take effect upon signature and shall remain in force
until terminated in writing by the parties.
Signed this __________, at Pagadian City, Zamboanga del Sur.

29
HON. EDILBERTO ADLAON, M.D. RAMON O. BLANCIA, JR, M.D.
Chairman, Committee on Health Provincial Health Officer
Provincial Board Member Province of Zamboanga del Sur
Province of Zamboanga del Sur

RICHARD SISON, M.D. MA. ROVEL A. BLANCIA, M.D.

Medical Center Chief Chief of Hospital
Margosatubig Regional Hospital Zamboanga del Sur Medical Center

JESUS MARTIN SANCIANGCO III, M.D. TEODORA ORTIZ, RMT

Chief of Hospital Chapter Administrator
Mayor Hilario A. Ramiro Sr (MHARS) Philippine Red Cross – Zamboanga del Sur
Medical Center

MEDEL T. TOMADA, M.D. CERIACO S. LAGARE, M.D.

Chief of Hospital Chief Operating Officer
Kapatagan Provincial Hospital Midsalip Infirmary Hospital

JERALD O. RAMOS, M.D. JAIME R. NAVARRO, M.D.

Chief of Hospital Medical Director – OIC
Mahayag Municipal Hospital Pagadian City Medical Center

JOSE F. HOFILENA III BRANDO KHALIF JALLY, M.D.

Medical Director Medical Director
Hofilena Hospital Aisah Medical Hospital

LIZ CORAZON PARANGAN, M.D. ALAN T. SY, M.D.

Medical Director Medical Director
J. Cabahug General Hospital Inc. Pagadian Doctor Hospital
ROLYNN S. IGANO, M.D. ANGELA J. ESPANOLA, M.D.
Medical Director Medical Director
Salug Valley Medical Center Jamelarin Hospital

NOEL E. CENIZA, M.D. AGNES E. FERNANDO, RN, ED.D.

City Health Officer Development Management Officer V
Pagadian City Provincial DOH Office – Zamboanga del
Sur

MARILYN C. SAYSIP, R.M. ERLINDA D. SABATE, R.M.

Saint Mary’s Lying-in Clinic Blessed Mother Birthing Home Clinic
Pagadian City Pagadian City

MARY SILYNE A. CABAHUG, M.D. GRETCHEN A. DUBRICO, M.D.

Municipal Health Officer Municipal Health Officer
Municipality of Aurora Municipality of Bayog

JU KANRA PANUGAO, M.D. APRIL ROSE SUZETTE S. EXILE, M.D.

Municipal Health Officer Municipal Health Officer
Municipality of Dumingag Municipality of Dimataling

RHOEL ELUMBARING, M.D. NURDAYA ABUBAKAR, M.D.

Municipal Health Officer Municipal Health Officer – OIC
Municipality of Josefina Municipality of Dinas

MAILYN O. MANUPAC, M.D. WILRIC C. ASUNCION, M.D.

Municipal Health Officer Municipal Health Officer
Municipality of Labangan Municipality of Kumalarang

1
WILSON G. LUMAPAS, M.D. SAYLEN KUYONG-ASUNCION
Municipal Health Officer Municipal Health Officer
Municipality of Mahayag Municipality of Lakewood

CARLA INDANAO, R.N. HERBERT W.S. SAAVEDRA, M.D.

Public Health Nurse Municipal Health Officer – OIC
Municipality of Midsalip Municipality of Lapuyan

LEAH F. YU, M.D. DULCE ANN Y. ALBARICO, M.D.

Municipal Health Officer Municipal Health Officer
Municipality of Ramon Magsaysay Municipality of Margosatubig

PESABETH Z. APOSTOL, M.D. KRISTYN J. LIPAYON, M.D.

Municipal Health Officer Municipal Health Officer – OIC
Municipality of Sominot Municipality of Guipos

JANET A. HERNANDO, M.D. HERMERALDO M. CATUBIG, M.D.

Municipal Health Officer Municipal Health Officer
Municipality of Tambulig Municipality of San Pablo

KIZMAR ARANI PUEBLOS, M.D. FRANSISCO LOUIS M. ALCACHUPAS, M.D

Municipal Health Officer – OIC Municipal Health Officer – OIC
Municipality of Tukuran Municipality of San Miguel

GRACE F. SABELLANO, M.D. ROBERTO Q. PASTORIZA, M.D.

Municipal Health Officer Municipal Health Officer
Municipality of Vincenzo Sagun Municipality of Tabina

2
ERICKSON G. PADUNAN, M.D. GRAYVIMIN S. FIGUERAS, M.D.
Municipal Health Officer – OIC Municipal Health Officer – OIC
Municipality of Pitogo Municipality of Tigbao

3
ANNEX A: Standard Operating Procedure at Each Level of Facility

Community (CHT/ BHW/ BPVs/TBA/ BNS/ Kagawad on Health)

MNCHN FP AY
Pre-Pregnancy: Actions to be taken
-Masterlisting of WRA & children -Identify families for birthing -Identify and submit list of AY
below 1 yr. old plans and refer to RHMs for FP (10-24 y.o) and refer to RHU
- Info on PhilHealth benefits needs any health risk
- BPVs provide masterlist of - Encourage AY to visit health
WRA with FP unmet needs to facility
RHU - Invite OSY to attend Usapan
- BPVs refer clients with FP Pangkabataan and U4U for in-
unmet need to facility school
- Info on FP PhilHealth benefits
(PPIUD, IUD, BTL, PSI) - Provide IEC materials on
- Invite males for KATROPA responsible sexuality
(Kalalakihang Tumutugon sa
Responsibilidad at Obligasyon -Screen AY for risk-taking
sa Pamilya) session behavior and refer to RHM
Pregnancy
-Masterlisting of AP women - Interpersonal communication -Follow-up identified AY
(pregnancy tracking) & refer to (myths and misconception and pregnant for prenatal check-up
RHU fear of side effects) on FP (4 ANC= 1-1-2)
- Follow up on birth plan methods and refer to BHS/RHU -Referral to health facility for
-Follow-up for Prenatal per for counselling the services needed
trimester (4 ANC= 1-1-2)
-Promote for facility-based
delivery
-Educate AP of the danger signs
of pregnancy
-Facilitate transport for delivery to
health facility
-IEC on EBF (up to 6 mos. and
up)
Labor and Delivery
-Accompany term AP woman to - Accompany pregnant AY to
health facility for delivery (if hospital facility
possible)
- Accompany high risk pregnant
woman to hospital
-Provide emotional support and
care to AP
Post-partum

-Home visitation and check -Provide counseling on FP -Home visitation and check
condition of PP mother (e.g. services condition of PP mother (e.g.
bleeding) - BPV/BHW conducts follow up bleeding)
-Check BF for correct positioning on use of preferred FP method -Check BF for correct
and attachment positioning and attachment
-Reporting of maternal and -Reporting of maternal and
 MNCHN FP AY
neonatal death to RHMs neonatal death to RHMs

Newborn Care
-Advocate on NBS, EBF, - Integrate FP information on -Advocate on NBS, EBF,
Immunization EPI Immunization
-Refer to BHS/ RHU for any -Refer to BHS/ RHU for any
childhood disease (IMCI) childhood disease (IMCI)
Child Care

-Follow-up for immunization, - Integrate FP information on -Follow-up for immunization,

micronutrient supplementation, EPI during OPT and Vit.A micronutrient supplementation,
complementary feeding Supplementation complementary feeding
-Refer to RHU if any childhood -Refer to RHU if any childhood
diseases (IMCI) diseases (IMCI)
-IEC on Injury prevention, oral -IEC on Injury prevention, oral
health health

Barangay Health Station

MNCHN FP AY
Pre-Pregnancy

1. Identification/ masterlisting of 1. Masterlisting of WRA 1. Masterlisting of

WRA 2. From the masterlist, identify adolescence and youth
2. Share the list to TBAs and WRA with FP Unmet Need (age 10-24 y.o.)
BHWs 3. Information dissemination 2. Information dissemination
3. Screening of STI, refer if on FP (modern/ natural on STDs
services not being provided methods) 3. For those identified with
4. For those identified with risky behaviors during the
unmet need including those U4U, UP, and Youth
referred by BHWs/BPVs will Camps, RHM/PPM to
be counselled in compliance conduct risk assessment
with ICV using the HEADDS tool.
5. Provision of preferred MFP Refer clients to higher
methods and refer to other facility with high risk
facilities if desired MFP is behaviors (suicidal
not available tendencies, drugs)
6. Record client in the FP 4. Provide appropriate
Form 1 and TCL services
5. Record client in the TCL
Pregnancy

1
 MNCHN FP AY
1. Masterlisting of pregnant 1. Provide FP counseling 1. Masterlisting of
women / pregnancy tracking pregnant teens/
2. Provide updated masterlist of pregnancy tracking
pregnant women to birthing 2. Provide updated
homes/hospitals of SDN masterlist of pregnant
including high risk teens to hospitals
pregnancies including high risk
3. Provide ferrous sulfate and pregnancies
folate supplementation 3. Provide ferrous
4. Provide TT immunization sulfate and folate
5. Provision of Mother-Baby supplementation
book and IEC on safe 4. Screening for STDs
motherhood 5. Provide TT
6. Assist in birth planning: immunization
-Where to deliver 6. Assist in birth
-Whom to call planning:
-What to prepare -Where to deliver
6. Inform/ advocate on FBD and -Whom to call
EBF -What to prepare
7. Record client in the TCL 7. Inform/ advocate on
FBD and EBF
8. Record client in the
TCL

Labor and Delivery

1. Refer high risk pregnant N/A 1. Refer to CEMONC facility

women to CEmONC facility
2. Encourage clients from GIDA
to stay at the town center/
poblacion or maternity
waiting home one week
before expected delivery
3. Manage NSD in the facility /
BeMONC adhering to EINC
protocol
4. Facilitate availability of blood
and transport services

Postpartum Care

2
 MNCHN FP AY
1. Postpartum visit at least 1. Initiate LAM with adherence 1. Postpartum visit at
twice within 48 hours and to the three criteria least twice within 48
home follow up within 72 2. Introduce proper MFP hours and home
hours methods follow up within 72
2. Initiation of BF within 30 3. Provision of IEC materials hours
minutes to one hour after on MFP 2. Initiation of BF within
delivery 4. Provision of PPFP/PPIUD 30 minutes to one
3. Provision of iron and Vit.A 5. Record in the FP Form 1 hour after delivery
supplement at least for two and TCL 3. Provision of iron and
months Vit.A supplement at
4. Continue TT immunization least for two months
5. Monitor for any PP 4. Continue TT
complications and refer if immunization
needed 5. Monitor for any PP
6. Promotion of EBF complications and
7. Advocacy on IYCF refer if needed
8. Record in the TCL 6. Promotion of EBF
7. Advocacy on IYCF
8. Record in the TCL

Newborn Care
1. Perform NBS in birthing • Conduct FP-EPI 1. Perform NBS in
home integration and during birthing home
2. Provide Immunization provision of nutrition 2. Provide
services services Immunization
3. Encourage mother to practice • Record in the TCL services
EBF for at least six months 3. Encourage
(emphasize the benefits of mother to practice
EBF) EBF for at least
4. IMCI six months
5. Provision of complementary (emphasize the
feedings after 6 months benefits of EBF)
6. Record in the TCL 4. IMCI
5. Provision of
complementary
feedings after 6
months
6. Record in the TCL

Child Care
1. Immunization (EPI) Conduct FP-EPI integration 1. Immunization (EPI)
2. Growth monitoring 2. Growth monitoring
3. Micronutrient 3. Micronutrient
supplementation supplementation
4. Dental health services 4. Dental health services
5. IMCI 5. IMCI
6. Deworming 6. Deworming
7. Continue BF up to 2 years 7. Continue BF up to 2
old years old

3
 MNCHN FP AY
8. Record in TCL 8. Record in TCL

Rural Health Unit/ Main Health Centers

MNCHN FP AY
Pre-Pregnancy

1. Identify masterlist and 1. Counselling and provision of 1. Facilitate and provide IEC
validate Women and married services for unmet needs for for AY on STI, injury
women of reproductive age Modern family planning prevention, mental health
2. Micronutrient 2. Referral to other facilities for 2. Referral to other facilities
supplementation and services not available in the for services not available
deworming for women of RHU in the RHU
reproductive age 3. Ensure availability of FP and 3. Management/ referral of
3. Consultation MNCHN commodities and cases (STI/HIV, mental
conduct of regular inventory health, drug/substance
4. Submit listing of women with abuse)
unmet need on limiting to 4. Consultation
fixed facilities and during 6. For those identified with
outreach high risk behaviors during
5. Data Validation and the U4U, UP, and Youth
reconciliation (TCL with list Camps, provide
submitted by BHWs/BVPs) appropriate services.
6. Conduct regular PMC Refer clients to higher
facility with high risk
behaviors (suicidal
tendencies, drugs)
7. Record and reporting of
cases
Prenatal Care
1. Facilitate monitoring of 1. Counselling on MFP 1. Provision of prenatal
pregnancy tracking and services/ counseling
management of prenatal especially for hospital
services (TT. Iron delivery of teenage
supplementation, deworming, pregnancy
consultation, routine labs) 2. Technical assistance/
2. Referral to other facilities as guidance on birth planning
needed
Delivery

4
 MNCHN FP AY
1. Ensure adequacy of supplies, 1. Ensure adequacy of
safe delivery (FBD), and supplies, safe delivery
logistics (FBD), and logistics
2. Provide intrapartum 2. Provide intrapartum
monitoring (partograph) monitoring (partograph)
3. Referral of cases to 3. Referral of cases to
CEMONC facility as needed CEMONC facility as
for high risk patients needed for high risk
4. Ensure practice of EINC patients
protocols 4. Ensure practice of EINC
5. Micronutrient protocols
supplementation 5. Micronutrient
supplementation
Post-partum
1. Vitamin A, Fe SO4 and folic Counselling Vitamin A, Fe SO4
acid supplementation Provision of MFP and folic acid
services supplementation

ANNEX B: REFERRAL CATEGORIES

A. Group A category (Subspecialist level) – This referral category pertains to maternal and neonatal
conditions that require subspecialist care and management. The health service provider shall be a level 3
hospital with the obstetrics and pediatrics department providing perinatology and neonatology services
respectively. There shall be a high risk pregnancy unit and a neonatal intensive care that could provide
for sustained life support and multi-specialty referral for preterm neonates or low birth weight of < 2500.
The hospital must also have a staff specializing in reproductive health and RPRH.

1. Group A1 subcategory – are emergency (life threatening) conditions that require subspecialist
evaluation and management.

Condition Indication/s Category

Maternal

Pregnant women, in active Prolonged latent phase* A1

labor

Pregnant women, in active Primary dysfunctional labor* A1

labor

Pregnant women, in active Secondary arrest of dilatation* A1

labor

Pregnant women, in active Malpresentation A1

Pregnant women, in active With underlying complications: A1

labor Hypertension, Diabetes Mellitus, Heart
diseases, thyroid diseases

5
Pregnant women, NIL Placenta accreta – excessive bleeding A1
for evaluation; (History, needs
ultrasound to confirm)

Pregnant women, NIL Placenta Previa (excessive third A1

trimester painless bleeding- for
evaluation)
Postpartum Confirmatory (X-Ray) Pulmonary A1
atelectasis
Postpartum Deep vein thrombosis (Pain, Swelling, A1
Warmth on the affected leg)
Postpartum Pyelonephritis

Neonatal

Low birth weight babies < 2500 grams A1

Preterm baby < 32 weeks A1

*Note: Refer if the condition reach alert line

2. Group A2 subcategory – are urgent (non-life threatening but needs immediate care) and non-
urgent conditions that require subspecialist evaluation and management. (Base on health history,
and records taken during pre-natal visits)

Maternal
Pregnant women, in active Precipitate labor A2
labor
Pregnant women, NIL Tumor previa A2

Pregnant women, NIL Two consecutive abortions A2

Pregnant women, NIL Three or more repeated abortions A2

Pregnant women, NIL Prior pre-term delivery A2

Prior pregnancy with fetal or neonatal A2

Pregnant women, NIL
deaths
Pregnant women, NIL Previous birth with congenital anomaly A2
Heart Disease (Complex cardiac A2
Pregnant women, NIL
malformation, CAD, cardiomyopathy)
Pregnant women, NIL Bronchial Asthma A2
Obstructive or Restrictive Pulmonary A2
Pregnant women, NIL
Disease
Diabetes Mellitus (Large for gestational A2
Pregnant women, NIL
age)
Pregnant women, NIL Renal Disease A2
Hematologic Disorders/ A2
Pregnant women, NIL Hemoglobinopathy/ RH Connective
Tissue Disorder
Pregnant women, NIL Seizure Disorder A2
Infections (TORCH, STD, Acute & A2
Pregnant women, NIL
Chronic Hepatitis, Chickenpox)

6
 Pregnant women, NIL Alcoholic and substance abuse A2

Pregnant women, NIL Vascular Disease (Aneurysm) A2

Pregnant women, NIL Congenital anomalies A2

Pregnant women, NIL Incompetent Cervix A2

Pregnant women, NIL Uterine/ovarian tumors A2

Pregnant women, NIL Psychiatric or mental retardation A2

Pregnant women, NIL Genital and Extra-genital Malignancy A2

Pregnant women, NIL IUGR/ Macrosomia A2

Pregnant women, NIL Fetal congenital anomalies A2

Lower extremities edema but with A2
Pregnant women, NIL
normal BP
Pregnant women, NIL Multiple pregnancy, G5 and above A2

Scarred uterus with previous CS and A2

Pregnant women, NIL
myomectomy
Pre-pregnancy - post partum A2
stage STD/HIV/AIDS

**Note: If A2 conditions are symptomatic, manage as A1

Group B category (Specialist level) – This referral category pertains to maternal and neonatal conditions
that require general specialist care and management in obstetrics and pediatrics. The health service
provider shall preferably be a level 2 or at least a level 1 hospital with full CEmONC functionality. Their
obstetrics and pediatrics services must have a trained specialist and these units must have capabilities
for advanced neonatal resuscitation.

1. Group B1 subcategory – are emergency conditions that require specialist evaluation and
management.

Condition Indication/s Category

Maternal

Pregnant women, in active Placenta previa (excessive third

B1
labor trimester painless bleeding)
Pregnant women, in active
Placenta accrete B1
labor
Pregnant women, in active
Abruptio placenta B1
labor
Imminent delivery under exclusion
Pregnant women, NIL B1
criteria
Pregnant women, NIL Pre-eclampsia or hx of pre-eclampsia B1
Postpartum Deep perineal lacerations B1
Postpartum Uterine inversion B1

7
 Puerperal Fever – Endometritis, pelvic
abscess, septic, pelvic thrombophlebitis,
Postpartum Wound infection B1

Postpartum Mastitis B1
Pregnant women, in active
labor Cord prolapse B1

Pregnant women, in active

labor Uterine rupture B1
Pregnant women, in active
labor Shoulder dystocia B1
Pregnant women, NIL No fetal heart sounds B1
Intrapartum bleeding Retained placenta B1 or A1
Intrapartum bleeding Retained products of conception B1 or A1

Intrapartum bleeding Uterine atony B1 or A1

Postpartum hemorrhage, infection and
Postpartum complications
hypertension B1 or A1

2. Group B2 subcategory – are urgent and non-urgent conditions that require specialist evaluation
and management.

Condition Indication/s Category

Maternal

Pregnant women, NIL Weight of first baby - 2.3 kg B2

Unsure of LMP- (refer to hospital for
Pregnant women, NIL UTZ, FH measurement and determine B2
quickening)

with HBsAg positive with strict

Pregnant women, NIL B2
precaution
with PTB and without other medical
Pregnant women, NIL B2
conditions
Pregnant women, NIL Multiparity (more than 4) B2

Pregnant women, NIL Malpresentation (breech, transverse) B2

Pregnant women, NIL Previous Cesarean Section B2

History of vaginal bleeding during the

Pregnant women, NIL first and second trimester (ruled out B2
placental previa)

Pregnant women, NIL History of uterine procedure B2

Pregnant women, NIL Hypertension B2

8
 Pregnant women, NIL Iron Deficiency Anemia (Hgb <11 gms) B2
Pregnant women, NIL Malnutrition B2
Pregnant women, NIL Polyhydramnios or Oligohydramnios B2
Pregnant women, NIL Fundic Height of >32 cm B2
Pregnant women, NIL Multiple gestation B2

Pregnant women, NIL Hyperemesis gravidarum B2

Pregnant women, NIL Inappropriate weight gain B2
Pregnant women, NIL Abnormal laboratory examinations B2
Pregnant women, NIL Post datism (>42 weeks) B2
Gestational Hypertension (> 140/90
Pregnant women, NIL
mmHg) B2

RPRH

IUD extraction Detached filament B2

IUD extraction Impacted IUD B2

Group C category (Generalist level) – This referral category pertains to maternal and neonatal conditions
that require trained generalist care and management in obstetrics and pediatrics. The health service
provider shall be a BEmONC capable RHU or level 1 hospital. There shall be a team trained in essential
maternal and newborn care.

1. Group C1 subcategory – are emergency conditions that require trained generalist evaluation and
management.

Condition Indication/s Category

Maternal

Postpartum 1st degree lacerations C1

>Cervical dilatation 7-cm

>2nd stage of labor
Leaking BOW: >Effacement - 80% C1
>Amniotic fluid - clear
>Time of leaking is less than 8 hours

Neonatal
Neonate Sepsis/Infection C1 or B1 / A1

9
 2. Group C2 subcategory – are both urgent and non-urgent conditions that require trained generalist
evaluation and management.

Condition Indication/s Category

Maternal

Pregnant women, NIL with UTI C2

Pregnant women, NIL with Hgb >11 gms C2
Pregnant women, NIL with FHT 120-160 C2

Pregnant women, NIL Normal BP (110/70) C2

with normal BP or pre-pregnancy BP
Pregnant women, NIL not more than 30 mmHg systolic C2
compared to pre-pregnancy BP

Pregnant women, NIL With Disability (deaf and mute) C2

Pregnant women, NIL Height: 145 cm and gravida 2 C2

NSD Normal history and physical exam C2

Screening tests- CBC, Blood Typing,
Pregnant women, NIL Urinalysis, VDRL or RPR, HbSAg, C2 or B2
FBS-RBS, HbSAg, HCT

RPRH

FP clients ( OCP, DMPA, Condom,

Normal history and physical exam C2 or B2
NFP)

FP clients ( Interval IUD) Normal history and physical exam C2 or B2

FP clients ( Post -Partum IUD ) Normal history and physical exam C2 or B2

FP clients ( BTL-MLLA/NSV) Normal history and physical exam C2 or B2

10
ANNEX C: MATERNAL CASES

Referral Form

(LOGO)

__________________________________________________________
Name of Facility
________________________________________
Address of Facility
REFERRAL FORM
Referred to: __________________________________________________ Referred Date: ________ Time:
_______
Arrival Date: ________ Time: _______
REFERRAL CATEGORY A1 ( ) A2 ( ) B1 ( ) B2 ( ) C1 ( ) C2 ( ) Unclassified ( ) Note:
_____________________________________________________________________________________________
_______________________________________________________________________________________

NAME OF PATIENT: _____________________________________AGE: _________ SEX: ________

ADDRESS: ______________________________________________CIVIL STATUS: ______________

BRIEF HISTORY
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___
MOTHER BABY
LMP: ____________________ NAME: ______________________ SEX: _________
EDC: ____________________ BIRTH WEIGHT: _____________ APGAR SCORE: _________
AOG: ____________________ TERM: ______PRE-TERM:_______
VITAL SIGNS: ____________ VITAL SIGNS: ____________ IE:____cm
LABORATORY RESULT:
_____________________________________________________________________________________________
_______________________________________________________________________________________
MANAGEMENT/TREATMENT DONE/MEDICATION GIVEN AND TIME:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
______________________
REMARKS:
_____________________________________________________________________________________________

_______________________________________________
SIGNATURE OVER PRINTED NAME OF REFERRING HEALTH CARE PROVIDER
CELLPHONE NO: _______________________________

ACKNOWLEDGEMET SLIP

FROM RECEIVING FACILITY: ______________________________ Referred Date: ________Time: __________

Arrival / Received Date: ________Time: __________

NAME OF PATIENT: ______________________________________ AGE: _________ SEX: ___________

ADDRESS: ______________________________________________CIVIL STATUS: _________________

REMARKS: ___________________________________________________________________________________
__________________________________________________________________________________________

___________________________________________________
SIGNATURE OVER PRINTED NAME OF RECEIVING HEALTH CARE PROVIDER
CELLPHONE NO: _______________________________

11
ANNEX D: NEONATAL CASES
Referral Form

(LOGO)

__________________________________________________________
Name of Facility
________________________________________
Address of Facility
REFERRAL FORM
Referred to: __________________________________________________ Referred Date: ________ Time:
_______
Arrival Date: ________ Time: _______
REFERRAL CATEGORY A1 ( ) A2 ( ) B1 ( ) B2 ( ) C1 ( ) C2 ( ) Unclassified ( ) Note:
_____________________________________________________________________________________________
_______________________________________________________________________________________

NAME OF PATIENT: _____________________________________AGE: _________ SEX: ________

ADDRESS: ______________________________________________CIVIL STATUS: ______________

BRIEF HISTORY
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___
MOTHER BABY
LMP: ____________________ NAME: ______________________ SEX: _________
EDC: ____________________ BIRTH WEIGHT: _____________ APGAR SCORE: _________
AOG: ____________________ TERM: ________ PRE-TERM:__________
VITAL SIGNS: ____________ VITAL SIGNS: ____________
LABORATORY RESULT:
_____________________________________________________________________________________________
_______________________________________________________________________________________
MANAGEMENT/TREATMENT DONE/MEDICATION GIVEN AND TIME:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
______________________
REMARKS:
_____________________________________________________________________________________________

_______________________________________________
SIGNATURE OVER PRINTED NAME OF REFERRING HEALTH CARE PROVIDER
CELLPHONE NO: _______________________________

ACKNOWLEDGEMET SLIP

FROM RECEIVING FACILITY: ______________________________ Referred Date: ________Time: __________

Arrival / Received Date: ________Time: __________

NAME OF PATIENT: ______________________________________ AGE: _________ SEX: ___________

ADDRESS: ______________________________________________CIVIL STATUS: _________________

REMARKS: ___________________________________________________________________________________
__________________________________________________________________________________________

___________________________________________________
SIGNATURE OVER PRINTED NAME OF RECEIVING HEALTH CARE PROVIDER
CELLPHONE NO: _______________________________

12
ANNEX F: Referral Registry: Incoming Referrals

Monitoring Form for Incoming Referrals

Date Name of Patient Age Sex Complete Impression Referred Reason for Method of Referral Return Slip Name of
and time (2) (3) (4) Address (Given by From Referral Transport/ Code (returned or Referring
referred (5) Referring (7) (8) Communicati (10) not) Health
(1) Facility) on (11) Provider
(6) (9) (12)

Instructions:
Column 1 – Indicate the date and time the referral was received
Column 2 – Indicate the Surname, Given Name, and Middle Initial of the patient
Column 3 – Indicate the age in years
Column 4 – Indicate the gender of the client and gender at birth (M or F) for neonatal
Column 5 – Indicate the complete address of the client
Column 6 – Indicate initial clinical impression of the referring facility
Column 7 – Enter the name of the referring facility and if and SDN member, add M after the name or if an non-SDN member - NM
Column 8 – Indicate whether: Consultation, Diagnostic test, Transfer service or Family Planning and if FP further specify whether (BTL MLLA; NSV; PPFP/PPIUD/
Interval IUD, others), and others
Column 8 – Indicate whether the referral was accepted, not accepted or transferred
Column 9 – Indicate method of transport/communication
Column 10 – Indicate whether A1, A2, B1, B2, C1, C2, U – unclassified, UQ – Unqualified
Column 11 – Indicate if the return slip was returned or not returned
Column 12 – Indicate the full name of the Health Service Provider from the Referring Facility

13
ANNEX E: Referral Registry: Outgoing Referrals

Monitoring Form for Outgoing Referrals

Date Name of Patient Age Sex Complete Medical Referred Reason Method of Status Referral Patient’s/ Signatur
and (2) (3) (4) Address Impressio From for Transport/ Upon Code Relatives e of
time (5) n/ (7) Referral Communi Arrival (11) Signature Receivin
referred Diagnosis (8) cation (10) (12) g Health
(1) (6) (9) Provider
(13)

Instructions:
Column 1 – Indicate the date and time the referral was done.
Column 2 – Indicate the Surname, Given Name, and Middle Initial of the patient.
Column 3 – Indicate the age in years.
Column 4 – Indicate the gender at birth (M or F).
Column 5 – Indicate complete address of the client
Column 6 - Indicate clinical impression that prompted the referral.
Column 7 – Enter the name of the receiving facility.
Column 8 – Indicate whether: Consultation, Diagnostic test, Transfer service, or Family Planning and, if FP, further specify whether (BTL MLLA; NSV; PPFP/PPIUD/
Interval IUD, others), and others.
Column 9 – Method of Transportation
Column 10 – Status upon arrival: Indicate whether the referral was accepted or not accepted.
Column 11 – Indicate whether A1, A2, B1, B2, C1, C2, U – unclassified, UQ – Unqualified.
Column 12 – Secure consent of patient/s relatives
Column 13 – Indicate the fullname and secure the signature of the Health Service Provider in the Receiving Facility

14
15