CHN1 – Family

NCM 204 Lec

Community Health Nursing 1
Individual and Family as a Client

THE CONCEPT OF FAMILY

Learning Objectives:

At the end of the lesson, the BSN2 students will be able to:
a. define family;
b. identify the different family types and structures;
c. enumerate the major functions of the family;
d. determine the patterns of family organization based on residence and authority;
e. differentiate the traditional from the non-traditional types of family;
f. discuss the family’s tasks based on its developmental stages; and
g. describe the characteristics of a healthy family.

What is a family?

• It is the basic unit of the society

• Provides a set of functions important to the needs of the individual members and to
society as a whole.
• Provides the individual with the necessary environment for development and
interactions.
• Provides new and socialized members of the society.

DEFINITION OF FAMILY

• It is a group of persons united by ties of marriage, blood or adoption;

(Burgess and Locke,1992)

• A unity of interacting persons related by ties of marriage, birth or adoption, who’s

central purpose is to create and maintain a common culture which promotes the
physical, mental, emotional, and social development of each of its members
(Duvall, 1971)

• Composed of two or more people who are joined together by bonds of sharing and
emotional closeness and who identify themselves as being part of the family
(Friedman, 2003).

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 CHN1 – Family

TYPES OF FAMILY
Nuclear family - Defined as “the family of marriage, parenthood, or
procreation; composed of a husband, wife, and their
immediate children-natural, adopted or both”
(Friedman et al., 2003)

Dyad family - Consisting only of husband and wife, such as newly

married couples and “empty nesters”

Extended family - Consisting of three generations which may include

married siblings and their families and /or grandparents

Single adult family - Elderly man/woman living alone

Multigeneration family - Grandmother, daughter and granddaughter’s nuclear

Blended family - Results from a union where one or both spouses bring a
child or children from a previous marriage into a new
living arrangement

Compound family - Where a man has more than one spouse, approved by
Philippine authorities only among Muslims by virtue of
PD no. 1083 aka Code of Muslim Personal Laws of the
Philippines (Office of the President,1977)

Cohabiting family - Commonly described as a “live in“ arrangement

between an unmarried couple who are called common
law spouses and their child or children from such an
arrangement

Single parent - Results from the death of a spouse, separation, or

pregnancy outside of wedlock

Foster family - Children whose parents can no longer care for them may
be placed in a foster or substitute home by a child
protection.
- foster parents may or may not have children of their
own.

Group network - Nuclear families not related by birth or marriage but

bound by a common set of values as religious systems

Gay/ lesbian family - Made up of cohabiting couple of the same sex in a sexual
relationship
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 CHN1 – Family

Non- traditional
Commune family - Several unrelated couples living together
- And share facilities in some form of society they come
for economical reasons, beliefs, and cultures.

Group marriage - Several adults married to each other, share everything

commune family including sex and child raising

FUNCTIONS OF THE FAMILY

The family meets the needs of society through:

Procreation
- despite the changing forms of the family, it has remained the universally accepted
institution for reproductive function and child rearing

Socialization of Family Members

- involves transmission of the culture of a social group

Status placement
- family confers its social rank on the children
- Depending on the degree of social mobility in a society the family and children’s
future families may move from one social class to another (Medina, 2001)
Economic Function
- rural family is a unit of production (work as a team)
- urban family is more of a unit of consumption (work separately)

Specifically, the family meets the individual needs through:

Physical Maintenance
- family provides for the survival needs of its dependent members.

Welfare and Protection

- family supports spouses or partners by providing for companionship and meeting
affective, sexual, and socioeconomic needs.
- By developing a sense of love and belonging the family gives the children
emotional gratification and psychological security (Medina, 2001) The family is the
source of motivation and morale for its members

PATTERNS OF FAMILY ORGANIZATION

A. Based on Residence - arrangements on where the newlyweds will reside

1. Patrilocal o the married couple live with or near the husband’s family.

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 CHN1 – Family

2. Matrilocal o the husband leaves his family and sets up housekeeping with
or near his wife’s family.

3. Neolocal o the married couple establish a new home; they reside

independently of the parents of either groom or bride.

4. Bilocal o it gives the couple a choice of staying with either the groom’s
parents or the bride’s parents

B. Based on Authority - This refers to whom the power and decision-making is vested in the
family.

1. Patriarchy o authority is vested in the oldest male in the family

often the father

2. Matriarchy o authority is vested in the mother or the mother’s kin.

3. Equalitarian or o husband and the wife exercise a more or less equal

Egalitarian amount of authority.

4. Matricentric o authority is vested in the mother due to prolonged

absence of the father.

THE FAMILY AS A CLIENT

o CHN views family as an important unit of health care, with awareness that the individual
can be best understood within the social context of the family

It is important for nurses to work with families according to the following reasons:
1. The family is a critical resource
2. In a family unit, any dysfunction (illness, injury, separation) that affects one or more
family members will affect the members and unit as a whole. Also referred to as
“ripple effect”.
3. Case finding. While assessing an individual and family, the nurse may identify a
health problem that necessitates identifying risks for the entire family.
4. Improving nursing care

THE FAMILY AS A SYSTEM

o The General Systems Theory has been applied to the study of families. It is a way to
explain how the family as a unit interacts with larger units outside the family and with
smaller units inside the family (Friedman, 1998)

o The family may be affected by any disrupting force acting on a system outside the family
(suprasytem)

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 CHN1 – Family

o The family is embedded in social systems that have an influence to health (education,
employment, housing) just as it is affected by the systems within the family (subsytem )

o Parke (2002) stated that there are three subsystems of the family that are most
important :
o Parent-child subsystem
o Marital subsystem
o Sibling-sibling subsystem

DUVALL’S DEVELOPMENTAL STAGES AND TASK

Stage Task
Beginning Family 1. Establish couple identity and mutually satisfying marriage
2. Realign relationships with extended family to include
spouse
3. Make decisions about parenthood
Childbearing Family 1. Integrate infant into family
(Birth- 2 ½ Yrs) 2. Find mutually satisfying ways to deal with childcare
responsibilities
3. Expand relationships with extended family by adding
parenting and grand parenting roles
Families with Preschool 1. Socialize the children
Children (2 ½ - 6 Yrs Old) 2. Integrate new children while still meeting the needs with
other children
3. Maintain healthy relationships within the family ( marital
and parent-child) and outside the family ( extended
family and community )
4. Adjusting to cost of family life.
5. Adapting to the needs of pre-school child to simulate
growth and development
6. Coping with parental loss of energy and privacy
Families With School-Aged 1. Promote school achievement and foster the healthy peer
Children (6-13 Y.O. ) relations with the children
2. Maintain a satisfying marital relationships
3. Meet the physical health needs of the family
4. Adjusting to the activity of school age children
5. Promoting joint decisions between children and parents
Families with Teenagers 1. Balance freedom with responsibility as teenagers mature
and Young Adults and become more autonomous
(13 -20yrs Old) 2. Maintaining open communication among parents and
children
3. Supporting ethical and moral values within the family

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 CHN1 – Family

4. Releasing adults with appropriate rituals and assistance.

5. Strengthening marital relationships.
6. Maintaining supportive home base.
Families Launching Young 1. Develop adult-adult relationships with grown children
Adults 2. Expand family circle to include new members acquired by t
(First to Last Child Leaving he marriage of grown children
Home) 3. Assist aging and ill parents of husband and wife
4. Renew and negotiate marital relationships.
Middle-aged Parents 1. Strengthen marital relationship n
(Empty Nest to Retirement) 2. Provide health promoting lifestyle
3. Sustain satisfying relationships with aging parents and
children
Aging Family 1. Maintain satisfying living arrangement
(Retirement to Death of 2. Adjust to reduced income
Both Spouses) 3. Maintain marital relationships
4. Continue to make sense of one’s existence
5. Maintain intergenerational family ties
6. Adjust to loss of spouse

FAMILY HEALTH TASK (Freeman and Heinrich, 1981)

1. Recognizing interruptions of health or development
o A requisite step the family has to take to be able to deal purposefully with an
unacceptable health condition
2. Seeking health care
o Refers to skills and available time the family consults with health worker when
the health needs of the family are beyond its capability in terms of knowledge
3. Managing health and non-health crises
4. Providing nursing care to sick, disabled, or dependent members of the family
5. Maintaining a home environment conducive to good health and personal development
6. Maintaining a reciprocal relationship with the community and its health institutions

CHARACTERISTICS OF A HEALTHY FAMILY by De Frain (1999) and Montalvo (2004)

1. Members interacts with each other, they communicate and listen repeatedly in many
contexts
2. Healthy families can establish priorities. Members understand that family needs are
priority.
3. Health families affirm, support, and respect each other
4. The members engage in flexible role relationships, share power, respond to changes,
support the growth and autonomy of others and engage in decision making that affects
them
5. The family teaches societal values and beliefs and shares a spiritual core.
6. Healthy family foster responsibility and value service to others
7. Have the ability to cope with stress and crisis and grow from problems. They know when
to seek help with professionals
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 NCM 204
Family Nursing Process

Bevan B. Balbuena, RN, MN

At the end of the lesson 3. distinguish First Level
1. define the Family 2. determine the steps for
the BSN 2 students will Assessment from Second
Nursing Process assessment
be able to: Level Assessment

5. interpret data related 6. formulate a plan of

to the identified health care to address the
4. identify Health 7. determine barriers to
condition; health conditions, needs,
Problems of a Family joint setting of goals
problems, and issues
based on priorities;

Learning Objectives
 • is the blueprint in the care
that the nurse designs to
systematically minimize or
eliminate the identified
FAMILY health and family nursing
problems through explicitly
NURSING formulated outcomes of care
PROCESS (goals and objectives) and
deliberately chosen set of
interventions, resources,
evaluation criteria, standards
and tools.
 TOOLS FOR ASSESSMENT

1. Family Assessment Form to establish Initial Data Base

(IDB)
▪ Family structure, characteristics and dynamics
▪ Socio-economic and cultural characteristics
A. Family ▪ Home and environment
▪ Health status of family members
Health ▪ Values and practices on health promotion and disease prevention
Assessment
2. Typology of Nursing Problems
▪ First level assessment
▪ Second level assessment

3. Family Coping Index

4. Genogram
5. Ecomap
 FAMILY HEALTH ASSESSMENT FORM
• is a guide in data collection , as a means to record
pertinent information about the family that will
assist the nurse in working with family.
 Initial Data Base (IDB)
a. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS

1. Members of the household and relationship to the head of the family.

2. Demographic data: age, sex, civil status, position in the family
3. Place of residence of each member-whether living with the family or elsewhere
4. Type of family structure
• patriarchal, matriarchal, nuclear or extended
5. Dominant family members in terms of decision making especially on matters of
health care
6. General family relationship/dynamics
• presence of any obvious/readily observable conflict between members;
characteristics, communication/ interaction patterns among members
b. SOCIO-ECONOMIC AND CULTURAL CHARACTERISCTICS

1. Income and expenses

a. Occupation, place of work and income of each working member
b. Adequacy to meet basic necessities (food, clothing, shelter)
c. Who makes decision about money and how it is spent

2. Educational Attainment of each Member

3. Ethnic Background and Religious Affiliation
4. Significant others
• role(s) they play in family’s life

5. Relationship of the family to larger community

• nature and extent of participation of the family in community activities
c. HOME AND ENVIRONMENT
• information on housing and sanitation facilities, kind of
neighborhood and availability of social, health, communication and
transportation facilities

1. Housing
• Adequacy of living space
• Sleeping arrangement
• Presence of breeding or resting sites of vector of diseases (e.g.
mosquitoes, roaches, flies, rodents, etc.)
• Presence of accident hazard
• Food storage and cooking facilities
• Water supply - source, ownership, potability
Level I – handpumps, shallow well, rainwater collector
Level II – borewell, spring system
Level III – house connection
Housing….
• Toilet facilities - type, ownership, sanitary condition
Types of toilet:
• Water seal: Flush or dry
• Pit latrine
• Open defecation
• Garbage/refuse disposal - type, sanitary condition
• Drainage System - type, sanitary condition
Types of drainage system
• Surface drainage
• Subsurface drainage
• Slope drainage
• Downsprout and gutter system

2. Kind of Neighborhood, e.g. congested, slum etc.

3. Social and Health facilities available
4. Communication and transportation facilities available
d. HEALTH STATUS OF EACH FAMILY MEMBER
1. Medical/ Nursing history

• current or past significant illnesses

• beliefs and practices conducive to health and illness

2. Nutritional assessment
3. Developmental assessment
4. Risk factor assessment
5. Physical assessment
6. Laboratory/ diagnostic findings
2. Nutritional assessment (especially for vulnerable or at risk
members)
Anthropometric data: measures of nutritional status of children
• Weight, height, mid-upper arm circumference (MUAC)
• Risk assessment measures for obesity
• Body mass index (BMI) = weight (in kg) / height2 (in meters)
• Waist circumference (WC) greater than 90 cm. in men and greater than 80
cm. in women
• Waist hip ratio (WHR) = waist circumference in cm. / hip circumference in
cm.
• Central obesity: WHR is equal to or greater than 1.0 cm in men and 0.85 in
women

Dietary history specifying quality and quantity of food or nutrient per day

Eating/ feeding habits/ practice

3. Developmental assessment of infant, toddlers and preschoolers
e.g. Metro Manila Developmental Screening Test (MMDST).

4. Risk factor assessment indicating presence of major and

contributing modifiable risk factors for specific lifestyle diseases
e.g. hypertension, physical inactivity, sedentary lifestyle, cigarette/ tobacco
smoking, elevated blood lipids/ cholesterol, obesity, diabetes mellitus,
inadequate fiber intake, stress, alcohol drinking, and other substance abuse.

5. Physical Assessment indicating presence of illness state/s

(diagnosed or undiagnosed by medical practitioners)

6. Results of laboratory/diagnostic and other screening procedures

supportive of assessment findings.
e. VALUES and PRACTICES ON HEALTH PROMOTION, MAINTENANCE
AND DISEASE PREVENTION

1. Immunization status of family members

2. Healthy lifestyle practices.
3. Specify Adequacy of:
• Rest and sleep
• Exercise/activities
• Use of protective measure-e.g. adequate footwear in parasite-infested
areas; use of bed nets and protective clothing in malaria and filariasis
endemic areas.
• Relaxation and other stress management activities
4. Use of promotive-preventive health services
TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE

First Level Assessment

1. Presence of Wellness Condition
2. Presence of Health Threats
3. Presence of Health Deficit
4. Presence of Stress Points or Foreseeable Crisis

Second Level Assessment

1. Inability to recognize the presence of the condition
2. Inability to make decisions with respect to taking appropriate health action
3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at
risk member of the family
4. Inability to provide a home environment conducive to health maintenance and personal
development
5. Failure to utilize community resources for health care
 First Level Assessment

• is a process whereby existing and potential health

problems of the family are determined.
I. Presence of Wellness Condition

• stated as Potential or Readiness

• a clinical or nursing judgment about a client in
transition from a specific level of wellness or
capability to a higher level.

• Wellness potential is a nursing judgment on wellness state or condition

based on client’s performance, current competencies, or performance,
clinical data or explicit expression of desire to achieve a higher level of
state or function in a specific area on health promotion and
maintenance.
Examples of Wellness Conditions
A. Potential for Enhanced Capability for:
1. Healthy lifestyle-e.g. nutrition/diet, exercise/activity
2. Health maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being
• process of client’s developing/unfolding of mystery through
harmonious interconnectedness that comes from inner
strength/sacred source/God (NANDA 2001)
6. Others. Specify_____
Examples of Wellness Conditions
B. Readiness for Enhanced Capability for:
1. Healthy lifestyle
2. Health maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being
6. Others Specify____
II. Presence of Health Threats
• conditions that are conducive to
disease and accident or may result
to failure to maintain wellness or
realize health potential.

• Examples:
a. Presence of risk factors of specific diseases
(e.g. lifestyle diseases, metabolic syndrome)
b. Threat of cross infection from
communicable disease case
c. Family size beyond what family resources
can adequately provide
Health threats…

d. Accident hazards
1. Broken chairs
2. Pointed /sharp objects, poisons and
medicines improperly kept
3. Fire hazards
4. Fall hazards
5. Others: specify
Health threats…

e. Faulty/unhealthful nutritional/eating habits

or feeding techniques/practices.

1. Inadequate food intake both in quality

and quantity
2. Excessive intake of certain nutrients
3. Faulty eating habits
4. Ineffective breastfeeding
5. Faulty feeding techniques
Health threats…

f. Stress Provoking Factors

1. Strained marital relationship
2. Strained parent-sibling relationship
3. Interpersonal conflicts between
family members
4. Care-giving burden
Health threats…

g. Poor Home/Environmental Condition/Sanitation

1. Inadequate living space
2. Lack of food storage facilities
3. Polluted water supply
4. Presence of breeding or resting sights of vectors of
diseases
5. Improper garbage/refuse disposal
6. Unsanitary waste disposal
7. Improper drainage system
8. Poor lightning and ventilation
9. Noise pollution
10. Air pollution
Health threats…

h. Unsanitary Food Handling and Preparation

i. Unhealthy Lifestyle and Personal Habits/Practices

1. Alcohol drinking
2. Cigarette/tobacco smoking
3. Walking barefooted or inadequate footwear
4. Eating raw meat or fish
5. Poor personal hygiene
6. Self medication/substance abuse
Health threats…

Unhealthy lifestyle…..
7. Sexual promiscuity
8. Engaging in dangerous sports
9. Inadequate rest or sleep
10. Lack of /inadequate exercise/physical activity
11. Lack of/relaxation activities
12. Non use of self-protection measures (e.g. non
use of bed nets in malaria and filariasis endemic
areas).
 Health threats…

j. Inherent Personal Characteristics-e.g. poor

impulse control
k. Health History, which may Participate/Induce
the Occurrence of Health Deficit, e.g. previous
history of difficult labor.
l. Inappropriate Role Assumption- e.g. child
assuming mother’s role, father not assuming his
role.
m. Lack of Immunization/Inadequate Immunization
Status Specially of Children
Health threats…

n. Family Disunity-e.g.

1.Self-oriented behavior of member(s)

2.Unresolved conflicts of member(s)
3.Intolerable disagreement

o. Others. Specify._________
III. Presence of health deficits
• instances of failure in health
maintenance.
Examples:
1. Illness states, regardless of whether it is diagnosed or
undiagnosed by medical practitioner.
2. Failure to thrive/develop according to normal rate
3. Disability
• whether congenital or arising from illness
• transient/temporary (e.g. aphasia or temporary paralysis after a
CVA)
• permanent (e.g. leg amputation secondary to diabetes, blindness
from measles, lameness from polio)
IV. Presence of stress points/foreseeable crisis
situations
• anticipated periods of unusual
demand on the individual or family
in terms of adjustment/family
resources.

Examples:
a. Marriage
b. Pregnancy, labor, puerperium
c. Parenthood
d. Additional member-e.g. newborn, lodger
e. Abortion
f. Entrance at school
Stress points/foreseeable crisis situations…

g. Adolescence
h. Divorce or separation
i. Menopause
j. Loss of job
k. Hospitalization of a family member
l. Death of a member
m. Resettlement in a new community
n. Illegitimacy
o. Others, specify.___________
 Second-Level Assessment

• defines the nature or type of nursing problems that the

family encounters in performing the health tasks with
respect to a given health problem, and the etiology or
barriers to the family’s assumption of these tasks
I. Inability to recognize the presence of the
condition or problem due to:
a) Lack of or inadequate knowledge
b) Denial about its existence or severity as a result of fear of
consequences of diagnosis of problem, specifically:
1.Social-stigma, loss of respect of peer/significant others
2.Economic/cost implications
3.Physical consequences
4.Emotional/psychological issues/concerns
c) Attitude/Philosophy in life, which hinders recognition/acceptance
of a problem
d) Others. Specify _________
II. Inability to make decisions with respect to
taking appropriate health action due to:
a) Failure to comprehend the nature/magnitude of the
problem/condition
b) Low salience of the problem/condition
c) Feeling of confusion, helplessness and/or resignation brought about
by perceive magnitude/severity of the situation or problem, i.e.
failure to breakdown problems into manageable units of attack.
d) Lack of/inadequate knowledge/insight as to alternative courses of
action open to them
Inability to make decisions…

e) Inability to decide which action to take from among a list of

alternatives
f) Conflicting opinions among family members/significant others
regarding action to take.
g) Lack of/inadequate knowledge of community resources for care
h) Fear of consequences of action, specifically:
• Social consequences
• Economic consequences
• Physical consequences
• Emotional/psychological consequences
Inability to make decisions…

i) Negative attitude towards the health condition or problem-by

negative attitude is meant one that interferes with rational decision-
making.
j) In accessibility of appropriate resources for care, specifically:
1.Physical Inaccessibility
2.Costs constraints or economic/financial inaccessibility
k) Lack of trust/confidence in the health personnel/agency
l) Misconceptions or erroneous information about proposed course(s) of
action
m) Others specify._________
III. Inability to provide adequate nursing care to
the sick, disabled, dependent or vulnerable/at
risk member of the family due to:

a. Lack of/inadequate knowledge about the disease/health condition

(nature, severity, complications, prognosis and management)
b. Lack of/inadequate knowledge about child development and care
c. Lack of/inadequate knowledge of the nature or extent of nursing
care needed
d. Lack of the necessary facilities, equipment and supplies of care
e. Lack of/inadequate knowledge or skill in carrying out the necessary
intervention or treatment/procedure of care (i.e. complex
therapeutic regimen or healthy lifestyle program).
f. Inadequate family resources of care specifically:
1.Absence of responsible member
2.Financial constraints
3.Limitation/lack of physical resources
g. Significant person’s unexpressed feelings (e.g. hostility/anger, guilt,
fear/anxiety, despair, rejection) which his/her capacities to provide
care.
h. Philosophy in life which negates/hinder caring for the sick, disabled,
dependent, vulnerable/at risk member
i. Member’s preoccupation with own concerns/interests
j. Prolonged disease or disabilities, which exhaust supportive capacity
of family members.
k. Altered role performance, specify.
1.Role denials or ambivalence
2.Role strain
3.Role dissatisfaction
4.Role conflict
5.Role confusion
6.Role overload
l. Others. Specify.____
IV. Inability to provide a home environment
conducive to health maintenance and personal
development due to:
a. Inadequate family resources specifically:
1. Financial constraints/limited financial resources
2. Limited physical resources- e.i. lack of space to construct facility

b. Failure to see benefits (specifically long term ones) of investments

in home environment improvement

a. Lack of/inadequate knowledge of importance of hygiene and

sanitation
d) Lack of/inadequate knowledge of preventive measures
e) Lack of skill in carrying out measures to improve home environment
f) Ineffective communication pattern within the family
g) Lack of supportive relationship among family members
h) Negative attitudes/philosophy in life which is not conducive to health
maintenance and personal development
i) Lack of/inadequate competencies in relating to each other for mutual
growth and maturation (e.g. reduced ability to meet the physical and
psychological needs of other members as a result of family’s
preoccupation with current problem or condition.
j) Others specify._________
V. Failure to utilize community resources for
health care due to:
a) Lack of/inadequate knowledge of community resources for health care
b) Failure to perceive the benefits of health care/services
c) Lack of trust/confidence in the agency/personnel
d) Previous unpleasant experience with health worker
e) Fear of consequences of action (preventive, diagnostic, therapeutic,
rehabilitative) specifically :
1. Physical/psychological consequences
2. Financial consequences
3. Social consequences
f) Unavailability of required care/services
g) Inaccessibility of required services due to:
1. Cost constraints
2. Physical inaccessibility
h) Lack of or inadequate family resources, specifically
1. Manpower resources, e.g. baby sitter
2. Financial resources, cost of medicines prescribe
i) Feeling of alienation to/lack of support from the community, e.g.
stigma due to mental illness, AIDS, etc.
j) Negative attitude/ philosophy in life which hinders
effective/maximum utilization of community resources for health
care
k) Others, specify __________
 Family Coping Index (FCI)
• FCI is a profile of family’s capacity to deal with problems
associated with health care.
• Purpose: To provide a basis for estimating the nursing
needs of a particular family.

• Nursing Need or Health Care Need

A family health care need is present when:
1. The family has a health problem with which they are
unable to cope.
2. There is a reasonable likelihood that nursing will make
a difference in the family’s ability to cope.
Relation of Coping Nursing Need:

• COPING may be defined as dealing with problems associated with

health care with reasonable success.

• When the family is unable to cope with one or another aspect of

health care, it may be said to have a “coping deficit”
Direction for Scaling – a Coping Index has 2 parts:

1. a point on the scale- 1-3-5- coping capacity being rated.

1- no competence
3- moderate competence
5- complete competence

2. a justification statement – brief statements that explain why

such rate

The scale enables you to place the family in relation to their ability to
cope with the nine areas of family nursing at the time observed and as
you would expect it to be in 3 months or at the time of discharge if
nursing care were provided.
General Considerations
1. It is the coping capacity and not the underlying
problem that is being rated.
2. It is the family and not the individual that is being
rated.
3. Rating should be done after 2-3 home visits when
the nurse is more acquainted with the family.
4. Justification- a brief statement that explains why
you have rated the family as you have. These
statements should be expressed in terms of behavior
of observable facts.
5. Terminal rating is done at the end of the given
period of time. This enables the nurse to see
progress the family has made in their competence;
whether the prognosis was reasonable; and whether
the family needs further nursing service and where
emphasis should be placed.
Nine Areas to Be Assessed

1. Physical independence
• This category is concerned with the ability to move about
to get out of bed, to take care of daily grooming, walking
and other things which involves the daily activities.

2. Therapeutic Competence
• This category includes all the procedures or treatment
prescribed for the care of ill, such as giving medication,
dressings, exercise and relaxation, special diets.
3. Knowledge of Health Condition
• This system is concerned with the particular health
condition that is the occasion of care

4. Application of the Principles of General Hygiene

• This is concerned with the family action in relation to
maintaining family nutrition, securing adequate rest and
relaxation for family members, carrying out accepted
preventive measures, such as immunization
5. Health Attitudes
• This category is concerned with the way the family feels
about health care in general, including preventive
services, care of illness and public health measures.

6. Emotional Competence
• This category has to do with the maturity and integrity
with which the members of the family are able to meet
the usual stresses and problems of life, and to plan for
happy and fruitful living.
7. Family Living
• This category is concerned largely with the interpersonal with the
interpersonal or group aspects of family life – how well the
members of the family get along with one another, the ways in
which they take decisions affecting the family as a whole.

8. Physical Environment
• This is concerned with the home, the community and the work
environment as it affects family health.

9. Use of Community Facilities

• has to do with the degree of the family’s use and awareness of
the available community facilities for health education and
welfare
 GENOGRAM

• helps the nurse outline the family’s structure . It

is a way to diagram the family . Three
generations of family members are included
with symbols denoting genealogy.
Sample genogram
 Ecomap
• a classic tool that is used to depict a family’s linkages to its
suprasystem .
• Portrays an overview of the family in their situation ; it depicts the
important nurturant of a conflict laden connection between the
family and the world . It demonstrates the flow of resources or the
lacks and deprivation .
• A mapping procedure that highlights the nature of the interfaces
and points to conflicts to be mediated, bridges to built, and resources
to be sought and mobilized.
 NCM 204
Family Nursing Process
(Formulating a Family Nursing Care Plan)

Bevan B. Balbuena, RN, MN

At the end of the lesson 3. distinguish First Level
1. define the Family 2. determine the steps for
the BSN 2 students will Assessment from Second
Nursing Process assessment
be able to: Level Assessment

5. interpret data related 6. formulate a plan of

to the identified health care to address the
4. identify Health 7. determine barriers to
condition; health conditions, needs,
Problems of a Family joint setting of goals
problems, and issues
based on priorities;

Learning Objectives
 1. Assessment
• Data collection
• Data analysis
B. Family 2. Problem definition/ Nursing diagnosis
Nursing Care 3. Planning
Process • Prioritization of problems
• Setting goals and objectives
• Selecting nursing interventions
4. Implementation
5. Evaluation
 ASSESSMENT

• Purpose: to measure the status of the family as a client in

terms of its ability to

o maintain itself as a system and a functioning unit

o to maintain wellness, prevent, control or resolve problems in
order to achieve health and well-being among its members.
Two major types of nursing assessment

1st level is a process whereby existing and

assessment potential health problems of the family
are determined.

2nd level defines the nature or type of nursing

assessment problems that the family encounters in
performing the health tasks with respect
to a given health problem, and the etiology
or barriers to the family’s assumption of
these tasks
Steps in Family Nursing Assessment
DATA COLLECTION DATA ANALYSIS NURSING DIAGNOSES

 Observation/ Ocular  Sorting data  Defining the health problems

survey  Classifying/ Grouping data (First level assessment)
 Interview/ Completing  Relating data with each  Defining the family nursing
the Health History other problems (Second level
 Physical Assessment  Determining patterns assessment)
 Laboratory/ Diagnostic  Comparing patterns with  Statement of family’s failure to
Tests norms/ standards perform specific health tasks
 Review of Records and  Integrating data  Etiology (Barriers to the family’s
Reports  Making inferences capability to perform tasks)
 Making conclusions
Step 1: Data Collection
Types of Data in Family Nursing Assessment

1. Data taken during the first level assessment

a. Family structure, characteristics & dynamics
b. Socio-economic & cultural characteristics
c. Home & environment
d. Health status of each member
e. Values & practices on health promotion/maintenance & disease
prevention
2. Data taken during the second level assessment

a. The family’s perception of the problem

b. Decisions made & appropriateness; if none, reasons
c. Actions taken & results; if none, reasons
d. Effects of decisions & actions on the family members
Data gathering methods and tools

1. Observation – use of senses

2. Physical examination - IPPA, ROS – data may indicate presence of
health deficits
3. Interview
• Types of interview:
• Completing health history for each family member
• Collecting data by personally asking significant family
members/relatives questions regarding health, family life
experiences & home environment to generate data on what
health problems exist in the family.
• Tool: FAMILY ASSESSMENT FORM/ GUIDE
Data gathering methods and tools

4. Record review
• Individual clinical records of family members, laboratory &
diagnostic reports, immunization records, reports about the home &
environmental conditions.

5. Laboratory/ Diagnostic tests

• Lab tests, diagnostic procedures or other tests of integrity &
functions carried out by the nurse or other health workers.
Step 2: Data Analysis
• Classify data by type or nature
o Wellness state
o Health threat
o Health deficit
o Stress point/ foreseeable crisis

• Compare with standard or norms

o Normal health of individual members
o Home & environmental conditions conducive to health development
o Family characteristics, dynamics or level of functioning conducive
to family development.
Step 2: Data Analysis…

Standard/norm of the family as a functioning unit involves the ability to

perform the health tasks

1. Recognize the presence of a wellness state/ health condition/ problem

2. Make decisions about taking appropriate action to maintain wellness or
manage the health problem
3. Provide nursing care to the sick, disabled, dependent or at-risk members
4. Maintain a home environment conducive to health maintenance & personal
development
5. Utilize community resources for health care.
• End result 1st level assessment: a
conclusion, a definition of a health
problem classified as health
threat, health deficit or stress
point/foreseeable crisis.

• End result of 2nd level assessment:

definition of family nursing
problems
Step 3: Nursing Diagnoses: Family Nursing Problems
A nursing problem is a situation or condition which interferes with
the promotion and/or maintenance of health and recovery from illness
or injury, & which is subject to change/modification through nursing
intervention.

A health problem becomes a nursing problem when it is stated as the

family’s failure to perform adequately specific health tasks for a
particular health problem. This is called nursing diagnosis in family
nursing practice.

Tool: TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING

PRACTICE
 PLANNING
STEPS IN DEVELOPING A Family Nursing Care Plan (FNCP)

Generally, a FNCP consists of the ff steps:

1. The Prioritized Problem
2. Goals & objectives of nursing care
3. Plan of intervention
4. Plan for evaluating care
The Prioritized Problem
SCALE FOR RANKING FAMILY HEALTH PROBLEMS

Nature of the problem – categorized into health threat, health

deficit & foreseeable crisis

Modifiability of the problem – refers to the probability of success in

minimizing, alleviating or totally eradicating the problem through
intervention.

Preventive potential – refers to the nature and magnitude of future

problems that can be minimized or totally prevented if intervention is
done on the problem under consideration

Salience – refers to the family’s perception and evaluation of the

problems in terms of seriousness and urgency of attention needed.
 CRITERIA SCORE WEIGHT
1. Nature of the Condition or Problem presented
Wellness state 3 1
Health Deficit 3
Health Threat 2
Stress point/ Forseeable Crisis 1

2. Modifiability of the Problem or condition

SCALE FOR Easily modifiable 2 2
Partially modifiable 1
RANKING Not modifiable 0
FAMILY HEALTH
PROBLEMS 3. Preventive Potential
ACCORDING TO High 3 1
PRIORITIES Moderate 2
Low 1

4. Salience
Problem, needs immediate attention 2 1
Problem but not needing immediate attention 1
Not a felt need/ problem 0
Scoring:
1. Decide on a score for each of the criteria
2. Divide the score by the highest possible score and multiply by
weight
Score x weight
Highest score
3. Sum up the scores for all the criteria. The highest score is 5,
equivalent to the total weight.
FACTORS AFFECTING PRIORITY SETTING

Nature of the Problem

• Greater weight is assigned to a health deficit

over a health threat because the former
demands more immediate intervention and is
usually recognized or felt by the patient.
• Greater weight is given to wellness condition
because it can be easily reinforced
• Foreseeable crisis is given least weight.
FACTORS AFFECTING PRIORITY SETTING

Modifiability – nurse considers the availability of

the ff factors:

• Current knowledge, technology, &

interventions
• Resources of the family
• Resources of the nurse
• Resources of the community
FACTORS AFFECTING PRIORITY SETTING

Preventive Potential – to decide on appropriate

score, consider the ff factors:

• Gravity or severity of the problem

• Duration of the problem
• Current management
• Exposure of any high risk group
FACTORS AFFECTING PRIORITY SETTING

Salience

• determined based on the family’s

perception.

• As a general rule the family’s concerns

and felt needs require priority attention.
Goals & Objectives of Nursing Care

GOAL
• a general statement of the condition or state to
be brought about by specific courses of action.

• Cardinal principle:
Goals must be set jointly with the family.
Barriers to Joint Goal Setting Between the Nurse and Family

1. Failure on the part of the family to perceive the existence

of the problem.

2. The family may realize the existence of a health problem

but is too busy at the moment.

3. The family perceives the existence of a problem but does

not see it as serious enough to warrant attention.
Barriers to Joint Goal Setting Between the Nurse and Family

4. The family may perceive the presence of the problem and

the need to take action but refuse to do something
because of the ff:
• Fear of consequences of taking action
• Respect for tradition – elders play a part in decision-making
• Failure to perceive the benefits of action proposed
• Failure to relate the proposed action to the family’s goals

5. Failure to develop a working relationship.

OBJECTIVES
❖refer to more specific statements of the desired results
or outcomes of care. They specify the criteria by which
the degree of effectiveness of care is to be measured.

❖Goals tell where the family is going, while objectives are

the milestones to reach the destination.
Example:
Nursing goal: The family will manage PTB as a disease and
threat

Short-term After nursing intervention, the family can explain

objective: the indications of the different anti-TB drugs

Long-term All the members of the family will carry out TB

objective: control measures

Medium-term All members of the family will have medical

obj. check-up and laboratory check-up (sputum exam
and X-ray)
The Plan of Interventions
• Involves selection of appropriate nursing interventions
based on the formulated goals & objectives.

• Nurse decides on appropriate nursing actions among a set of

alternatives, specifying the most effective or efficient
method of nurse-family contact and the resources needed.
Developing Intervention Plan: Guidelines
• Develop or enhance cognition, volition and emotion

• Explore with the family choices based on live experiences.

• Focus on intervention to help the family perform health tasks

o Contracting strategy
o Help the family recognize the problem
o Guide the family on how to decide on appropriate hx action to take
Developing Intervention Plan: Guidelines…

• Develop the family’s ability and commitment to provide nursing

care to its member

• Enhance the capability of the family to provide a home

environment conducive to health maintenance

• Facilitate the family’s capability to utilize community resources

for health care (e.g. referral, list of resources)

• Catalyze behavior change through motivation and support

Types of Interventions
• Health Education Program
• Screening Programs
• Establishments of Services
• Increasing Community self-help
• Increasing power among individuals
Methods of nurse-family contact:
Home visit - expensive in terms of time, effort and logistics for the
nurse

Clinic conference - less expensive; empowering responsibility for

self-help

Visit in the workplace / School visit

Telephone call - monitoring health status during acute phase

Group approach (health classes)

Use of mail/ Written com - used in larger number of families

needing follow up
Resources
▪ Materials – supplies, equipment, teaching aids/
kits, visual materials, handouts, charts

▪ Human resources – other health team members,

development workers, community leaders

❖Resources must be specified in the plan to ensure that

necessary preparations, coordination and collaboration
are done before the implementation phase.
 IMPLEMENTATION
Strategies:

1. Single action
2. Phasing
3. Collaboration and networking
4. Coalition
Teaching-Learning methods and techniques
Provide

• information to shape attitudes

• experiential learning activities
• examples or models to shape
• opportunities for Small Group Discussions
• role playing exercises
Promoting Behavior Change
Factors Affecting Behavior
1. Personal
2. Environmental involving
socio-cultural factors
Principles and Strategies in Changing Behavior
• Behavior change is dependent on individual’s perceptions of the threat of a
health problem and acceptability of recommended behavior

• Behavior change is not only on the individual’s knowledge but also on

perceptions, motivations, skills and other factors.

• Behavior change is dependent on individual’s readiness to change.

• Behavior change is dependent on the individual’s relationship among

personal factors, behavior and environment.
Individual Perception that Influence Behavior Change

• Perceived Susceptibility
• Perceived Threat
• Perceived Benefits
• Perceived Barriers
Behavior Change Intervention
A. Strengthening individual intention to change
• increased awareness and knowledge

Choose a message that should be given

to your audience
Simple
Positive
Most useful
Keep repeating the message
Behavior Change Intervention….

B. Enhance motivation to change

• Understand audience perception and expectations

• Emphasize positive attitude
• Identify social norms
• Offer incentives and reward
• Encourage commitment
Behavior Change Intervention….

C. Teach the skills needed to establish and maintain behavior

• Set achievable goals

• Provide safe and guarded practice
• Encourage self monitoring
Behavior Change Intervention….

D. Enhance Readiness to Change

• Identify individual’s place in the stage of change

• Encourage progress from one stage to the next
 EVALUATION
1. Formative Evaluation - judgment made about effectiveness of nursing
interventions
• On going- analysis during implementation of activities and effectiveness

2. Summative evaluation - determining the end results of FNCP usually involves

measuring outcomes

3. Terminal evaluation - undertaken in 6-12 mos

4. Ex post evaluation - years of project completion

Developing the evaluation plan

❖Verifies the worth of nursing actions and outcomes.

❖Specifies how the nurse will determine achievement of the

outcome of care (goals & objectives).

❖The plan includes criteria, standards, evaluation methods

and sources of data.
 Format for family nursing care plan
Date / Health Family Goal of Objectives of Intervention Method of Resources Evaluation
Cues problem Nursing Care Care s Nurse- Needed
problem Family
contact
Date Based on Based on 2nd After After nursing Interventions Home visit References Goal Met
should be 1st level level nursing interventions, should be in Messaging for health Goal
based on assessment assessment interventi the family will tandem with Social teachings partially met
the day the typology: ons, the be able to: objectives Media Goal not
plan is family will a. and should Clinic visit Finances: met
formulated. Include all be able to b. be organized
statements ________ c. according to
Categorize: that apply _ Should have the
Subjective objectives for objectives.
cues & knowledge
Objective (cognitive),
cues skills
(psychomotor)
and attitude
(affective)
Name and
Signature
 NCM 204
Family Nursing Process
Categories of Interventions

Bevan B. Balbuena, RN, MN

Learning Objectives

At the end of the lesson, the BSN 2 students will be able to:

1. identify the different categories of nursing interventions in the

community setting;
2. describe the roles of various agencies involved in interprofessional
care in the community; and
3. discuss the importance of evaluation.
 Implementing Family Nursing Care Plan

Categories of Intervention
• Promotive
• Preventive
• Curative
• Rehabilitative
PROMOTIVE
• Enabling people to increase control
over and improve their health.
• It involves the population as a whole
in the context of their everyday
lives.
Four (4) core service elements related to health promotion

1. prevention of disease, injury and illness;

2. health education, anticipatory guidance and parenting skill

development;

3. support that builds confidence and is reassuring for

mothers, fathers and carers; and

4. community capacity building.

Examples of Promotive Care
• Dietary teaching during pregnancy
• Education and counseling regarding dental care or nutrition
• Adequate housing
• Mothers’ class on breastfeeding
• Flouride water supplementation
• Healthy lifestyle practices
• Promoting physical activity
PREVENTIVE
• Deals with the prevention of illness to
decrease the burden of disease and
associated risk factors .
• Focuses on preventing disease and
illness and promoting overall general
health and well being.
Examples of Preventive Care
• Removal of environmental hazards
• Campaign for drug abuse prevention for high school students
• Counseling about smoking cessation
• Screening for cancer
• HIV testing
• Diabetes screening for family at risk
• Mass sputum exam in low-income neighborhood
• Vision screening for first-grade class
• Hearing tests at a center for the elderly
CURATIVE
• Is to cure a disease or promote
recovery from an illness, injury or
condition; involves treatment
intended to alleviate the symptoms
or cure a current medical condition.
Examples of Curative Care
• Shourtcourse chemotherapy for TB patients
• Radiation therapy and surgery for cancer
• Drug therapy for stroke
• Dialysis treatment for kidney failure
• Surgery for appendicitis
• Cast for a fractured limb
• Antibiotics for bacterial infection
REHABILITATIVE
• Nurses assist patients with
temporary and long-term disabilities
or chronic illnesses.
• They assist in adapting to their
conditions, meeting their highest
potential, and living more
independent lives.
Examples of Rehabilitative Care
• Exercise therapy for stroke
• Mental health counseling or referral for family in crisis
• Teaching diabetic clients how to administer insulin
• Group counseling for children with asthma
• Exercise program for diabetics
• Home care services for chronically ill
• Mental health services for military veterans
• Alcoholic anonymous and other self-help groups
• Shelter for typhoon victims
 Types of Family-Nurse Contact
Clinic Visit Home Visit
• health care services provided to patients on • allows the health worker to assess the
an ambulatory basis, rather than by home and family situations in order to
admission to a hospital or other health care provide the necessary nursing care and
facility. health related activities.

Group Conference Written Communication

• often involves the entire family and can be • Is another less time consuming option for
done at home, clinic, school or work place. the nurse when there are a large number of
families needing follow-up on top problems
• It is useful in a situation where the family
of distance and travel time if the family is
has a chronic problem that is having a
motivated and independent.
negative effect on the entire family.

Telephone calls
• May be effective , efficient and appropriate
if the objectives and outcomes of care
require immediate access to data, given
problems on distance or travel time .
Interprofessional Care in the Community
Interprofessional Practice (IPP) -is a collaborative
practice which occurs when healthcare
providers work with people from within their
own profession, with people outside their
profession and with patients and their families

1. Rural Health Unit Personnel

2. Local Government Units
3. Government Organizations
4. Non-government Organizations
Government Organizations

1. Department of Social Welfare and

Development (DSWD)
- mandated to develop poverty-reduction solutions for
and with the poor, vulnerable, and disadvantaged.

The following agencies are attached to the DSWD:

• Council for the Welfare of Children
• Inter-Country Adoption Board
• National Youth Commission
• National Council on Disability Affairs
2. Nutrition Council

National Nutrition Council Core Functions

• Formulate national food and nutrition policies and strategies
and serve as the policy, coordinating and advisory body of food,
nutrition and health concerns
• Coordinate planning, monitoring , and evaluation of the
national nutrition program
• Coordinate the hunger mitigation and malnutrition prevention
program to achieve Millennium Development Goals;
Nutrition council…
• Strengthen competencies and capabilities of stakeholders
through public education, capacity building and skills
development
• Coordinate the release of funds, loans, and grants from
government organizations (GO’s) and non government
organizations (NGO’S); and
• Call on any department, bureau, office, agency, and other
instrumentalities of the government for assistance in the
form of personnel, facilities and resources as the need
arises
3. Population Commission

The Commission on Population (POPCOM)

- is a government agency mandated as the over-all
coordinating, monitoring and policy making body of the
population program
Non- Government Organizations
• Socio-Civic Organizations
- a nonprofit organization or corporation that is operated exclusively for
the promotion of social welfare

• Religious Organizations

• Schools
Evaluation of Family Nursing Care
Evaluation Process and Outcomes:

Evaluation
• Provides critical Information to decision makers:
• Evaluation of public health programs
• Performance of health facilities/human resources
• Nursing care given to clients
Evaluation…

Public Health Nurses

• primarily responsible for evaluating the nursing care

Head of the unit/Physician

• primarily responsible in the evaluation of the local
health program
• PHNs participates in these evaluation
Evaluation of the Nursing Care
As to Alfaro-LeFevre, evaluating nursing care to individuals and
families includes analyzing nursing inputs in each step of nursing
process

Assessment
• determine whether there are changes in health status

Diagnosis
• determine if problems requiring nursing care are resolved,
improved or controlled consider if there are new problems
Planning
• determines if the intervention are appropriate and adequate to
achieve client outcomes .

Implementation
• analyzes how the plan was implemented to determine what
factors are related with the success in implementing the plan;
• specify what factors created problems or barriers to care-once
steps are taken.
Evaluation
• Evaluation is a distinct process
• Evaluation is related with and primarily based on the
objectives of nursing care
• Evaluation is comparing “what actually” is with “what
should be”
• Evaluation Process can be initiated at the planning stage
where objectives and criteria are specified
 NCM 204
Community Health Nursing

Bevan B. Balbuena, RN, MN

Learning Objectives

At the end of the lesson, the BSN 2 students will be able to:

1. define community health nursing, public health, and other related

terms;
2. identify the clientele of the community health nurse;
3. discuss the principles and standards of public health nursing;
4. trace the history of community health nursing; and
5. describe the roles of the public health nurse;
 INTRODUCTION TO
Community Health Nursing
• Unnecessary and unfair gaps in the health care
delivery system that deprive the poor of access
to basic services must be reduced.

• The system must work efficiently to reach the

highest possible health standards that can be
shared by all Filipinos, given the limited
resources available for health.

• The primary health care (PHC) approach,

especially in a devolved set-up, ensures the
widest participation of people and their
communities in attaining health for
themselves.
Community defined
• It is a local area over which people are using the same
language, conforming to the same feelings, more or
less the same sentiments and acting upon the same
attitudes. (Sutherland)

• Community can be viewed 3 Ways:

❖geographical location
❖social system
❖collection of people

• a social group determined by geographical boundaries

and/or common values and interests (WHO)
Community Health Nursing defined
• is a learned practice discipline with the
ultimate goal of contributing as individuals,
and in collaboration with others, to the
promotion of the client’s optimum level of
functioning through teaching and delivery of
care. (Jacobson)

Goal: promotion of
Learned practice Strategy: Teaching &
optimum level of
discipline delivery of care
functioning (OLOF)
Community Health Nursing defined
• A service rendered by the professional nurse with the
Community
Schools
Groups
Place of work
Families
Clinic
Individuals at home
Health center
Community Health Nursing defined
• The utilization of the nursing process in the
different levels of clientele – individuals, families,
population groups and communities, concerned
with the promotion of health prevention of
disease and disability and rehabilitation (Maglaya, et al)

• Promotion of health, prevention of illness, care of

the sick at home and rehabilitation (Ruth B. Freeman).
Community Health Nursing defined
• The synthesis of nursing practice and public health practice applied to
promoting and preserving the health of populations (ANA, 1980)

The philosophy of CHN is based on the

worth and dignity of man (Dr. Margaret Shetland).
 CONCEPTS of CHN
1. The primary focus of CHN practice is on HEALTH PROMOTION.
2. CHN practice is extended to the benefits not only the individual but
the whole family and community.
3. CH nurses are generalists in terms of their practice through life’s
continuum.
4. Contact with the client continues over a long period of time and
includes all ages and all types of health care.
5. CHN practices requires utilization of current knowledge derived from
the biological and social sciences, ecology, clinical nursing, and
community health organization.
6. Implicit in the practice of CHN is the dynamic process of assessment,
planning, implementing, and intervening, providing periodic
assessments of progress, evaluation and a continuum of the cycle
until the termination of nursing of nursing is implicit in the practice
of CHN.
 OBJECTIVES
GOAL 1. To participate in the development of an over-all health plan
for the community and in its implementation and evaluation.
2. To provide quality nursing service to IFCs utilizing as basis,
To raise the the standards sets for CHN practice.
3. To coordinate nursing services with various members of the
level of health team, community leaders and significant others,
government and non-government agencies/organization in
health of achieving the aims of public health services within the
community.
citizenry 4. To participate in and/ or conduct researches relevant to
community, health and community health nursing services
and disseminate their results for improvement of health care.
5. To provide CHN personnel with opportunities for continuing
education and professional growth thru staff development.
 PRINCIPLES of CHN
Primary responsibility: health teaching

Resources available in the community is utilized

Integrates with other health team member

Needs are recognized by community, family, groups, individuals

Caters all people

Inaccuracy in recording & reporting is avoided

Policies & objectives must be understood

Look at the family as the unit of service

Evaluate existing organization are used

Staff education
 CLIENTS OF THE CH NURSE:
Family

Population Groups

Individual

Community
PUBLIC HEALTH (Dr. C.E. Winslow)

Public health is a science and art of preventing

disease, prolonging life, promoting health and
efficiency through organized community efforts for:

1. the sanitation of the environment,

2. control of communicable diseases,
3. the education of individuals in personal hygiene,
4. the organization of the medical and nursing service for
the early diagnosis and preventive treatment of disease,
and
5. the development of the social machinery to ensure
everyone a standard of living adequate for the
maintenance of health, so organizing these benefits as to
enable every citizen to realize his birth right of health
and longevity.
PUBLIC HEALTH

• refers to the health status of the

members of the community, to the
problems affecting their health and to
the totality of health care provided
for the community. (WHO)
 Principles of Public Health
1. Health care should be shaped around
life patterns of the population. It should
serve and should meet the needs of the
community.

2. Primary health care should be an

integral part of the national health
system and other echelons of services
should be designed in support of the
needs of the peripheral level.
Principles of Public Health….
3. Health care activities should be fully
integrated with the activities of other sectors
involved in community development.

4. The local population should be actively

involved in the formulation &
implementation of health care activities.

5. The health care offered should place

maximum reliance on available community
resources and should remain within the cost
limitations relevant to each country.
Principles of Public Health….
6. Health care should be an integrated
approach of preventive and
rehabilitative services for the individual,
family and community.

7. The majority of interventions should be

undertaken at the most peripheral
practice level of the health services by
workers most suitably trained for
performing these activities.
 STANDARDS of PHN
1. Theoretical application of concept into the nursing practice.
2. Accurate & comprehensive data collection.
3. Formulation of diagnosis based on data collected.
4. Developing plans for a specific nursing care based on the unique needs of the client.
5. Formulation of interventions to promote, prevent, restore health & rehabilitation.
6. Evaluates goal based on the responses of the individual, family and community whether
it was achieved, and if not, possible revision of database, diagnosis & plan.
7. Quality assurance & Professional development
8. Collaboration with other health care team in assessing, planning, implementing, and
evaluating community programs.
9. Nursing research
 Historical Background of CHN

• 1901- Phil. Commission created a BOARD OF HEALTH (Act No. 157)

• 1905- (Reorganization Act) Bureau of Health
• 1912- Fajardo Act (Act 2156) created SANITARY DIVISIONS
• Male nurses were assigned to perform the duties of the President,
Sanitary Division
• 1912- PGH sent nurses to Cebu to take care mothers & babies
• 1941 Outbreak of World War II, Public Health Nurses in Manila were
assigned in devastated areas
 Historical Background of CHN…

1987-1989- Executive order No. 119 reorganized the Department of

Health and created several offices & services within the DOH

1990-1992 Local Government Code (RA 7160) was passed &

implemented

1993-1998 National League of Nurses, Inc. made repeated

representations with the incumbent secretary of health
 ROLES OF A PUBLIC HEALTH NURSE

1. Planner & programmer

• Identifies needs,
priorities and problems
of individuals, family
and community.

2. Provider of Nursing Care

• Provision of nursing
care to the sick/disabled
in the home, clinic,
school or place or work.
Roles of a public health nurse

3. Manager & supervisor

• Organizes workforce, resources,
equipment and supplies and
delivery of health care at local
levels.

4. Community organizer
• Responsible for motivating and
enhancing community participation
in terms of planning, organizing, and
implementing and evaluating hx
programs and services.
Roles of a public health nurse

5. Coordinator of services
• Coordinates with individuals, family, and groups
for health and health-related services by various
members of health team and other Government
Organizations (GO) and Non-government
organizations (NGO).

6. Trainer/Health Educator/ Counselor

• Identifies and interprets training needs of
barangay health workers(BHW), Hilots and
registered midwives(RM)
• Information & education campaign (IEC) activities
• Pre & Post conference for clinic patients.
Roles of a public health nurse

7. Health monitor
Detects deviation from health of
the people through visits/contacts
with them.

8. Role model
Provides good example/model of 9. Change agent
healthful living to the Motivates changes in health behavior of
public/community. individuals, families, group, and
community including lifestyle in order to
promote and maintain health.
Roles of a public health nurse

10. Recorder, Reporter, Statistician

• Prepares and submits reports
and records.

11. Researcher
• Participates/assist in the conduct of
survey studies and researches on
nursing and health related subjects.
 Department of health
Programs & services

Bevan B. Balbuena, RN, MN

San Pedro College
DOH PROGRAMS RELATED
TO FAMILY HEALTH
1. Expanded Program of Immunization (EPI)
2. Integrated Management of Childhood Illnesses (IMCI)
3. Essential Intrapartal and Newborn Care (EINC)
4. Newborn Screening
5. BEmONC/CEmONC
6. Nutrition
7. Mental Health Gap Action Program (MhGAP)
 National Immunization Program/
Expanded Program on Immunization ( EPI )
• in the Philippines began in July 1979
• every Wednesday is designated as immunization day

GOALS
To achieve the over-all goal of reducing the
morbidity and mortality among children against the
most common vaccine-preventable diseases.
Mandates:
• PD 996, in 1976 - Providing for compulsory basic immunization for
infants and children below eight years of age

• RA 10152- known as Mandatory Infants and Children Health

Immunization Act of 2011 requires all children under 5 years old to
be given basic immunization against vaccine preventable diseases.

• RA 7846 - Provides for compulsory immunization against Hepatitis B

for infants and children below 8 years old . It also provided for
Hepatitis B immunization within 24 hours of birth
IMMUNIZATION: Concepts
• Immunization is the process whereby a person
is made immune or resistant to an infectious
disease, typically by the administration of a
vaccine.

• Vaccines stimulate the body’s own immune

system to protect the person against
subsequent infection or disease

• Six vaccine-preventable diseases were initially

included in the EPI: tuberculosis,
poliomyelitis, diphtheria, tetanus, pertussis
and measles.
 Vaccinations promote health and protect
children from disease–causing agents.

 Infants and newborns need to be

vaccinated at an early age since they
belong to vulnerable age group. They are
susceptible to childhood disease.
The fully immunized child (FIC)
must have completed one dose of
BCG, 3 doses of OPV, 3 doses of
DPT, 3 doses of Hepatitis B or 3
doses of Pentavalent and one dose
of measles vaccines before the
child reaches 12 months of age.
COMPLETELY IMMUNIZED CHILDREN ( CIC) –refers to
children who completed their immunization schedule at the
age of 12-23 mos.

CHILD PROTECTED AT BIRTH (CPAB)

- a term used to describe a child whose mother has
received:
✓2 doses of TT during this pregnancy provided that the
second dose was given at least a month prior to delivery
✓At least 3 doses of TT anytime prior to pregnancy with this
child
 Vaccine Reason

Bacillus Calmette- Protects the possibility of TB meningitis and other TB

Guérin infections in which infants are prone

Diphtheria-
An early start with DPT reduces the chance of severe
Pertussis-Tetanus pertussis.
Vaccine
The extent of protection against polio is increased the
Oral Polio Vaccine
earlier the OPV is given.

An early start of Hepatitis B vaccine reduces the chance

Hepatitis B of being infected and becoming a carrier.
Vaccine Prevents liver cirrhosis and liver cancer which are more
likely to develop if infected with Hepatitis B early in life

Measles Vaccine
At least 85% of measles
.
can be prevented by
immunization at this age
(not MMR)
 IMMUNIZATION SCHEDULE
Vaccine Minimum # of Dosage Interval Route Site
Age of First Doses between doses
Dose
BCG At Birth 1 0.05mL - ID R deltoid region of the arm

Pentavalent 6 weeks 3 0.5mL 4 weeks IM Vastus Lateralis

OPV 6 weeks 3 2 drops 4 weeks Oral Mouth
Hep B At birth 3 0.5mL 4 weeks IM Vastus Lateralis
Measles 9 months 1 0.5mL - SQ Upper Outer Portion of the
AMV1 Arm

MMR 12-15 months 1 0.5mL - SQ Upper Outer Portion of the

Arm

IPV 14 weeks 1 0.5mL - IM Vastus Lateralis

PCV 6 weeks 3 0.5mL 4 weeks IM Vastus Lateralis
RTV 6 weeks 3 1mL 4 weeks PO Side of the mouth
 Concepts…
• Maintain a master list of eligible children for
immunization.

• Administer immunization following the

protocols:
• right administration of vaccines
• right dose
• right route
• right schedule
• right interval
• proper utilization of cold chain
Concepts..
Infuse proper aseptic technique and
infection control
 one syringe: one child
 proper disposal of syringes

Provide health teachings to enhance the

awareness of community.
• Conduct visits in the community to
assess their needs and to identify cases
of EPI diseases.

• Have an updated record of children who

had received immunization and the like
and report cases if there is.
 PRINCIPLES IN HANDLING, TRANSPORTING
& STORING VACCINES
 COLD CHAIN Cold chain” refers to the process used to
Equipment: maintain optimal conditions during the
 Cold room transport, storage, and handling of vaccines,
 Freezer / Refrigerator starting at the manufacturer and ending
 Transport box with the administration of the vaccine to
 Vaccine carrier the client.
 Thermometer
 Cool dog
Temperature monitoring A "first expiry and first out" (FEFO)
Vaccine vial monitor (VVM) vaccine system is practiced to assure that
all vaccines are utilized before its expiry
 FIRST EXPIRY FIRST OUT date
 COLD CHAIN LOGISTIC MANAGEMENT
• VVM (Vaccine Vial Monitoring)
• Thermo chromic label- colored lilac
• A round disc of heat-sensitive material placed on a vaccine vial to register cumulative heat
exposure.
• Indicator that the vaccine was kept at the temperature that the potency required.
❖ Temperature monitoring of vaccines is done in all levels
of health facilities to monitor vaccine temperature

❖ Temperature checking is done by the nurse twice a day in

the morning and in the afternoon before going home

❖ Temperature is plotted every day in monitoring chart to

monitor break in cold chain
 Sensitivity to TYPE OF STORAGE HOURS OF LIFE
temperature VACCINE TEMPERATURE AFTER OPENING

Most Sensitive to OPV -15 to -25 oC @ the

Heat freezer

Most Sensitive to Hepatitis B, +2to +8 oC Body of

Cold PENTA, Tetanus the refrigerator
toxoid, Rotavirus

MMR/Measles 6 hours

Sensitive to sunlight BCG 2 to 8 oC Body of 6 hours

and Flourescent light the refrigerator
OTHER CONSIDERATIONS TO MAINTAIN POTENCY

1. Multidose liquid vaccine

(Penta, TT, Hep B) may be used to a maximum of 4 weeks

2. Reconstituted freeze dried vaccine (BCG, AMV, MMR )will be

discarded within 6 hours
a. Use designated diluents for reconstitution
b. Protect BCG from sunlight and Rotavirus from light
Important Considerations Related to the schedule and manner of
administering infant immunization

1. There is no need to restart a vaccination regardless of the

time that has elapsed between doses.
2. All the EPI antigens are safe and effective when administered
simultaneously
3. It is not recommended to mix different vaccines in one syringe
4. Vaccines should be administered in different sites
5. If more than one vaccine has to be given on the
same limb injection site must be 2.5-5cm apart

6. OPV first, followed by Rotavirus

7. First dose of Rotavirus is administered only to infants

aged 6-15 weeks 2nd dose is given to aged 10
weeks -32 weeks only
CONTRAINDICATIONS

1. Anaphylaxis or severe hypersensitivity reaction to a previous dose

2. Person with a known allergy to a vaccine component SHOULD NOT

be vaccinated

3. Pentavalent vaccine/DPT to a child with recurrent convulsions or

another active neurological disease
Contraindications …

4. Pentavalent 2 or 3 to a child who has had convulsions within 3 days

of the most recent dose (WHO, 2005)

5. Rotavirus vaccine when the child has a history of previous dose of the
vaccine, intussusception or intestinal malformation or AGE (DOH,
2012)

6. Do not give live vaccines like BCG to an immunosuppressed client

7. A child with signs and /symptoms of severe dehydration

8. Fever of 38.5C and above

SIDE EFFECTS OF VACCINATION AND THEIR MANAGEMENT
Vaccine Side Effects Management
BCG Koch’s phenomenon: an acute No management is needed
inflammatory reaction 2-4 days after
vaccination, usually indicates previous
exposure to tuberculosis

Deep abscess at vaccination site Refer to physician for

incision and drainage

Indolent ulceration: an ulcer which persist Treat with INH Powder

after 12 weeks from vaccination

Glandularenlargement: enlargement of the If suppuration occurs, treat

lymph glands draining the injection site as deep abscess
Vaccine Side Effects Management
Hepatitis B Local soreness at the No treatment is needed
Vaccine injection site

Pentavalent Fever that lasts for 1 day, but fever Advise parent to give antipyretic
beyond 24 hours is not due to the
vaccine but to other causes
Local soreness of the injection site Reassure parents that soreness
will disappear after 3-4 days
Convulsions : although very rare may Proper management of
occur in children older than 3 months convulsions ; pertussis vaccine
caused by pertussis vaccine should not be given anymore

OPV None
Vaccine Side Effects Management

AMV Fever 5-7 days after vaccination in Reassure parent and instruct
some children; sometimes there is a to give antipyretic to the child
mild rash
MMR Local soreness, fever , irritability, Reassure parent and instruct
and malaise in some children to give antipyretic

Rotavirus Some children develop mild Reassure parents and

vomiting and diarrhea , fever and instruct them to give
irritability antipyretic and oresol to the
child

Tetanus toxoid Local soreness at the injection site Apply cold compress at the
site; no other treatment
Integrated Management of
Childhood Illnesses (IMCI)
IMCI…
• is an integrated approach to child health that focuses on the well-
being of the whole child.

Aim:
❖ to reduce death, illness and disability, and to promote improved
growth and development among children under five years of age.
Who are the children covered by
the IMCI protocol ?

• Sick children birth up to 2

months
(Sick Young Infant)

• Sick children 2 months up to 5

years old
(Sick child)
STEPS IN THE IMCI
CASE MANAGEMENT PROCESS
• Assess the child ‘s illness.
• Classify the illness based on signs
• Identify the treatment
• Treat the child.
• Counsel the mother.
• Follow-Up
 Main Symptoms
• Cough or difficult breathing
• Fever
• Diarrhea
• Ear Problems
▪ Is a package of evidence-based practices
recommended by the Department of Health (DOH),
Philippine Health Insurance Corporation (Philhealth),
and the World Health Organization (WHO) as the
standard care in all births by skilled attendants in all
government and private settings.

▪ It is a basic component of DOH’s Maternal Newborn and

Child Health and Nutrition (MNCHN) strategy.
EINC practices for newborn care
constitute a series of time bound
chronologically-ordered, standard
procedures that a baby receives at birth.

At the heart of the protocol are four time

bound interventions such as:
▪ Immediate drying
▪ Skin to skin contact
▪ Proper cord clamping and cutting
▪ Non separation of baby from mother
and breastfeeding initiation
▪ The Comprehensive Newborn Screening (NBS) Program was
integrated as part of the country’s public health delivery system
with the enactment of the Republic Act no. 9288 otherwise known
as Newborn Screening Act of 2004.

▪ Department of Health (DOH) acts as the lead agency in the

implementation of the law and collaborates with other National
Government Agencies (NGA) and key stakeholders
▪ It is also a service that has been available in the
Philippines since 1996. Under the DOH, NBS is part of the
Child Development and Disability Prevention Program at
the Disease Prevention and Control Bureau.
PURPOSES:
▪ To ensure early detection and management of several
congenital metabolic disorders, which if left untreated,
may lead to mental retardation and/or death.

▪ Early diagnosis and initiation of treatment, along with

appropriate long-term care

▪ Help ensure normal growth and development of the

affected individual.
VISION

▪ The National Comprehensive Newborn Screening System

envisions all Filipino children will be born healthy and
well,
with an inherent right to life,
endowed with human dignity; and
reaching their full potential with the right
opportunities and accessible resources.
MISSION
▪ To ensure that all Filipino children will have access
to and avail of total quality care for the optimal
growth and development of their full potential.

GOAL
▪ To reduce preventable deaths of all Filipino
newborns due to more common and rare congenital
disorders through timely screening and proper
management
Newborn screening program in the Philippines currently includes screening of six
disorders:
▪ congenital hypothyroidism (CH)
▪ congenital adrenal hyperplasia (CAH)
▪ phenylketonuria (PKU)
▪ glucose-6- phosphate dehydrogenase (G6PD) deficiency
▪ galactosemia (GAL)
▪ maple syrup urine disease (MSUD).

▪ The expanded screening will include 22 more disorders such as hemoglobinopathies

and additional metabolic disorders, namely, organic acid, fatty acid oxidation, and
amino acid disorders. The latter are included in the standard care across the globe.
Newborn screening tests may include:

• Phenylketonuria (PKU). PKU is an inherited disease in which the body

cannot metabolize a protein called phenylalanine. Without treatment, PKU
can cause intellectual disability.

• Congenital hypothyroidism. This is a condition in which the baby is

born with too little thyroid hormone. Untreated low thyroid hormone levels
can lead to mental developmental problems and poor growth.

• Galactosemia. This is an inherited disorder in which the baby is unable to

metabolize galactose, a milk sugar. Without treatment (avoidance of milk),
galactosemia can be life threatening. Symptoms may begin in the first two
weeks of life.
▪ G6PD deficiency is an inherited condition. It is when the body doesn't have enough of
an enzyme called G6PD (glucose-6-phosphate dehydrogenase). This enzyme helps red blood cells
work correctly. A lack of this enzyme can cause hemolytic anemia. This is when the red blood cells
break down faster than they are made.

▪ Congenital adrenal hyperplasia Babies born with congenital adrenal

hyperplasia (CAH) cannot make enough of the hormone cortisol, which helps control energy, sugar
levels, blood pressure, and how the body responds to the stress of injury or illness. CAH may also
affect the development of the genitals and the hormones of puberty.

▪ Maple syrup urine disease. This is an inherited disorder caused by an inability

of the body to properly process certain parts of protein called amino acids. The name comes from
the characteristic odor of maple syrup in the baby's urine caused by the abnormal protein
metabolism. If untreated, it is life threatening as early as the first two weeks of life. Even with
treatment, severe disability and paralysis can occur.
BASIC EMERGENCY OBSTETRIC AND NEWBORN
CARE (BEmONC)

PROVIDER FACILITIES: These facilities are upgraded or

enhanced Barangay Health Station (BHS), Rural Health Unit
(RHU), District and Community Hospitals that are required to
provide the following services:
1. Pre-pregnancy package of services include the
following provisions:

A. Micronutrient supplementation consisting of important minerals

and vitamins such as zinc, iodine, calcium, vitamin A capsules
and iron tablets
▪ Iron folate 60 mg tablets 1 tablet daily
▪ Vitamin A at least 5000 IU every week (a daily multivitamin
supplement maybe taken as option when the required vitamin A is
not available)
▪ Promotion of use of iodized salt
B. Tetanus toxoid immunization following the recommended schedule

C. Family Planning
▪ IEC and FP counseling with focus on modern methods and fertility
awareness and observing the principles of informed choice, birth
spacing, responsible parenthood and respect for life
▪ Contraceptive provision as appropriate.

D. Provision of oral health services

E. Counselling on STI/HIV/AIDS, nutrition, personal hygiene, and the

consequences of abortion
F. STI screening using syndromic approach

G. Adolescent and youth health services including peer and professional

counselling and RH education

H. Promotion of healthy lifestyle including advice relative to smoking

cessation, healthy diet, regular exercise and moderate alcohol intake.

I. Management of lifestyle-related diseases like diabetes,

cardiovascular disease (CVD), etc.

J. Prevention and Management of other diseases including tuberculosis,

malaria (e.g. provision of insecticide treated bed nets for malaria-
infested areas), schistosomiasis, and anemia.
2. Complete Pre-Natal Package

A. Provision of essential antenatal care services

▪ Monitoring of height and weight

▪ Taking the blood pressure

▪ Screening and blood testing including Complete Blood Count, blood Typing,
urinalysis, VDRL or RPR, HbSAg, blood sugar screening, pregnancy test,
cervical cancer screening using acetic acid wash and papanicolau smear.

▪ Micronutrient supplementation (iron, folate and Vitamin A supplementation)

▪ Malaria prophylaxis where appropriate

▪ Deworming

▪ Birth planning
B. Promotion of exclusive breastfeeding, newborn
screening, BCG and Hepatitis B birth dose immunization.

C. Counselling on
▪ use of modern FP methods especially lactation amenorrhea
(LAM), with focus on health caring and health seeking
behaviors; and

▪ contraception including surgical procedures where appropriate:

bilateral tubal ligation (BTL), no-scalpel vasectomy (NSV) and
management of complications resulting from contraception.
D. Laboratory screening and medical management of STI-
HIV cases and their complications.

E. Counselling on Healthy Lifestyle with focus on

smoking cessation, healthy diet and nutrition, regular
exercise, STI control HIV prevention and oral health .

F. Prevention and management of early bleeding in

pregnancy.

G. Administration of antenatal loading dose of steroids for

threatened premature delivery.

H. Early detection and management of signs of

complications of pregnancy.
I. Measurement of fundic height against the age
of gestation, fetal heart beat and fetal
movement count to assess the adequacy of
fetal growth and well being.

J. Prevention and management of other

conditions as indicated:
• Hypertension
• Anemia
• Diabetes
• Tuberculosis
• Malaria
• Schistosomiasis
• STI/HIV/AIDS
K. Provision of other support services

▪ Antenatal registration
▪ Birth Planning
▪ Home visits and follow up
▪ Safe blood supply
▪ Transportation and communication support services
3. Complete Childbirth Package for the mother :
▪ Monitoring vital signs and the progress of labor using the partograph.

▪ Identification of early signs and symptoms and administration of

appropriate management of prolonged labor, hypertension, abnormal
presentation, bleeding.

▪ Active management of the third stage of labor.

▪ Provision of immediate post-partum nursing care

(prior to discharge from the delivery room)
▪ Perineal washing
▪ Changing of hospital gown
▪ Checking vital signs
▪ Rooming-in
For the newborn:
▪ Drying to keep the baby warm

▪ Provision of appropriate thermal care through mother and

newborn skin-to skin contact, maintaining a delivery room
temperature of 25-28 degrees centigrade and wrapping the
newborn with clean, dry cloth.

▪ Immediate latching on and initiation of breastfeeding within first

hour after birth.
▪ Non-immediate cord clamping (1-3 minutes or until cord
pulsation stops)

▪ Should complications occur, a BEmONC provider facility must

be able to: administer the following emergency care services:
▪ Parenteral administration of oxytocin in the third stage of labor.
▪ Parenteral administration of loading doses of anti-convulsant.
▪ Parenteral administration of initial dose of antibiotics.

▪ Assisted vaginal delivery during imminent breech delivery.

▪ Manual removal of placenta
▪ Removal of retained placental products.
▪ Administration of loading dose of steroids for premature
labor.
▪ Administration of intravenous fluid, blood volume expander
and/or blood transfusion.
▪ Newborn resuscitation
▪ Treatment of neonatal sepsis as necessary.
▪ Oxygen support for newborns
4. Complete Post-Partum and Post-Natal Package

For the mother:

▪ Post-partum check up including identification of early signs and symptoms of
postpartum complications like hemorrhage, infection and hypertension
▪ Micronutrient supplementation, including iron and folate.
▪ Counselling on
1. Proper Nutrition.
2. Benefits of exclusive breastfeeding up to six months.
3. Benefits of skin to skin contact especially among preterm babies
4. Essential neonatal care
▪ Laboratory screening and medical management of STI-HIV cases and
their complications

▪ Provision of FP services and contraception including surgical procedures

where appropriate: bilateral tubal ligation (BTL), no-scalpel vasectomy
(NSV) and management of complications resulting from contraception.

▪ Prevention and management of other diseases as indicated:

Hypertension Malaria
Diabetes Schistosomiasis
Anemia STI/HIV/AIDS
Tuberculosis
For the baby:
▪ Post-natal care required within 24 hours after birth includes
▪ Cord care
▪ Breastfeeding
▪ Vitamin K injection
▪ Eye prophylaxis
▪ Delayed bathing until 6 hours of life
▪ BCG and first dose of Hepatitis B Immunization
▪ Newborn screening
▪ Counselling on post-partum/post-natal check-up, home care and
immunization
5. Provision of other support services
▪ Birth registration
▪ Safe blood
▪ Transportation and communication
 COMPREHESIVE EMERGENCY OBSTETRIC AND
NEWBORN CARE (CEmONC)

PROVIDER FACILITIES are departmentalized district, provincial

and regional hospitals. These hospitals shall provide the
following services:
1. Pre-pregnancy care
2. Prenatal care package
3. Complete childbirth package

Basic Emergency Obstetric and Newborn Care

▪ Parenteral administration of oxytocin in the third stage of labor.
▪ Parenteral administration of initial dose of antibiotics.
▪ Assisted vaginal delivery during imminent breech delivery.
Basic Emergency Obstetric and Newborn Care

▪ Manual removal of placenta.

▪ Removal of retained placental products.
▪ Administration of loading dose of steroids for premature labor.
▪ Intravenous fluid administration, blood volume expander and/or blood
transfusion.
▪ Newborn resuscitation.
▪ Treatment of neonatal sepsis
▪ Oxygen support for the newborn.
▪ Comprehensive Emergency Obstetric and Newborn Care
Caesarian section
Blood transfusion
Management of newborn complications
4.) Postpartum/ postnatal care
▪ Postpartum care package

In addition, the CEmONC provider facilities shall provide

comprehensive emergency postnatal care that include life support
management for -
▪ low birth weight newborns
▪ premature newborns
▪ sick newborns
▪ sepsis
▪ fetal alcohol syndrome
▪ asphyxia
▪ severe birth trauma
▪ severe jaundice
▪ others
Micronutrient Program

Goal of Micronutrient:
▪ Achievement of better health outcomes, sustained health financing
and responsive health system by ensuring that all Filipinos
especially the disadvantaged group (lowest 2 income quantiles)
have equitable access to affordable health care.
Objectives:
1. Contribute to the reduction of disparities related to nutrition through a focus on
population groups and areas highly affected or at risk to malnutrition

2. To provide vitamin A capsules, iron and iodine supplements to treat or prevent

specific micronutrient deficiencies

3. Go to scale with key interventions on micronutrient supplementation, food

fortification, salt iodization and nutrient education.

4. Revive, identify, document and adopt good practices and models for nutrition
improvement.

5. Build Nutrition human resource in relevant departments/ agencies.

INTERVENTIONS/ STRATEGIES EMPLOYED OR
IMPLEMENTED

1. Micronutrient Supplementation- is the provision of

pharmaceutically prepared vitamins & minerals for treatment
or prevention of specific micronutrient deficiency.

2. Food Fortification- the addition of essential micronutrients to

widely consumed food product at levels above its normal state.
INTERVENTIONS/ STRATEGIES EMPLOYED OR IMPLEMENTED…

3. Improving diet/ dietary diversification- the adoption of proper

food and nutrition practices thru nutrition education food
production & consumption.

4. Growth monitoring and promotion- is an educational strategy

for promoting child health, human development and quality of
life through sequential measurement of physical growth and
development of individuals in the community.
The following policies were formulated and implemented:

▪ AO No. 2010-0010: revised Policy on Micronutrient

Supplementation to support achievement of 2015 MDG
Targets to reduce under-five and maternal deaths and
micronutrient needs of other population groups

▪ AO No. 2007-0045: Zinc Supplementation and

reformulated Oral rehydration salt in the Management of
diarrhea among children
▪ ASIN Law- R.A. 8172, “An act promoting salt iodization
nationwide and for other purposes”, signed into law on
Dec. 20, 1995

▪ Food Fortification Law, R.A. 8976, “An act establishing

the Philippine Food Fortification Program and for other
purposes” mandating fortification of flour, oil and sugar
with Vit A and flour and rice with iron by November 7,
2004 and promoting voluntary fortification through the
SPSP, signed into law on November 7, 2000
▪ Department Memorandum No. 2011-0303 “Micronutrient
powder supplementation for children 6-23 months”

▪ Micronutrient supplementation manual of operations was

developed to guide local, regional and national managers
and implementers in providing good quality micronutrient
supplementation services to targeted populations
nationwide
▪ is WHO’s action plan to scale up services for
mental, neurological and substance use
disorders for countries especially with low and
lower middle incomes.
▪ The priority conditions addressed by mhGAP are:
depression, schizophrenia and other psychotic disorders, suicide,
epilepsy, dementia, disorders due to use of alcohol, disorders due to
use of illicit drugs, and mental disorders in children.

▪ The mhGAP package consists of interventions for prevention

and management for each of these priority conditions.
 NCM 204
Health Care Delivery System

Bevan B. Balbuena, RN, MN

Learning Objectives
At the end of the lesson, the BSN 2 students will:
1. describe the health care delivery system of the country
2. determine the MDG’s and SDG’s as well as the imperatives leading to its
formulation
3. explain DOH mission, vision, major roles, and goals
4. classify the different types of health facilities known in the country based on DOH
AO 2012-0012.
5. discuss the goals, values, guarantees, and strategy of the Philippine Health Agenda
2016-2022; and
6. discuss the essence of Primary Health Care, its goals, essential elements, and
principles.
The Health Care Delivery System

A health care delivery system is an

organization of people, institutions, and
resources to deliver health care services to
meet the health needs of a target population.
 World Health Organization (WHO)
• a specialized agency of the United Nations that provides
global leadership on health matters

• Working with 194 Member States, across six regions, and

from more than 150 offices, WHO staff are united in a
shared commitment to achieve better health for
everyone, everywhere.
• The Constitution of the WHO was adopted by the
International Health Conference held in New York on
June 19 – July 22, 1946 signed by the representatives of
61 States and entered into force on April 7, 1948.

Source: https://www.who/constitution
World Health Organization (WHO) …

Guiding principle: all people should enjoy the highest

standard of health, regardless of race, religion, political
belief, economic or social condition.

Objective of the World Health Organization: the

attainment by all peoples of the highest possible level of
health.

Source: https://www.who.int/about/who-we-are/constitution
WHO remains firmly committed to the principles set out in the preamble to
the Constitution

• Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.

• The enjoyment of the highest attainable standard of health is one of the

fundamental rights of every human being without distinction of race, religion,
political belief, economic or social condition.

• The health of all peoples is fundamental to the attainment of peace and security
and is dependent on the fullest co-operation of individuals and States.

• The achievement of any State in the promotion and protection of health is of

value to all.

• Unequal development in different countries in the promotion of health and control

of diseases, especially communicable disease, is a common danger.
• Healthy development of the child is of basic importance; the ability to live
harmoniously in a changing total environment is essential to such
development.

• The extension to all peoples of the benefits of medical, psychological and

related knowledge is essential to the fullest attainment of health.

Informed opinion and active co-operation on the part of the public are of
the utmost importance in the improvement of the health of the people.

• Governments have a responsibility for the health of their peoples which

can be fulfilled only by the provision of adequate health and social
measures.
 Building blocks
A health system of the health system
consists of all
organizations,
Health
people, and Service Health
information
actions whose delivery workforce
systems
primary intent is
to promote,
restore, or Medical Leadership
maintain health. products,
vaccines & Financing and
technologies governance
 • A common vision of poverty
reduction and sustainable
MILLENIUM development in response to the
DEVELOPMENT global and country health trends.
GOALS
• based on the fundamental values
(MDG) of freedom, equality, solidarity,
tolerance, health, respect for
nature, and shared responsibility.
Imperatives leading to the formulation of
MDGs:
• shift in demographic and epidemiological trends in
disease

• new technologies for healthcare, communication and

information

• existing and emerging environmental hazards

• health norms
 MDGs
1. Eradicate extreme poverty
and hunger
2. Achieve universal primary
education
3. Promote gender equality
and empower women.
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria
& other diseases
7. Ensure environmental
sustainability
8. Develop a global
partnership for
development.
Sustainable
Development
Goals
(SDG)
Philippine Health Care Delivery System

A nation’s health care delivery system has a

tremendous impact on the health and
development of its people.

Health care reforms, demographics,

globalization, poverty and growing disparities,
and social disintegration influence health care
delivery system in the 21st century (Anderson &
McFarlane, 2011 as cited in Famorca, 2013)
Definition:

Health care delivery system is the totality of all policies,

infrastructures, facilities, equipment, product, human
resources, and services that address the health needs,
problems and concerns of the people.
Composed of 2 sectors
a. Public sector
• largely financed through tax-based budgeting system at both
national and local levels and where health care is generally
given free at the point of service

b. Private sector
• largely market-oriented and where health care is paid through
user fees at the point of service
 Department of Health (DOH)

• national government’s biggest health care provider

• exercises regulatory powers of health facilities and products

• takes the lead in the formulation of policies and standards

related to health facilities, health products and health human
resources
 Vision Mission
To guarantee equitable, sustainable, and
The DOH is the quality health for all Filipinos, especially the
leader, staunch poor and shall lead the quest for excellence in
advocate and model health
in promoting • by making services available
HEALTH FOR ALL • by arousing community awareness
in the Philippines • by mobilizing resources
• by promoting the means to better health
 Major Role of DOH

1. Leader in health DOH CORE VALUES

Integrity
2. Enabler and Excellence
capacity builder Compassion and respect
for human dignity
3. Administrator of Commitment
Professionalism
specific services Teamwork
Stewardship of the health
of the people
GOAL
Overriding goal of the DOH is the Health Sector Reform Agenda
(HSRA), the five major reforms of which are:

• provide fiscal autonomy to government hospitals

• secure funding for priority public health programs

• promote the development of local health systems and ensure its

effective performance

• strengthen the capacities of health regulatory agencies

• expand the coverage of the National Health Insurance Program

Framework for Implementation of HSRA

FOURmula ONE for Health (F1)

• It is the strategy for implementing health reforms .

• Spells out the program imperatives of the health sector

• Intends to implement critical interventions as a single
package backed by effective management of infrastructure
and financing arrangements following a sectoral approach
Goals of FOURmula ONE for Health (F1)

• Better health outcomes

• More responsive health systems

• Equitable health care financing

Principles of F1
• Universal access to basic health services must be ensured.

• The health and nutrition of vulnerable groups must be

prioritized.

• The epidemiologic shift from infectious to degenerative

diseases must be managed.

• The performance of the health sector must be enhanced

Goals and Objectives of HSRA
• Improve the general health status of the population.

• Reduce morbidity and mortality from certain diseases

• Eliminate certain diseases as public health problems

• Promote healthy lifestyle and environmental health

• Protect vulnerable groups with special health and nutrition
needs
 Local Health Systems

• A health system at the sub-national level

• The core element of local or district health system is the
integrated primary health care and the first referral
hospital serving a well-defined population (Segall, 2003).

• The inter-local health zone (ILHZ) is the ideal governance

structure for local health system development. It is a
district health system in a devolved setting. It addresses
the problem of fragmentation of the delivery of health
services
Inter-Local Health Zone

Any form of organized arrangement for coordinating the

operations of an array and hierarchy of health providers
and facilities serving a common population within a local
geographic area under the jurisdictions of more than one
local government (DOH, CY 2006)
Composition of an ILHZ
1. Primary Health Care Providers (Barangay Health Station, Rural
Health Unit, health centers, community hospital, private
practitioners, traditional/alternative providers, caregivers,
household

2. Core referral hospital(s): District Hospital or Provincial Hospital

3. End referral hospital(s): Higher level hospitals

Guiding Principles for ILHZs
1. Voluntary actions for mutual benefits

2. Flexible forms of organization

3. Results-oriented

4. Sustained and evolutionary

5. Purposive and developmental

6. Universal and non–partisan
 Devolution of Health Services

RA 7160 - Local Government Code

• one of the significant laws that radically changed the landscape of health care
delivery
• enacted to bring about genuine and meaningful local autonomy
• mandates devolution of basic services from the national government to LGUs

Aim:
• To transform local government units into self-reliant
communities and active partners in the attainment of national
goals through a more responsive and accountable local
government structure instituted through a system of
decentralization
• Devolution – refers to the act by which the national
government confers power and authority upon the various
LGUs to perform specific functions and responsibilities
(Congress of the Phils., 1991)

• 1993- Health services were devolved or transferred from

the DOH to the LGU - all provincial, district and municipal
hospitals to the provincial governments and the rural
health units (RHUs) and barangay health stations (BHSs) to
the municipal governments.
 LEVELS OF HEALTH CARE & REFERRAL SYSTEM

PRIMARY LEVEL OF CARE

• Health services offered at this level are to individuals in fair health

and to patients with diseases in the early symptomatic stage

• Primary care is devolved to the cities and the municipalities.

• It is the health care provided by center physicians, public health

nurses, rural health midwives, BHWs, traditional healers.
SECONDARY LEVEL OF CARE

• Service offered to patients with symptomatic stages of disease which

require moderately specialized knowledge and technical resources for
adequate treatment

• Is given by physicians with basic health training.

• This is usually given in health facilities either owned or government

operated such as infirmaries, municipal, and district hospitals, OPD of
provincial hospitals.
• Capable of performing minor surgeries and perform some simple
laboratory examinations.
TERTIARY LEVEL OF CARE

• Are the highly technological and sophisticated services offered by

medical centers and large hospitals. These are specialized national
hospitals.

• Services are for clients afflicted with diseases which seriously

threaten their health & which require highly technical and specialized
knowledge, facilities and personnel to treat effectively.
Referral
• Referral is a set of activities undertaken by a health care
provider or facility in response to its inability to provide the
necessary the necessary health interventions to satisfy a
patient’s need.
Classification:

• Internal Referral – referral that occurs within the

health facility from one personnel to another.
• External Referral – a movement of a patient from one
health facility to another .
 Classification of Health Facilities
(DOH AO-0012a)

HOSPITALS OTHER HEALTH FACILITIES

General hospital A. Primary Care Facility
• Level 1 B. Custodial Care Facility
• Level 2 C. Diagnostic/ Therapeutic
• Level 3 (teaching/ training) Facility
Specialty hospital D. Specialized Outpatient Facility
Classification of hospitals

General hospitals – provide services for all kinds of illnesses,

injuries or deformities
• Services offered are classified as level 1, level 2 or level 3

Specialty hospital – offers services for a specific disease or

condition or type of patient, such as children, elderly or
women (DOH, 2012a)
 Classification of general hospitals (DOH, 2012)
Hospitals Clinical Services for inpatients Ancillary services
Level 1 Consulting specialists in Medicine, Pedia, OB-Gyne, Surgery Secondary clinical laboratory
Emergency & outpatient services Blood station
Isolation facilities First level X-ray
Surgical/ maternity facilities Pharmacy
Dental clinic
Level 2 Level 1 plus: Tertiary clinical laboratory
Departmentalized clinical services Second-level X-ray with mobile
Respiratory unit unit
General ICU
High-risk pregnancy unit
NICU
Level 3 Level 2 plus: Tertiary clinical laboratory with
Teaching/training with accredited residency training program in 4 histopathology
major clinical services Blood bank
Physical medicine and rehabilitation unit Third-level X-ray
Ambulatory surgical unit
Dialysis clinic
 Further Classification:
such as, but no limited to the ff.
Laboratory Facility Clinical Laboratory
HIV Testing Center
Blood Service Facility
Drug Testing Laboratory
Newborn Screening Laboratory
Laboratory for drinking water analysis

Radiologic Facility X-ray, CT scan, Mammography, MRI, ultrasonography

Nuclear Medicine a facility regulated by the Philippine Nuclear Research

facility Institute utilizing radioactive materials in diagnosis,
treatment, or medical research.
Classification of other health facilities
(DOH AO 2012-0012)

Category A – Primary care facility

• A first-contact health care facility that offers basic services

including emergency services and provision for normal deliveries

• E.g health center, outpatient clinics, dental clinics, birthing/lying-

in facilities
Classification of other health facilities
(DOH AO 2012-0012)

• Category B – Custodial care facility

• A health facility that provides long-term care, including basic

services like food and shelter, to patients with chronic conditions
requiring ongoing health and nursing care due to impairment and
reduced degree of independence in ADL, and patients in need of
rehabilitation

• E.g. custodial psychiatric facilities, nursing homes

Classification of other health facilities
(DOH AO 2012-0012)

Category C – Diagnostic/therapeutic facility

• A facility for the examination of the human body, specimens from

the human body for diagnosis, treatment of disease, or water or
drinking water analysis.

• E.g. Laboratory, radiologic, & nuclear medicine facility

Classification of other health facilities
(DOH AO 2012-0012)

Category D – Specialized outpatient facility

• A facility that performs highly specialized procedures on an

outpatient basis

• E.g. dialysis clinic, ambulatory surgical clinic, cancer

chemotherapeutic center, cancer radiation facility
 Philippine Health Agenda 2010-2022
Government efforts to bring about health sector reforms

• Health Sector Reform Agenda (1999-2004)

• FOURmula One for Health (2005-2010)

• Universal Health Care/ Aquino Health Agenda (2010-2015)

• Philippine Health Agenda (2010-2022)

 Primary Health Care (PHC)

1.Brief History
2.Legal Basis
3.Definition
4.Goals
5.Elements
6.Principles and Strategies
Brief History of PHC
❑ May 30, 1977 World Health Assembly decided that the main health target
of the government and WHO is the attainment of a level of health that
would permit them to lead a socially and economically productive life by
the year 2000.
❑ September 6-12, 1978 – First International Conference on PHC in Alma
Ata, Russia (USSR)
❑ Initiated by WHO and United Nations Children’s Fund (UNICEF)
❑ The Alma Ata Declaration stated that PHC was the key to attain the
“health for all” goal
 Alma Ata declaration on Primary Health Care

• Health is a basic fundamental right

• There exists a global burden of health
inequalities among populations
• Economic and social development is of basic
importance for the attainment of health for
all
• Governments have a responsibility for the
health of their people
Legal Basis

• October 19, 1979 – Letter of Instruction (LOI) 949, the

legal basis of PHC was signed by Pres. Ferdinand E.
Marcos,

• LOI 949 adopted PHC as an approach towards the design,

development and implementation of programs focusing
on health development at the community level.
Definition

PRIMARY HEALTH CARE is an essential health care

made universally accessible to individuals and families
in the community by means acceptable to them, through
their full participation and at a cost that the community
can afford at every stage of development. (WHO)
 HEALTH FOR ALL FILIPINOS by the
year 2000 and
HEALTH IN THE HANDS OF THE MAIN OBJECTIVES

Goals PEOPLE by the year 2020. • Promotion of healthy

of lifestyles
PHC An improved state of health and • Prevention of diseases
quality of life for all people
• Therapy for existing
attained through SELF RELIANCE.
conditions
 Education for Health

Locally Endemic Disease Control

Expanded Program on Immunization

Elements
of Maternal and Child Health and Family Planning

Primary Environmental Sanitation and Promotion of

Health Safe Water Supply

Care Nutrition and Promotion of Adequate Food

Supply

Treatment of Communicable Diseases and

Common Illnesses

Supply of Essential Drugs

 Principles of PHC
1. 4 A’s = Accessibility, Availability, Affordability &
Acceptability, Appropriateness of health services.
2. Community Participation
3. People are the center, object and subject of
development.
4. Self-reliance
Principles…
5. Partnership between the community and the health
agencies in the provision of quality of life.
6. Recognition of interrelationship between the health and
development
7. Social Mobilization
8. Decentralization
9. Equitable distribution of resources
10. Appropriate technology
Principles
9. Equitable distribution of resources
• PHC advocates for care that is community based and
preventive in orientation
Two Programs of DOH to ensure distribution of
manpower to the rural areas

• Doctor to the Barrios (DTTB) Program – DTTB volunteers

are fielded to manage the RHU of 5th or 6th class
municipalities for 2 years and have the option to be absorbed
with competitive compensation by the DOH and LGU

• Registered Nurses Health Enhancement and Local Service

(RN HEALS) – deployment of nurses for 1 year to address the
inadequate nursing workforce in rural communities
10. Appropriate technology
• People’s technology or Indigenous technology

Criteria:
• Safety
• Effectiveness
• Affordability
• Simplicity
• Acceptability
• Feasibility and reliability
• Ecological effects
 Major Strategies of Primary Health Care

• Elevating health to a comprehensive and sustained

national effort.
• Promoting and supporting community managed
health care
• Increasing efficiencies in the health sector
• Advancing essential national health research
 LEVELS OF PREVENTION
Primary Prevention

• relates to activities directed at preventing a problem before it

occurs by altering susceptibility or reducing exposure for
susceptible individuals.

• It is consist of 2 elements :
a) general health promotion – good nutrition, adequate shelter, regular
exercise
b) specific protection - eliminate risk factors and includes such measure
immunization, water purification
Secondary Prevention
• refers to the early detection and prompt intervention
during the period of early disease and pathogenesis .

• It is implemented after a problem has begun but before

signs and symptoms appear and targets those population
who have risk factors

Ex. mammography, BP monitoring, mass sputum examination

Tertiary Prevention
• targets the population that experienced disease or injury
and focuses on limitation of disability and rehabilitation .

• Aims are to reduce the effects of disease and injury and

to restore individuals to their optimal level of functioning

Ex. performing insulin injection , referring patient with spinal

cord injury to PT .
PHILIPPINE HEALTH AGENDA 2016-2022
Healthy Philippines 2022
GOALS

The Health System We Aspire For

FINANCIAL BETTER HEALTH

RESPONSIVENESS
PROTECTION OUTCOMES
Filipinos, especially the Filipinos attain the Filipinos feel
poor, marginalized, and best possible health respected, valued, and
vulnerable are outcomes with no empowered in all of
protected from high
disparity their interaction with
cost of health care
the health system
2
VALUES

The Health System We Aspire For

EQUITABLE & INCLUSIVE TRANSPARENT &

TO ALL ACCOUNTABLE

USES RESOURCES PROVIDES HIGH

EFFICIENTLY QUALITY SERVICES
3
 During the last 30 years of Health Sector Reform, we have
undertaken key structural reforms and continuously built on
programs that take us a step closer to our aspiration.

Milestones

Devolution Use of Generics Milk Code PhilHealth (1995)

DOH resources to Fiscal autonomy Good Governance Funding

promote local for government Programs for UHC
health system hospitals (ISO, IMC, PGS)
development
 Persistent Inequities in Health Outcomes

2000
Every year, around A Filipino child born to the Three out of 10
2000 mothers die due poorest family is 3 times children are
to pregnancy-related more likely to not reach his stunted.
complications. 5th birthday, compared to
one born to the richest
family.
5
 Restrictive and Impoverishing Healthcare Costs

Tiisin ko na
lang ito..

Every year, 1.5 million Filipinos forego or delay Php 4,000/month

families are pushed to care due to prohibitive healthcare expenses
poverty due to health and unpredictable user considered
care expenditures fees or co-payments catastrophic for single
income families
6
 Poor quality and undignified care synonymous
with public clinics and hospitals

Limited autonomy Less than hygienic restrooms,

Long wait times to choose provider lacking amenities

Privacy and confidentiality Poor record-keeping Overcrowding &

taken lightly under-provision of care
7
 Lahat Para sa Kalusugan!
Tungo sa Kalusugan Para sa Lahat
 • UNIVERSAL HEALTH
COVERAGE

• STRENGTHEN
IMPLEMENTATION OF
RPRH LAW

Investing in People • WAR AGAINST

DRUGS

• ADDITIONAL
Protection Against FUNDS FROM
Instability PAGCOR
 ATTAIN HEALTH-RELATED SDG TARGETS
Financial Risk Protection | ttain  Health-­Related  SDG  Targets
Goals:  A Better Health Outcomes | Responsiveness
Financial  Risk  Protection,  Better  Health  Outcomes,  Responsiveness
Values: Equity, Quality, Efficiency, Transparency, Accountability, Sustainability, Resilience
Values:  Equity,  Efficiency,  Quality,  Transparency

SERVICE  DELIVERY  
NETWORK

3 Guarantees ALL  LIFE  STAGES  &  

TRIPLE  BURDEN  OF  
DISEASE

UNIVERSAL  
HEALTH  
INSURANCE

A C H I E V E
 GUARANTEE #1

ALL LIFE STAGES &

TRIPLE BURDEN OF DISEASE
Services for Both the Well & the Sick
Guarantee 1: All Life Stages & Triple Burden of Disease
Pregnant Newborn Infant Child Adolescent Adults Elderly

First 1000 days | Reproductive and sexual health | maternal, newborn,

and child health | exclusive breastfeeding | food & micronutrient
supplementation | Immunization | Adolescent health | Geriatric Health
| Health screening, promotion & information

NON-
DISEASES OF RAPID
COMMUNICABLE COMMUNICABLE
URBANIZATION &
DISEASES DISEASES & INDUSTRIALIZATION
MALNUTRITION
12
Guarantee 1: All Life Stages & Triple Burden of Disease

NON-
DISEASES OF RAPID
COMMUNICABLE COMMUNICABLE
URBANIZATION &
DISEASES DISEASES & INDUSTRIALIZATION
MALNUTRITION

• HIV/AIDS, TB, Malaria • Cancer, Diabetes, Heart • Injuries

• Diseases for Elimination Disease and their Risk • Substance abuse
• Dengue, Lepto, Factors – obesity, • Mental Illness
Ebola, Zika smoking, diet, • Pandemics, Travel Medicine
sedentary lifestyle • Health consequences of
• Malnutrition climate change / disaster

13
 GUARANTEE #2

SERVICE DELIVERY NETWORK

Functional Network of Health Facilities
Guarantee 2: Services are delivered
by networks that are
FULLY FUNCTIONAL
(Complete Equipment, PRACTICING
Medicines, Health GATEKEEPING
Professional)

COMPLIANT WITH LOCATED CLOSE

CLINICAL PRACTICE TO THE PEOPLE
(Mobile Clinic or Subsidize
GUIDELINES Transportation Cost)

AVAILABLE 24/7 &

ENHANCED BY
EVEN DURING
TELEMEDICINE
DISASTERS
15
 GUARANTEE #3

UNIVERSAL
HEALTH INSURANCE
Financial Freedom when Accessing Services
Guarantee 3: Services are financed predominantly by PhilHealth

• 100%  of  Filipinos are  members

PHILHEALTH  AS  THE  
• Formal  sector premium  paid  through payroll  
GATEWAY  TO  FREE  
• Non-­formal  sector  premium  paid  through  tax  
AFFORDABLE  CARE
subsidy

SIMPLIFY •No  balance  billing  for  the  poor/basic  

PHILHEALTH accommodation  &  Fixed  co-­payment
RULES   for  non-­basic  accommodation

PHILHEALTH  AS  MAIN   • Expand  benefits  to  cover  comprehensive

REVENUE  SOURCE   range  of  services
FOR  PUBLIC  HEALTH   • Contracting  networks of  providers  within  
CARE    PROVIDERS SDNs
17
 Our Strategy
A Advance quality, health promotion and primary care

C Cover all Filipinos against health-related financial risk

H Harness the power of strategic HRH development

I Invest in eHealth and data for decision-making

E Enforce standards, accountability and transparency

Value all clients and patients, especially the poor,
V marginalized, and vulnerable
Elicit multi-sectoral and multi-stakeholder support for
E health
18
A Advance quality, health promotion and primary care

1. Conduct annual health visits for all poor families and

special populations (NHTS, IP, PWD, Senior Citizens)
2. Develop an explicit list of primary care entitlements that
will become the basis for licensing and contracting
arrangements
3. Transform select DOH hospitals into mega-hospitals with
capabilities for multi-specialty training and teaching and
reference laboratory
4. Support LGUs in advancing pro-health resolutions or
ordinances (e.g. city-wide smoke-free or speed limit
ordinances)
5. Establish expert bodies for health promotion and
surveillance and response
C Cover all Filipinos against health-related financial risk

1. Raise more revenues for health, e.g. impose health-

promoting taxes, increase NHIP premium rates, improve
premium collection efficiency.
2. Align GSIS, MAP, PCSO, PAGCOR and minimize overlaps with
PhilHealth
3. Expand PhilHealth benefits to cover outpatient diagnostics,
medicines, blood and blood products aided by health
technology assessment
4. Update costing of current PhilHealth case rates to ensure that
it covers full cost of care and link payment to service quality
5. Enhance and enforce PhilHealth contracting policies for
better viability and sustainability
H Harness the power of strategic HRH development

1. Revise health professions curriculum to be more

primary care-oriented and responsive to local and
global needs
2. Streamline HRH compensation package to
incentivize service in high-risk or GIDA areas
3. Update frontline staffing complement standards
from profession-based to competency-based
4. Make available fully-funded scholarships for HRH
hailing from GIDA areas or IP groups
5. Formulate mechanisms for mandatory return of
service schemes for all heath graduates
I Invest in eHealth and data for decision-making

1. Mandate the use of electronic medical records in all health

facilities
2. Make online submission of clinical, drug dispensing,
administrative and financial records a prerequisite for
registration, licensing and contracting
3. Commission nationwide surveys, streamline information
systems, and support efforts to improve local civil
registration and vital statistics
4. Automate major business processes and invest in ware-
housing and business intelligence tools
5. Facilitate ease of access of researchers to available data
E Enforce standards, accountability and transparency

1. Publish health information that can

trigger better performance and
accountability
2. Set up dedicated performance
monitoring unit to track
performance or progress of reforms
 Value all clients and patients, especially the poor,
V marginalized, and vulnerable

1. Prioritize the poorest 20 million Filipinos in all health

programs and support them in non-direct health
expenditures
2. Make all health entitlements simple, explicit and
widely published to facilitate understanding, &
generate demand
3. Set up participation and redress mechanisms
4. Reduce turnaround time and improve transparency
of processes at all DOH health facilities
5. Eliminate queuing, guarantee decent
accommodation and clean restrooms in all
government hospitals
E Elicit multi-sectoral and multi-stakeholder support for health

1. Harness and align the private sector in planning

supply side investments
2. Work with other national government agencies to
address social determinants of health
3. Make health impact assessment and public health
management plan a prerequisite for initiating
large-scale, high-risk infrastructure projects
4. Collaborate with CSOs and other stakeholders on
budget development, monitoring and evaluation
 ATTAIN HEALTH-
SERVICE DELIVERY RELATED SDGs
NETWORK

ALL LIFE STAGES &

TRIPLE BURDEN OF
DISEASE

UNIVERSAL
HEALTH
INSURANCE

Financial Risk Protection

Better Health Outcomes
Responsiveness
 50 Facts: Global health situation and trends 1955-2025(WHO)

Population
The global population was 2.8 billion in 1955 and is 5.8 billion now. It will increase
by nearly 80 million people a year to reach about 8 billion by the year 2025.
In 1955, 68% of the global population lived in rural areas and 32% in urban areas.
In 1995 the ratio was 55% rural and 45% urban; by 2025 it will be 41% rural
and 59% urban.
Every day in 1997, about 365 000 babies were born, and about 140 000 people
died, giving a natural increase of about 220 000 people a day.
Today's population is made up of 613 million children under 5; 1.7 billion children
and adolescents aged 5-19; 3.1 billion adults aged 20-64; and 390 million over
65.
The proportion of older people requiring support from adults of working age will
increase from 10.5% in 1955 and 12.3% in 1995 to 17.2% in 2025.
In 1955, there were 12 people aged over 65 for every 100 aged under 20. By 1995,
the old/young ratio was 16/100; by 2025 it will be 31/100.
The proportion of young people under 20 years will fall from 40% now to 32% of
the total population by 2025, despite reaching 2.6 billion - an actual increase of
252 million.
The number of people aged over 65 will rise from 390 million now to 800 million by
2025 - reaching 10% of the total population.
By 2025, increases of up to 300% of the older population are expected in many
developing countries, especially in Latin America and Asia.
Globally, the population of children under 5 will grow by just 0.25% annually
between 1995-2025, while the population over 65 years will grow by 2.6%.
The average number of babies per woman of child-bearing age was 5.0 in 1955,
falling to 2.9 in 1995 and reaching 2.3 in 2025. While only 3 countries were
below the population replacement level of 2.1 babies in 1955, there will be 102
such countries by 2025.

Life expectancy
Average life expectancy at birth in 1955 was just 48 years; in 1995 it was 65 years;
in 2025 it will reach 73 years.
By the year 2025, it is expected that no country will have a life expectancy of less
than 50 years.
More than 50 million people live today in countries with a life expectancy of less
than 45 years.
Over 5 billion people in 120 countries today have life expectancy of more than 60
years.
About 300 million people live in 16 countries where life expectancy actually
decreased between 1975-1995.
Many thousands of people born this year will live through the 21st century and see
the advent of the 22nd century. For example, while there were only 200
centenarians in France in 1950, by the year 2050, the number is projected to
reach 150 000 - a 750-fold increase in 100 years.
 Age structure of deaths
In 1955, 40% of all deaths were among children under 5 years, 10% were in 5-19
year-olds, 28% were among adults aged 20-64, and 21% were among the
over-65s.
In 1995, only 21% of all deaths were among the under-5s, 7% among those 5-19,
29% among those 20-64, and 43% among the over-65s.
By 2025, 8% of all deaths will be in the under-5s, 3% among 5-19 year-olds, 27%
among 20-64 year-olds and 63% among the over-65s.

Leading causes of global deaths

In 1997, of a global total of 52.2 million deaths, 17.3 million were due to infectious
and parasitic diseases; 15.3 million were due to circulatory diseases; 6.2
million were due to cancer; 2.9 million were due to respiratory diseases, mainly
chronic obstructive pulmonary disease; and 3.6 million were due to perinatal
conditions.
Leading causes of death from infectious diseases were acute lower respiratory
infections (3.7 million), tuberculosis (2.9 million), diarrhoea (2.5 million),
HIV/AIDS (2.3 million) and malaria (1.5-2.7 million).
Most deaths from circulatory diseases were coronary heart disease (7.2 million),
cerebrovascular disease (4.6 million), other heart diseases (3 million).
Leading causes of death from cancers were those of the lung (1.1 million),
stomach (765 000), colon and rectum (525 000) liver, (505 000), and breast
(385 000).

Health of infants and small children

Spectacular progress in reducing under 5 mortality achieved in the last few
decades is projected to continue. There were about 10 million such deaths in
1997 compared to 21 million in 1955.
The infant mortality rate per 1000 live births was 148 in 1955; 59 in 1995; and is
projected to be 29 in 2025. The under-5 mortality rates per 1000 live births for
the same years are 210, 78 and 37 respectively.
By 2025 there will still be 5 million deaths among children under five - 97% of them
in the developing world, and most of them due to infectious diseases such as
pneumonia and diarrhoea, combined with malnutrition.
There are still 24 million low-birthweight babies born every year. They are more
likely to die early, and those who survive may suffer illness, stunted growth or
even problems into adult life.
In 1995, 27% (168 million) of all children under 5 were underweight. Mortality rates
are 5 times higher among severely underweight children than those of normal
weight.
About 50% of deaths among children under 5 are associated with malnutrition.
At least two million a year of the under-five deaths could be prevented by existing
vaccines. Most of the rest are preventable by other means.

Health of older children and adolescents

One of the biggest 21st century hazards to children will be the continuing
spread of HIV/AIDS. In 1997, 590 000 children age under 15 became
 infected with HIV. The disease could reverse some of the major gains in
child health in the last 50 years.
The transition from childhood to adulthood will be marked for many in the
coming years by such potentially deadly "rites of passage" as violence,
delinquency, drugs, alcohol, motor accidents and sexual hazards such as
HIV and other sexually transmitted diseases. Those growing up in poor
urban areas are more likelly to be most at risk.
The number of young women aged 15-19 will increase from 251 million in 1995
to 307 million in 2025.
In 1995, young women aged 15-19 gave birth to 17 million babies. Because of
population increase, that number is expected to drop only to 16 million in
2025. Pregnancy and childbirth in adolescence pose higher risks for both
mother and child.

Health of adults
Infectious diseases will still dominate in developing countries. As the economies of
these countries grow, non-communicable diseases will become more
prevalent. This will be due largely to the adoption of "western" lifestyles and
their accompanying risk factors - smoking, high-fat diet, obesity and lack of
exercise.
In developed countries, non-communicable diseases will remain dominant. Heart
disease and stroke have declined as causes of death in recent decades, while
death rates from some cancers have risen.
About 1.8 million adults died of AIDS in 1997 and the annual death toll is likely to
continue to rise for some years.
Diabetes cases in adults will more than double globally from 143 million in 1997 to
300 million by 2025 largely because of dietary and other lifestyle factors.
Cancer will remain one of the leading causes of death worldwide. Only one-third of
all cancers can be cured by earlier detection combined with effective
treatment.
By 2025 the risk of cancer will continue to increase in developing countries, with
stable if not declining rates in industrialized countries.
Cases and deaths of lung cancer and colorectal cancer will increase, largely due
to smoking and unhealthy diet respectively. Lung cancer deaths among
women will rise in virtually all industrialized countries, but stomach cancer will
become less common generally, mainly because of improved food
conservation, dietary changes and declining related infection.
Cervical cancer is expected to decrease further in industrialized countries due to
screening. The incidence is almost four times greater in the developing world.
The possible advent of a vaccine would greatly benefit both the developed and
developing countries.
Liver cancer will decrease because of the results of current and future
immunization against the hepatitis B virus in many countries.
In general, more than 15 million adults aged 20-64 are dying every year. Most of
these deaths are premature and preventable.
Among the premature deaths are those of 585 000 young women who die each
year in pregnancy or childbirth. Most of these deaths are preventable. Where
women have many pregnancies the risk of related death over the course of a
 lifetime is compounded. While the risk in Europe is just one in 1 400, in Asia it
is one in 65, and in Africa, one in 16.

Health of older people

Cancer and heart disease are more related to the 70-75 age group than any other;
people over 75 become more prone to impairments of hearing, vision, mobility
and mental function.
Over 80% of circulatory disease deaths occur in people over 65. Worldwide,
circulatory disease is the leading cause of death and disability in people over
65 years.
Data from France and the United States show breast cancer on average deprives
women of at least 10 years of life expectancy, while prostate cancer reduces
male average life expectancy by only one year.
The risk of developing dementia rises steeply with age in people over 60 years.
Women are more likely to suffer than men because of their greater longevity.

NATIONAL HEALTH SITUATION

The Philippines has made significant investments and advances in health in
recent years. Rapid economic growth and strong country capacity have
contributed to Filipinos living longer and healthier. However, not all the benefits
of this growth have reached the most vulnerable groups, and the health
system remains fragmented. Health insurance now covers 92% of the
population. Maternal and child health services have improved,with more
children living beyond infancy, a higher number of women delivering at health
facilities and more births being attended by professional service providers than
ever before. Access to and provision of preventive, diagnostic and treatment
services for communicable diseases have improved, while there are several
initiatives to reduce illness and death due to noncommunicable diseases
(NCDs). Despite substantial progress in improving the lives and health of
people in the Philippines, achievements have not been uniform and challenges
remain. Deep inequities persist between regions, rich and the poor, and
different population groups. Many Filipinos continue to die or suffer from
illnesses that have well-proven, cost-effective interventions, such tuberculosis,
HIV and dengue, or diseases affecting mothers and children. Many people lack
sufficient knowledge to make informed decisions about their own health. Rapid
economic development, urbanization, escalating climate change, and widening
exposure to diseases and pathogens in an increasingly global world increase
the risks associated with disasters, environmental threats, and emerging and
re-emerging infections
HEALTH POLICIES AND SYSTEMS The Government’s vision for the
Philippines has been translated by the Department of Health into the
Philippine Health Agenda 2016–2022. Under the motto All for Health
Towards Health for All, universal health coverage is the platform for health
and development in the Philippines –driven by action within and outside
the health sector. Reducing health inequities is singled out as the most
important result of three health guarantees:
1. ensuring financial protection for the poorest people;
2. improving health outcomes with no disparities; and
3 .building health service delivery networks for more responsiveness.
 COOPERATION FOR HEALTH The global vision of the world in 2030,
spelled out in the Sustainable Development Goals, aligns with the
Philippines’ 25-year vision AmBisyon Natin 2040. There is an ongoing
process of integrating SDGs into AmBisyon Natin 2040 and into national,
sectoral and subnational plans and frameworks. WHO supports the
Government of the Philippines to foster well-being through action by the
health sector and across sectors. WHO convenes platforms for health
involving multiple stakeholders and in addressing the social, economic and
environmental determinants of health. WHO also takes the lead in
coordinating with other health partners to ensure all stakeholders are
aware of health issues and activities in the country.

Philippines
WHO region: Western Pacific

World Bank income group Lower-middle-income

Child health
Infants exclusively breastfed for the first six (2008) 34
months of life (%)
Diphtheria tetanus toxoid and pertussis (DTP3) (2015) 60
immunization coverage among 1-year-olds (%)
Demographic and socioeconomic statistics
68.5 (Both sexes)
Life expectancy at birth (years) (2015) 72.0(Female)
65.3 (Male)
Population (in thousands) total (2015) 100699
% Population under 15 (2015) 31.9
%Population over 60 (2015) 7.3
Poverty headcount ratio at $1.25 a day (PPP) (% 18.4
of population) (2009) )
Literacy rate among adults aged >= 15 years 95
(%(2007-2012)
Gender Inequality Index rank (2014) 89
Human Development Index rank (2014) 115
Health systems
Total expenditure on health as a percentage of 4.71
gross domestic product (2014)
Private expenditure on health as a percentage of 65.72
total expenditure on health (2014)
General government expenditure on health as a 10.01
percentage of total government expenditure
(2014)
Physicians density (per 1000 population)()
Nursing and midwifery personnel density (per
1000 population) ()
Mortality and global health estimates
Neonatal mortality rate (per 1000 live births) 12.6 [9.0-17.1]
(2015)
Under-five mortality rate (probability of dying by 28.0 [21.2-36.7
age 5 per 1000 live births) (2015)
] Maternal mortality ratio (per 100 000 live births) 114 [ 87 - 175]
(2015)
Births attended by skilled health personnel (%) 72.8
(2013)
Public health and environment
Population using improved drinking water 91.8 (Total)
sources (%) (2015) 93.7 (Urban)
90.3 (Rural)
Population using improved sanitation 77.9 (Urban)
facilities (%) (2015) 70.8 (Rural)
73.9 (Total)
Sources of data: Global Health Observatory May
2017 http://apps.who.int/gho/data/node.cco