NCM 104 Theory/ CHN Lecture Notes

I. OVERVIEW OF PHN IN THE PHILIPINES (Week 1: 4 hours)

Community
 a group of people with common characteristics or interests living together within
a territory or geographical boundary place where people under usual conditions
are found, derived from a latin word “comunicas” which means a group of
people.

Community Health 
 Part of paramedical and medical intervention/approach which is concerned on the
health of the whole population

Factors Affecting Health

Aim:
 Health Promotion and Disease Prevention

Health Promotion: The first step to fighting a disease

Health promotion covers a wide aspect governed by multitude factors.
 As defined by WHO it is The process of enabling people to increase control over,
and to improve, their health.
 It moves far beyond the comprehension of individual behavior towards a wider
dimension of socio-demographic, environmental and political interventions. 

Disease Prevention: A way to better health

Primary Disease Prevention essentially means averting the occurrence of the disease
and secondary prevention means halting the progression of a disease.
Prevention is way of providing unprecedented social, economic, and health dividends.
The most efficient approach to combating any form of disease or disability is to
assess, analyze and modify the risk factors that underlie them and find ways and
measures to decrease them either by interventions or by knowledge thus accelerating
the health and increasing the longevity.

Aims:
Health promotion
Disease prevention
Management of factors affecting health

Nursing
Both profession & a vocation.
Assisting sick individuals to become healthy and healthy individuals achieve optimum
wellness

Community Health Nursing

 “a synthesis of nursing knowledge and practice and the science and practice of
public health, implemented via a systematic use of the nursing process and other
processes to promote health and prevent illness in population groups. “ (Clark)
 concerned with the, promotion of health, prevention of disease and disability
rehabilitation. ( Maglaya, et al)

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 Special field of nursing that combines the skills of nursing, public health and
some phases of social assistance and functions as part of the total public health
program for the promotion of health, the improvement of the conditions in the
social and physical environment, rehabilitation of illness and disability.
( WHO Expert Committee of Nursing)
 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 thru’ teaching and delivery of care
 “nursing practice in a wide variety of community services and consumer advocate
areas, and in a variety of roles, at times including independent practice…
community nursing is certainly not confined to public health nursing agencies.”
(Jacobson)
 It refers to “a service rendered by a professional nurse with communities, groups,
families, individuals at home, in health centers, in clinics, in schools, in places of
work for the promotion of health,, prevention of illness, care of the sick at home
and rehabilitation.” (DR. Ruth B. Freeman)
 as an art - the practice of CHN, entails active interaction and partnership between
the nurse and the client.
 Such partnership recognizes the autonomy of both parties and the potential of
each one in enriching their relationship.

As science- Community health nurses should use practice-based and evidence-based

methods and tools.

They also need to engage in generating evidence to support their practice through
research.
Goal: “
To raise the level of citizenry by helping communities and families to cope with the
discontinuities in and threats to health in such a way as to maximize their potential for
high-level wellness”
( Nisce, et al)
Philosophy:
Dr. Margaret Shetland
Philosopy of CHN is based in the worth and dignity of man

Characteristics:

1) Promotion of health and prevention of disease are the goals of professional

practice;
2) CHN practice is comprehensive, general, continual, and not episodic;
3) There are different levels of clientele-individuals, families and population groups
and the practitioner recognizes the primacy of the population as a whole;
4) The nurse and the client have greater control in making decisions related to health
care and the collaborate as equals;
5) The nurse recognizes the impact of different factors on health and has a greater
awareness of his/her clients ‘ lives and situations.

Rules of CHN Nurses

1. Client-oriented roles

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Caregiver
Educator
Counselor
Referral resource
Role model
Case manager

2. Delivery-Oriented roles
Coordinator
Collaborator
Liaison

3. Population-oriented roles
Case finder
Leader
Change agent
Community mobilizer
Coalition builder
Policy advocate
Social marketer
researcher

Frameworks of CHN - four components

1. The health care delivery system, with its CHN subsystem;

2. The clients:
Individual
Family
Population group
Community

3. Health which is the goal of the health care delivery system (HCDS)

4. The economic, sociocultural, political and environmental factors that affect the
HCDS, the practice of CHN and people’s health

Clients of CHN Nurses:

1. Individual – sick and well – on a daily basis

Since the health problems of individuals are intertwined with those of the other
members of the family and community, they are also considered as an “entry point” in
working with these clients.
2. Family
A collection of people who are integrated, interacting and interdependent.
Family members interact with each other and the action of one affects the other
members
3. Population group

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A group of people who share common characteristics, developmental stage or
common exposure to particular environmental factors and consequently common
health problems, issues and concerns
Are the usual targets or beneficiaries of social services and health programs.
4. Community
A group of people sharing common geographic bounderies and/or common values
and interest within specific social system.
The social system includes health system, family system, economic system, education
system, religious system, welfare system, political system, recreational system, legal
system and communication system.

Basic Principles of CHN:

The community is the patient in CHN, the family is the unit of care and there are four
levels of clientele: individual, family, population group (those who share common
characteristics, developmental stages and common exposure to health problems – e.g.
children, elderly), and the community.
In CHN, the client is considered as an ACTIVE partner NOT PASSIVE recipient of
care

Responsibilities of CHN:
be a part in developing an overall health plan, its implementation and evaluation for
communities
provide quality nursing services to the four levels of clientele
maintain coordination/linkages with other health team members, NGO/government
agencies in the provision of public health services
conduct researches relevant to CHN services to improve provision of health care
provide opportunities for professional growth and continuing education for staff
development

Reference:
Community Health Nursing
Ms. Adel Morong R.N., M.S.N.

Health

Health is a basic human right. On the 6th Global Conference on Health Promotion in
2005 the UNs affirmed its recognition that the enjoyment of the highest standard of
health is one of the fundamental rights of every human being (The Bangkok Charter
for Health Promotion, 2005).
Health which is viewed as a continuum, is considered as the goal of public health
in general, and CHN, in particular. It is an important prerequisite (and consequence)
of development. By promoting health and preventing disease, CHNs therefore,
contribute to the country’s economic and social development.
An integral method of functional which is oriented toward maximizing the potential
which the individual is capable .It requires that the individual maintain a continuum of
balance and purposeful direction within the environment where he is functioning
(Dunn, 1959, in Pender, 1987)
“HEALTH is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”
(WHO,1995)

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A quality of life, involving social, emotional, mental, spiritual and biological fitness
on the part of the individual, which results from adaptions to the environment. (Rene
Dubos)

Florence Nightingale looked into health and illness in relation to the environment,
ventilation, noise, light, cleanliness, diet, and restful bed. She prescribed ways to
improve health by manipulating the environment

State characterized by soundness and wholeness of human structures and bodily and
mental functions
(Dorothea Orem, in Pender, 1985

Factors Affecting Health Determinants of Health

1. Income and social status

Higher income and social status are linked to better health
2. Education
Low education levels are linked with poor health, more stress and lower self-
confidence
3. Physical environment
Safe water and clean air, healthy work places, safe houses, communities and roads all
contribute to good health.
4. Employment and working conditions
People in employment are healthier, particularly those who have more control over
their working conditions.
5. Social Support Networks
Greater support from families, friends and communities is linked to better health.
6. Culture, customs and traditions, and the belief of the family and community all
affect health.
7. Genetics
Inheritance plays a part in determining lifespan, healthiness and the likelihood of
developing certain illnesses
8. Personal behavior and coping skills
Balanced eating, keeping active, smoking, drinking, and how we deal with life’s
stresses and challenges all affect health.
9. Health Services
Access the use of services that prevent and treat diseases influences health
10. Gender
Men and women suffer from different types of diseases at different ages.

HEALTH CARE DELIVERY SYSTEM

A health care delivery system is the totality of ‘societal services and activities
designed to protect or restore the health of individuals, families, groups and
communities.
It includes both government and non-government health facilities, programs, services
and activities (preventive, promotive, curative and rehabilitative).

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Preventive health care is a major concern of the government-owned health centers
while curative care is provided by hospitals, both government and private

Public Health

The “science and art of preventing disease, prolonging life, promoting health and
efficiency through organized community effort for the sanitation of the environment,
control of communicable diseases, the education of individuals in personal hygiene,
the organization of medical and nursing services for the early diagnosis and
preventive treatment of disease, and 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 the birthright of health
and longevity.”
Dr. C.E. Winslow
“art of applying science in the context of politics so as to reduce inequalities in health
while ensuring the best health for the greatest number”.
(WHO)

Today public health could be defined in terms of its 3 core functions:

1) Assessment is the regular collection and analysis of health data.
These data are used for program planning and policy development.
2) Policy development involves advocacy and political action to develop policies in
various levels of decision making.
3) Assurance is making sure that health services are effective, available and accessible
to the people (Institute of Medicine, 1988 in Clark

10 Essential Health Services

1) Monitoring health status to identify community health problems;

2) Diagnosing and investigating health problems and hazards in the community;
3) Informing, educating and empowering people about health issues;
4) Mobilizing community partnerships to identify and solve health problems;
5) Developing policies and plans that support individual, family and community
efforts;
6) enforcing laws and regulations that protect health and ensure safety;
7) linking people to needed personal health services and ensuring the provision of
health care that is otherwise unavailable;
8) ensuring competent public health and personal health care workforce;
9) evaluating effectiveness, accessibility and quality of personal and population-based
health services; and,
10) researching for new insights and innovative solutions to health problems

PHNursing

A “special field of nursing that combines the skills of nursing, public health and some
phases of social assistance and functions as part of the total public health programmed
for the promotion of health, the improvement of the conditions in the social and
physical environment, rehabilitation of illness and disability.”
(WHO Expert Committee of Nursing)
The Standards of Public Health Nursing in the Philippines 2005..

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 -refers to the practice of nursing in national and local government health
departments (which includes health centers and rural health units), and public
schools. It is community health nursing practiced in the public sector.

PHNurse
- refers to the nurses in the local/national health departments or public schools
whether their official position title is Public Health Nurse or Nurse or School Nurse
                 vs.     
CHN PHN
1. Deliver health services to individuals, > Assessing the populations health
groups, and families needs
2. Diagnosis is based on the needs of > Diagnose and develop policy in relation
individuals, family, or group to community health needs.
3. Work to promote health and prevent > Plan for the community as a whole in
illness in groups and families with the order to prevent disease and disability
main goal being to increase community and preserve the health of the
health. For example, meeting with a community. For example, after an illness
group of young mothers to provide outbreak, the public health nurse will
information on immunizations. assess the need and develop a program
for an immunization clinic.
4. Implementation is based on individual > Implementing the plan means the nurse
needs. For example, a new diabetic who ensures the resources are available to all
is a kinesthetic learner would be taught who need them within the community.
how to give insulin injections by
practicing with an orange.
5. Evaluate whether health needs were Evaluate the health status of the whole
met on the individual, family or group community and whether planned goals
level. and objectives were met.

How Do they relate?

Public health nursing is an umbrella term that encompasses community health

nursing.
Both have the main goal of promoting, preserving, and maintaining the community’s
health.  

What boundaries exists?

Boundaries between these two concepts exist in relation to the level of assessment.
Public health nurses are trained and educated to assess the population overall.
Whereas the community health nurse's knowledge lies within assessing the needs of
individuals and families within the population that they work. 

Public Health
The science and art of preventing disease, prolonging life and efficiency through
organized community effort for:
The sanitation of the environment
The control of communicable infections
The education of the individual in personal hygiene

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The organization of medical and nursing services for the early diagnosis and
preventive treatment of disease
The development of a social machinery to ensure every one a standard of living,
adequate for maintenance of health to enable every citizen to realize his birth right of
health and longevity
(Dr. C.E Winslow)

Roles of the PHN

1. Clinician, who is a health care provider, taking care of the sick people at home or in
the RHU
2. Health Educator, who aims towards health promotion and illness prevention
through dissemination of correct information; educating people
3. Facilitator, who establishes multi-sectoral linkages by referral system
4. Supervisor, who monitors and supervises the performance of midwives
5. Health Advocator, who speaks on behalf of the client
6. Advocator, who act on behalf of the client
7. Collaborator, who working with other health team member

*In the event that the Municipal Health Officer (MHO) is unable to perform his
duties/functions or is not available, the Public Health Nurse will take charge of the
MHO’s responsibilities.

PHCDS
2 Major Players:
The public sector – largely financed through a tax-based budgeting system at both
national and local levels and where health care is generally given free at the point of
service (although socialized user fees have been introduced in recent years for certain
types of services).
The private sector (for profit and non-profit providers – largely market-oriented and
where health care is paid through user fees at the point of service.

Devolution of Health Care Services

RA 7160 or more commonly known as the Local Government Code – The Code aims
to: transform local government units into self-reliant communities an active partners
in the attainment of national goals through a more responsive and accountable local
government structure instituted through a system of decentralization.

With the devolution of health services, the local health system is now run by LGUs.
The provincial and district hospitals are under the provincial government while the
city/municipal government manages the health centers/ rural health units (RHUs) and
barangay health stations (BHSs).
In every province, city or municipality, there is a local health board chaired by the
local chief executive, its function is mainly to serve as advisory body to the local
executive and the sanggunian or local legislative council on health-related matters.

DOH
The DOH leads in effort to improve the health of Filipinos, in partnership with other
government agencies, the private sector, NGOs and communities.

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 It remains to be the national government’s biggest health (particularly curative) care
provider.

Is the principal health agency in the Philippines

It is responsible for ensuring access to basic public health services to all Filipinos
through the provision of quality health care and regulation of providers of health
goods and services.

DOH: MISSION AND VISION

VISION
Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by
2040
MISSION
To lead the country in the development of a productive, resilient, equitable and
people-centered health system for universal health care

Roles and Functions of DOH.

1. Leadership in Health.
Serve as the national policy and regulatory institution from which the local
government units, NGOs and other members of the health sector involved in social
welfare and development will anchor their thrusts and directions for health.
Provide leadership in the formulation, monitoring and evaluation of national health
policies, plans and programs.
The DOH shall spearhead sectoral planning and policy formulation and assessment at
the national and regional levels.
Serve as advocate in the adoption of health policies, plans and programs to address
national and sectoral concerns.

2. Enabler and capacity builder

Innovate new strategies in health to improve the effectiveness of health programs,
initiate public discussion on health issues and undertaking and disseminate policy
research outputs to ensure informed public participation in policy decision-making.
Exercise oversight functions and monitoring and evaluation of national health plans,
programs and policies.
Ensure the highest achievable standards of quality health care, health promotion and
protection.

3. Administrator of specific services

Manage selected national health facilities and hospitals with modern and advanced
facilities that shall serve as national referral centers and selected health facilities at
sub-national levels that are referral centers for local health systems (i.e., tertiary and
special hospital, reference Laboratories, training centers, centers for health promotion,
regulatory offices, among others).
Administer direct services for emergent health concerns that require new complicated
technologies that it deems necessary for public welfare; administer special
components of specific programs like TB, schistosomiasis, HIV/AIDS, in as much as
it will benefit and affect large segments of the population.

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Administer health emergency response services including referral and networking
system for trauma, injuries and catastrophic events in cases of epidemics and other
widespread public danger, upon the direction of the President and in consultation with
concerned LGU.

NOH

The NOH 2017-2022 was produced by the Department of Health (DOH) under the
technical guidance and supervision of Undersecretary Mario C. Villaverde.

The WHO, under the leadership of Dr. Gundo Weiler, also provided technical support
in the review and finalization of the health sector core indicators for the NOH and
through the Strategic Engagement for Enabling Development (SEED) Inc.

This publication was written by Rhodora Tiongson, Joyce Encluna, Napoleon Espiritu
II, Donabelle de Guzman and Jocelyn Ilagan based on the earlier work of the Ateneo
de Manila University School of Government. Consuelo Aranas served as senior
technical resource person while Nayda Bautista and Ma. Alma Mariano provided
technical as well as administrative support.

The DOH Health Policy Development and Planning Bureau (HPDPB) and the WHO
managed the conduct of consultative workshops on FOURmula One Plus for Health
as well as the writing, editing and printing of the document.
The National Objectives for Health (NOH) 2017–2022 serves as the medium-term
roadmap of the Philippines towards achieving universal healthcare (UHC).
It specifies the objectives, strategies and targets of the Department of Health (DOH)
FOURmula One Plus for Health (F1 Plus for Health) built along the health system
pillars of:
> financing,
> service delivery,
> regulation,
> governance
> and performance accountability..

This ultimately leads to the three major goals that the Philippine Health Agenda
aspires for:
(1) better health outcomes with no major disparity among population groups;
(2) financial risk protection for all especially the poor, marginalized and vulnerable;
and
(3) a responsive health system which makes Filipinos feel respected, valued and
empowered

Core values
Professionalism
Responsiveness
Integrity
Compassion
Excellence

Universal Health Care

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February 20, 2019, President Rodrigo Roa Duterte signed into law the Universal
Health Care Act (UHC) also known as Republic Act 11223, heralding a health
systems shift and reform in the Philippines.
To support the implementation of the UHC Act, the Department of Health,
particularly the Health Promotion and Communication Service, has created a strategic
communication and implementation plan to communicate UHC effectively to key
stakeholders and the public. Key activities, products and initiatives are expected to be
rolled out on the coming months nationwide. As part of the initiatives, the Health
Promotion and Communication Service is hereby disseminating the Universal Health
Care Act Frequently Asked Questions Master Guide (see attached document) to all
DOH bureaus, offices and facilities, and to local government units. The document will
serve as a guide for all health care workers, both in the national and local level, in
responding to queries and comments on Universal Health Care Act. The document is
for internal use only. For information and guidance.

GENERAL 1. What is Universal Health Care? . UHC means all Filipinos are
guaranteed equitable access to quality and affordable health care goods and services,
and protected against financial risk.
President Duterte signed R.A. 11223 or the Universal Health Care Act into law last
February 20, 2019. The UHC Act contains comprehensive and progressive reforms
that will ensure every Filipino is healthy, protected from health hazards and risks, and
has access to affordable, quality, and readily available health service that is suitable to
their needs.

Who will benefit from the UHC Act? All Filipinos will benefit from the UHC
Act.The government will ensure that the well being and health needs of all Filipinos,
especially those of the vulnerable population, will be addressed.

How will the UHC Act ensure that every Filipino has access to quality and affordable
health care?
Every Filipino should be able to access preventive, promotive, curative, rehabilitative,
and - palliative health services.
The UHC Act will improve and strengthen existing health sector processes and
systems by highlighting primary care close to families and communities, supported by
hospitals that are contracted as part of a network, and making PhilHealth membership
automatic for every Filipino. This will eventually lead to the establishment of better
networks of providers and facilities, making health accessible for all.

Will all health services be free through UHC?

One of the goals of the UHC Act is to decrease the out-of-pocket expenses of
families. This means that some health services may become more affordable, but not
everything will be free. At the very least, the prices of health goods and services will
be predictable and affordable.
Depending on the available budget, such as additional revenue from tobacco, alcohol,
and sugar-sweetened beverage taxes, and the value-based decisions of health
technology assessment, DOH and PhilHealth will design benefits for this.

What do you mean by a primary care-focused health system?

In a primary care-focused health system, the front line of health services will be
strengthened so that every Filipino will have a trusted primary care provider.

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The primary care provider will be the initial and continuing point-of-contact of
patients/clients with the health system. He/She will provide the needed basic health
services. If higher-level health services are needed, the primary care provider will
navigate patients/clients to a health care provider that can give the appropriate care.
By providing clinical leadership and guidance, hospitals may influence the design of
these primary care services while allowing them to focus on more complicated cases.

When will the UHC Act be operationalized?

The IRR is expected to be approved by September 2019. Initially, there are 33
advanced implementation sites preparing for the roll-out of UHC in 2020, to be
followed by two more batches of implementation sites to cover the country in the
subsequent years.

What should provinces/HUCs/ICCs that are not AI Sites do to enact the UHC Act?
LGUs that are not AI Sites may take the initiative to implement the various
provisions of the UHC Act as they deem necessary. Further, they are encouraged to
join the succeeding batches of AI Sites in order for DOH and PHIC to provide them
the appropriate support in integrating their health systems.

Fourmula for Health

sTrATEgiC gOAls And TArgETs

In response to the challenges identified in improving health outcomes and the health
system, the DOH pursues FOURmula One Plus (F1 Plus) for Health, which aims to
provide Universal Health Care (UHC) for all Filipinos in the medium to long term.

The national policy on UHC espouses three strategic thrusts:

- better health outcomes,
- responsive health system, and
- equitable and sustainable health financing

OUR STRATEGIC GOALS

2017-2022
1. Better health outcomes
- The health sector will sustain gains and address new challenges especially in:
maternal,
newborn and child health,
nutrition,
communicable disease elimination,
and NCD prevention and treatment.
- Improvements in health outcomes will be measured through sentinel
indicators such as:
life expectancy,
maternal and infant mortalities,
NCD mortalities,
TB incidence,
and stunting among under-fiveyear-olds

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2. More responsive health system
- The quality of health goods and services as well as the manner in which they
are delivered to the population will be improved to ensure people-centered healthcare
provision.
- This may be done through instruments that routinely monitor and evaluate
client feedback on health goods used and services received.

3. More equitable healthcare financing

- Access of Filipinos, especially the poor and underserved, to affordable and
quality health goods and services will be expanded through mechanisms that provide
them with adequate financial risk protection from the high and unpredictable cost of
healthcare.
- These may include efforts to reduce catastrophic OOP payments, such as
through public subsidies targeted towards the poor.

Pillars of the FOURmula One Plus for Health

Health Service Delivery

Ensure the accessibility of essential quality health products and services at appropriate
levels of care.
1. Increase access to quality essential health products and services.
2. Ensure equitable access to quality health facilities.
3. Ensure Equitable Distribution of human resources for health.
4. Engage Service Delivery Networks to delivery comprehensive package of health
services.

Elements of the strategy are:

Health financing
Health regulation
Health service delivery
Good governance
Performance accountability

FINANCING:
- Secure Sustainable investments to improve health outcomes and ensure efficient and
equitable use of health resources

SERVICE DELIVERY:
- Ensure the accessibility of essential quality health services at appropriate level of
care
- Wider access to essential health care

REGULATION:
- Safe, quality and affordable health care
- Ensure high quality and affordable health products, devices, facilities and services.

GOVERNANCE:
- functional and people-centered health system

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- Strengthen leadership in management capacities, coordination, and support
mechanisms necessary to ensure functional, people oriented and participatory health
system.

PERFORMANCE ACCOUNTABILITY:
- transparent and responsive health sector
- Use management systems to drive better execution of policies and programs in the
DOH while ensuring responsibility to all stakeholders

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