MANUAL OF STANDARDS FOR THE SANITARIA

DEPARTMENT OF HEALTH HEALTH FACILITY DEVELOPMENT BUREAU

MANUAL OF STANDARDS FOR THE SANITARIA

Copyright 2021 by the Department of Health. All rights reserved. Subject to the acknowledgement of the Health Facility Development Bureau (HFDB), Department of Health, the Manual may be freely abstracted, reproduced or translated in part or in whole for noncommercial purposes only. If the entire Manual or substantial portions will be translated or reproduced, permission should be requested from the HFDB. Printed in the Republic of the Philippines.

National Library Cataloging-in-Publication Data

ISBN

Published by

Department of Health San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila 1003 PHILIPPINES

PRODUCTION CREDITS

Project Leader: Terence John Antonio, MD, MBA

Ibrahim V. Pangato, Jr, MD, MAHA, CESE

Copy Editor: Camille Ann C. Ople

Development of this Manual was initiated, completed and subsequently published through the HFDB. For inquiries, contact the Bureau:

Phone: +63 2 8651 7800 locals 1401, 1403, 1408

Email Address: hfdb@doh.gov.ph

Table of Contents

MESSAGE	V
MESSAGE	vi
PREFACE	vii
FOREWORD	viii
ACKNOWLEDGEMENT	ix
LIST OF ABBREVIATIONS	xi
DEFINITION OF TERMS	xii
LIST OF ANNEXES	xiv
MANUAL OF STANDARDS FOR THE SANITARIA
SANITARIA IN THE PHILIPPINES	1
SANITARIA SERVICE	15
SPECIAL SERVICES IN THE SANITARIA	18
OPERATION STANDARDS AND PROCEDURES	20
INFRASTRUCTURE AND EQUIPMENT	29
CONTINUOUS QUALITY IMPROVEMENT (CQI) IN THE SANITARIA	33
RESEARCH AND LEARNING DEVELOPMENT INTERVENTIONS	39
ANNEXES	41
REFERENCES	רח

Filipinos have access to quality and affordable health services and are protected against financial risk, the Department of Health (DOH) urges the health sector to move towards the development of a productive, resilient, equitable, and people-centered health system, as outlined in the DOH's strategy map to boost UHC, the FOURmula One Plus (F1 Plus) for Health. Aiming for better health outcomes, more responsive health systems, and more equitable health care financing are of paramount importance, especially now that we are accelerating

harmonizing with the entire health sector in ensuring high quality and affordable health products, With this, I heartily commend the Health Facility Development Bureau (HFDB) for their initiative and commitment to harmonize and streamline the standards and processes for the

operations of all health facilities, which encompasses the formulation of the Manual of Standards for the Sanitaria. Moreover, the development of this updated manual of standards is aligned with

the Philippine Health Facility Development Plan (2020-2040) and has been designed to further improve the quality of care provided to the Persons Affected by Leprosy through the 8 DOH sanitaria. Hence, let the standards defined in this manual stand as relevant bases for the enrichment of equitable access to safe and quality health facilities and services compliant to the standards of care. Keeping in mind performance accountability across all pillars of F1 Plus, particularly in the

quality healthcare for all, this manual shall be instrumental in the achievement of UHC. Together, let us realize a new health system which focuses on people's needs, while recognizing the Filipino people's varying cultures, beliefs, and values.

Secretary of Health

shall endeavor to ensure that every Filipino has better access to appropriate health care services without experiencing financial hardships and that a more responsive health system makes them This goal entails improving the quality of the delivery of health services in health facilities where patients experience health care first hand. Health facilities must then be venues of clinical

Thus, the Manual of Standards for the Sanitaria aims to ensure that the 8 DOH Sanitaria abide by the standards set for health facility operations and to provide continuous improvement

of the quality of care in these sanitaria.

The manual, which shall serve as a reference of policies and guidelines for effective implementation of the leprosy control program, emphasizes the important role of the sanitaria in the overall achievement of decreasing the burden of leprosy in the country. In its 7 chapters, the

standards for services, equipment and infrastructure, human resources, and continuous quality improvement measures for the operations of a sanitarium shall be discussed. With this, we enjoin every stakeholder to promote health through continuous learning, peer support, and mentorship, and to implement the standards in this Manual as most appropriate in their respective settings.

Thank you very much and best wishes to all!

LILIBETH C. DAVID, MD, MPH, MPM, CESO I Undersecretary of Health Health Facilities and Infrastructure Development Team

PREFACE

Leprosy has been a problem besetting humanity since biblical times. Today, the disease continues to pose a huge challenge to people affected with leprosy (PALs) and to our healthcare workers. The Philippines currently has eight (8) sanitaria that have been at the forefront of the fight to eradicate this dreaded and debilitating disease, and these healthcare facilities have since evolved from their original mandate.

A technical working group composed of experts from the eight sanitaria with the help of the technical and support staff from the Health Facility Development Bureau (HFDB) was organized to convene in a series of consultative meetings to oversee the creation of this manual.

The making of this manual has been challenging, especially since it was carried out virtually from the onset to completion. The process has also proven to be engaging to the participants, as shown in the TWG's willingness and enthusiasm in finishing the manual on time and coming up with a manual that will be useful and responsive to the needs of the sanitaria.

The creation of this Manual of Standards for the Sanitaria may be long overdue, but follows the stride of the updated guidelines on the treatment and prevention of leprosy in the Philippines that was release early this year. The main objective of this manual is to standardize the roles and responsibilities of each of the existing sanitarium, revisit its mandate, reexamine its practices, improve its capabilities, and adapt to the changing times in the treatment of leprosy.

In the end, the ultimate aim of the manual is to create a standard for the sanitariums and serve as a guide to further improve health care facilities engaged in the management of leprosy.

IBRAHIM V. PANGATO, JR., MD, MAHA, CESE

Chairperson Technical Working Group Manual of Standards for the Sanitaria

The Department of Health's (DOH) Health Facility Development Bureau (HFDB) is at the

relevant health facility policies, programs, and standards, as well as the provision of technical assistance and advisory services in the development, planning, operations, and maintenance of health facilities. The Manual of Standards for the Sanitaria dutifully integrates the DOH's policy framework and objectives in the implementation of Republic Act No. 11223, also known as the Universal Health Care Act. In addition, the manual underscores the improvement in the quality of

care provided to and received by the Persons Affected by Leprosy. The Bureau recognizes the importance of these measures in decreasing, and possibly eradicating, the burden of leprosy in the country. With this, the HFDB extends the utmost gratitude for the generosity of the Technical Working Group members and experts, invited resource persons, and other stakeholders, who have dedicated their time, expertise, and effort to ensure that this latest edition of this manual shall be

responsive and sufficient to address the health facilities' needs for continuous quality improvement. The health facility is the people's primary interface with the health system. It is at this juncture, where the Filipinos' expectations and the genuine changes brought by Universal Health

Care intersect. We trust that through this and our other initiatives, as well as our other stakeholders' sustained enthusiastic cooperation, we shall fortify the DOH's efforts of providing financial risk protection, a more responsive health service delivery, and better health outcomes for

MA. THERESA G. VERA, MD, MHA, MSc, CESO III Director IV

ACKNOWLEDGEMENT

Sincerest gratitude to the Health Facility Development Bureau (HFDB) Director Dr. Ma. Theresa G. Vera, and to the Undersecretary of the Health Facilities and Infrastructure Development Team (HFIDT), Dr. Lilibeth C. David, for their support in the completion of this manual.

Special thanks to the hardworking members of the Sanitaria Manual Technical Working Group who shared their expertise and patiently reviewed and took necessary changes to make this new edition relevant to the current needs of the 8 DOH sanitaria:

Chairperson:

Dr. Terence John M. Antonio Medical Officer IV, HFDB

Co-Chairperson:

Dr. Ibrahim V. Pangato, Jr Chief of Hospital II, Cotabato Sanitarium

Members:

Dr. Vilma C. Ramilo

Medical Specialist III, Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium

Dr. Frederica Veronica Marquez-Protacio

Medical Specialist IV, Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium

Dr. Amelia P. Poblete

Medical Officer IV, Mindanao Central Sanitarium

Mr. Vladimir C. Amiruddin

Nurse I, Mindanao Central Sanitarium

Dr. Edgardo R. Sarmiento

Medical Center Chief I, Bicol Region General Hospital and Geriatric Medical Center

Mr. Dionesio D. Abergos

Training Specialist IV, Bicol Region General Hospital and Geriatric Medical Center

Dr. Mangontawar Daing

Medical Specialist II, Cotabato Sanitarium

Mr. Mukim Sibba

Medical Social Welfare Officer II, Sulu Sanitarium

Mr. Anthony General

Administrative Officer III, Sulu Sanitarium

Dr. Faith Daphne H. Estrada

Medical Specialist II, Western Visayas Sanitarium

Dr. Gemma M. Suelo

Chief Medical Professional Staff I, Western Visayas Sanitarium

Dr. Emily Apas

Medical Officer III, Eversley Childs Sanitarium and General Hospital

Ms. Llewelyn Cabrera

Nurse II, Eversley Childs Sanitarium and General Hospital

Dr. Arturo C. Cunanan, Jr

Medical Center Chief I, Culion Sanitarium and General Hospital

Ms. Marai Luz M. Gante

Administrative Officer II/ Executive Assistant, Culion Sanitarium and General Hospital

Ms. Donna Ruzzel B. Gacasan

Data Controller II/ Executive Assistant, Culion Sanitarium and General Hospital

Technical Secretariat:

Dr. Armaine Bel V. Santos

Medical Officer III, HFDB

Ms. Josephine L. Guiao

Development Management Officer IV, HFDB

Administrative Support Staff:

Mr. Henry Ryan Dominic Cajandig

Administrative Assistant III, HFDB

Appreciation is extended to the following technical staff from the DOH Central Office sharing their time in reviewing these standards and providing valuable inputs:

• Ms. Faye Diana C. Chua, Development Management Officer IV, HFDB
• Mr. Erickson A. Feliciano, Development Management Officer IV, HFDB
• Ar. Katrine Aira A. Veridiano, Development Management Officer III, HFDB
• Ar. Jean Paolo Policarpo, Development Management Officer III, HFDB
• Mr. Glenn A. Cruz, Development Management Officer III, HFDB
• Ms. Camille Ann C. Ople, Senior Administrative Assistant II, HFDB
• Ms. Lea Erlandez, Administrative Assistant VI, HFDB
• Ms. Pacita Alano, Senior Health Program Officer, Disease Prevention and Control Bureau

LIST OF ABBREVIATIONS

CQI	Continuous Quality Improvement
DMAIC	Define-Measure-Analyze-Improve Control
ENL	Erythema Nodosum Leprosum
EPU	Emollients Production Unit
FDA	Food and Drug Administration
OPD	Out-Patient Department
PAL	Persons Affected by Leprosy
PDSA	Plan-Do-Study-Act
PHU	Public Health Unit
NLCP	National Leprosy Control Program
NOH	National Objectives for Health
NTD	Neglected Tropical Diseases
UHC	Universal Health Coverage

DEFINITION OF TERMS

Continuous Quality Improvement	refers to a process through which the level of quality is defined, pursued, achieved and continuously improved through the establishment of formal mechanisms/systems and structure within the organization. It is a strategic approach to provide the best health care possible for all. It is also a preventive strategy that uses constant innovation to improve work processes and systems by reducing time-consuming and low-value activities.
Custodial Care	is the spectrum of long-term services provided (i.e., humanitarian, medical, social, rehabilitation) for persons affected with active disease or had completed treatment for leprosy, who are old, disabled, poor, and abandoned.
Emollients	are moisturizing agents applied directly to the affected areas of the skin for soothing and hydration purposes by covering the skin with a protective film to trap in moisture and to prevent patches of inflammation and flare-ups of dermatologic conditions
Leprosy	is a chronic and mildly communicable disease caused by Mycobacterium leprae and Mycobacterium lepromatosis , both acid-fast, rod-shaped bacillus. The disease mainly affects the skin, the peripheral nerves, the eyes and mucosa of the upper respiratory tract
Leprosy case	is a person showing clinical signs of leprosy with or without bacteriological confirmation of the diagnosis and requiring chemotherapy
Leprosy elimination	is the reduction in the proportion of leprosy patients in a community to <1 per 1,000,000 population.
Leprosy eradication	is the total disappearance of the disease-causing organism, which results in total and complete interruption of disease transmission, i.e. zero disease.
Multibacillary (MB) Leprosy	shows 6 or more lesions, nodules, plaques, thickened dermis or skin infiltration, and in some instances involvement of the nasal mucosa.
Paucibacillary (PB) Leprosy	is characterized by five or less hypo-pigmented, anaesthetic skin lesions that are pale or reddish in color

Multi-Drug Therapy (MTD	is the World Health Organization (WHO)-recommended standard treatment regimen for leprosy, of which 2-3 drugs in Dapsone, Rifampicin, and Clofazimine are combined as treatment regimen for leprosy.
Palliative Care	is an approach to improve the quality of life of leprosy patients through the provision of care for leprosy patients with acute needs (needing 24 hour observation)
Sanitarium	is an institution established to make available hospital services (leprosy prevention, treatment, control, and rehabilitation) to include custodial care specifically for Hansenites (Hansen Disease). It shall serve as the referral center for the management of complications, patient and family counselling, and community education for leprosy. It shall also aim to integrate multidrug therapy (MDT) for leprosy (DOH AO 2005-2013).

LIST OF ANNEXES

Annex 1	Relevant Links to this Manual
Annex 2	Custodial Ward Model Floor Plan
Annex 3	Palliative Ward Floor Plan
Annex 4	Dedicated OPD Space for Dermatology Care Floor Plan
Annex 5	Disability Prevention Service Floor Plan
Annex 6	Emollients Compounding Service Floor Plan
Annex 7	World Health Organization's Guidelines for the Diagnosis, Treatment, and Prevention of Leprosy 2018

MANUAL OF STANDARDS FOR THE SANITARIA

Chapter 1 SANITARIA IN THE PHILIPPINES

I. Situation of Leprosy in the Philippines

In the Global Leprosy Strategy 2016-2020, the Philippines is identified as one of the 23 global priority countries for strategies to be implemented to help accelerate the eradication of leprosy. In their 2019 report, the Philippines records a trend of detection of new cases with a range of 1617 to 2176 from 2009 to 2018. In the same report, new cases with Grade 2 deformities in the Philippines were reported to be consistently low from 2014 to 2018 with 56, 60, 68, 36, and 51 cases reported respectively year on year.

On February 17, 1994, former Secretary of Health Juan M. Flavier signed Department Order (DO) No. 72 s. 1994 to redirect the roles and responsibilities of the eight sanitaria (See bit.ly/sanitariaissuances). Meanwhile, on February 28, 1995, Dr. Flavier issued Administrative Order (AO) No. 6-A, s. 1995 "Implementing guidelines for cash incentives to negative, able-bodied Leprosy patients in sanitaria" to encourage the patients to go back and reintegrate to their native communities since Multi-Drug Therapy (MDT) against Hansen's Disease has been discovered. Aside from mandating functions on leprosy control, each sanitarium was tasked to provide emergency and outpatient treatment/care for the general population in its immediate catchment area. Each sanitarium was mandated to upgrade its emergency room to perform minor surgery and expand the coverage of its outpatient service to non-leprosy cases.

Due to the massive positive result of MDT application, there was an unprecedented decrease in the prevalence of leprosy in the Philippines from 2.4 cases/10,000 population in 1992 to 0.57 cases/10,000 population in 2000, thus the eight sanitaria needed to adjust targets and priorities.

The prevalence rate of leprosy per 10,000 population has declined from 0.88 per 2008 to 0.22 cases in 2013, but rose aggressively to 0.4 in 2014, possibly due to the case detection rate that dwindled and non-completion of treatment among patients. However, keeping track of the re-emergence of leprosy remains a challenge due to weak surveillance and epidemiologic monitoring and evaluation.

Figure 1 shows the prevalence rate of leprosy per 10,000 population for the year 2018 in the Philippines. The Eastern Visayas Region and the Northern Mindanao Region (Red), need intensified or special efforts for leprosy elimination campaigns (LECs) to succeed; while Soccsksargen (Yellow), needs accelerated or stepped-up efforts. The rest of the regions need sustained or continuing efforts for LECs to succeed, as indicated by the green bar.

Figure 1. Prevalence Rate of Leprosy in the Philippines, per 10,000 population, by Region, 2018 (FHSIS, 2018)

The National Leprosy Control Program (NLCP), which is a joint effort of various organizations to control, eliminate, and eradicate leprosy in the Philippines, strategically implements public-private partnership to achieve its end goal of lessening the burden of the disease through maintaining and sustaining its elimination initiatives, with the vision of Leprosy-free Philippines by the year 2022, and having the mission of ensuring the provision of comprehensive, integrated quality leprosy services at all levels of healthcare.

Its strategic objectives have focused according to three groups of prevalence rates and new cases detected per area, which are as follows:

Table 1. Types of effort needed for areas depending on prevalence rate per 10,000 population (Source: National Leprosy Control Program)

Types of Effort Needed	Prevalence Rate (per 10,000 population)
Intensified (special effort)	At least 1.0
Accelerated (step up effort)	0.6 to 0.9
Sustained (continuing effort)	0.5 or < 0.5

By 2022, NLCP aims to achieve the following target indicators:

• a. Zero G2D rate among pediatric leprosy patients;
• b. Reduction of new leprosy cases to <1/1,000,000 population; and
• c. No local government units (LGUs) with local legislation allowing discrimination on basis of leprosy.

The program has also added MDT and health promotion as additional components, as per DOH AO 26-A, s. 1997, Guidelines on Elimination of Leprosy as a Public Health Problem (See bit.ly/sanitariaissuances). Its budget has increased over the last eight years, from PhP 79 million in 2011 to PhP 151 million in 2019.

II. Alignment in Global, Macro, and National Plans

A. Sustainable Development Goals

In 2015, the United Nations (UN) Member States adopted the integrated 17 Sustainable Development Goals (SDG), or the Global Goals, as a universal call to action to end poverty, protect the planet by tackling climate change, and ensure that all people enjoy peace and prosperity by fighting inequality and injustice by 2030. These SDGs recognize that action in one area could affect outcomes in the others, and that social, economic, and environmental sustainability must be balanced by development. The Member States have committed to fast-track progress first for the SDGs that are furthest behind through the pledge to Leave No One Behind, which includes the most marginalized groups of the population, including those affected by leprosy.

The goal to ease the burden of leprosy in the population will contribute to the attainment of Sustainable Development Goal 3, which is to ensure healthy lives and promote well-being for all at all ages by 2030. One part of this goal is to further reduce the burden of leprosy at the global and local levels. One of the indicators for SDG 3 is "people requiring interventions against Neglected Tropical Diseases (NTD)". Despite being classified as an NTD, the current surveillance system lacks data on leprosy with poor disaggregation across ages and regions of the country. Data availability is crucial in the monitoring of any leprosy control and prevention strategy to provide evidence-based decisions among stakeholders.

B. AmBisyon Natin 2040

Regarded as the collective long-term vision and aspirations of the Filipinos by 2040, AmBisyon Natin 2040 outlines the kind of life that Filipinos want to live and how the Philippines will fare by 2040. The National Economic Development Authority describes this macro-plan as an image of the future, a set of Filipino goals both for themselves and for the Philippines. This vision guides the future of the Filipino people and anchors the plans of the government across all agencies.

Part of the goals of AmBisyon Natin 2040 is to eradicate neglected tropical diseases in the Philippines by 2040, which includes leprosy, to ease the burden of the people afflicted by these various diseases. It envisions the Philippines to have a prosperous middle class society where no one is poor, where people live long healthy lives, are smart, and are innovative. This macro-plan also aims to eliminate any stigma associated with any disease, such as leprosy.

C. Universal Health Care (UHC) Act or Republic Act No. 11223

Described by the World Health Organization (WHO) as a new dawn for healthcare, Republic Act (RA) No. 11223 or the Universal Health Care (UHC) Act, automatically enrolls all Filipino citizens in the National Health Insurance Program (NHIP) and prescribes complementary reforms in the Philippine health system. This law provides citizens access to the full continuum of health services they need, while also protecting them from enduring financial hardship as a result. This Act is the culmination of decades of progress and two years of dedicated political and technical work.

This Act mandates the Philippine health system to provide every necessary and essential means to eliminate, if not eradicate, NTDs causing burden to the Filipinos. UHC shall monitor equity with essential services for marginalized communities, including those afflicted with NTDs, such as leprosy.

III. Legal Mandates of Sanitaria

The existence of sanitaria was first strengthened and given mandate under Act No. 1711 of the Philippine Commission or the Segregation Law, which was promulgated in 1907. It compulsorily segregated and isolated leprosy patients in Culion Leper Colony, Palawan in 1906; then in regional treatment centers in Cebu (Eversley Childs Sanitarium, now Eversley Childs Sanitarium and General Hospital), in Bicol (Bicol Sanitarium, now Bicol Region General Hospital and Geriatric Medical Center), and in Central Luzon (Tala Sanitarium, now Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium).

The Sanitarium has housed thousands of leprosy patients and their families. The sanitarium has been the initial testing ground for treatment using chaulmoogra oil derivatives like ethyl ester with iodine (Mercado mixture); but it is the caring, the segregation/isolation, and finding a place away from discrimination and stigma, that made the sanitarium or "leper colony" more noted and known for.

To date, the following national laws and legislations were enacted to control the spread of leprosy, to protect the human and social rights of persons afflicted with leprosy, and to advocate against the stigma caused by leprosy:

A. Republic Acts

• 1. Republic Act No. 753: An Act Amending Sections of 1058 1071 of Article 15 of Act No. 2711 Known as the Revised Administrative Code, Providing for the Control of Leprosy and for Other Purposes.
• 2. Republic Act No. 4073: An Act further liberalizing the treatment of leprosy by amending and repealing certain sections of the revised Administrative Code
• 3. Proclamation No. 467: Declaring the Last Week of February of every year as Leprosy Week
• 4. Presidential Decree No. 384: Amending Republic Act No. 4073 entitled An Act further liberalizing the treatment of leprosy by amending and repealing certain sections of the revised Administrative Code

B. Department of Health Issuances

Table 2 lists down all DOH policy issuances pertinent to the legal mandates of the eight DOH hospitals with sanitaria services.

Table 2. Issuances released by the Department of Health pertinent to the control and prevention of leprosy in the Philippines, CY 1965-2005

Issuance Date	Issuance Number	Title	Objectives
October 19, 1965	Administrative Order No. 167, s. 1965	Rules and Regulations on Leprosy Control in the Philippines	To define the rules and regulations of leprosy control in the Philippines
November 29, 1977	Administrative Order No. 336, s. 1977	Placing the Leprosy Research Laboratory and Training Center under the Dermatology Research and Training Project	To place the Leprosy Research Laboratory and Training Center under the administrative direction and control of the Dermatology Research and Training Project following the concept that leprosy is principally a disease of the skin
December 6, 1977	Administrative Order No. 337, s. 1977	Amending Administrative Order No. 336, s. 1977, placing the Leprosy Control Service, instead of the Leprosy Research Laboratory and Training Center under the Dermatology Research and Training	To transfer the personnel of Leprosy Control Service to Dermatology Research and training
February 17, 1994	Department Order No. 72 s. 1994	Redirection of Roles & Responsibilities of the 8 Sanitaria and Department	To redirect the roles and responsibilities of the 8 sanitaria

		of Health Regional Field Office (DIRFO)
February 28, 1995	Administrative Order No. 6-A, s. 1995	Implementing guidelines for cash incentives to negative, able bodied Leprosy patients in sanitaria	1. To define the coverage and criteria for eligibility of the cash incentives 2. To implement the grant of cash incentives to negatives and able bodied former leprosy patients upon discharge from any of the 8 sanitaria of the Department of Health 3. To standardize the cash incentives to be provided/subsidized by the sanitaria
November 5, 1997	Administrative Order No. 26- A, s. 1997	Guidelines on Elimination of Leprosy as a Public Health Problem	To eliminate leprosy as a public health problem by attaining a PR of less than 1 case per 10,000 population at the national level by end of 1998 and at the sub-national level by end of year 2000.
January 30, 1998	Administrative Order No. 2-A, s. 1998	Shorter Treatment Course for Leprosy	To shorten the duration of treatment of eligible Paucibacillary (PB) and Multibacillary (MB) leprosy cases thereby improving treatment compliance
February 12, 1999	Administrative Order No. 6-A, s. 1999	Treatment Protocol for Leprosy	To standardize and simplify management of paucibacillary and multibacillary type of

			leprosy
January 12, 2000	Administrative Order No. 5-A, s. 2000	Guidelines on the Integration of Leprosy Services in Hospitals	To make leprosy services available in medical centers, regional, provincial, city, and district hospitals by the end of year 2000.
October 17, 2003	Department Circular No. 352, s. 2003	First Leprosy Forum of the Philippine Dermatological Society	To provide a venue for exchange of ideas, updates, and discussion of different aspects of leprosy from the medical, epidemiological, to the social and developmental aspects
October 27, 2003	Department Circular No. 366-B, s. 2003	First Leprosy Forum and 27th Annual National Convention of the Philippine Dermatological Society	To provide a venue for exchange of ideas, updates, and discussion of different aspects of leprosy from the medical, epidemiological, to the social and developmental aspects
August 16, 2004	Department Memorandum No. 79, s.2004	Recommendations to Pursue Leprosy Elimination Activities in All Areas in the Country	"Developing a holistic approach to the problem of leprosy" To provide recommendations on how to pursue leprosy elimination in the Philippines
September 1, 2004	Department Circular No. 254, s. 2004	2nd Leprosy Forum of the Philippine Dermatological Society	"Dilemmas and Difficulties in Leprosy" To enhance the

			competence of our health professionals in epidemiologic and clinical problems of persons with leprosy
May 30, 2005	Administrative Order 2005- 0013	Revised Roles and Responsibilities of the Eight {8) Sanitaria Hospitals	To expand the legal mandate of the eight (8) Sanitaria nationwide

Issuances mentioned above are found in bit.ly/sanitariaissuances

IV. Expanded mandate of the eight sanitaria in the Philippines

On May 30, 2005, Department Order No. 72 s. 1994 was amended when former Secretary of Health Manual M. Dayrit expanded the legal mandate of the eight sanitaria in the Philippines, through the issuance of DOH Administrative Order 2005-0013 entitled Revised Roles and Responsibilities of the Eight (8) Sanitaria Hospitals (See bit.ly/sanitariaissuances). Due to the dual roles of sanitaria in providing general hospital services and in custodial services, financial and human resources became more limited. As such, the DOH conducted consultations with various Centers for Health Development and hospitals, and proposed the Sanitaria Conversion Plan as part of the DOH Hospital Upgrading Plan. Cognizant to this issuance, all sanitaria were tasked to convert existing buildings to hospital wards to accommodate inpatients for general hospital service care, and to ensure the availability of five major hospital services/departments; medical, surgical, obstetrics and gynecology, family medicine, and pediatrics.

In 2005, Administrative Order No. 2005-0013 mandated that all sanitaria should provide 24/7 services in the 4 major fields in general clinical care, specifically Surgery, Obstetrics, Pediatrics and Internal Medicine in addition to its Leprosy service.

The proposed Sanitaria Conversion Plan was conceptualized and the following options were made available:

• a. Conversion to a general hospital;
• b. Conversion to a tertiary level rehabilitation facility or health facility with research and learning and development intervention capabilities;
• c. Merger with Medical Center; and
• d. Other options as recommended by CHD Officials and other concerned hospital chiefs in the affected catchment area.

The expanded role initially created confusion, as well as challenges, in the administration of the sanitarium. Whereas before, the sanitarium was under the Bureau of Sanitaria services, then later under the Infectious Disease services, it has moved to the Hospital Operations Management Service (HOMS) of the Department of Health, which was one of the services absorbed by the National Center for Health Facility Development (NCHFD) - now named as the Health Facility Development Bureau (HFDB). This transformation has put great challenges in operating the sanitarium into an income-generating and self-sustaining DOH-retained hospital, considering the number and capacity of existing staff, health infrastructure and the population of which it will serve and cover. The past years had also brought significant adjustments and success stories to some sanitaria, like Cebu, Culion, and Tala, while others had to struggle to fit-in with the new expanded role. To date, much has still to be desired and to be improved to fully transform to meet the standards.

While the sanitarium transformed and expanded its role, the leprosy services also continued in terms of detection, diagnosis, treatment of new cases, and management of leprosy complications like leprosy reactions and neuritis, and rehabilitation. Some sanitaria are also involved in active case detection like LEC and also in training RHU personnel at the provincial level. However, the main bulk of its activities and budget goes to custodial care of old, disabled, cured patients who were victims of the segregation policy before, and those with no families or whose families are poor to look after these patients.

The national leprosy situation was also significantly improving in terms of reducing the disease burden with the elimination of leprosy as a public health problem in 1998 using the WHO indicator of a prevalence rate of less than one (1) per 10,000 population. The MDT program, since 1988, has been implemented as an integrated program into the general health system with the National Leprosy Control Program (NLCP) at the DOH Central Office providing the lead role. The Devolution Law of 1991, which placed the ownership of the leprosy program under the LGUs, has also made significant changes in the MDT implementation, progress and sustainability. Though leprosy has been eliminated at the National level, leprosy continues to be a public health problem in several provinces, cities, municipalities, and the absolute number of new cases detected has not changed significantly, where the Philippines continued to be the highest in the Western Pacific Region. The current national leprosy statistics posed a challenge to further improve and reduce leprosy burden particularly in the sub-national level and to sustain quality leprosy activities into the general health care service, to include prevention of disabilities and rehabilitation (Physical, Social and Economic). It is recognized that the role and contribution of the sanitaria in the furtherance of these goals and objectives is very essential.

Administrative Order No. 2005-0013 dated May 30, 2005, provided the Revised Roles and Responsibilities of the eight (8) sanitaria. This included the following:

a. Responsibilities for the learning and development of health workers in their respective catchment areas regarding updates, learning and development, and retention of the Leprosy Control Program.

• b. Integrate the Multiple Drug Therapy (MDT) services fully with the existing general health care services.
• c. Serve as the referral center for the management of complications, patient and family counseling and community education.
• d. Conduct community dialogues about Leprosy and the National Leprosy Control Program (NLCP)
• e. Provide emergency, out-patient treatment/care for the general population in its immediate catchment area. Each Sanitarium shall upgrade its emergency room, provide for the out-patient department, and convert existing buildings as wards to accommodate in-patients for general service care.
• f. Make available initially the following five major Service Departments namely: Medical, Surgical, Obstetrics and Gynecology, Family Medicine and Pediatrics.

V. Expansion and Conversion of Five Sanitaria

Moreover, of the eight DOH hospitals that were originally mandated to cater to leprosy patients, five have already been expanded and converted to a general hospital through the following Republic Acts and Implementing Rules and Regulations (See bit.ly/sanitariaissuances for a copy of these):

1. Culion Sanitarium

• a. RA No. 9790 An Act Converting the Culion Sanitarium in the Municipality of Culion, Province of Palawan into the Culion Sanitarium and General Hospital and Appropriating Funds Therefor
• b. DOH AO No. 2015-0016 – Implementing Rules and Regulations of Republic Act No. 9790, "An Act Converting the Culion Sanitarium in the Municipality of Culion, Province of Palawan into the Culion Sanitarium and General Hospital and Appropriating Funds Therefor"

2. Bicol Sanitarium

• a. RA No. 11108 An Act Expanding the Mandate and Service Capability of the Bicol Sanitarium in the Municipality of Cabusao, Province of Camarines Sur, to Be Known as the Bicol Region General Hospital and Geriatric Medical Center, Upgrading Its Service Facilities, Authorizing the Increase of Its Medical Personnel and Appropriating Funds Therefor
• b. DOH AO No. 2019-0011 – Implementing Rules and Regulations of Republic Act 11108, "An Act Expanding the Mandate and Service Capability of the Bicol Sanitarium in the Municipality of Cabusao, Province of Camarines Sur, to Be Known as the Bicol Region General Hospital and Geriatric Medical Center, Upgrading Its Service Facilities, Authorizing

the Increase of Its Medical Personnel and Appropriating Funds Therefor"

3. Eversley Childs Sanitarium Hospital

• a. RA No. 11273 An Act Increasing the Bed Capacity for General Hospital Services of the Eversley Childs Sanitarium Hospital in Mandaue City, Province of Cebu, From Fifty (50) Beds to Two Hundred (200) Beds, Renaming the Hospital as the Eversley Childs Sanitarium and General Hospital, and Appropriating Funds Therefor
• b. DOH AO No. 2019-0024 – Implementing Rules and Regulations of Republic Act 11273, "An Act Increasing the Bed Capacity for General Hospital Services of the Eversley Childs Sanitarium Hospital in Mandaue City, Province of Cebu, From Fifty (50) Beds to Two Hundred (200) Beds, Renaming the Hospital as the Eversley Childs Sanitarium and General Hospital, and Appropriating Funds Therefor"

4. Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium

• a. RA No. 11286 An Act Increasing the Bed Capacity for Tertiary General Health Care Services of the Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium in Tala, Caloocan City from Two Hundred (200) to Eight Hundred (800) Beds, Reapportioning the Authorized Two Thousand (2,000) Bed Capacity of the Hospital Amending for the Purpose Republic Act No. 9420, and Appropriating Funds Therefor
• b. DOH AO No. 2019-0038 – Implementing Rules and Regulations of Republic Act 11286, "An Act Increasing the Bed Capacity for Tertiary General Health Care Services of the Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium in Tala, Caloocan City from Two Hundred (200) to Eight Hundred (800) Beds, Reapportioning the Authorized Two Thousand (2,000) Bed Capacity of the Hospital Amending for the Purpose Republic Act No. 9420, and Appropriating Funds Therefor"

5. Mindanao Central Sanitarium

• a. RA No. 11325 An Act Upgrading the Mindanao Central Sanitarium in Pasobolong, Zamboanga City into a Tertiary Level Hospital, Increasing Its Bed Capacity for General Care Services from Fifty (50) to Two Hundred (200) Beds, and Appropriating Funds Therefor
• b. DOH AO No. 2019-0053 – Implementing Rules and Regulations of Republic Act 11325, "An Act Upgrading the Mindanao Central Sanitarium in Pasobolong, Zamboanga City into a Tertiary Level Hospital, Increasing Its Bed Capacity for General Care Services from Fifty (50) to Two Hundred (200) Beds, and Appropriating Funds Therefor"

VI. The Hospital Development Plan of the Eight Sanitaria in the Philippines

As per the Hospital Development Plans of the eight sanitaria, all eight DOH hospitals providing sanitaria services shall retain their function as such, in addition to expanded functions and services as general services. As such, seven of the eight hospitals shall upgrade to, at least, Level 2 General Hospital, while one will expand its services to upgrade into a Level 3 General Hospital. As part of their respective Healthcare Provider Network (HCPN), select of the mentioned eight hospitals shall develop chronic care facilities to help decongest their network's DOH Level 3 hospitals.

Moreover, as may be recommended by the respective apex, when minimum service capabilities are attained, dermatologic services shall be established among the eight hospitals. Meanwhile, Bicol Region General Hospital and Geriatric Medical Center (BRGHGMC) shall establish geriatric specialty services.

Five of the eight hospitals have expanded their mandates from sanitaria alone to general hospital, through the issuance of a Republic Act. The remaining three have pending bills filed in the Congress for expansion and development plan purposes to be converted to a general hospital, while also maintaining their mandates in providing healthcare services to leprosy cases.

In line with the FOURmula One Plus (F1 Plus) for Health and the Philippine Health Facility Development Plan (2020-2040) and the Individual Development Plans of these facilities, which envisions all DOH hospitals as tertiary referral hospitals within functional service delivery networks, all the eight (8) DOH sanitaria are enjoined to:

• a. Provide emergency, out-patient and in-patient treatment/care for the general population in its immediate catchment area. Which shall be implemented through the upgrading of the Emergency Room, Outpatient Department and hospital wards.
• b. Make available the following major clinical departments, namely: Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics as required by the DOH Licensing Standards for all Level 2 hospitals, in line with the direction of the Philippine Hospitals Development Plan.
• c. In addition, all DOH sanitaria are targeted to be upgraded and be developed to have expanded hospital services, including a dermatologic center or clinic, as follows:

					Table 3. The Hospital Development Plan of the Sanitaria in the Philippines

Name of Hospital	Expanded Health Services	Type of Dermatologic Center/Unit	Target Year of Establishment
Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium (DJNRMHS)	General Hospital, to Level 3, 250 beds With Training Center for Leprosy Treatment	Advanced	2022

Culion Sanitarium and General Hospital (CSGH)	General Hospital, at least Level 2, 100 beds	Clinic	2020
Bicol Region General Hospital and Geriatric Medical Center (BRGHGMC)	General Hospital, at least Level 2, 100 beds; and Geriatric Hospital (Regional counterpart for the National Center for Geriatric Health	Clinic	2020
Western Visayas Sanitarium (WVS)	General Hospital, at least Level 2, 100 beds	Clinic	2020
Eversley Childs Sanitarium and General Hospital (ECSGH)	General Hospital, at least Level 2, 100 beds	Clinic	2020
Sulu Sanitarium (Sulu San)	Mother and Child Hospital, at least Level 2, 100 beds	Clinic	2020
Mindanao Central Sanitarium (MCS)	General Hospital, at least Level 2, 100 beds; and Regional Trauma Center	Clinic	2020
Cotabato Sanitarium (CotSan)	General Hospital; at least Level 2, 100 beds and Mother and Child Hospital	Clinic	2020

d. Continuous updating of the 5 Year Sanitaria Expansion and Development Plan - by each Sanitarium, in coordination with the concerned Regional Offices and Central Office Bureaus.

Lastly, the following table lists down the specialty centers planned to be established in four of the eight DOH hospitals with sanitaria mandates:

Table 4. Specialty Centers to be established in four Sanitaria

Name of Hospital	Specialty	Facility Classification	Target Year of Upgrading or Establishment
Dr. Jose N. Rodriguez Memorial Hospital and	Mental Health	Basic Comprehensive Center	2023
Sanitarium (DJNRMHS)	Dermatology	Advanced Comprehensive Center	2022
Culion Sanitarium and General Hospital (CSGH)	Eye Care	Basic Comprehensive Center	2022
Bicol Region General Hospital and Geriatric Medical Center	Geriatric Care	Advanced Comprehensive Center	2020
(BRGHGMC)	Eye Care	Basic Comprehensive Center	2021
Western Visayas Sanitarium (WVS)	Toxicology	Basic Comprehensive Center	2025

Chapter 2

SANITARIA SERVICE

I. Guiding Principle

In line with the FOURmula One Plus for Health (F1) and the Updated Philippine Health Facility Development Plan (2020-2040), which envisions all DOH hospitals as tertiary referral hospitals within a functional service delivery network, all the eight (8) DOH sanitaria are enjoined to:

• 1. Provide emergency, out-patient and in-patient treatment/care for the general population in its immediate catchment area. Which shall be implemented through the upgrading of Emergency Room, Outpatient Department and hospital wards; and
• 2. Make available the following major clinical departments, namely: Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics as required by the DOH Licensing standards for all Level 2 hospitals, in line with the direction of the Philippine Hospitals Development Plan.

General hospital is defined as follows based on Administrative Order No. 2012-0012 as amended by AO No. 2012-0012-A and AO No. 2012-0012-B on the Rules and Regulations Governing the New Classification of Hospitals and Other Health Facilities in the Philippines:

A hospital that provides services for all kinds of illnesses, diseases, injuries, or deformities. A general hospital shall provide medical and surgical care to the sick and injured, maternity, newborn, and child care. It shall be equipped with the service capabilities needed to support board certified/ eligible medical specialists and other licensed physicians rendering services in, but not limited to, the following:

• a. Clinical Services
  • Family Medicine
  • Pediatrics
  • Internal Medicine
  • Obstetrics and Gynecology
  • Surgery
• b. Emergency Services
• c. Outpatient Services
• d. Ancillary and Support Services such as, clinical laboratory, imaging facility and pharmacy

The Sanitaria Service of each of the eight sanitaria shall have a guiding philosophy that shall be articulated and cascaded to its human resources. It shall formulate its own philosophy, depending on its core values, which shall provide the anchor for its goals, objectives, programs, activities, and projects of the Sanitaria Service.

The following key points shall serve as guidance in the formulation of a philosophy of the Sanitaria Service:

• 1. The Sanitaria Service is organized to promote optimal health and well-being for the leprosy-afflicted patients, for the staff, and for other stakeholders regardless of race, religion, social status, gender, and political affiliation through the provision of high quality leprosy care services;
• 2. Leprosy is a chronic illness and symptoms usually appear years after contracting infection. As such, every patient diagnosed with leprosy shall be given care appropriate to individual needs for better prognosis;
• 3. The Sanitaria Service human resources shall be oriented, guided, and evaluated on a timely basis in their roles and responsibilities within the context of prevailing local conditions to achieve efficient and effective output; and
• 4. The goals of the Sanitaria Service shall be attained through unwavering support, cooperation, coordination, mutual understanding, dedication, and hard work of all those concerned with quality patient care.

II. Vision, Mission, and Goals

Vision

To be the center of excellence and premiere provider of care for patients affected with leprosy, and to set the highest standards of excellence and integrity in maintaining and developing quality improvement towards the elimination and eradication of leprosy in the Philippines.

Mission

In order to achieve optimal well-being of people affected by leprosy, there has to be (a) a well-organized, up-to-date, and innovative plan of action governed by effective and efficient utilization of resources, (b) highest quality of care provided to people affected with leprosy including medical, social, and rehabilitation, (c) commitment to provide continuous education to patients, their respective family, hospital staff, and other partners on leprosy care, (d) continuing research and development on leprosy, and (e) preserve the rich history and practice of leprosy in the Philippines for purposes of heritage preservation, education, and medical tourism.

Goals

The end goal of the hospitals providing sanitaria services is to uphold their original mandate in the prevention, control, treatment, and rehabilitation of persons affected with leprosy. Moreover, each of these facilities shall follow the standards stated herein in the provision of quality health care services to patients affected with leprosy (PAL) that are in line with the Universal Health Care (UHC) Act.

III. Objectives of the Sanitaria Service

General

To act as focal facilities in the elimination and eradication of leprosy in the Philippines through the provision of comprehensive and integrated quality leprosy services at all levels of health care.

Specific

• To provide essential continuum of medical, social, and rehabilitative care to the people affected with leprosy for the improvement of their well-being and for them to achieve a better quality of life
• To implement programs and projects in mobilizing resources aimed to diagnose and treat patients affected with leprosy
• To provide treatment to patients admitted in the hospital and for those patients living in the community
• To provide health promotion, advocacy, social mobilization, and education to patients affected with leprosy and their family
• To prepare the patients for their integration back to the community
• To conduct research and development in leprosy
• To promote and maintain coordination with units of the hospital towards the achievement of total patient care
• To preserve the cultural and historical significance of the sanitaria
• To contribute significantly in the eradication of leprosy in the Philippines

Chapter 3

SPECIAL SERVICES IN THE SANITARIA

As part of its mandate as a sanitarium, the eight (8) DOH Sanitaria shall provide the following services within the sanitarium unit:

• 1. Custodial Care provision of services to improve quality of life through adequate nursing/geriatric care, support activities of daily living to old, poor, abandoned/disabled post-treated (cured) person affected by leprosy, who are mostly left in the Sanitarium until their demise.
• 2. Palliative Care provision of treatment and relief of suffering and pain and other medical, psychosocial and special needs of people affected by leprosy. This will include the acute management of leprosy complications and adverse drug reactions, which need 24-hour care.

In the revised roles of the Sanitaria published in Administrative Order No. 2005-0013, the Sanitaria became general and/or specialized hospitals with the retention of health services for Person Affected by Leprosy (PAL) such as inpatient and outpatient care for PALs suffering from reactions and other complications, custodial care, and rehabilitation.

Custodial and Palliative Care for PALs assist and empower them to meet their own needs and gain social acceptance. Leprosy, being a long term illness with disabling nature and potential, can foster a state of dependence, which can make a man socially crippled. Provision of custodial care as a health service would allow the patients a means of becoming independent, useful citizens; and help reduce, if not eliminate, the stigma and pathological hopelessness of many people who have the disease. This is particularly beneficial for PALs such as the elderly, the abandoned and destitute, who need institutional care and management of leprosy complications.

• 3. Clinical Management (Diagnosis, Treatment, Case holding) of new cases seen or referred to the Outpatient Department and new cases detected inside the sanitarium community.
• 4. Rehabilitation provision of mainly Physical Rehabilitation for Prevention of Disability (POD) among patients suffering from leprosy. This will include the following:
  • a. Assessment of new and old cases of leprosy for:
    • Nerve and motor functions
    • Level of disability before, during and after treatment
    • Prevention of occurrence of disabilities and or progression of more disabilities
  • b. Physical / Therapeutic exercises –use of modalities and gadgets
  • c. Footwear provision
  • d. Prosthesis and artificial assistive devices for mobility
  • e. Occupational Therapy to improve quality of life for activities of daily living.
• 5. Advocacy/Health Education/Teaching Information, education and communication campaign about leprosy as a disease and its concomitant prevention, treatment, stigma reduction practices, control and Rehabilitation to be done at the Outpatient

• Department (OPD) and other assembly as integrated with other DOH health programs.

• 6. Learning and Development Intervention To improve and update knowledge, awareness and skills of Sanitarium and Public Health Staff in the catchment area in clinical, nursing, laboratory and rehabilitation as part of leprosy prevention, treatment, control and rehabilitation.
• 7. Research To conduct basic and operational research in the early diagnosis of leprosy, management of reactions, new anti- leprosy drugs and molecular epidemiology to further understand the disease and improve leprosy program implementation toward leprosy prevention and control.
• 8. Patient Empowerment To empower patients and families through stigma reduction, promotion of Human Rights and Dignity, Strengthening Participation of People Affected by Leprosy in Leprosy Services, economic opportunities and livelihood programs.
• 9. Preservation of Leprosy History and Heritage establishment of leprosy museum and archives.

In addition to the services identified above, the eight (8) DOH Sanitaria shall also conduct the following activities in support of the National Leprosy Control Program:

• 1. Capacity Building on the following:
  • a. Basic Module on addressing the Stigma in Leprosy and other Infectious Diseases for Frontline Health Workers and Leprosy Advocates
  • b. Basic Leprosy Diagnosis for Physicians, Nurses and other Allied Health Professionals
  • c. Basic Laboratory Leprosy Diagnosis for Medical Technologists
• 2. Diagnosis and Confirmation of Diagnosis
• 3. Slit skin smear examination /Histopathology /Serology
• 4. Quality Management through Peer reviews and case presentations or discussion
• 5. Referral Center for the Disease Surveillance
• 6. Advocacy through the Kilatis Kutis Campaign
  • Kilatis Kutis campaign is one of the strategies of the Department of Health through the National Leprosy Control Program to actively do leprosy case finding in high prevalence areas through consultation of skin lesions. It has been considered as a strength of the country in sustained elimination of Leprosy as a national public health problem. Through this campaign, a greater number of recipients is reached and has increased leprosy awareness in the community. Moreover, it promotes good health seeking behaviors by emphasizing the importance of skin health and voluntary reporting of suspicious skin lesions to the local rural health units or other health facilities for diagnosis and treatment.
• 7. As an optional service, compounding of emollients and ointments may be provided under the Hospital's Pharmacy Services. Should manufacturing be explored by the facility, it shall be subjected to the latest FDA licensing and approval.

Chapter 4

OPERATION STANDARDS AND PROCEDURES

I. Organizational Structure

The organizational structure shall follow the latest model organizational structure of general hospitals as provided in the latest edition of Revised Organizational Structure and Staffing Standards as issued by the Department of Budget and Management and the Department of Health. In addition, the different Units to support the services of the Sanitaria shall be subsumed in the following units or departments:

Table 5. Services of the Sanitaria and the General Services Department they are Subsumed under

Service	Subsumed under the following:
Custodial Care Service
Palliative Care Service
Disability Prevention and Rehabilitation Service	Medical Service Department
Dermatology Care in the Outpatient Department
Diagnostic Service
Psychosocial Support Service	Medical Social Worker Department
Leprosy Surveillance and Referrals to Primary Care Facilities	Public Health Unit (Office of the Medical Center Chief)
Emollient Compounding Services*	Pharmacy Department
Heritage Support*	Hospital Operation and Patient Support Service

^* Optional Services

II. Operations Standards and Procedures

The operations of these health facilities shall follow the guidelines for a general hospital as specified by the latest hospital procedures manual (see bit.ly/HFDBManualsDrive). As for the special services under the Sanitaria, the operations shall be guided by the following:

a. In-patient Care

i. Custodial Care Service

The Custodial Care shall provide long-term care for the PALs admitted in the facility. Aside from providing basic necessities such as food, clothing, and shelter, this unit shall be in-charge of facilitating activities and programs for the clinically-recovered PALs that would support their physical, mental, and social rehabilitation to enhance their interaction with people and reintegration as productive members of the community. These activities include but not limited to the following:

• a. Livelihood training and capacity building activities
• b. Health and nutrition counseling and monitoring
• c. Psychosocial support
• d. Gratuity workers
• e. Patient advocacy

Patients housed within the custodial care unit requiring other clinical care shall be referred to the appropriate unit under the general hospital service. More specifically, these patients shall be referred to the palliative care unit for any acute leprosy related concerns.

ii. Palliative Care Service

The palliative care service shall provide in-patient acute care and treatment for leprosy patients for their leprosy-related concerns such as leprosy complications (Erythema Nodosum Leprosum or ENL) and adverse drug reactions. They shall be admitted to the Palliative Ward of the hospital.

Patients seen at the OPD and likewise custodial patients who need in-patient acute care for leprosy-related concerns shall be referred to this unit.

b. Out-patient Department

1. Dermatology Care Service

A section of the general hospital's outpatient department shall be dedicated to Leprosy-related concerns under its Dermatology Care Service.

The Services offered in this unit are as follows:

• a. Initial consultation and follow up
• b. Referral to other services
• c. Teledermatology consultation
• d. Case monitoring
• e. General medical procedures
• f. Counselling

g. Clinical assessments: Sensory and motor function assessment

2. Diagnostic Service

• a. Histopathologic, and other laboratory services
• b. Slit skin smear
• c. Skin punch biopsy and histopathologic readings
• d. Serology and molecular biology

For PALs with non-leprosy clinical and medical concerns, they shall be seen at the appropriate OPD section.

3. Disability Prevention and Rehabilitation Service

This service is under the Rehabilitation Section of the general hospital. This service shall focus on PALs as they require more rehabilitative care due to the manifestations of Leprosy.

The following are the services of this unit:

• a. Physical therapy
• b. Occupational therapy
• c. Prosthetics and Orthotics
• d. Provision of footwear and assistive devices

III. Other Services

The services and units listed below are considered essential for the Sanitaria Service. All are not required except for the Public Health Unit, which has additional roles for the Sanitaria.

1. Emollients Compounding Service

This service shall be under the Pharmacy Department of the hospital.

Pharmaceutical preparations for treatment of dermatological complications due to leprosy or Hansen's Disease are usually supplied in the form of a cream or ointment to provide effective means of applying the active ingredient directly to the affected area. Products can be in two forms of emulsions: water in oil (w/o) or oil in water (o/w).

The following general principles are to be followed in the Emollients Compounding Service of the Pharmacy Department. Other guidelines in the Pharmacy Manual regarding procedures shall also be followed. The Manual is found at bit.ly/HFDBManualsDrive.

• a. Temperature Control Appropriate temperature should be maintained in accordance with the guidelines in the Pharmacy Manual.

• b. Infection Prevention and Control The provisions in the National Standards in Infection Prevention and Control for Health Facilities, 3rd edition shall be followed. Please see bit.ly/HFDBManualsDrive for the link to the manual.

• c. Cleaning and Disinfection

  • Cleaning shall be done using a germicidal detergent and sterile water.

• The use of sporicidal agents is required to be used at least monthly.

• Disinfection, using a suitable sterile agent, shall also occur on all surfaces in the ISO Class 5 PEC frequently, including:

  • At the beginning of each shift;
  • At least every 30 minutes when compounding involving human staff is occurring or before each lot;
  • After each spill; and
  • When surface contamination is known or suspected.

• d. Ventilation Proper ventilation, natural or mechanical, should be followed according to the National Standards in Infection Prevention and Control for Health Facilities, 3rd edition.

• e. Proper packaging and labelling

  • Proper packaging and labelling of products compounded shall be ensured at all times.
  • Products shall then be stored appropriately in designated shelves or areas.

2. Public Health Unit

Pursuant to DOH Administrative Order no. 2018- 0023: "Guidelines in Strengthening the Capacity of Public Health Units (PHU) of DOH Hospitals and All Level 3 Hospitals (Government and Private) on Sentinel Surveillance System for Notifiable Diseases of Epidemic Potential", all DOH hospitals and all Level 3 hospitals (government and private) shall establish a functional public health unit or equivalent unit in private hospitals that will house and institute the Hospital Surveillance System (HSS), whose functions will be carried out under the supervision of the head of the hospital. According to Administrative Order 2020-0019 entitled "Guidelines on the Service Delivery Design of Health Care Provider Networks, a public health unit is a unit in the hospital facilitating the provision of population-based services, implementation of national public health programs, coordination with primary care provider networks, and provision of a one-stop shop patient navigation system within the hospital.

All hospitals shall have a Public Health Unit (PHU) to facilitate the provision of population-based health services and patient navigation. The PHU shall:

• 1. Ensure that hospital policies are aligned with national public health programs.
• 2. Assist the hospital management in ensuring surveillance and reporting of notifiable diseases through the disease surveillance officer or disease surveillance coordinator.
• 3. Ensure proper referral and navigation of patients within the hospital and from the hospital to primary care facilities and other necessary facilities in the network.

4. Be established under the Office of the Medical Center Chief or Chief of Hospital

Hence, the PHU shall be involved in the preventive and promotive aspects of Leprosy service with a focus on promoting the health and wellbeing of the community it serves. It shall be in-charge of the following:

Alignment of the sanitaria's programs and projects with that of the National Leprosy Control Program

One of which is the Kilatis Kutis Campaign wherein:

Health workers shall be enabled to provide screening of dermatologic complications from the simplest form possible such as allergic dermatitis to more complex complications such as that of leprosy's. This specific strategy reaches a greater number of clients without causing possible alarm to the community. It is also an excellent avenue in promoting good health seeking behavior among the community and provides an avenue for the realization of early diagnosis, treatment, and management of dermatologic complications due to leprosy.

• 5. Case finding and investigation, in the interest of the community to which the PALs belong, in cooperation with the Clinical Services
• 6. Ensure referrals are made if warranted, within the hospital and from the hospital to primary care facilities and other necessary facilities in the network

3. Psychosocial Support Service

The psychosocial support services are subsumed under the Medical Social Worker Department. This shall be in-charge of the psychological well-being and psychosocial processing of the PALs. They shall facilitate the socialization activities of those living in the Custodial ward. In addition, this unit shall also be responsible for the counselling of in-patient and outpatient PALs, throughout their treatment duration. They shall coordinate closely with the Medical social service department of the hospital, and the local social service workers in order to assist those that are living in the community. They shall also be in-charge of the endorsement to the community once patients are for re-integration and shall advocate postdischarge follow-up.

4. Heritage Preservation Unit

This unit is under the Hospital Operation and Patient Support. Leprosy settlements, due to their presumed architectural insignificance and disregarded historical significance, have never been put into a priority for historic and heritage preservation. Because of the association of pain, anger, and shame in the history of these places considered as exile for people affected with leprosy, heritage preservation is disregarded.

As such, recognizing that segregation and isolation of people affected with leprosy from the rest of the population has gained historical social and health significance, a unit designed to preserve the rich heritage and history of the facility as a leprosarium shall be created. This unit shall be in charge of preserving the facility to symbolize the success of science over leprosy. In the Philippines, the sanitaria shall be made as an apparatus of social memory for its contribution in the field of medicine and social science. Establishing heritage sites in the sanitaria is a way of looking back at the rich history and contributions of sanitaria to medicine.

In view hereof, the National Historical Commission of the Philippines (NHCP) realized the need to preserve the historical records pertaining to leprosy in the Philippines. As an initial work, in January 2019, the NHCP turned over completed restored and rehabilitated historical structures and sites including three buildings, two monuments, and three parks, to CSGH's management.

NHCP is the national government agency mandated to promote and preserve Philippine historical heritage through research and publications, conservation, marking of historic sites and structures, and administration of national shrines and historic museums.

In view hereof, the following guidelines of NHCP shall be utilized in the process of preserving the rich history and heritage of sanitaria in the Philippines:

• a. The Process of Architectural Restoration;
• b. Techniques Involved in the Restoration of Historic Structures;
• c. Standards and Guidelines in Maintaining Historic Sites and Structures;
• d. Standard Design of Marker Pedestal (Illustration);
• e. Guidelines, Policies and Standards for the Conservation and Development of Historic Centers/Heritage Zones;
• f. Guidelines on the Identification, Classification and Recognition of Historic Sites and Structures in the Philippines; and
• g. Basic Conservation Principles.

Moreover, the establishment of sanitaria as heritage sites shall also be utilized as educational and training sites. It can also be used to generate additional income for the facility through payments on entrance and tours. Lastly, the concept of medical tourism can be applied to sanitaria as heritage sites since these facilities can attract visitors who want to look back at how the Philippines has combated leprosy in the last century.

IV. Human Resource Standards

The sanitaria shall serve as a separate service unit under the Clinical Service of the hospital. The Department of Budget and Management (DBM) - Department of Health (DOH) Joint Circular 2013-1 Revised Standards on Organizational Structure and Staffing Pattern of Government Hospitals, CY 2013 Edition contains the latest standards on organizational structure and staffing pattern of government hospitals according to their bed capacity. See bit.ly/HFDBManualsDrive for the link to a copy of this document.

The ratios for the out-patient services are based on cadre to patient. As for in-patient services, it is cadre to bed capacity. For the Disability Prevention and Rehabilitation Care services, this includes both in-patient and out-patient services.

The table below shows the recommended additional HRH under each service to support its functions. These ratios are to support the services alone. For the sanitaria who would want to implement residency training programs for Dermatology, the ratios in table 7 are recommended.

Table 6. Recommended Personnel Per Service

Out-patient Service	Designation	Position Title Based on DBM	Ratio (Cadre: patient)
	Dermatology Specialist	Medical Specialist II	1:50
	General physicians	Medical Officer III	1:100
Dermatology	Nurses	Nurse I	1:12
Care Services	Medical Technologist II	Medical Technologist II	1:25
	Medical Technician	Medical Laboratory Technician II	1:50
In-patient Service	Designation	Position Title Based on DBM	Ratio (Cadre: bed)
	Nutritionist-Dietitian	Nutritionist-Dietitian I	1:25
Custodial Care	Cook	Cook II	1:100
Custodial Care	Food service Worker	Administrative Aide III	1:100
Services	Nurses	Nurse I	1:12
	Nursing attendants	Nursing attendant II	1:24
Delliative Core	Dermatology Specialist	Medical Specialist II	1:200
Palliative Care	Infectious Disease Specialist	Medical Specialist II	1:200
Services	Nurses	Nurse I	1:12
	Medical Specialist II	Medical Specialist II	1:200
	Medical Officer III	Medical Officer III	9:200
	Occupational Therapist III	Occupational Therapist	1:200
Disability	Physical Therapist III	Physical Therapist III	1:200
Prevention and	Occupational Therapist II	Occupational Therapist II	3:200
Rehabilitation Care Services	Physical Therapist II	Physical Therapist II	3:200
Care Services	Speech Therapist II	Speech Therapist II	1:100
	Occupational Therapist I	Occupational Therapist I	3:200
	Speech Therapist I	Speech Therapist I	1:200
	Physical Therapist I	Physical Therapist I	1:50
Emollients Compounding Services	Pharmacist	Pharmacist II	1:100
	Administrative Aide	Administrative Aide IV	1:200
	Utility Worker	Administrative Aide III	1:200
Davidaariid	Psychiatrist	Medical Specialist II	1:200
Psychosocial	Psychologist	Psychologist II	1:200
Support Services	Psychometrician	Psychometrician	1:200
Services	Social Workers	Social Welfare Officer	1:25
	Public Health Advisor	Medical Specialist IV	1:200

	Health education and Promotion Officer	Health education and Promotion Officer III	1:200
Public Health Unit (As per Administrative	Disease Surveillance Officer	Nurse II/ Health Education and Promotion Officer II	1:200
Order 2020- 0019)	Disease Surveillance Coordinator	Nurse II	1:200
	Care navigator/ Educator	Nurse II	1:200
	Administrative officer	Administrative Officer III	1:200
Heritage	Health Education and Promotion Officer	Health education and Promotion Officer II	1
Preservation	Administrative Officer	Administrative Officer III	1
Unit	Administrative Assistant	Administrative Assistant IV	1

Table 7. Recommended Personnel for Dermatology Residency Training Program

Service	Designation	Position Title Based on DBM	Ratio
Dermatology Residency Training Program	Chairman	Medical Specialist IV	1
	Training Officer	Medical Specialist III	1
	Dermatology Specialist	Medical Specialist II	1:3 residents
	Residents	Medical Officer III	1:4 patients/day (minimum)
	Nurses	Nurse I	1:12
	Medical Technologist II	Medical Technologist II	1:25
	Medical Technician	Medical Laboratory Technician II	1:50

V. Financial Services

• a. Maintenance and Other Operating Expenses (MOOE) Funding for the Primary mandate of providing services to leprosy patients and expansion of sanitaria services will be sourced from the General Appropriations Act (GAA); Sub-allotments may be provided by the NLCP, other MOOE sources like hospital income that includes PhilHealth payments, funding through public-private partnership and other financing mechanisms:

  • i. MOOE budget requirements of the Sanitaria for Leprosy treatment, prevention, control and support to leprosy patients (gratuity workers, food ration, etc.), Custodial /Palliative Care services.
  • ii. MOOE budget requirements shall also be provided for the expanded health services for patients catered under the general hospital's care and specialized care.

• b. Capital Outlay requirements to carry out the expanded services shall be included in the funding of the Health Facilities Enhancement Program

• (2022 onwards), as aligned with the directions of the Philippine Health Facility Development Plan (2020-2040) .

• c. Personnel Services (PS) shall be appropriated to carry out the full implementation of the staffing pattern of the Sanitaria expanded services.

Chapter 5

INFRASTRUCTURE AND EQUIPMENT

This particular chapter shall focus on the infrastructure necessary to support the special services that sanitaria provides to combat leprosy.

I. Infrastructure Standards

The infrastructure standards for the general hospital as mandated in DOH AO No. 2012-0012 and other standards for general hospitals shall remain in effect. Please see Annex 2 to 5 for the model floor plan for the following wards.

The guidelines for the creation of these infrastructure shall follow the provisions of the latest Implementing Rules and Regulations of the National Building Code of the Philippines.

A. Custodial Ward

The custodial ward is an area in the hospital compound where PALs reside. These are separate from the main building of the hospital and are far from where hospital waste is collected and processed.

This shall be a separate building in the hospital compound with access to electricity and running water for the consumption of the PALs.

B. Palliative Ward

The palliative ward is an area in the general hospital where PALs who need acute care shall be admitted. This shall follow the specifications for an infectious ward, as listed in the Hospital Design Manual (see bit.ly/HFDBManualsDrive)

C. Dedicated OPD space for Dermatology Care Service

There shall be a designated area in the General Hospital OPD for the Dermatology Care Service. This may need not be in a separate building but shall be delineated from the rest of the services of the general hospital OPD through proper labelling of the area.

In order to increase the accessibility of the OPD for the PALs, the following shall be installed:

• 1. Ramps, steps, and wide door for easy accessibility
• 2. Tiled flooring with a slope towards outlet
• 3. The reception area shall be positioned after the main door
• 4. Chairs distanced appropriately according to infection prevention and control (IPC) standards along the waiting hall for patients and their company
• 5. Essential signages and layout plan posted
• 6. Bay for trolleys and wheelchairs
• 7. Toilets separate for males and for females
• 8. Access to telecommunication
• 9. A board indicating the names of consultants on duty and on leave

D. Disability Prevention and Rehabilitation Service

This may need not be separate from the general hospital's main rehabilitation unit. However, specific equipment may be allocated and human resources may be designated for the provision of rehabilitative care of the PALs.

This service shall be responsible for the rehabilitation therapy and the manufacturing of prosthesis, orthosis, and other mobility assistive devices.

E. Emollients Compounding Service

The emollients compounding service shall be divided into the following areas listed below. All areas shall be properly divided and shall have a visible perimeter to establish boundaries. All areas shall have planned foot traffic to maintain the cleanliness of the area.

1. Anteroom

• A transition area where high-particulate producing activities are done
• Adjacent to the compounding area
• Shall have the sink area
• Where hand hygiene is performed
• Where personnel don and doff PPE

2. Buffer Area

● Transition area between the anteroom and the compounding area

3. Compounding Area

• Shall follow the standards for a clean room area
• Shall have visible perimeter to establish the boundaries
• Where emollients are compounded

4. Packaging and Storage Area

• Where compounded emollients are packed and stored
• Compounded emollients should be properly labelled
• Shall have shelves where the emollients can be stored properly

See bit.ly/EmollientsFDA for the Food and Drug Administration (FDA) infrastructure and equipment requirements for an emollients manufacturing unit.

II. Equipment Requirements

A. Custodial Ward

The materials and equipment for the custodial ward shall be able to support the daily living activities of the PALs.

B. Palliative Ward

The following assistive equipment and devices are required as part of the minimum standards in providing palliative care services for leprosy patients:

• 1. Wheel chair
• 2. Stainless axillary crutches
• 3. Quad or walking cane
• 4. Walker, stainless
• 5. Walking bars
• 6. Complete set of hospital bed with bedside table;
• 7. Mobile shower commode
• 8. Rollators
• 9. Cushions
• 10. Lumbar rolls/pillows
• 11. Shower chairs/stools
• 12. Bath boards/seats
• 13. Recliner chairs
• 14. Plaster of Paris
• 15. Plaster cast electric cutter/saw

C. Dedicated OPD space for Dermatology Care Service

The following equipment and devices are required as part of the minimum standards in providing leprosy care services at the Dermatology Care Unit:

• 1. Dermatologic surgical instruments
• 2. Patch testing kits, such as the European standard series
• 3. Treatment bed and table
• 4. Cooling device
• 5. Fume evacuator
• 6. Microscope
• 7. Dermatoscope
• 8. Wood's lamp
• 9. Face analysis
• 10. Mexamater
• 11. TEWL meter
• 12. Minor surgical instruments
• 13. Wound care dressing instruments
• 14. Punch biopsy, with different sizes, in mm
• 15. Derma-electrocautery
• 16. Derma-sterilization equipment
• 17. Wound care dressing kit

In addition, the following optional equipment and devices may be given in providing leprosy care services:

• 1. Narrowband UVB and UVA phototherapy cabinet
• 2. Hand and foot UVB and UVA unit
• 3. Wound care laser
• 4. Ablative (Erbium YAG)
• 5. Nd:YAG (Neodymium-doped yttrium aluminum garnet)/Q-switched Alexandrite for vascular lesions and pigmented lesions

D. Disability Prevention and Rehabilitation Service

The following equipment and devices are required as part of the minimum standards in providing rehabilitation care services for leprosy patients:

• 1. Walking device
• 2. Complete set of hospital beds with bedside table
• 3. Lifters and hoists
• 4. Mobility aids
• 5. Wheelchairs, manual and electric
• 6. Scooters
• 7. Recliners
• 8. Foot protection device
• 9. Lumbar rolls/pillows
• 10. Recliner chairs
• 11. Walking sticks
• 12. Stainless axillary crutches
• 13. Quad cane
• 14. Shoulder pulley
• 15. Stationary exercise machine (bicycle or rower)
• 16. Biometric ball wrist stretching, shoulder, fingers exerciser
• 17. Squeeze ball
• 18. Free weights
• 19. Treadmill
• 20. Push-up bars
• 21. Paraffin wax boxes
• 22. Neuromuscular stimulator
• 23. Electrotherapy
• 24. Ultrasound therapy
• 25. Non-luminous infrared light
• 26. Luminous infrared light

E. Emollients Compounding Service

• 1. 1 Unit Electrical mixing machine
• 2. Mechanical mixer (for more than 5kg)
• 3. 1 pc Plastic Sealer
• 4. 1 pc Weighing scale
• 5. Mortar and pestle
• 6. Calibrated cylinder
• 7. Basin
• 8. Spatula

F. Other Services:

For the Kilatis Kutis Campaign to be conducted, the following equipment and devices are required:

• 1. 4 x 4 transport vehicle
• 2. 15-seater van
• 3. Two sets of Blood Pressure Monitoring Device
• 4. Two sets of Thermometer
• 5. Two sets of Diagnostic Kits
• 6. Two pieces of Neurological Hammers
• 7. Two sets of utility boxes
• 8. Two units of push carts
• 9. Two units of weighing scale
• 10. DSLR camera
• 11. Heavy-duty storage boxes
• 12. One unit of laptop
• 13. One unit of printer

Chapter 6

CONTINUOUS QUALITY IMPROVEMENT (CQI) IN THE SANITARIA

I. Rationale

With the vision of a Leprosy-free Philippines by the year 2022, the Continuous Quality Improvement (CQI) in Sanitaria Services aims to define, pursue and continuously improve the healthcare system by establishing a structured approach within the organization. In line with AO 2020-0034-A entitled "Revised Guidelines on the Implementation of Continuous Quality Improvement (CQI) Program in Health Facilities in Support of Quality Access for Universal Health Care," these efforts support the Department of Health's FOURmula One Plus for Health to implement provisions of the UHC Law. This also aims to eliminate leprosy as one of the endemic diseases posing as a public health threat in the country, together with malaria, filariasis, schistosomiasis and rabies through NOH 2017-2022.

While CQI has become one of the standards for all hospitals, it encourages all healthcare members to continuously ask questions of "How can we do better?" Hence, this system of approach should be incorporated in the ways and means of the eight (8) DOH Sanitaria Hospitals to improve its services and meet its goals to provide optimum healthcare to all patients. The quality of services they offer can be improved without necessarily increasing the resources. Costs will be reduced through eliminating waste and other redundant tasks in the sanitaria care delivery pathway.

Benefits of CQI

• 1. Provides the highest level of care for leprosy patients
• 2. Effective utilization of resources by increasing efficiency, reducing risks, preventing adverse effects, and medication errors
• 3. Reduce hospital and sanitaria liability

II. Tools

A. Service Quality

SERVQUAL is one of the most well-known models for the assessment of quality for the Service Industry. This was created by A. Parasuraman, Valarie Zeithaml and Leonard L. Berry in 1985 and has undergone revisions since then. The SERVQUAL model initially has 10 dimensions namely: reliability, responsiveness, competence, access, courtesy, communication, credibility, security, understanding/knowing the customer, and tangibles. Later in 1988, the 10 dimensions were reduced into 5: tangibles, reliability, responsiveness, assurance, and empathy.

Table 8. SERVQUAL Dimensions and Components

Dimensions Components
--------------------------

Reliability	The ability to perform the promised service on time, credibly, consistently and accurately
Assurance	The knowledge and courtesy of employees and their ability to inspire trust and confidence
	Builds credibility through professional services, excellent technical knowledge, attitude courtesy, and good communication skills
Tangibles	The appearance of physical facilities, equipment and personnel
	Refer to the effect of physical facility, equipment, personnel and communication materials on customer
	The atmosphere, also called servicescapes, influences directly both employees and customers in physiological, psychological, sociological, cognitive and emotional ways
Empathy	The provision of individual care and attention to customer
	Involves caring, consideration, and the best preparation for customers, so that they can feel as 'guests' of the firm and are always welcome at any time
Responsiveness	The willingness to help customers and provide prompt service
	Measures the ability to solve the problem fast and effectively
	This measures the willingness to help customers, as well as meet the customers' requirements

B. Conceptual Framework in Building a QMS

Several methodological frameworks have been established to facilitate quality improvement. Frameworks in CQI provide a system of organization in its dynamic environment over time. One of the most well-known is the PDSA Cycle, also known as the Deming Wheel. Figure 2 shows the components of the cycle.

Figure 2. The PDSA Cycle

The PDSA cycle allows rapid identification of effective solutions. It also allows small scale testing and a more structured and organized improvement process. Through this approach, systematic documentation is ensured to facilitate learning and dissemination of ideas. Effectiveness of strategies through the PDSA cycle is done through evaluation of processes, outcomes and balancing measures.

Table 9. The PDSA Cycle - Step by Step

The PDSA Cycle

PLAN: Define the problem and identify the root cause

Step 1: Identify areas for improvement.

Identify the area, problem, or opportunity for improvement.

Estimate and commit the needed resources.

Step 2: Assemble a team.

Identify and assemble team members.

Specify team member roles and responsibilities.

Specify meeting frequency and structure.

Develop a SMART aim.

Step 3: Identify the current process.

Examine the current approach or process flow.

Obtain existing baseline data or create a plan to obtain needed baseline data. Obtain input from stakeholders.

Determine root causes of the problem.

Step 4: Identify potential change strategies.

Identify all potential change strategies based on root causes.

Select change strategy 9or strategies) most likely to achieve the SMART aim.

Step 5: Identify improvement theory.

Develop a theory of change for the change strategy.

Develop a strategy to test the theory on a small scale (small number of participants.)

What is the strategy? Who will apply it? How will it be measured? What is success?

DO: Customer Protection and Countermeasure

Step 6: Test the theory.

Carry out the test on a small scale.

Collect, chart, and display data to determine the effectiveness of the change strategy.

Monitor fidelity of implementation of the change strategy; document problems, unexpected observations, and unintended side effects.

STUDY: Confirm effectiveness

Step 7: Study the results.

Was the improvement successful on a small scale?

Did the results match the theory/ prediction?

Were there any unintended consequences?

Describe and report what you learned.

ACT: Feedback/ Feed forward

Step 8: Scale up implementation.

Scale up successful change strategies and continue testing until improvement is achieved.

Develop and test new theories for unsuccessful changes.

Standardize successful improvements.

Step 9: Establish future plans.

Repeat the PDSA cycle, when needed.

Take steps to preserve gains and sustain successes.

Make long-term plan for additional improvements.

Celebrate your successes.

C. Tools for Quality Control

1. Six Sigma Steps

Six Sigma is a performance improvement program with the goal summarized by the mantra "improvement by eliminating process variation". It aims to improve performance, quality, bottom line, customer and employee satisfaction. Six Sigma is a structured process based upon statistical measurements wherein process defects or errors are analyzed, potential causes are identified, and improvements are implemented. The goal of Six Sigma is to reduce the numbers of defects to near zero. Within the Six Sigma process, defects are generally measured per million opportunities (DPMO).

Table 10: The Six Sigma Steps: DMAIC

Steps	Explanation
Define	Define the project goal or other deliverable that is critical to quality
Measure	Measure baseline performance and related variables
Analyze	Analyze data using statistics and graphs to identify and quantify root cause
Improve	Improve performance by developing and implementing a solution
Control	Control factors related to impact, validate benefits, and monitor over time

By lowering the defects, quality of care is improved. Savings could be generated by eliminating waste, unnecessary steps, and redundant staff time.

2. Lean System

Lean methodology is a system of reducing waste ("non-valued activities") in every process, procedure, and task through an ongoing system of improvement as adopted into the health care system, including Sanitaria services. Under this approach, the Sanitaria continually focuses on identifying waste and eliminating anything that does not add value to the care of the patient. This method utilizes few resources, reduces costs, enhances productivity, promotes staff morale, and improves the quality of patient care.

Goals to eliminate the "eight wastes" include:

• 1. Reduce idle times for employees as well as waiting period for patient management
• 2. Identify excessive inventory and find new ways to decrease the excess
• 3. Eradicate unsafe practices and failures in the system's flow chart
• 4. Ensure that patient, caregiver, equipment and supply movement is efficient
• 5. Reduce caregiver motion to prevent injuries and save time
• 6. Maximize resources by minimizing health care overproduction
• 7. Eliminate repetitive, redundant, or less valuable processes in the system which do not promote efficient patient care
• 8. Reduce unnecessary tasks that will lead to improved patient care and employee morale.

III. CQI in the Sanitaria Service

The framework and models mentioned above shall be utilized by the Sanitaria in order to ensure continuous quality improvement in its operations and services.

In addition, Continuous Quality Improvement (CQI) of the Sanitaria Service shall follow the provisions prescribed in DOH AO 2020-0034 (Revised Guidelines on the Implementation of Continuous Quality Improvement Program in Health Facilities).

The hospital CQI committees shall monitor and evaluate the special services of the Sanitaria.

Sanitaria CQI Committee shall have the following activities:

• 1. Create a CQI plan based on the PDSA Cycle and other recommended tools.
• 2. Periodic monitoring of deliverables as indicated in the plans shall be done as guided by the PDSA cycle.
• 3. The committee shall monitor annually using facility-based monitoring tools and shall submit the approved reports to the Center for Health Development (CHD) through the Health Facility Development Unit (HFDU).
• 4. In addition, a self-audit shall also be implemented regularly. The results of the self-audit shall be discussed among the members in order to come up with the plans and actions needed in order to improve on their processes and consequently, the outcomes.
• 5. Benchmarking shall also be done with the standards and policies published by the DOH.
• 6. Meet at least once each quarter in order to facilitate incident report discussion.
  • a. Review all incident reports generated for each reportable event in the sanitaria using the tools specified previously.
  • b. Establish the steps taken or to be taken to prevent a recurrence of the incident
• 7. The following documents shall be stored and compiled by the CQI committee:
  • a. Minutes of the meeting
  • b. Self-audit results
  • c. Copies of the reports, plans, and other documents
  • d. Other proof of implementation of the CQI plans

IV. Self-Assessment Tools

There are self-assessment tools incorporated in the different manuals stated in this document. These tools can be used by the health facilities for performance management and quality improvement. See the manual at bit.ly/HFDBManualsDrive.

The use of tools for People-Centered Care for Responsiveness is also recommended, as aligned with the provisions of AO No. 2020-0003 entitled "Strategic Framework on the Adoption of Integrated People-Centered Health Services in All Health Facilities."

Other guidelines stated in AO No. 2020-0034 entitled "Revised Guidelines on the Implementation of Continuous Quality Improvement (CQI) Program in Health Facilities in Support of Quality Access for Universal Health Care" shall be applied in the Sanitaria.

Chapter 7

RESEARCH AND LEARNING DEVELOPMENT INTERVENTIONS

The following are the research priorities for Leprosy according to the World Health Organization's Guidelines for the Diagnosis, Treatment, and Prevention of Leprosy 2018 (WHO, 2018). Please see Annex 7 for the description of each topic.

• 1. Diagnostic Tests for Leprosy
• 2. Efficacy of treatment for leprosy that offer shorter duration
• 3. Prevention of Leprosy through 1) Chemoprophylaxis and 2) vaccination

All Sanitaria staff must have undergone Leprosy-related training. The scope of the training shall include diagnosis and management of Leprosy, including the biopsychosocial aspects of these.

In addition, the continuous medical education of the staff shall be endorsed in order to ensure the quality of services they provide.

The Sanitaria shall provide its own training program for healthcare workers in its catchment area, as stated in Administrative Order No. 2005-0013. A sample of the training program is provided below.

The Research Institute for Tropical Medicine offers the Intensive Training on Recognition and Management of Common Skin Diseases and Leprosy. This training is funded by the NLCP and is offered for physicians, nurses, medical technologists, midwives, and barangay health workers.

Table 11. Leprosy Training by Research Institute for Tropical Medicine

Components	Content
General objective	This training aims to train physicians, nurses, med techs and health personnel from different cities and provinces on how to recognize, diagnose and treat common skin diseases and leprosy
Specific objectives	1. Discuss basic skin lesions and give examples of diseases; 2. Discuss common skin diseases and management; 3. Give updates on the Global and National Leprosy Status; 4. Discuss the Epidemiology and Clinical Spectrum of Leprosy; 5. Discuss the differential diagnosis of leprosy; 6. Discuss and demonstrate Skin Smear Examination, Staining

	and Microscopy; 7. Discuss the diagnostic tests done for Leprosy patients; 8. Demonstrate how to properly do Nerve Function Assessment; 9. Discuss MDT and Alternative treatment for Leprosy; 10. Discuss treatment of Lepra Reactions; 11. Differentiate between and Treatment failure and Relapse; and 12. Discuss research conducted on Leprosy.
Competencies	1. Knowledge on Basic skin lesions 2. Diagnosis and Management of Common skin diseases 3. Updates on the Global and National Leprosy Status 4. Basic Facts about Leprosy: Epidemiology, Classification and Treatment Regimens (MDT and Alternative treatment) 5. How to do Skin Smear Examination, Staining and Microscopy 6. Differential diagnosis of leprosy 7. Proper performance of Nerve Function Assessment (NFA) 8. Management of Lepra Reactions and Relapse 9. Caring for the leprosy patients
Number of days	5 days
Target professions	Physicians • Nurses • Medical Technologists • Midwives • Barangay Health workers
Cost	Free (funded by NLCP)
Unit Conducting Training	Leprosy Unit Dermatology Department

The Sanitaria shall also provide training for the community members, to be led by the Public Health Unit. This training shall focus on the social aspects of Leprosy so as to ease the integration of the PAL among his/her community.

ANNEXES

Annex 1 Relevant Links

Manual	Link
DOH Issuances Relative to the 8 Sanitaria	https://bit.ly/sanitariaissuances
Food and Drug Administration Circular for Emollients Manufacturing Requirements	https://bit.ly/EmollientsFDA
Health Facility Development Bureau Manuals	https://bit.ly/HFDBManualsDrive
DBM-DOH Joint Memorandum Circular 2013-1 Revised Standards on Organizational Structure and Staffing Pattern of Government Hospitals, CY 2013 Edition	https://bit.ly/RSSGH3Manual

Annex 2 Custodial Ward Floor Plan

Description	Developmental Standards
Access/ Location	Should be designed in conjunction with the main ● hospital Medical Department
Size	Number of beds is dependent on the average ● custodial ward census at least 7.43 sqm/ bed to accommodate the ● following: Space for at least 1 companion o Space for bedside equipment o Reception area and activity area with 0.65 sqm ● allotted per person
Design/Functional requirements	Dedicated area for lobby and reception ● Dedicated area for visitor receiving area, which ● also serves as the activity room Admin office has computer terminals with access to ● EMR Size of windows provide adequate natural ● ventilation Accessible to wheelchair and stretcher ● Access to running water and stable electricity ● Adequate lighting ●
Equipment Requirements	● See chapter 5

Annex 3 Palliative Ward Floor Plan

Description	Developmental Standards
Access/ Location	Should be designed in conjunction with the hospital ● Medical Department
Size	At least 7.43 sqm/ bed ● Nurses station: 5.02 sqm/ staff ● Receiving/ visitors area: 0.65 sqm allotted per ● person
Design/Functional requirements	Dedicated area for visitors at the entrance of the ● ward Adequate work surface for medical staff (i.e. for ● writing or encoding) Adequate space to prepare medication o Access to computer terminals with access to o EMR Size of windows provide adequate natural ● ventilation Access to running water and stable electricity ● Accessible to wheelchair and stretcher ● Adequate lighting ●
Equipment Requirements	● See chapter 5

Annex 4 Dedicated OPD Space for Dermatology Care Floor Plan

Description	Developmental Standards
Access/ Location	Should be designed in conjunction with the hospital ● out-patient department
Size	Waiting/reception area with 0.65 sqm should be ● allotted per person Exam & consult room with at least 7.43 sqm/ bed ● Provision of 1 patient bed per cubicle/room for ● examination
Design/Functional requirements	Dedicated waiting and reception area ● Adequate space to perform procedures and ● consultation in exam & consultation rooms Link to main Out-patient department ● With computer terminals that have access to EMR ● Size of windows provide adequate natural ● ventilation Access to running water and stable electricity ● Accessible to wheelchair and stretcher ● Adequate lighting ●
Equipment Requirements	● See chapter 5

Annex 5 Disability Prevention and Rehabilitation Medicine Service Floor Plan

Description	Developmental Standards
Access/ Location	Should be designed in conjunction with the ● Rehabilitation Medicine Unit
Size	Waiting/reception area with 0.65 sqm should be ● allotted per person Exam & consult room with at least 7.43 sqm/ bed ● Provision of 1 patient bed for examination ●
Design/Functional requirements	Dedicated waiting area at the entrance ● Link to main rehabilitation medicine unit ● Provision to ensure privacy such as Polyvinyl ● Chloride (PVC) accordion or walls Adequate space to perform procedures and ● examination Access to separate male and female toilet with sink ● Computer terminals with access to EMR ● Area of windows provide adequate natural ● ventilation Access to running water and stable electricity ● Accessible to wheelchair and stretcher ● Adequate lighting ●
Equipment Requirements	● See chapter 5

Annex 6 Emollients Compounding Service Floor Plan

Description	Developmental Standards
Access/ Location	Component of the hospital Pharmacy Department ●
Size	Dedicated space of 5.02 sqm/ staff ●
Design/Functional requirements	With dedicated ante room that provides for PPE ● storage and donning/doffing area for workers Adequate space for both sterile non-hazardous and ● sterile hazardous areas for compounding services Shall follow USP 797 or USP 800 standards ● depending on medications compounded, with access to sinks and biosafety cabinets Link to main pharmacy ● Access to running water and stable electricity ● Access to good natural or mechanical ventilation ● Adequate lighting ●
Equipment Requirements	● See chapter 5

Annex 7

World Health Organization's Guidelines for the Diagnosis, Treatment, and Prevention of Leprosy 2018

• 1. Leprosy Diagnostic Tests with promising results for higher diagnostic accuracy (e.g. PCR tests using tissue samples) should be assessed in larger, well-designed studies using assays that are standardized and feasible for use in field settings. Such studies should also evaluate their accuracy for predicting the development of leprosy in contacts. In addition, research is needed on the diagnostic utility of other tools, including ultrasound and other imaging tests, as possible aids to diagnosis. New biomarkers are needed to identify persons with leprosy. Tests for these should be more accurate than previously-evaluated enzyme-linked immunosorbent assay or ELISA test and lateral flow tests. A test protocol study reported the utility of mixed assays that detect cell-mediated responses (cytokines and chemokines) as well as M. leprae-specific antibodies to detect both PB and MB leprosy (94). More studies are needed to determine the use of identified biomarkers for diagnosis. Longitudinal studies are needed to assess how well these tests predict the development of overt leprosy in contacts of persons with leprosy.
• 2. Leprosy treatment Adequately powered, appropriately designed studies are needed on the benefits and harms of shorter MDT regimens for MB leprosy, including effects on bacteriological outcomes (e.g. tests of M. leprae viability in skin and nerves). For both PB and MB leprosy, more well-conducted studies are needed to better understand optimal treatment strategies.
  • Treatment for drug-resistant leprosy The GDG emphasizes the need to enhance current antimicrobial resistance surveillance for leprosy. Given the small numbers of detected leprosy resistance, an RCT on the efficacy of different second-line regimens is unlikely to be feasible. However, observational studies that employ systematic methods to collect clinical and bacteriological outcomes of treatment for resistant M. leprae would be useful for understanding potential benefits and harms of alternative strategies

3. Prevention of leprosy

• a. Prevention of leprosy through chemoprophylaxis Studies that evaluate the effectiveness of alternatives to SDR for chemoprophylaxis (e.g. regimens that use drugs other than rifampicin or multiple doses) are needed. In addition, research is needed to understand the effectiveness of chemoprophylaxis provided through a "blanket/high-risk population" approach rather than through identification of contacts, since the former might increase feasibility and reduce the risk of stigma compared to contact tracing-based approaches.
• b. Prevention of leprosy through vaccines Trials are needed on new and existing vaccines, including studies on LepVax, a new subunit vaccine currently in stage 1a studies. Trials are also needed on the effects of combined postexposure immunoprophylaxis and chemoprophylaxis. The GDG recommends that any new TB vaccine be evaluated for the prevention of other mycobacterial diseases such as leprosy and Buruli ulcer and vice versa.

REFERENCES

• 1 United Nations Development Programme. (20 July 2014). What are the Sustainable Development Goals. https://www.undp.org/content/undp/en/home/sustainabledevelopment-goals.html. Accessed on 16 July 2019.
• 2. World Health Organization. Guidelines for the Diagnosis, Treatment, and Prevention of Leprosy. 2018.