Public Health Unit

Manual of Operations

Department of Health Manila 2025

PUBLIC HEALTH UNIT MANUAL OF OPERATIONS

Copyright 2025 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 Lead: Health Systems Development and

Management Support Division

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, 1406

Email Address: hfdb@doh.gov.ph

The Universal Health Care (UHC) Act of 2019 reformed our health system by ensuring equitable access to quality health services through a coordinated network of providers across all levels of care. This was further strengthened by Administrative Order No. 2020-0019, Guidelines on the Service Delivery Network of the UHC Act, which established the Health Care Provider Network (HCPN) as the standard for organizing and operationalizing service delivery.

The HCPN emphasizes the role of every health provider, including our hospitals, not only in delivering clinical services but also in advancing public health. In line with our medium-term strategy, the DOH 8-Point Action Agenda reinforces this through Action Agenda 2: Ligtas, Dekalidad at Mapagkalingang Serbisyo, which reminds us that

true health care must always be safe, of the highest quality, and centered on the dignity and needs of people.

At the heart of this mission are our Public Health Units (PHUs), which bridge national programs with hospital services. Without them, we risk fragmentation; with them, we strengthen responsiveness and coherence across the system. This Manual of Operations provides a comprehensive guide to strengthen PHU functions by setting clear standards. It serves as a reference to ensure seamless patient referrals, accurate health data reporting, and effective health promotion strategies across the network.

I commend the Health Facility Development Bureau (HFDB) for leading the development of this manual, and to the Technical Working Group, composed of partners from both public and private hospitals, DOH Central Office bureaus, and our Centers for Health Development (CHDs). Your expertise, commitment, and spirit of collaboration have brought us closer to a health system that is not only accessible and integrated, but also compassionate and truly people-centered.

Dahil sa Bagong Pilipinas, Bawat Buhay Mahalaga!

TEODORO J. HERBOSA, MD

Secretary of Health

MESSAGE OF THE ASSISTANT SECRETARY OF HEALTH

The Universal Health Care (UHC) Act of 2019 is more than just legislation; it represents a government's promise to its people. It envisions a health system where services are accessible, equitable, and responsive to the needs of every Filipino, made possible through a strong and coordinated network of providers.

Within this network, the Public Health Unit (PHU) plays a vital role by ensuring that hospitals function not only as institutions of care but also as reliable hubs for patient navigation and referral, epidemiology and surveillance, and health promotion. Through these functions, the PHU strengthens the role of hospitals in delivering continuous, coordinated, and people-centered services.

This Manual of Operations establishes the standards and guidance necessary to strengthen PHUs across the country. It underscores the commitment to efficiency, accountability, and improved coordination within the health system. More importantly, it reflects a collective effort to make public service more consistent, effective, and impactful.

Recognition is extended to the Health Facility Development Bureau (HFDB), the Technical Working Group (TWG), and to all partners for their dedication in developing this manual. Their collaboration demonstrates the results that can be achieved when expertise, commitment, and shared purpose converge.

May this manual serve as an inspiration to continue working together, grounded in integrity, guided by compassion, and united by the vision of a healthier, more resilient Philippines.

Dahil sa Bagong Pilipinas, Bawat Buhay Mahalaga!

ATTY. CHRISTIAN LEL M. SAQUILABON

Assistant Secretary of Health

FOREWORD

The Universal Health Care (UHC) Act of 2019 charted the course for a health system that is equitable, integrated, and people-centered. Pursuant to Section 17.4 of its Implementing Rules and Regulations, all hospitals are mandated to establish a Public Health Unit (PHU) to support the implementation of national public health programs, institutionalize coordination with primary care provider networks, and provide a one-stop shop patient navigation mechanism within the hospital.

This Manual of Operations has been developed to guide hospitals in establishing, managing, and standardizing their PHUs. It embodies the policy directions of the Department of Health (DOH) and the collective expertise of the Technical Working Group (TWG). Composed of representatives from the DOH, LGUs, private hospitals, and DOH Central Office bureaus, the TWG provided invaluable technical inputs to ensure that this manual is both practical and responsive to the realities of hospital operations.

On behalf of the Health Facility Development Bureau (HFDB), sincere appreciation is extended to the TWG members and all partner institutions that contributed to this important work. Their dedication demonstrates a shared commitment to strengthening hospital-based public health services, institutionalizing patient navigation and referral within the hospital and across the health care provider network, and ensuring that PHUs can effectively fulfill their mandate.

This manual serves as the official reference for hospitals in operationalizing their PHUs. All hospitals are enjoined to adopt and implement its provisions to strengthen the integration of public health and clinical services, safeguard communities, and contribute to a more resilient and responsive health system.

Through this collective effort, we affirm our commitment to building a health system that is truly centered on the health and well-being of every Filipino.

MELISSA T. SENA, MD, MPH, DDM

Director IV

Health Facility Development Bureau

PREFACE

The implementation of the Universal Health Care (UHC) Law marks a milestone in the Philippines' pursuit of equitable and accessible health care. This Manual of Operations for the Public Health Unit (PHU) provides the framework to translate UHC principles into practice by setting standards, systems, and processes for patient navigation and referral, epidemiology and surveillance, and health promotion.

This manual is intended for health professionals, hospital administrators, policymakers, and partners as a practical reference for strengthening PHU structures and systems nationwide. By institutionalizing patient navigation and referral, ensuring timely epidemiologic data, and aligning hospital policies with national programs, PHUs can address health inequities, enhance outcomes, and advance the vision of Health for All.

The chapters are comprehensive yet adaptable to the varying contexts of Level 1 to Level 3 hospitals, whether public or private. They emphasize the interdependence of infrastructure and systems, with dedicated sections on governance, leadership, and continuous quality improvement to ensure accountability, adaptability, and sustainability in PHU operations.

This manual is the product of more than a year of hospital visits, workshops, and consultations. On behalf of the Technical Working Group (TWG), I extend my sincere gratitude to the Department of Health (DOH), particularly the Health Facility Development Bureau (HFDB), for spearheading this initiative; to my fellow TWG members for their expertise and dedication; and to stakeholders from across the health sector for their valuable contributions.

May this manual guide our collective efforts in strengthening PHUs nationwide, empowering hospitals to become not only centers of treatment but also champions of prevention, wellness, and equity, in line with the vision of UHC.

ARVIN D. ESCUETA, MD, FPPS, MPH

Chairperson

Technical Working Group on the Crafting of the Public Health Unit Manual of Operations

ACKNOWLEDGEMENT

Our sincerest gratitude is extended to Dr. Melissa T. Sena, Director of the Health Facility Development Bureau (HFDB), and Assistant Secretary Atty. Christian Lel M. Saquilabon for their invaluable support in the completion of this manual.

Special recognition is likewise given to the dedicated members of the Technical Working Group (TWG) for their tireless efforts in developing the Public Health Unit (PHU) Manual of Operations. Their commitment—through reviewing relevant resources, conducting hospital visits, actively participating in writeshops, and meticulously drafting this manual—has been instrumental in ensuring standardized and streamlined PHU operations across the country.

The TWG includes representatives from:

Jose R. Reyes Memorial Medical Center
Epidemiology Bureau
Health Promotion Bureau
Health Facilities and Services Regulatory Bureau
Dr. Jose Fabella Memorial Hospital
Vicente Sotto Memorial Medical Center
Conner District Hospital
Sulu Sanitarium and General Hospital
Ospital ng Makati
Manila Doctors Hospital

Acknowledgment is also extended to the HFDB family, the technical staff of Department of Health (DOH) Central Office bureaus and Centers for Health Development (CHDs), the PHU staff in DOH hospitals, and representatives from selected private and local government hospitals for their invaluable contributions to this work.

LIST OF ABBREVIATIONS AND ACRONYMS

Laws, Executive Orders, and Other Issuances

EO – Executive Order

EO No. 56, s. 2018 – Executive Order on Institutionalizing the Emergency 911 Hotline

IRR – Implementing Rules and Regulations

MC – Memorandum Circular

MC No. 11, s. 1996 – Skills Eligibility – Category II

RA – Republic Act

RA No. 10173 – Data Privacy Act of 2012

RA No. 1080 – Bar and Board Examinations as Civil Service Examinations

RA No. 11223 – Universal Health Care Act

RA No. 11332 – Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act

Department of Health Issuances

AO – Administrative Order

AO No. 2010-0029 - Policies and Guidelines on the Establishment of Operation Center for Emergencies and Disasters

AO No. 2012-0012 - Rules and Regulations Governing the New Classification of Hospitals and Other Health Facilities

AO No. 2013-0005 – National Policy on the Unified Registry Systems of the DOH

AO No. 2014-0002 – Revised National Policy on Violence and Injury Prevention

AO No. 2018-0023 – Guidelines in Strengthening the Capacity of Public Health Units on Sentinel Surveillance System

AO No. 2019-0060 – Guidelines on the Implementation of the National Health Facility Registry

AO No. 2020-0019 – Guidelines on the Service Delivery Design of Health Care Provider Networks

AO No. 2021-0057 - Revised Guidelines on the Philippine Integrated Disease Surveillance and Response

AO No. 2023-0005 – Guidelines on the Implementation of the Routine Information and Statistics for Enhancement of Public Health (RISE PH) Repository System

AO No. 2023-0007 - Revised Guidelines on the Surveillance and Management of Adverse Events Following Immunization

AO No. 2024-0014 – Guidelines on the Implementation of the 8-Point Action Agenda Monitoring, Evaluation, Accountability and Learning System

DO – Department Order

DO No. 2024-0126 – Guidelines on the DOH Strategy Map and Scorecard

DM – Department Memorandum

DM No. 2024-0373 - Guidelines on the Health Promotion Bureau - Public Engagement Grid

DM No. 2023-0434 – Interim Revision of Section III (ESR Processes) of the ESR Manual of Procedures Version 2016

DM No. 2025-0104 – Guidelines on the Collection, Reporting, Management, Generation, and Release of Health Statistics through the FHSIS

Department Circular (DC)

DC No. 2023-0569 - Dissemination of the "Healthy Pilipinas, The Philippines' Health Promotion Framework Strategy 2030

Department Order (DO)

DO No. 2021-0001 - Designation of Selected DOH Hospitals as Specialty Centers

Others

AEFI – Adverse Events Following Immunization

BARMM – Bangsamoro Autonomous Region in Muslim Mindanao

CHD – Center for Health Development

CI/RF – Case Investigation/Report Form

CQI – Continuous Quality Improvement

CS – Civil Service

CSC – Civil Service Commission

C/MHO – City/Municipal Health Office

DOH – Department of Health

DSC – Disease Surveillance Coordinator

DSO – Disease Surveillance Officer

DPCB – Disease Prevention and Control Bureau

DUS – Data Uploading System

ED – Emergency Department

EDCS-IS – Epidemic-prone Disease Case Surveillance – Information System

EMR – Electronic Medical Records

ESR – Event-Based Surveillance and Response

ESU – Epidemiology and Surveillance Unit

EWAR – Early Warning, Alert, and Response

FHSIS – Field Health Services Information System

GIS – Geographic Information System

HCPN – Health Care Provider Network

HEDMU – Health Emergency and Disaster Management Unit

HEPO – Health Education and Promotion Officer

HPO – Health Program Officer

HPFS – Health Promotion Framework Strategy

HSS – Hospital Surveillance System

ICNCDRS – Integrated Chronic Non-Communicable Disease Registry System

IEC – Information, Education, and Communication

IPCC – Infection Prevention and Control Committee

IT – Information Technology

KPI – Key Performance Indicator

KP – Kontra Paputok

LGU – Local Government Unit

MEAL – Monitoring, Evaluation, Accountability, and Learning

MOH - Ministry of Health

NCD – Non-Communicable Disease

NOH – National Objectives for Health

ONEISS – Online National Electronic Injury Surveillance System

OPD – Outpatient Department

PDCA – Plan–Do–Check–Act

PEG – Public Engagement Grid

PhilHealth / PHIC – Philippine Health Insurance Corporation

PHO – Provincial Health Office

PHU – Public Health Unit

PIDSR – Philippine Integrated Disease Surveillance and Response

PIDSR-IS – Philippine Integrated Disease Surveillance and Response – Information System

PIR – Program Implementation Review

QA – Quality Assurance

QMS – Quality Management System

RA – Republic Act

RISE PH – Routine Information and Statistics for Enhancement of Public Health

RHU – Rural Health Unit

RTI – Road Traffic Injury

SBAR – Situation Background Assessment Recommendation

SBCC – Social and Behavior Change Communication

SDOH – Social Determinants of Health

SOP – Standard Operating Procedure

SUC – State University and College

UHC – Universal Health Care

DEFINITION OF TERMS

Adverse Events Following Immunization – Any untoward medical occurrence following immunization, not necessarily causally related to the vaccine. It may manifest as an unfavorable or unintended sign, abnormal laboratory finding, symptom, or disease. (Administrative Order 2023-0007)

Apex or End-Referral Hospital – A hospital that offers specialized services as determined by the Department of Health, contracted as a stand-alone facility by the Philippine Health Insurance Corporation. (Administrative Order 2020-0019)

Epidemic-prone Disease Case Surveillance – A system that monitors disease trends, alerts, and epidemic thresholds for diseases with epidemic potential, as well as those targeted for elimination or eradication. (Administrative Order 2021-0057)

Epidemiology and Surveillance Unit – A unit that systematically receives and manages reports of epidemic-prone diseases and other health events, as prescribed in Republic Act 11332. Units are established at regional, provincial, municipal/city, and hospital levels. Other agencies may establish surveillance units if they meet the requirements set by the Department of Health. (Administrative Order 2021-0057)

Event-Based Surveillance and Response – The organized and rapid capture of information on events posing public health risks, including disease occurrences and risk exposures. Core processes include capture, verification, filtering, assessment, response, and feedback or information dissemination. (Administrative Order 2021-0057)

Field Health Services Information System – A health statistical system managed by the Epidemiology Bureau and designated by Executive Order 352, s. 1996, to generate critical data on health service coverage, health status of the population, and health system capacity for decision-making in both government and private sectors. (Department Memorandum 2025-0104)

General Hospital – A hospital that provides services for all kinds of illnesses, diseases, injuries, or deformities. It shall provide medical and surgical care to the sick and injured, as well as maternity, newborn, and child care. It must be equipped with the service capabilities needed to support board-certified or eligible medical specialists and other licensed physicians in, but not limited to, the following areas: Family Medicine, Pediatrics, Internal Medicine, Obstetrics and Gynecology, Surgery, Emergency Services, Outpatient Services, and Ancillary and Support Services (clinical laboratory, imaging, pharmacy). (Administrative Order 2012-0012)

Service Capability of General Hospitals:

Level 1 Hospital A non-departmentalized hospital that provides clinical care and management of prevalent diseases in the locality with services including general medicine, pediatrics, obstetrics and gynecology, surgery, and anesthesia. It provides administrative and ancillary services (clinical laboratory, radiology, pharmacy), and nursing care for patients requiring intermediate, moderate, or partial supervision for 24 hours or longer.
Level 2 Hospital A departmentalized hospital that manages prevalent diseases in the locality and provides specialized forms of treatment, surgical procedures, and intensive care. It offers the same services as Level 1, plus specialty clinical care, enhanced ancillary services, and total nursing or intensive skilled care.
Level 3 Hospital A teaching and training hospital providing specialized and subspecialized treatment, surgical procedures, and intensive care. It offers all Level 2 services plus subspecialty clinical care, continuous nursing, and highly specialized critical care.

Health Care Provider Network – A group of primary to tertiary care providers, whether public, private, or mixed, offering people-centered and comprehensive care in an integrated and coordinated manner, with the primary care provider serving as navigator and coordinator of health care. (Administrative Order 2020-0019)

Health Emergency and Disaster Management Unit – Also known as the Disaster Risk Reduction and Management in Health Unit, this serves as the hospital's Operations Center during emergencies and disasters, overseeing patient transfer, referral, and coordination. (Administrative Order 2010-0029)

Health Promotion – A strategic, coordinated approach by the Department of Health and stakeholders to enable and encourage healthy behaviors, environments, and systems. It goes beyond individual education, building supportive governance, policies, settings, and health literacy so healthy choices become easier for all Filipinos. (Health Promotion Framework Strategy 2030)

Health Promotion Framework Strategy 2030 – The basis for all Department of Health programs to increase health literacy and address social determinants of health. (Department Circular 2023-0569)

Integrated Chronic Non-Communicable Disease Registry System – A Department of Health registry for systematic collection of hospital data on chronic non-communicable diseases such as diabetes, hypertension, and cancer. (Administrative Order 2013-0005)

Online National Electronic Injury Surveillance System – A Department of Health information system that collects and analyzes nationwide injury data to guide prevention and response programs. Together with the Philippine Network for Injury Data Management System, it institutionalizes reporting, recording, collection, and analysis of injury data. (Administrative Order 2014-0002)

Patient Navigation and Referral – The process of guiding patients through the health care system, ensuring appropriate care, and facilitating referrals within and across health facilities.

Primary Care Provider Network – A coordinated group of public, private, or mixed primary care providers, serving as the foundation of the Health Care Provider Network. (Administrative Order 2020-0019)

Public Engagement Grid – A tool of the Health Promotion Bureau to operationalize campaign architecture, serving as a reference schedule and assigning responsible offices for health events and celebrations. (Department Memorandum 2024-0373)

Public Health Unit – A hospital unit that facilitates population-based services, implements national public health programs, coordinates with primary care provider networks, and provides a one-stop shop patient navigation system. (Administrative Order 2020-0019)

Specialty Center – A unit or department in a hospital that offers specialized care addressing particular conditions, procedures, or case management requiring specific expertise and equipment. (Department Order 2021-0001)

Specialty Hospital – A hospital specializing in a particular disease, condition, or patient group. Examples:

Disease-specific (e.g., Philippine Orthopedic Center, National Center for Mental Health, San Lazaro Hospital).
Organ-focused (e.g., Lung Center of the Philippines, Philippine Heart Center, National Kidney and Transplant Institute).
Population-specific (e.g., Philippine Children's Medical Center, National Children's Hospital, Dr. Jose Fabella Memorial Hospital). (Administrative Order 2012-0012).

i	Message of the Secretary of Health
ii	Message of the Assistant Secretary of Health
iii	Foreword
iv	Preface
v	Acknowledgement
vi - x	List of Abbreviations and Acronyms
xi - xiii	Definition of Terms
1 - 3	Chapter 1 - Introduction The Public Health Unit within the Context of ● Universal Health Care ● Legal Mandate and General Functions of the Public Health Unit
4 - 9	Chapter 2 - Public Health Unit Services ● Patient Navigation and Referral ● Epidemiology, Surveillance, and Health Statistics Health Promotion ●
10 - 24	Chapter 3 - Governance: Leadership and Management ● General Overview ● Organizational Structure and Staffing Pattern ● Roles, Responsibilities, and Qualifications of the Public Health Unit Staff Other Considerations ●
25 - 27	Chapter 4 - Office Space and Equipment Needs
28 - 44	Chapter 5 - Systems and Procedures
45 - 49	Chapter 6 - Continuous Quality Improvement in the Public Health Unit
50 - 52	Chapter 7 - Functionality Assessment of the Public Health Unit
	Appendices

CHAPTER 1. INTRODUCTION

The Public Health Unit within the Context of Universal Health Care

The Universal Health Care (UHC) Act, or Republic Act (RA) No. 11223, is grounded in an integrated and comprehensive approach to the health system, ensuring that all Filipinos are health literate, live in healthy environments, and are safeguarded against hazards and risks that could impact their health. Central to this framework is Section 18 of the UHC Act, which mandates the establishment of Health Care Provider Networks (HCPNs) to promote integration and facilitate the effective delivery of both population-based and individual health services.

HCPNs can consist of integrated local health systems, which may be province-wide or city-wide; networks of private health care providers that complement the services offered by public health facilities; or mixed public-private networks. Furthermore, the Department of Health (DOH) plays a critical role in identifying apex or end-referral hospitals for patients requiring specialized care not available within these networks.

According to DOH Administrative Order No. 2020-0019, which outlines the Guidelines on the Service Delivery Design of HCPNs, public, private, or mixed HCPNs will be established to provide continuous health care across all population groups, from primary to tertiary levels. This care will be delivered through safe, efficient, and coordinated mechanisms. Within these networks, care coordination will be a priority, with the Primary Care Provider Network (PCPN) serving as the initial contact and navigator for patients.

Each HCPN is expected to implement a patient navigation and coordination system that includes effective patient record management, harmonized information and communication technology, and an efficient medical transport system. The networks will also standardize operational mechanisms and oversee financial and performance management. Public HCPNs may enhance their service capabilities through contractual arrangements with private providers, while private HCPNs can similarly partner with public facilities.

All HCPNs will encompass primary to tertiary care providers with established connections to apex hospitals and other facilities offering specialized services for their respective catchment populations. The goal is for all DOH hospitals to become apex hospitals; however, those that do not meet the criteria at this time may still be contracted by the Philippine Health Insurance Corporation (PhilHealth) as stand-alone facilities. The DOH will determine which hospitals qualify as apex or end-referral hospitals, ensuring these facilities are contracted as stand-alone entities based on guidelines issued by PhilHealth. Each hospital will be required to have a Public Health

Unit (PHU) to facilitate the implementation of population-based health services and ensure seamless patient navigation within the HCPN.

Moreover, the guidelines emphasize the importance of establishing a functional referral system rooted in effective primary care navigation throughout the network. HCPNs are tasked with developing localized referral protocols that adhere to clinical practice guidelines, considering local contexts such as transportation availability and the local health care workforce. The networks will implement a patient record management system featuring an interoperable electronic medical record (EMR) across all member facilities, enabling real-time information sharing. This system will include patient records, diagnostics, treatment histories, and other pertinent medical information, all while complying with guidelines from the DOH and PhilHealth and adhering to the Data Privacy Act, or RA No. 10173.

To ensure effective patient transport, HCPNs will maintain an adequate supply of ambulances and patient transport vehicles for their catchment populations. They will also standardize communication processes, ensuring that appropriate communication facilities are available for operational contact. This will include standardized communication tools for endorsements, such as the Situation Background Assessment Recommendation (SBAR) tool, along with a uniform referral form that contains essential data components and a back-referral form for follow-up and home instructions. These forms may be digitized to facilitate electronic reporting. Additionally, a local call center or chat hotline for health will ideally be established, incorporating a geographic information system (GIS) to coordinate patient emergency referrals in compliance with Executive Order (EO) No. 56, s. 2018, which institutionalizes the Emergency 911 Hotline as the nationwide emergency answering point.

In terms of the linkage between HCPNs and apex hospitals, apex hospitals will be connected to HCPNs, providing specialty health care services that are typically unavailable within the networks. The DOH will evaluate and designate eligible apex hospitals based on their service capabilities. This may include single specialty hospitals designated by law or licensed by the DOH, or general hospitals that offer accredited teaching and training in major departments such as Medicine, Pediatrics, Surgery, and Obstetrics and Gynecology. Furthermore, these hospitals must have at least two Specialty Centers that meet DOH standards.

Apex hospitals are expected to demonstrate the capacity and commitment to provide performance mentoring and technical assistance to HCPNs in areas such as quality, efficiency, and patient-centered clinical services; training and development of health care personnel; functionality of the referral system; and conducting clinical, public health, and operations research. These apex hospitals may be owned and managed by

the DOH, other National Government Agencies (NGAs), State Universities and Colleges (SUCs), or private entities.

Legal Mandate and General Functions of the Public Health Unit

Pursuant to Section 17.4 of the Implementing Rules and Regulations of the UHC Act, all hospitals shall establish a PHU to support the implementation of national public health programs, institutionalize a coordination mechanism with primary care provider networks, and provide a one-stop shop patient navigation support mechanism within the hospital. ¹ This unit shall focus on protecting health by preventing disease, illness, and injury and promoting health and well-being at a population or whole of community level, including the implementation of the Hospital Surveillance System in accordance with RA No. 11332, or the Mandatory Reporting of Notifiable Disease and Health Events of Public Health Concern Act. A functional PHU will bridge the gap between public health and clinical care services in the hospital, as well as between the hospital and external government and private sectors.

The unit shall have the following functions: 2

1. Ensures that hospital policies are aligned with national public health programs;
1. Assists the hospital management in ensuring surveillance and reporting of notifiable diseases through the disease surveillance officer or disease surveillance coordinator;
1. Provides timely, accurate, and reliable epidemiologic information to appropriate agencies and coordinates needed response;
1. Ensures proper referral and navigation of patients within the hospital and from the hospital to primary care facilities and other necessary facilities in the network; and
1. Implements health promotion programs.

¹ Section 17.4 Implementing Rules and Regulations of the Universal Health care Act

² DOH Administrative Order No. 2020-0019, Guidelines on the Service Delivery Design of Health Care Provider Networks; Revised Organizational Structure and Staffing Standards for Level III General Government Hospitals Phase I CY 2022 Edition

CHAPTER 2. PUBLIC HEALTH UNIT SERVICES

Chapter 2 presents the three core services of the Public Health Unit (PHU) in hospitals in line with its mandated functions. The PHU plays a key role in implementing national public health programs and ensuring that patients receive comprehensive, coordinated, and responsive health services. It serves as the central hub for patient navigation and referral, epidemiology, surveillance and health statistics, and health promotion.

First, the PHU manages patient navigation and referral, guiding individuals through the health care system and strengthening linkages within the hospital and across the Health Care Provider Network (HCPN). This reduces fragmentation, minimizes delays, and supports both emergency and non-urgent referrals.

Second, the PHU leads epidemiology, surveillance, and health statistics to safeguard patient and community health. Through the Hospital Surveillance System (HSS), it monitors notifiable diseases, non-communicable diseases, and injuries, serving as an early warning system for health threats. The PHU also consolidates and reports reliable health data to guide policies, support timely responses, and reinforce national health information systems.

Third, the PHU directs health promotion by advancing health literacy, promoting healthy behaviors, and fostering supportive environments for patients, families, and hospital staff. These initiatives, aligned with the Health Promotion Framework Strategy (HPFS) 2030 and Department of Health (DOH) priority programs, ensure that hospitals function not only as centers of treatment but also as venues for prevention, wellness, and empowerment.

Taken together, these services enable the PHU to fulfill its mandate as a strategic unit in the hospital—bridging clinical care and public health, promoting collaboration with hospital departments and external partners, and contributing to a stronger, more resilient health system.

The PHU is responsible for coordinating patient care by ensuring a seamless navigation and referral process within the hospital and across the HCPN. These services help guide patients through the complexities of the health care system while addressing barriers such as knowledge gaps, fear, lack of coordination, and systemic fragmentation. The PHU shall work in collaboration with key hospital departments and units, including but not limited to the Emergency Department, Outpatient Department, Medical Social Work Department, Hospital Information Management Department, and the Health Emergency and Disaster Management Unit (HEDMU), to institutionalize a comprehensive patient navigation and referral system.

a. The PHU shall provide patient navigation services by assisting individuals in accessing appropriate health care services within the hospital, across the HCPN, and at other facilities outside the HCPN. Patient navigators shall offer practical support, particularly for those with complex medical, surgical, or chronic conditions, by coordinating care across various levels and facilities to ensure a smooth patient journey.
b. The PHU shall ensure seamless referrals within the hospital by strengthening linkages among departments and units, enabling timely and appropriate patient care while minimizing delays.
c. The PHU shall coordinate external referrals of non-urgent patients to other facilities, ensuring proper management of both upward and downward referrals.
d. The PHU shall support the Emergency Department by establishing a structured system for emergency referrals. In urgent and emergent situations, the PHU shall assist the Emergency Department in facilitating timely patient transfers.
e. The PHU shall collaborate with the Health Emergency and Disaster Management Unit in developing and implementing patient navigation and referral protocols during public health emergencies. This includes ensuring a systematic approach to managing patient surges, directing cases to appropriate facilities, and addressing logistical challenges.
f. The PHU shall have access to a comprehensive directory of all relevant health facilities, including their service capabilities and contact information, to optimize navigation and referral efficiency.

2. Epidemiology, Surveillance, and Health Statistics

Administrative Order (AO) No. 2018-0023, or the Guidelines in Strengthening the Capacity of Public Health Units of DOH Hospitals and All Level Three Hospitals (Government and Private) on Sentinel Surveillance System for Notifiable Diseases of Epidemic Potential reiterated the mandate of the PHU to consolidate and analyze local epidemiology reports in relation to hospital epidemiology reports and to ensure that hospital policies and services are responsive and relevant to disease patterns and trends in the community. Under this Order, all DOH Hospitals and Level 3 hospitals, whether government or private, shall establish a HSS within the PHU.

a. Surveillance of Notifiable Diseases and Health Events of Public Health Concern

i. Pursuant to Republic Act (RA) No. 11332 or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act and its Revised Implementing Rules and Regulations (IRR), health facilities defined under the AO No. 2019-0060 or the Guidelines on the Implementation of the National Health Facility Registry, including public and private hospitals, are mandated to report notifiable diseases and health events of public health concern to public health authorities for disease surveillance ¹ and response.
ii. Through AO No. 2020-0019 (Guidelines on the Service Delivery Design of Health Care Provider Networks), the PHU is mandated to assist the hospital management in ensuring surveillance of notifiable diseases.
iii. In the hospital setting, the HSS acts as an early warning for public health threats, informing priority actions to protect both patients and hospital staff, mitigate the spread of notifiable diseases and health events of public health concern, and ensure a coordinated response among hospital units.
iv. The PHU shall lead the surveillance of notifiable diseases and health events of public health concern in accordance with the latest guidelines of the Philippine Integrated Disease Surveillance and Response (PIDSR).

b. Surveillance of Non-communicable Diseases (NCDs) and Injuries

i. In addition to communicable diseases monitored under the PIDSR, AO No. 2018-0023 identified (1) the leading cause of non-communicable diseases as identified in the top leading causes of morbidity in the Integrated Chronic Non-Communicable Disease Registry (ICNCDRS) of hospital statistics and (2) the leading cause of injuries as identified in the top leading causes of injury reported in the Online National Electronic Injury Surveillance System (ONEISS) in the hospital statistics as two of the health conditions and events to be included in the Hospital Sentinel Report.
ii. AO No. 2013-0005, or the National Policy on the Unified Registry Systems of the Department of Health (Chronic Non-Communicable Diseases, Injury-Related Cases, Persons with Disabilities, and Violence Against Women and Children Registry System), also mandated all government and private hospitals to submit cases of chronic non-communicable diseases, injuries, violence, and disabilities to the DOH.
iii. This is consistent with AO No. 2014-0002, or the Revised National Policy on Violence and Injury Prevention, which identified the Online National

¹ Surveillance refers to the ongoing systematic collection, analysis, interpretation, and dissemination of outcome-specific data for use in planning, implementing, and evaluating public health practice

Electronic Injury Surveillance System (ONEISS) as one of the official systems for data collection, management, and analysis of injuries at the national, regional, and local levels.
iv. Likewise, road traffic injuries (RTIs) have been identified as one of the DOH 8 Priority Health Outcomes, as articulated in AO No. 2024-0014, or the Guidelines on the Implementation of the 8-Point Action Agenda Monitoring, Evaluation, Accountability, and Learning System, and Department Order (DO) No. 2024-0126, or the Guidelines on the DOH Strategy Map and Scorecard.
v. The maintenance of hospital-level patient registries on NCDs and Injuries, including RTIs, shall enable the systematic collection, management, analysis, interpretation, and dissemination of NCD and injury data for epidemiologic studies, policy formulation, and development of prevention and control programs.
vi. The PHU shall lead in the complete, accurate, and timely submission of patient registry data under the ICNCDRS and ONEISS and coordinate relevant insights with the Emergency Department, Health Emergency and Disaster Management Unit, and other relevant hospital units, as necessary.

c. Health Statistics

i. The IRR of RA No. 11223, or the Universal Health Care Act, stated that a PHU shall be established to support the implementation of national public health programs.
ii. In line with this, AO No. 2023-0005, or the Guidelines on the Implementation of the Routine Information and Statistics for Enhancement of Public Health (RISE PH) Repository System, reiterated the Field Health Services Information System (FHSIS) as a nationwide facility-based recording and reporting system to support the implementation of public health programs across the country. This is consistent with the Revised IRR of RA No. 11332, designating the FHSIS as an official public health information and disease surveillance and response system.
iii. Moreover, Department Memorandum (DM) No. 2025-0104, or the Guidelines on the Collection, Reporting, Management, Generation, and Release of Health Statistics through the Field Health Services Information System (FHSIS), has identified public and private hospitals as one of the reporting units in the data pipeline of the FHSIS.
iv. The PHU shall lead the complete, accurate, and timely reporting of morbidity, mortality, and health services coverage data in the FHSIS and coordinate with relevant hospital units, as necessary, to support such public health programs.

3. Health Promotion

The PHU is responsible for overseeing and coordinating all health promotion initiatives in the hospital to benefit patients, families, and employees. These services aim to strengthen health literacy, encourage healthy behaviors, and create supportive environments that enable individuals and groups to take control of their health. The PHU shall work in collaboration with hospital departments and units, as well as the DOH Centers for Health Development (CHDs), Local Government Units (LGUs), and other relevant stakeholders, to institutionalize a comprehensive health promotion system aligned with the HPFS 2030.

a. The PHU shall ensure that patients, families, and hospital staff are provided with education on healthy behaviors, including the Seven Healthy Habits of the HPFS and key disease risk factors. It shall likewise ensure that all health communication materials are developed to be clear, accurate, and accessible to their intended audiences.
b. The PHU shall ensure the development and promotion of programs that encourage healthy lifestyles among hospital employees and foster a health-promoting workplace that sustains positive health behaviors.
c. The PHU shall oversee the organization of patient, family, and staff support groups, including coaching for patient watchers and caregivers, to strengthen recovery, prevent disease, and promote wellness through shared learning and mutual support.
d. The PHU shall lead the planning and coordination of annual and monthly health promotion programs aligned with the DOH Health Calendar and the Public Engagement Grid (PEG). These programs shall address the HPFS priority areas of diet and physical activity, environmental health, immunization, substance use prevention, mental health, sexual and reproductive health, and violence and injury prevention.
e. The PHU shall ensure the provision of training opportunities to disseminate up-to-date scientific information on public health and clinical practice, thereby supporting the adoption of evidence-based practices, policies, and programs within the hospital.
f. The PHU shall monitor and evaluate all health promotion programs within the hospital to ensure effectiveness, alignment with national standards, and continuous improvement in promoting health and well-being.
g. As necessary, the PHU shall collaborate with the Centers for Health Development, Local Government Units, and other relevant stakeholders to address the social, economic, and environmental factors that affect health outcomes. The PHU may also serve as resource persons in the health promotion activities of the HCPN; however, the responsibility for organizing such activities shall remain with the Local Government Unit.
h. As necessary, the PHU shall support hospital personnel in adopting a person-centered approach to care that promotes the physical, mental, emotional, and social well-being of patients.

CHAPTER 3. GOVERNANCE: LEADERSHIP AND MANAGEMENT

General Overview

Given its mandate under the Universal Health Care (UHC) Act and related policies, the Public Health Unit (PHU) functions as a strategic unit within the hospital that bridges clinical care and public health. It plays a central role in implementing national public health programs, ensuring seamless patient navigation and referral, leading epidemiology, surveillance, and health statistics, and advancing health promotion.

To effectively perform these functions, the PHU shall be guided by capable leadership and a clear organizational structure with defined duties and responsibilities. Its mission-vision shall place public health at the core of hospital services and be communicated to all staff to foster alignment and accountability.

Consistent with this mission-vision, the PHU leadership and management shall ensure the following:

1. Alignment of hospital policies and services with national public health programs and priorities;
1. Effective surveillance, reporting, and response to notifiable diseases, non-communicable diseases, and injuries;
1. Seamless patient navigation and referral within the hospital and across the Health Care Provider Network (HCPN);
1. Implementation of health promotion programs that improve health literacy, encourage healthy behaviors, and support wellness in the hospital setting; and
1. Strong collaboration with hospital departments, Centers for Health Development (CHDs), Local Government Units (LGUs), and other stakeholders to strengthen community health outcomes and health system resilience.

Organizational Structure and Staffing Pattern

1. The PHU shall operate directly under the Chief of Hospital, Medical Center Chief, or Medical Director, and shall be supported by both technical and administrative staff to ensure the effective delivery of its three core services.
1. The staffing patterns per hospital level are outlined in the table below.

Level 2 Hospital	Level 3 Hospital
PHU Head (1) ➔ Medical Officer III	PHU Head (1) ➔ Medical Officer IV (SG 23) for
	(SG 21) for

Level	Level	Level
1	2	3
Hospital	Hospital	Hospital
government	government	government
hospitals	hospitals	hospitals
or	or	or
the	the	the
equivalent	equivalent	equivalent
position	position	position
in	in	in
private	private	private
hospitals	hospitals	hospitals
-	-	Assistant PHU Head (1) ➔ Supervising Health Program Officer (SG 22) for government hospitals or the equivalent position in private hospitals
Patient	Patient	Patient
Navigators	Navigators	Navigators
(4)	(7)	(10)
➔	➔	➔
Health	Health	Health
Program	Program	Program
Officer	Officer	Officer
I	I	I
(SG11)	(SG11)	(SG11)
for	for	for
government	government	government
hospitals	hospitals	hospitals
or	or	or
the	the	the
equivalent	equivalent	equivalent
position	position	position
in	in	in
private	private	private
hospitals	hospitals	hospitals
➔	➔	➔
Minimum	Minimum	Minimum
of	of	of
1	2	3
navigator	navigators	navigators
per	per	per
shift	shift	shift
plus	plus	plus
1	1	1
reliever	reliever	reliever
➔	➔	➔
+1	+1	+1
additional	additional	additional
navigator	navigator	navigator
for	for	for
every	every	every
30	40	50
patients	patients	patients
being	being	being
referred/navigated	referred/navigated	referred/navigated
beyond	beyond	beyond
the	the	the
first	first	first
60	100	150
patients	patients	patients
per	per	per
day	day	day
Disease Surveillance Coordinator (1) ➔ Senior Health Program Officer (SG 18) for government hospitals or the equivalent position in private hospitals	➔ Disease Surveillance Coordinator (1) ➔ Senior Health Program Officer (SG 18) for government hospitals or the equivalent position in private hospitals	Disease Surveillance Coordinator (1) ➔ Senior Health Program Officer (SG 18) for government hospitals or the equivalent position in private hospitals
Disease	Disease	Disease
Surveillance	Surveillance	Surveillance

Level 1 Hospital	Level 2 Hospital	Level 3 Hospital
Officers (2) ➔ Health Program Officer II (SG 15) for government hospitals or the equivalent position in private hospitals	Officers (4) ➔ Health Program Officer II (SG 15) for government hospitals or the equivalent position in private hospitals	1 Officers (4) ➔ Health Program Officer II (SG 15) for government hospitals or the equivalent position in private hospitals
Hospital Surveillance System (HSS) Data Encoder (1) ➔ Administrative Assistant II (SG 8) for government hospitals or the equivalent position in private hospitals	HSS Data Encoder (1) ➔ Administrative Assistant II (SG 8) for government hospitals or the equivalent position in private hospitals	HSS Data Encoder (1) ➔ Administrative Assistant II (SG 8) for government hospitals or the equivalent position in private hospitals
Health Education and Promotion Officers (2) ➔ 1 HEPO III (SG 18) and 1 HEPO II (SG 14) for government hospitals or the equivalent positions in private hospitals	Health Education and Promotion Officers (3) ➔ 1 HEPO III (SG 18) and 2 HEPO II (SG 14) for government hospitals or the equivalent positions in private hospitals	Health Education and Promotion Officers (4/6) ➔ For Level 3 hospitals with up to 900 beds: 2 HEPO III (SG 18) and 2 HEPO II (SG 14) for government hospitals or the equivalent positions in private hospitals ➔ For Level 3 hospitals with 1,000 beds and above, 2 HEPO III (SG 18) and 4 HEPO II (SG 14) for government hospitals or the equivalent

¹ DOH Department Memorandum No. 2022-0010

Level	Level	Level
1	2	3
Hospital	Hospital	Hospital
		positions in private hospitals
Administrative	Administrative	Administrative
Staff	Staff	Staff
(1)	(1)	(1)
➔	➔	➔
Administrative	Administrative	Administrative
Aide	Aide	Aide
IV	IV	IV
(SG	(SG	(SG
4)	4)	4)
for	for	for
government	government	government
hospitals,	hospitals,	hospitals,
the	the	the
equivalent	equivalent	equivalent
position	position	position
in	in	in
private	private	private
hospitals	hospitals	hospitals

3. Proposed Organizational Structure for Level 1 Hospitals

4. Proposed Organizational Structure for Level 2 Hospitals

5. Proposed Organizational Structure for Level 3 Hospitals

Roles, Responsibilities, and Qualifications of the Public Health Unit Staff

1. PHU Head

1.1. Roles and Responsibilities of the PHU Head

A. Overall Operations

Lead and supervise PHU operations in alignment with hospital policies, Department of Health (DOH) directives, and the UHC Act.
Set strategic direction and approve unit targets, reports, and plans.
Monitor program implementation and ensure coordination with internal and external stakeholders.
Represent the PHU in management committee meetings.
Perform other related tasks as assigned.

Supervise the Assistant PHU Head in managing patient navigation and referral functions.
Ensure alignment of patient navigation and referral services with hospital policies, DOH directives, and the UHC Act.
Provide guidance and approve major reports, plans, and recommendations submitted by the Assistant PHU Head.

C. Epidemiology, Surveillance, and Health Statistics

Act as a focal person for hospital-based disease surveillance, epidemiology, and health statistics.
Review surveillance alerts and reports for action by hospital leadership and committees.
Ensure timely and accurate submission of data through official reporting systems, including but not limited to: Philippine Integrated Disease Surveillance and Response (PIDSR), Integrated Chronic Non-Communicable Disease Registry System (ICNCDRS), Online National Electronic Injury Surveillance System (ONEISS), and Field Health Services Information System (FHSIS).
Supervise outbreak investigations in collaboration with the Infection Prevention and Control Committee (IPCC) and the Epidemiology and Surveillance Unit (ESU).
Build staff capacity in surveillance and ensure compliance with the Data Privacy Act of 2012.
Represent the PHU in meetings related to epidemiology, surveillance, and health statistics.

D. Health Promotion

Provide overall leadership in institutionalizing health promotion as a core hospital function, aligned with the Health Promotion Framework Strategy (HPFS) 2030 and DOH priorities.
Supervise the Senior Health Education and Promotion Officer (HEPO) in developing, implementing, and monitoring health promotion programs and strategies.
Approve hospital-wide health promotion campaigns, reports, and recommendations.
Represent the hospital in HCPN health promotion initiatives and other stakeholder engagements.

1.2. Qualifications of the PHU Head

Education: Doctor of Medicine, preferably with a postgraduate degree (Masters in Public Health or its equivalent)
Experience: At least 1 year of relevant experience, preferably in positions involving management and supervision
Eligibility: RA 1080
Training: 4 hours of relevant training (e.g., Basic Epidemiology, Event-based Surveillance, Epidemic-prone Disease Case-based Surveillance, Basic Health Promotion)

2. Assistant PHU Head

2.1. Roles and Responsibilities of the Assistant PHU Head

A. Overall Operations

Assist the PHU Head in supervising daily PHU functions and ensuring coordination across all sections.
Consolidate and endorse reports, plans, and recommendations to the PHU Head.
Facilitate communication between PHU staff and the PHU Head.
Perform other related tasks as assigned.

Manage and implement patient navigation and referral protocols, ensuring compliance and efficiency.
Strengthen referral networks within the hospital and across the HCPN.
Consolidate reports on referral trends and endorse recommendations for policy or staffing adjustments to the PHU Head.
Coordinate with the HEDMU during emergencies and patient surges.
Ensure the development and regular updating of the Health Facility Directory.

C. Epidemiology, Surveillance, and Health Statistics

Assist the PHU Head and Disease Surveillance Coordinator in reviewing surveillance reports, outbreak investigations, and capacity-building activities.
Support consolidation and endorsement of reports to the PHU Head.
Facilitate coordination with other hospital units to ensure data submission and compliance with the Data Privacy Act.

D. Health Promotion

Assist the PHU Head and Senior Health Education and Promotion Officer in planning, implementing, and monitoring hospital health promotion programs.
Support the development of hospital-wide health education and communication activities.
Facilitate coordination with Centers for Health Development (CHDs), Local Government Units (LGUs), and other stakeholders for health promotion activities.
Assist in consolidating reports and endorsing them to the PHU Head.

2.2. Qualifications of the Assistant PHU Head

Education: Bachelor's Degree relevant to the job (i.e., medical or allied health course), preferably with a postgraduate degree (Masters in Public Health or its equivalent)
Experience: 3 years of relevant experience, preferably in positions involving management and supervision
Eligibility: Civil Service (CS) Professional/Second Level Eligibility or RA 1080
Training: 16 hours of relevant training (e.g., Basic Epidemiology, Event-based Surveillance, Epidemic-prone Disease Case-based Surveillance, Basic Health Promotion)

3. Patient Navigator

3.1. Roles and Responsibilities of the Patient Navigator

● Assist patients, families, and providers in accessing appropriate hospital services and referral destinations.

● Receive, document, and coordinate referral calls and requests from partner hospitals or facilities.
● Collect, encode, and transmit referral documents to receiving facilities, and notify relevant hospital units of incoming patients.
● Guide and accompany patients through hospital processes to ensure smooth navigation.
● Maintain referral forms, records, and data, and provide feedback to referring facilities as appropriate.
● Record and report daily referral transactions, issues, and updates to the Assistant PHU Head.
● Ensure the availability and functionality of materials and equipment for patient navigation and referral.
● Support orientation sessions and policy updates related to referral systems.
● Perform other related tasks as assigned.

3.2. Qualifications of the Patient Navigator

● Education: Bachelor's Degree

● Experience: none required

● Eligibility: CS Professional/Second Level Eligibility or RA 1080

● Training: none required

4. Disease Surveillance Coordinator (DSC)

4.1. Roles and Responsibilities of the DSC

Responsible for the day-to-day public health surveillance operations, including the supervision of data collection activities across hospital departments.
Manage and analyze hospital-level data, such as the generation of alerts and epidemic thresholds, and the calculation of surveillance performance indicators.
Coordinate with the physician, hospital laboratory, ESUs, and referral laboratory for the collection, storage, and transport of specimens for confirmatory testing.
Regularly prepare surveillance reports and other knowledge products, as necessary, for the entire hospital.
Notify the PHU Head of signals of health events and monitor response actions.
Conduct outbreak investigations in collaboration with the IPCC and the appropriate ESU.
Review and seek approval of the PHU Head for all relevant reports and other knowledge products prior to submission to the appropriate ESU

and/or the DOH-Central Office or through the appropriate information system.

Ensure complete, accurate, and timely submission of reports, including:
- Surveillance data on notifiable diseases and health events of public health concern
- Data from patient registries on chronic NCDs, violence, and injuries
- Health statistical data in the FHSIS
Regularly organize capacity development activities on epidemiology, surveillance, and health statistics for DSO, physicians, and other hospital staff; and
Perform other related tasks as assigned.

4.2. Qualifications of the DSC

Education: Bachelor's Degree, preferably medical or allied health course
Experience: 2 years of experience in disease surveillance of notifiable diseases and health events
Eligibility: CS Professional/Second Level Eligibility or RA 1080
Training: 8 hours of relevant training, preferably on Basic Epidemiology, Event-based Surveillance, and Epidemic-prone Disease Case-based Surveillance

5. Disease Surveillance Officer (DSO)

5.1. Roles and Responsibilities of the DSO

Ensure the list of diseases, syndromes, and health events to be reported is placed for ready reference of doctors, either on the table under a glass or hung on the wall.
Remind physician/s on duty at the Outpatient Department and Emergency Room of completing provisional diagnoses.
Manage and analyze department-level data.
Regularly prepare surveillance reports and other knowledge products, as necessary, for their respective departments.
Notify the DSC of signals of health events and monitor response actions.
Support the DSC in the conduct of outbreak investigations involving their respective departments, in collaboration with the IPCC and the appropriate ESU.
Ensure complete, accurate, and timely submission of disease surveillance and health statistical data from their respective departments to the DSC.
Assist the DSC in organizing capacity development activities on epidemiology, surveillance, and health statistics for hospital staff.

● Perform other related tasks as assigned.

5.2. Qualifications of the DSO

Education: Bachelor's Degree, preferably medical or allied health course
Experience: 2 years of experience in disease surveillance of notifiable diseases and health events
Eligibility: CS Professional/Second Level Eligibility or RA 1080
Training: Preferably trained on Basic Epidemiology, Event-based Surveillance, and Epidemic-prone Disease Case-based Surveillance

6. HSS Data Encoder

6.1. Roles and Responsibilities of the HSS Data Encoder

Encode complete and accurate information of cases and health events within the prescribed timeline to the established information systems;
Ensure zero reporting, if applicable, to appropriate information systems;
Assist the DSC and DSOs in the conduct of surveillance and health statistics activities, including, but not limited to, data collection, data management, and preparation of relevant reports; and
Assist the DSC in organizing capacity development activities on epidemiology, surveillance, and health statistics for hospital staff;
Performs other related tasks as assigned.

6.2. Qualifications of the HSS Data Encoder

Education: Completion of two-year studies in college
Experience: 1 year of relevant experience
Eligibility: CS Subprofessional/First Level Eligibility or RA 1080
Training: 4 hours of relevant training

7. Senior Health Education and Promotion Officer (HEPO)

7.1. Roles and Responsibilities of the Senior HEPO

Leads health education for patients, families, and staff, focusing on the Seven Healthy Habits of the HPFS and key disease risk factors.
Oversees the development of health communication materials, ensuring clarity, accuracy, and accessibility.
Plans and implements programs that encourage healthy lifestyles among hospital employees and foster a health-promoting workplace.
Organizes patient, family, and staff support groups, including coaching for patient watchers and caregivers.
Leads the planning and coordination of annual and monthly health promotion programs aligned with the DOH Health Calendar, Public Engagement Grid (PEG), and the HPFS priority areas.
Provides training opportunities to hospital personnel, disseminating up-to-date scientific information and promoting evidence-based practices and policies.
Monitors and evaluates health promotion programs to ensure effectiveness, national alignment, and continuous improvement.
Strengthens collaboration with CHDs, LGUs, and other stakeholders to address social, economic, and environmental determinants of health.
Supports hospital personnel in applying person-centered approaches to care that promote overall patient well-being.
Provides mentorship and supervision to the Junior HEPO.
Performs other related tasks as assigned.

7.2. Qualifications of the Senior HEPO

Education: Bachelor's Degree, preferably medical or allied health course
Experience: 2 years of experience in health promotion
Eligibility: CS Professional/Second Level Eligibility or RA 1080
Training: 8 hours of relevant training, preferably on Basic Health Promotion

8. Junior Health Education and Promotion Officer (HEPO)

8.1. Roles and Responsibilities of the Junior HEPO

Coordinates health education activities for patients, families, and staff, supporting the promotion of the Seven Healthy Habits of the HPFS and key disease risk factors.
Assists in the development and dissemination of health communication materials to ensure clarity, accuracy, and accessibility.
Facilitates programs and activities that encourage healthy lifestyles among hospital employees and contribute to a health-promoting workplace.
Organizes patient, family, and staff support groups, including health education sessions and caregiver coaching.
Coordinates the conduct of health promotion programs aligned with the DOH Health Calendar, PEG, and the HPFS priority areas.
Supports training activities for hospital personnel, ensuring the use of up-to-date scientific information and evidence-based practices.
Monitors and documents daily health promotion activities and submits reports to the Senior HEPO.
Coordinates with CHDs, LGUs, and community groups in implementing health promotion initiatives.
Assists hospital personnel in applying person-centered approaches to care that promote overall patient well-being.
Performs other related tasks as assigned.

8.2. Qualifications of the Junior HEPO

Education: Bachelor's Degree, preferably medical or allied health course
Experience: 1 year of experience in health promotion
Eligibility: CS Professional/Second Level Eligibility or RA 1080
Training: 4 hours of relevant training, preferably on Basic Health Promotion

9. Administrative Staff

9.1. Roles and Responsibilities of the Administrative Staff

Provides administrative support to the PHU.
Manages office supplies, materials, and equipment, including regular inventory and replenishment.
Maintains staffing schedules, leave requests, and hospital documents for timely submission.
Handles and records communications, prepares memorandums, reports, and organizes meetings.
Ensures proper filing and safekeeping of PHU records for easy retrieval.
Facilitates the transmission and dissemination of documents to concerned personnel or departments.
Helps maintain a clean and orderly office environment.
Performs other related tasks as assigned.

9.2. Qualifications of the Administrative Staff

Education: High School Graduate or completion of relevant vocational/trade courses
Experience: none required
Eligibility: Relevant Memorandum Circular (MC) No. 11 s. 1996
Training: none required

Other Considerations

The PHU shall maintain active representation in the hospital Management Committee (Mancom) meetings through the PHU Head or, in his/her absence, the Assistant PHU Head. This ensures that public health perspectives are consistently integrated into hospital-wide decision-making processes, particularly in aligning hospital services with

national programs under the Universal Health Care (UHC) Act. Through this representation, the PHU will regularly present updates on patient navigation and referral, surveillance, and health promotion, allowing public health concerns to be prioritized and addressed within the overall governance framework of the hospital.

To effectively support its operations, the PHU shall also be provided with a dedicated budget allocation within the hospital's annual operating plan. This budget shall cover personnel services, maintenance and other operating expenses, and capital outlay for equipment and infrastructure needed for patient navigation and referral. surveillance, and health promotion activities. In addition to hospital funding, the PHU may tap external support from the DOH, LGUs, and development partners to strengthen its programs. Transparent financial management and reporting shall be practiced to ensure accountability in the use of resources.

Finally, the PHU shall prioritize capacity building and professional development of its staff to maintain high standards of service delivery. Continuing education and training programs will be institutionalized to enhance competencies in surveillance, health promotion, patient navigation, and data management. Partnerships with the DOH, academic institutions, and professional organizations will be leveraged to provide specialized training and certification opportunities. A system of performance evaluation and recognition shall also be implemented to promote accountability, motivation, and continuous professional growth among PHU staff.

CHAPTER 4. OFFICE SPACE AND EQUIPMENT NEEDS

To effectively deliver its mandate, the Public Health Unit (PHU) requires adequate office space, equipment, and resources that support both administrative and technical functions. A well-designed and properly equipped office environment ensures efficiency in daily operations, confidentiality in patient navigation and referral, and a conducive setting for health promotion activities, stakeholder engagement, and staff development.

This chapter outlines the essential physical space requirements, workstations, information and technology (IT) and communication tools, storage facilities, office equipment, supplies, and software needed to optimize the PHU's operations. These resources are critical in enabling the PHU team to plan, implement, monitor, and evaluate health promotion programs, as well as to provide responsive and person-centered public health services within the hospital and the community it serves.

Physical Space

The PHU must be provided with sufficient and functional office space to ensure smooth operations and an environment conducive to collaboration and service delivery. Dedicated areas are required for staff work, patient navigation and referral, meetings, and secure storage of sensitive materials.

☐ Dedicated PHU office – adequate space for staff workstations,	storage, and
meetings
☐ Soundproof call room – for patient navigation and referral communications
☐ Conference room – with tables and chairs for planning, training,	and stakeholder
meetings
☐ Secure storage area – for confidential records, information,	education, and
communication (IEC) materials, and equipment

Workstations and IT Equipment

Efficient work requires reliable technology and dedicated workstations. Each staff member should have the necessary tools to perform their functions effectively, both within the PHU and during fieldwork. An interoperable electronic medical record (EMR) system and stable internet connectivity are essential to support patient navigation, data management, and communication.

☐ Designated desk and computer for each staff
☐ Laptop – for fieldwork, presentations, and mobile use

☐ Interoperable EMR system ☐ Internet connection – supports EMR, video conferencing, and data uploads ☐ Dedicated phone line – for patient navigation and referrals ☐ Peripherals – printer, scanner, photocopier, paper shredder, external hard drives, universal serial bus (USB) flash drives, etc.
Communication and Presentation Tools
The PHU requires communication and presentation equipment to effectively conduct training sessions, stakeholder meetings, health promotion activities, and community outreach. These tools ensure that information is disseminated clearly and effectively, whether on-site or virtually.
☐ Light-emitting diode (LED) projector with white screen ☐ Smart TV – for health promotion displays and virtual meetings ☐ Portable speaker with microphone ☐ Voice recorder – for interviews and focus group discussions ☐ Connectivity accessories – high-definition multimedia interface (HDMI) cables and related devices ☐ Digital camera – for documentation and IEC production
Office and Storage Equipment
Organized storage and display systems are essential to maintain order and ensure easy access to materials and records. The PHU should be equipped with filing and display units that facilitate efficient documentation, record-keeping, and presentation of health information.
☐ Filing cabinets and organizers ☐ Display cabinet for IEC materials ☐ Bulletin board and leaflet holders ☐ Promotional booth – for outreach and community activities (optional)
Supplies
Sufficient office and health communication supplies are needed for the day-to-day operations of the PHU. These include general office supplies as well as health promotion collaterals to support education and awareness campaigns.
☐ General office supplies – paper, ink, markers, folders, and related materials ☐ IEC collaterals – tarpaulins, posters, flyers, leaflets ☐ Tarpaulin stand (optional)

Software and Subscriptions

Digital tools and platforms strengthen the PHU's capacity for creative health promotion,
efficient data management, and seamless collaboration. Licensed or open-access
software should be available for design, reporting, and monitoring purposes.

☐ Design tools – Canva, Adobe Photoshop (or equivalent)
☐ Cloud storage and collaboration tools – Google Drive, Microsoft OneDrive (optional)
☐ Statistical and data management platforms – EpiInfo, Stata, Power BI, R Studio,
Excel
☐ Teleconferencing applications - Cisco WebEx, Zoom

CHAPTER 5: SYSTEMS AND PROCEDURES

This chapter outlines the systems and procedures that guide the operations of the Public Health Unit (PHU). It provides a structured framework to ensure that the PHU delivers coordinated, efficient, and evidence-based public health services in line with the hospital's mandate and the Department of Health's (DOH) standards.

The chapter is organized into three core services of the PHU. Each section provides the policies, purposes, and step-by-step procedures to guide PHU staff and partner units in carrying out their responsibilities, ensuring consistency, accountability, and quality in service delivery.

Operating Hours of the Public Health Unit

The PHU provides services according to defined operating hours to ensure the availability, continuity, and responsiveness of public health functions. Regular office operations are maintained from 8:00 AM to 5:00 PM, Monday to Friday, while selected services such as Patient Navigation and Referral remain available 24/7 to respond to urgent health needs. Epidemiology and surveillance functions are ensured during regular working hours, with one staff on duty during weekends and holidays. Health promotion activities are carried out daily during regular office hours to maximize patient, staff, and community engagement.

This section describes the systems and procedures for navigating patients across appropriate levels of care. It establishes processes for triage, referral documentation, coordination, and transfer to ensure patients receive the right care at the right time. It also includes procedures for surge response in emergencies and the maintenance of a health facility directory for efficient referrals.

To ensure timely and efficient access to appropriate health care services through systematic patient navigation and referral procedures.

A. Initial Patient Assessment and Triage

Purpose: To classify patient conditions based on severity and direct them to appropriate care levels.

1. The patient seeks consultation at a health care facility with specific symptoms or conditions.
1. The triage officer classifies the patient's condition as Emergent, Urgent, or Non-Urgent.
a. Emergency and urgent cases are referred to the Emergency Department (ED) and Urgent Care and Ambulatory Service Centers, as applicable.
b. Non-urgent cases are referred to the Outpatient Department.
1. The health care provider performs an initial assessment and provides initial management.

B. Evaluation for Admission or Higher-Level Referral

Purpose: To identify patients requiring admission or referral to a higher-level facility.

Steps:

1. The health care provider identifies patients for:
- a. In-facility admission
- b. Referral to higher-level care
1. For in-facility admissions, proceed with the standard admission procedure.
1. If referral is deemed necessary, the health care provider must discuss and confirm the need for referral, then escalate the case to the PHU for proper documentation and coordination.

C. Preparation of Referral Documents

Purpose: To complete accurate documentation for efficient referral and transfer of care.

Steps:

1. The patient navigator records:
- a. Referring facilities
- b. Patient demographic data
- c. Brief clinical history, findings, and diagnosis
- d. Reason for referral
- e. Clinical status before transfer (level of consciousness, blood pressure, capillary refill, respiratory rate, triage classification, etc)
1. The patient navigator prepares:
- a. Electronic referral form
- b. Patient's medical records
- c. Laboratory and imaging results
- d. Medication list and treatment plan

D. Selection of Receiving Facility

Purpose: To choose the most appropriate receiving facility based on the patient's clinical needs.

1. The patient navigator and health care provider select a facility based on:
- a. Triage category
- b. Availability of specialty services and diagnostics
- c. Accessibility and location

E. Communication and Coordination

Purpose: To ensure smooth communication between referring and receiving facilities and prepare for patient transfer.

Steps:

1. The patient navigator provides the relevant patient and case information, and confirms the receiving facility's capability and bed availability for patient transfer through appropriate communication channels (e.g., phone call, secure messaging platform, or designated referral coordination group).
1. The patient navigator electronically sends referral documents via an interoperable platform.

F. Transfer Confirmation

Purpose: To finalize coordination and confirm the readiness of the receiving facility.

Steps:

1. The patient navigator of the receiving facility reviews the referral documents submitted through the interoperable platform and coordinates with the appropriate physician or specialty department to confirm referral acceptance within one hour.
1. Once accepted, the navigator sends a "go" signal to the referring facility via communication channel (e.g., secure messaging platform or designated chat group) to proceed with the transfer.
1. The referring facility is responsible for arranging patient transport, ensuring that the patient is adequately stabilized and medically cleared for transfer.
1. For emergent and urgent cases, a designated health care provider should accompany the patient during transfer.
1. If the referral is not accepted, the patient navigator of the referring facility will return to Step D. Selection of Receiving Facility.

G. Patient Reception and Endorsement

Purpose: To ensure proper reception, handover, and acknowledgment of the referred patient.

1. Upon arrival at the receiving facility, the patient navigator from the referring hospital shall:
- a. Endorse the patient to the triage officer for initial assessment and direction.
- b. The triage officer will direct the patient to the appropriate specialty department.
- c. Endorse the patient to the ED physician or designated receiving health care provider.
1. Ensure that all referral and transfer documentation is properly completed, including the following key details:
- a. Receiving facility
- b. Time of referral and time of transfer
- c. Patient's clinical status upon arrival
- d. Name of accompanying person and mode of transport
1. Issue an acknowledgment receipt to the referring facility as confirmation of patient handover and document receipt.

Activity 2: Support to the Health Emergency and Disaster Management Unit (HEDMU)

To ensure an effective, coordinated, and systematic response for patient navigation and referral during public health emergencies, including surge situations, by aligning PHU procedures with HEDMU protocols.

Purpose: To establish standardized guidelines for patient navigation and referral during public health emergencies.

Steps:

1. PHU and HEDMU convene to form a Joint Protocol Development Team.
1. Conduct risk assessments and hazard mapping to identify potential patient surge scenarios.
1. Draft standard operating procedures (SOPs) for patient triage, referral flow, facility allocation, and communication mechanisms.
1. Validate protocols through simulation exercises and scenario-based drills.
1. Disseminate final protocols to all navigators and partner health facilities.

Purpose: To manage increased patient volume during outbreaks, disasters, or mass casualty events.

Steps:

HEDMU issues an alert or activation order for the emergency navigation system.

1. Navigators are mobilized to key triage and entry points (e.g., emergency tents, checkpoints, and temporary treatment facilities).
1. Triage Officers apply crisis-level triage classification to prioritize patients.
1. Emergent and urgent patients are directed to higher-level care or specialized emergency centers.
1. Non-critical patients are routed to alternative sites (e.g., local isolation units, temporary treatment, and monitoring facilities).

C. Real-Time Coordination with Receiving Facilities

Purpose: To ensure accurate, timely referral and distribution of patients to facilities with available resources.

Steps:

1. The navigator accesses real-time bed and resource availability dashboards maintained by HEDMU.
1. Identify suitable receiving facilities based on:
- a. Bed capacity
- b. Equipment availability (e.g., ventilators, dialysis machines)
- c. Human resources and specialty support
1. Communicate with facility focal points and confirm acceptance of referral.
1. Record all referrals and transfers in the emergency referral registry system.

D. Addressing Logistical Challenges

Purpose: To secure transportation, escort personnel, and documentation during mass transfers or remote facility navigation.

Steps:

1. Coordinate with HEDMU logistics for ambulance deployment and escort teams.
1. The navigator prepares a compressed emergency referral packet, including:
- a. Rapid clinical summary
- b. Referral form
- c. Triage category
- d. Accompanying person info
1. Document patient movement using HEDMU's emergency tracking system, as applicable.
1. Provide real-time updates to referring and receiving facilities on transfer status.

Purpose: To track performance, identify gaps, and improve patient navigation systems post-emergency.

1. PHU and HEDMU conduct joint debriefings after emergency response operations.
1. Collect and analyze data on:
- a. Number and classification of referrals
- b. Turnaround time for transfers
- c. Facility capacity utilization
1. Update protocols based on feedback and identified bottlenecks.
1. Submit reports to the hospital Incident Command System (ICS) and local health authorities.

To ensure efficient and accurate patient navigation and referral by maintaining a regularly updated directory of all relevant health care facilities, including their service capabilities and contact details.

A. Directory Development and Structure

Purpose: To build a comprehensive, standardized directory of health facilities relevant to patient referral needs.

Steps:

1. The navigator compiles a list of public and private health facilities, including:
- a. Primary care facilities
- b. Level 1 to Level 3 hospitals
- c. Apex and specialty hospitals
- d. Urgent care and ambulatory service centers
1. Classify facilities based on:
- a. Level of care (primary, secondary, tertiary)
- b. Available specialties (e.g., cardiology, pediatrics, orthopedics)
- c. Ancillary services (laboratory, imaging, dialysis, etc.)
- d. Capacity (e.g., bed count, ICU, isolation rooms)
- e. Collect and record contact information:
  - i. Direct lines to ED
  - ii. Referral focal persons
  - iii. Transport service contacts (ambulance or emergency medical services)
  - iv. Email, Viber, or other platforms for document transmission

B. Directory Update and Validation

Purpose: To maintain current and accurate information for real-time use in navigation and referrals.

1. Assign a navigator as the Directory Focal Person.
1. Conduct quarterly validation of directory data by contacting facilities directly.
1. Confirm any changes in:
- a. Contact numbers or referral coordinators
- b. Services offered or suspended
- c. Surge capacities or limitations
1. Enter validated updates into:
- a. Digital referral system platforms (if available)
- b. Offline backup copies (printed directories or spreadsheets)
- c. Use version control (e.g., version number, date of last update) to monitor changes.

Purpose: To enhance decision-making during patient referral through ready access to facility information.

Steps:

1. Navigator uses the directory during patient referral planning in coordination with health care providers.
1. Reference directory to:
- a. Match patient condition with facility capabilities
- b. Determine the nearest or most accessible facility
- c. Quickly contact referral focal points for coordination and acceptance
1. Document facility selection rationale in the referral form for accountability.

D. Directory Access and Distribution

Purpose: To ensure that all relevant PHU and health facility personnel have access to the latest directory version.

Steps:

1. Store the updated directory in both:
1. Central electronic system (intranet/shared drive)
1. Printed copies in key offices and emergency desks
1. Provide controlled access to navigators, triage officers, ED staff, and referral coordinators.
1. Train all users on how to navigate and use the directory effectively.

E. Monitoring and Feedback Mechanism

Purpose: To assess the directory's usefulness and address gaps in information.

1. Collect feedback from navigators and providers on accuracy of contact info, service availability mismatches, and suggestions for improvement.
1. Include directory review in regular PHU team meetings.
1. Update procedures based on identified gaps or new referral trends.

5.2. Epidemiology, Surveillance, and Health Statistics

This section details the mandatory reporting systems and surveillance processes required of the hospital under Republic Act (RA) No. 11332 and DOH guidelines. It covers procedures for:

Reporting of notifiable diseases through Philippine Integrated Disease Surveillance and Response – Information System (PIDSR-IS),
Event-based surveillance for emerging health threats,
Reporting of Adverse Events Following Immunization (AEFI),
Surveillance of non-communicable diseases and injuries, and
Submission of morbidity, mortality, and service coverage data through the Field Health Services Information System (FHSIS).

Together, these processes form the hospital's contribution to the Early Warning, Alert, and Response (EWAR) system and provide essential data for planning, policy, and program implementation.

Activity 1: Reporting of Notifiable Disease through the PIDSR-IS Epidemic-prone Disease Case Surveillance - Information System (EDCS-IS) Module

Policy: health care facilities, including hospitals, are subject to mandatory reporting of notifiable diseases as defined in Rule II of the 2020 Revised Implementing Rules and Regulations (IRR) of RA No. 11332.

Purpose: Case-based surveillance contributes to the EWAR system of the hospital through continuous monitoring and response to epidemic-prone diseases, each with specific case definitions.

1. Detect notifiable diseases based on standard case definitions. The PHU shall capture all suspect, probable, and confirmed cases of notifiable diseases from their hospital units.
1. Register the case. The Disease Surveillance Coordinator (DSC) shall gather case information to accomplish the Case Investigation/Report Form (CI/RF) and coordinate with Disease Surveillance Officers (DSOs) designated in other hospital units, as necessary.
1. Report the case through the EDCS-IS. Data from the accomplished CI/RF shall be
submitted through the EDCS-IS module of the PIDSR-IS within 24 hours of detection for Category I (Immediately Notifiable) diseases and every Friday of the week for Category II (Weekly Notifiable) diseases.
1. Facilitate laboratory testing and confirmation. The PHU shall coordinate specimen collection, storage, and transport with the concerned hospital laboratory and the Epidemiology and Surveillance Unit (ESU).
1. Perform data management. The DSC and the Hospital Surveillance System (HSS) Data Encoder shall maintain and manage the hospital-level databases for surveillance purposes.
1. Analyze, interpret, and generate report/s. The DSC shall analyze and generate reports on notifiable diseases, subject to the approval of the Assistant PHU Head and the PHU Head prior to dissemination to other relevant stakeholders.

References

RA No. 11332, Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act) and its Revised Implementing Rules and Regulations
Administrative Order (AO) No. 2021-0057, Revised Guidelines on the PIDSR
Latest PIDSR Manual of Procedures

Performance Indicator

Indicator 1: Epidemiology and Surveillance and Health Statistics Results Generated and Disseminated
Indicator 2: Timeliness and Completeness of Reporting of Category I Notifiable Diseases within 24 hours from detection
Indicator 3: Timeliness and Completeness of Reporting of Category II Notifiable Diseases within 7 days from detection

Activity 2: Reporting of Health Events of Public Health Concern through the Online Event-Based Surveillance and Response (Online ESR) Module of the PIDSR-IS

Policy: health care facilities, including hospitals, are subject to mandatory reporting of health events of public health concern as defined in Rule II of the 2020 Revised IRR of RA No. 11332. Pursuant to Department Memorandum (DM) No. 2023-0434, or the Interim Revision of Section III (ESR Processes) of the ESR Manual of Procedures Version 2016, health events shall be detected within seven (7) days of occurrence, notified to public health authorities within one (1) day of detection, and responded to within seven (7) days of notification.

Purpose: Event-based surveillance contributes to the EWAR system by enabling rapid detection and response to acute public health events that may not be captured by case-based surveillance.

1. Detect signals of health events. The PHU shall monitor signals as enumerated in DM No. 2023-0434 or its subsequent amendments.
1. Notify public health authorities of the health event through the Online ESR. Once verified, the PHU shall accomplish the Revised ESR Form in the Online ESR system for submission to the next higher level ESU.
1. Respond to the reported health event. The PHU Head shall alert hospital management and coordinate response actions with relevant stakeholders.

References

RA No. 11332, Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act and its Revised Implementing Rules and Regulations
AO No. 2021-0057, or the Revised Guidelines on the PIDSR
Department Memorandum No. 2023-0434, or the Interim Revision of Section III (ESR Processes) of the ESR Manual of Procedures Version 2016
Latest PIDSR Manual of Procedures

Performance Indicator

● Indicator 4: Health events reported within 24 hours of detection

Activity 3: Reporting of Adverse Events Following Immunization (AEFI) to the Next Higher Level ESU

Policy: Health care facilities must report AEFIs because they are classified as immediately notifiable diseases (Category I) in the 2020 Revised IRR of RA No. 11332.

Purpose: Reporting AEFIs generates signals for monitoring vaccine safety and helps maintain public confidence in immunization programs.

Steps

1. Detect suspect AEFI cases. The PHU shall detect all suspect AEFI cases involving vaccine recipients who received their doses from the same hospital within 24 hours.
1. Report suspect AEFI cases to the next higher level ESU for AEFI Investigation. The PHU shall ensure that the CI/RF is accomplished and submitted to the next higher level ESU to trigger AEFI Investigation.

References

RA No. 11332, or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act, and its Implementing Rules and Regulations
AO No. 2023-0007, or the Revised Omnibus Guidelines on the Surveillance and Management of Adverse Events Following Immunization (AEFI)

Performance Indicator

● Indicator 5: Reporting of AEFI cases within 24 hours from detection to the next higher ESU

Activity 4: Reporting of the Leading Causes of Non-Communicable Diseases through the Integrated Chronic Non-Communicable Disease Registry System (ICNCDRS)

Policy:

The country shall adopt an integrated, comprehensive, and community-based response for the prevention and control of chronic lifestyle-related non-communicable diseases (NCDs), including cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. Health promotion strategies shall be intensified to reduce morbidity and mortality from NCDs, while ensuring complementary accountabilities of all stakeholders in implementing evidence-based interventions. The ICNCDRS, as part of the Unified Registry Systems (URS), provides the platform for systematic surveillance and monitoring of NCD cases, in line with AO No. 2011-0003 and AO No. 2013-0005

Purpose:

The goal of NCD surveillance through ICNCDRS is to reduce morbidity, mortality, and disability due to lifestyle-related NCDs by generating accurate, timely, and validated data. This data guides hospitals and health systems in program planning, service delivery, and policy development. ICNCDRS supports hospitals in their mandate to provide promotive, preventive, curative, rehabilitative, and palliative care for patients with NCDs, while strengthening surveillance, monitoring, and evaluation of chronic disease burden

1. Accomplish and/or validate the entries in the DOH-prescribed forms for each NCD registry (Cancer, Chronic Obstructive Pulmonary Disease, Diabetes, Stroke, Renal, and others). The PHU of registered reporting facilities under ICNCDRS shall ensure the completeness and accuracy of these forms, especially mandatory fields. If other hospital units are responsible for encoding patient registry data, the PHU shall coordinate with the concerned unit and validate the data prior to submission.
1. Submit the accomplished form/s to ICNCDRS. The PHU shall ensure that NCD data are reported to ICNCDRS in a timely manner through the:
- a. Online Data Entry Module for direct encoding; or
- b. Data Uploading System (DUS) for facilities with an electronic medical records (EMR) system.
1. Adhere to the prescribed reporting frequency, submitting monthly reports within the first five (5) working days of the following month.
1. Review and validate the encoded data using the ICNCDRS tools to identify and correct any missing fields, logical inconsistencies such as discrepancies between age and diagnosis, and duplicate entries.
1. Generate reports on the leading causes of NCD morbidity. The PHU shall regularly generate hospital-level reports from ICNCDRS to provide actionable insights for hospital management in program planning, service delivery, and resource allocation.

References:

AO No. 2013-0005, National Policy on the Unified Registry Systems of the Department of Health
AO No. 2011-0003, National Policy on Strengthening the Prevention and Control of Chronic Lifestyle-Related Non-Communicable Diseases

Performance Indicator

● Indicator 1: Epidemiology and Surveillance and Health Statistics Results Generated and Disseminated

Activity 5: Reporting of Injuries through the Online National Electronic Injury Surveillance System (ONEISS)

Policy: Injury surveillance is a core PHU deliverable under the Hospital Sentinel Report. ONEISS also supports monitoring of National Objectives for Health (NOH) 2023–2028, specifically Indicator No. 3.4: Death rate due to road traffic injuries per 100,000 population.

Purpose: The final link of the surveillance chain is the application of gathered injury surveillance data to prevention and control interventions. Injury surveillance shall aid the hospitals in fulfilling their mandate to ensure the provision of quality promotive, preventive, curative, rehabilitative, and palliative care for patients involved in violence and injury.

1. Accomplish and/or validate the entries in the Patient Injury Form and Kontra Paputok (KP) Form. The PHU of registered reporting facilities under ONEISS shall ensure the completeness and accuracy of the Patient Injury Form and KP Form, especially its mandatory fields. If other hospital units are responsible for encoding patient registry data on injury, the PHU shall be accountable for coordinating with the unit concerned and ensuring that data is validated prior to submission.
1. Submit the accomplished form/s to ONEISS. The PHU shall ensure that injury data are reported to ONEISS in a timely manner, either through the:
- a. Data Uploading System (DUS) for health facilities with a computer-based,
electronic medical records (EMR) system; or
b. Injury Reporting System (IRS) for those without it.
1. Generate reports on the leading causes of injuries. The PHU shall regularly generate hospital-level reports on the leading causes of injuries from ONEISS, providing actionable insights for hospital management.

References

AO No. 2024-0014, Guidelines on the Implementation of the 8-Point Action Agenda Monitoring, Evaluation, Accountability and Learning System
AO No. 2018-0023, Guidelines in Strengthening the Capacity of Public Health Units of DOH Hospitals and All Level Three Hospitals (Government and Private) on Sentinel Surveillance System for Notifiable Diseases of Epidemic Potential
AO No. 2014-0002, Revised National Policy on Violence and Injury Prevention
AO No. 2013-0005, National Policy on the Unified Registry Systems of the Department of Health (Chronic Non-Communicable Diseases, Injury-Related Cases, Persons with Disabilities, and Violence Against Women and Children Registry System

Performance Indicator

● Indicator 1: Epidemiology and Surveillance and Health Statistics Results Generated and Disseminated

Activity 6: Reporting of Morbidity, Mortality, and Health Service Coverage through the Field Health Services Information System (FHSIS)

Policy: The FHSIS is the official statistical activity of the DOH that identifies and generates critical and essential health statistics needed for planning and analysis based on approved criteria by administrators, planners, and policymakers.

Purpose: The submission of hospital-level data to the FHSIS aims to enhance the national-level epidemiological profile in terms of leading causes of morbidity and mortality and the local burden of disease, as well as health service coverage patterns, to support the monitoring and evaluation of public health programs of the Department.

1. Accomplish and/or validate the entries in the FHSIS Reports. The PHU shall ensure the completeness and accuracy of FHSIS Reports, covering morbidity, mortality, and health services utilization data within their jurisdiction. If other hospital units are responsible for encoding health statistical data, the PHU shall be accountable for coordinating with the unit concerned and ensuring that data is validated prior to submission.
1. Submit the accomplished reports to the appropriate oversight office. The PHU

shall ensure that the accomplished FHSIS Reports are only submitted once, either to the Rural Health Unit (RHU) or the Primary Care Facility (PCF), City/Municipality Health Office (C/MHO), Provincial Health Office (PHO), Center for Health Development (CHD), or the Minister of Health—Bangsamoro Autonomous Region in Muslim Mindanao (MOH-BARMM) based on the latest FHSIS Reporting Mechanism.

References

AO No. 2023-0005 or the Guidelines on the Implementation of the Routine Information and Statistics for Enhancement of Public Health (RISE PH) Repository System
Department Memorandum (DM) No. 2025-0104 or the Guidelines on the Collection, Reporting, Management, Generation, and Release of Health Statistics through the Field Health Services Information System (FHSIS)
Latest FHSIS Manual of Procedures

Performance Indicator

● Indicator 1: Epidemiology and Surveillance and Health Statistics Results Generated and Disseminated

5.3. Health Promotion

This section presents the hospital's procedures for implementing health promotion programs targeting patients, staff, and the community. It outlines activities on patient education, workplace wellness, staff training, stakeholder collaboration on social determinants of health (SDOH), and the development of SBCC materials. These activities align with the Health Promotion Framework Strategy (HPFS) and support the hospital's role in building a health-promoting environment.

Activity 1: Patient education on healthy behaviors and disease risk factors

Policy: The hospital, through the PHU, shall provide clear, accessible, and comprehensive patient education on healthy behaviors and disease risk factors, aligned with the Seven Healthy Habits of the HPFS, to empower patients and families to make informed health choices.

Purpose: To equip patients and families with knowledge and skills to adopt healthy behaviors, prevent disease, and support recovery and well-being.

1. Identify health topics using the DOH Health Calendar, Public Engagement Grid (PEG), and the hospital's leading causes of morbidity and mortality.
1. Develop clear and accurate health education materials (flyers, slide decks, and visual aids).
1. Prepare logistics (schedule, venue, materials).
1. Identify resource persons:
- a. For simple topics HEPO may serve as resource persons.
- b. For complex topics coordinate with health care professionals (e.g., Chief Fellow, Resident).
1. Ensure alignment between PHU and health care professionals on materials for complex topics.
1. Engage patients interactively and monitor understanding through feedback or simple assessments.
1. Provide follow-up support through counseling or additional education sessions as needed.

Activity 2: Hospital staff education on healthy behaviors

Policy: The hospital shall provide regular health promotion sessions for staff, aligned with the HPFS, to foster a health-promoting workplace.

Purpose: To empower staff to adopt and model healthy behaviors, contributing to a culture of wellness.

Steps

1. Identify priority topics through surveys or interviews.
1. Identify resource persons:
- a. HEPO for simple topics.
- b. Health professionals for more technical subjects.
1. Develop staff-focused health education materials.
1. Prepare logistics (schedule, venue, materials).
1. Incorporate interactive learning (discussions, demonstrations, challenges).
1. Assess understanding and provide coaching or follow-up wellness sessions.

Activity 3: Staff training on public health and clinical practice updates

Policy: The PHU shall organize capacity-building and training activities to disseminate updated scientific information on public health and clinical practice, supporting person-centered care.

Purpose: To strengthen staff competencies in delivering evidence-based, person-centered care.

Steps

Coordinate with hospital units to identify training needs (e.g., emerging diseases, mental health, patient-centered care).

1. Identify resource persons (HEPO for simple topics; health professionals for complex topics).
1. Develop training materials that are simple and evidence-based.
1. Prepare logistics (schedule, venue, materials).
1. Facilitate interactive learning (group discussions, case studies, practical demonstrations).
1. Assess comprehension and application through feedback or evaluation tools.
1. Provide mentorship or coaching for staff needing additional support in integrating person-centered practices.

Activity 4: Collaboration with stakeholders on SDOH

Policy: The PHU shall collaborate with CHDs, LGUs, and other stakeholders to address the social, economic, and environmental determinants of health, serving as a resource person or technical support upon request.

Purpose: To support LGU-led initiatives that address SDOH and promote community wellness, while ensuring hospital-based insights contribute to wider health promotion goals.

Steps

1. Provide patient-level data and technical inputs to complement LGU community assessments.
1. Ensure alignment of engagement activities with HPFS and hospital priorities.
1. Participate as a resource person or provide technical support in LGU-led health fairs, workshops, or outreach.
1. Support monitoring and evaluation by sharing hospital-based data and insights when requested.
1. Provide technical guidance to strengthen long-term LGU-led community engagement strategies.

Policy: The hospital, through the PHU, shall develop, adapt, and disseminate evidence-based SBCC materials, aligned with HPFS and national campaigns, to support healthy behaviors.

Purpose: To influence knowledge, attitudes, and practices of patients, families, staff, and the community through clear, culturally appropriate health communication.

1. Review DOH-issued SBCC packages and adapt them for the hospital context and priority health areas.
1. Ensure messages are simple, evidence-based, and culturally sensitive.
1. Customize materials for different groups (patients, staff, families, and caregivers).
1. Select effective dissemination channels (hospital displays, social media, waiting room posters, newsletters, intranet, etc.).
1. Pretest materials with small groups to ensure clarity and impact.
1. Secure hospital management clearance for dissemination.
1. Implement campaigns and ensure materials are visible and accessible.
1. Monitor effectiveness through feedback, surveys, or behavioral indicators.
1. Revise and sustain efforts based on evaluation results.

CHAPTER 6: CONTINUOUS QUALITY IMPROVEMENT IN THE PUBLIC HEALTH UNIT

Continuous Quality Improvement (CQI) is a systematic and data-driven approach to enhancing the delivery of public health services within the Public Health Unit (PHU). It ensures that systems and procedures are consistently monitored, evaluated, and improved to meet Department of Health (DOH) standards and the hospital's commitment to patient-centered, responsive, and evidence-based care.

This chapter outlines the CQI framework, activities, and performance indicators across the three core services of the PHU: Patient Navigation and Referral, Epidemiology/Surveillance and Health Statistics, and Health Promotion.

6.1 CQI Framework

The PHU adopts the Plan–Do–Check–Act (PDCA) cycle as its guiding framework for continuous quality improvement.

1. Plan Identify service delivery gaps using indicators, reports, and stakeholder feedback.
1. Do Implement corrective actions or test new strategies to address identified gaps.
1. Check Measure outcomes against performance indicators and evaluate effectiveness.
1. Act Institutionalize successful interventions or revise measures for further improvement.

The PDCA cycle is applied at all levels of PHU operations to promote accountability, consistency, and excellence in public health service delivery.

6.2 CQI Activities and Indicators

CQI Activities

Conduct monthly audits of referral documentation for accuracy and completeness.
Monitor referral turnaround time (from initiation to acceptance/transfer).
Review quarterly feedback from referring and receiving facilities to identify gaps and bottlenecks.
Hold case reviews of delayed or failed referrals and implement corrective actions.
In coordination with the Quality Improvement. Infection Prevention and Control, and Patient Safety (QI-IPC-PS) Unit, establish a structured process for collecting feedback from clients (patients, relatives, or caregivers) through tools such as the Hospital Client Experience Survey (HCES) to support continuous improvement of the patient navigation and referral system.
Conduct annual surge navigation simulation drills in coordination with the Health Emergency and Disaster Management Unit (HEDMU).

Performance Indicators

Percentage of referrals with complete documentation.
Average referral turnaround time (in hours).
Percentage of referrals successfully transferred to appropriate facilities.
Number of case reviews conducted for delayed/failed referrals.
Percentage of client feedback collected and analyzed through structured tools (e.g., HCES).
Frequency and results of surge navigation drills.

6.2.2 Epidemiology, Surveillance, and Health Statistics

CQI Activities

Weekly review of surveillance reports for timeliness and completeness.
Cross-validate reported data with laboratory results and hospital service statistics.
Conduct quarterly data quality checks on accuracy, completeness, and consistency.
Convene quarterly meetings with Disease Surveillance Officers (DSOs) and hospital unit reporters for troubleshooting.
Provide refresher training to PHU staff on surveillance protocols and reporting tools.

Performance Indicators

Percentage of Category I notifiable diseases reported within 24 hours of detection.
Percentage of Category II notifiable diseases reported within 7 days of detection.
Percentage of Event-Based Surveillance and Response (ESR) signals verified and reported within 24 hours.
Percentage of Adverse Events Following Immunization (AEFI) cases reported within 24 hours.
Data accuracy score from quarterly data quality checks.
Number of refresher training conducted per year.

6.2.3 Health Promotion

CQI Activities

Conduct pre- and post-tests for patient and staff health education sessions to measure knowledge gains.
Gather patient and staff feedback on health education activities and SBCC materials.
Monitor the visibility and accessibility of SBCC materials within hospital premises.
Track staff participation in workplace wellness programs and education activities.
Review collaboration activities with LGUs, CHDs, and other stakeholders to assess the effectiveness of PHU technical support.

Performance Indicators

Percentage of patient education sessions with at least 75% post-test improvement.
Percentage of hospital staff reporting improved knowledge/skills after wellness sessions.
Number and reach of SBCC materials disseminated/displayed.
Percentage of hospital staff participating in wellness activities.
Number of technical assistance engagements provided to LGU-led health promotion activities.

6.3 CQI Implementation Process

To operationalize CQI, the PHU shall:

1. Assign CQI Focal Persons Each core service (navigation, surveillance, and health promotion) shall designate a focal person responsible for data collection, monitoring, and improvement planning.
1. Establish Routine Monitoring Performance indicators shall be monitored monthly or quarterly, depending on reporting cycles.
1. Conduct Review Meetings CQI findings shall be discussed during quarterly PHU meetings with the participation of hospital management when needed.
1. Implement Corrective Actions Based on findings, corrective measures shall be piloted and evaluated before full adoption.
1. Document and Report All CQI activities shall be documented in CQI reports for internal reference and external submission as required by DOH.

6.4 Reporting and Review

Quarterly Reports CQI progress and indicator performance shall be presented during PHU quarterly review meetings.
Annual Reports An annual CQI summary report shall be submitted to hospital management and the Center for Health Development (CHD).
Feedback Integration Lessons learned and recommendations shall be integrated into operational procedures and future planning.

6.5 CQI Matrix

Service Area	CQI Activities	Performance Indicators	Frequency	Responsible Person
Patient Navigation and Referral	Monthly audit of referral documentation	% of referrals with complete documentation	Monthly	Navigation Focal Person
	Monitor referral turnaround time	Average referral turnaround time	Monthly	Navigation Focal Person
	Review quarterly feedback from referring and receiving facilities to identify gaps and bottlenecks	% of referrals successfully transferred to appropriate facilities	Quarterly	Navigation Focal Person / Asst. PHU Head / PHU Head
	Hold case reviews of delayed or failed referrals and implement corrective actions	Number of case reviews conducted	Quarterly	Navigation Focal Person / Asst. PHU Head / PHU Head
	Collect structured client feedback (e.g., HCES) with QI-IPC-PS Unit	% of client feedback collected and analyzed	Semi-annu al	PHU / Q-IPC-PS Unit
	Annual surge drill with HEDMU	Frequency of surge drills conducted	Annual	PHU Head / HEDMU
Epidemiology, Surveillance, and Health Statistics	Weekly review of reports	% of timely and complete submissions	Weekly	DSC / DSO
	Quarterly data quality checks	Data accuracy score	Quarterly	Surveillance Focal Person
	Refresher trainings	# of trainings conducted	Annual	PHU Head / HEPO

Service Area	CQI Activities	Performance Indicators	Frequency	Responsible Person
Health Promotion	Pre- and post-tests for education sessions	% of sessions with ≥75% post-test improvement	Per activity	HEPO
	Monitor visibility of SBCC materials	# of SBCC materials displayed/disseminated	Quarterly	HEPO
	Track staff participation in wellness programs	% of staff participation	Quarterly	HEPO

6.6 Summary

CQI is integral to the operations of the PHU. Through systematic monitoring, evaluation, and continuous improvement, the PHU ensures that its services remain responsive, efficient, and aligned with national public health priorities. By embedding CQI into routine operations, the PHU fosters a culture of accountability, innovation, and excellence in public health service delivery.

CHAPTER 7: FUNCTIONALITY ASSESSMENT OF THE PUBLIC HEALTH UNIT

7.1 Introduction

The functionality of the Public Health Unit (PHU) must be regularly assessed to ensure that it delivers efficient, responsive, and quality public health services in line with Department of Health (DOH) standards and hospital priorities. Functionality assessment provides a structured approach to monitor the performance of the PHU, identify gaps, and guide corrective actions for continuous improvement.

This chapter outlines the functionality assessment framework, indicators, and scoring guide to determine whether a PHU is functional, partially functional, or non-functional.

7.2 Objectives

The PHU Functionality Assessment aims to:

1. Establish a standardized framework for assessing PHU functionality.
1. Monitor the extent to which PHU systems, staffing, facilities, and processes are in place and operational.
1. Provide evidence to inform hospital management in decision-making, resource allocation, and policy support.
1. Strengthen accountability and continuous improvement in PHU performance.

7.3 Assessment Domains and Indicators

The PHU Functionality Assessment is organized into seven domains. Each domain contains a set of indicators that represent the minimum standards of functionality.

7.3.1 Governance and Organization

The PHU organizational structure was established and approved by hospital management.
The PHU Head is designated with clear roles and responsibilities.
Clear delineation of functions among PHU staff (Navigation, Surveillance, Health Promotion).
Regular PHU meetings are conducted and documented.

7.3.2 Operations and Service Delivery

PHU operates Mondays–Fridays, 8:00 AM–5:00 PM, with designated 24/7 services for Patient Navigation and Referral.
The Patient Navigation and Referral system is functional, with documentation. Epidemiology and Surveillance functions are performed, with timely and complete reporting.

● Health Promotion activities are implemented, including patient education and SBCC initiatives.

7.3.3 Human Resources

Staffing pattern consistent with hospital level and PHU service requirements.
Staff designated as focal persons for each PHU service area.
Staff provided with relevant capacity building and training.

7.3.4 Physical Space and Logistics

Dedicated PHU office space available.
Soundproof call room or designated area for patient navigation.
Conference/meeting room available for planning, training, and stakeholder meetings.
Secure storage area for confidential records, IEC materials, and equipment.
Workstations provided for staff (desks, chairs, computers, and other supplies).

7.3.5 Systems and Procedures

The PHU Manual of Operations is available and utilized.
Standard forms and tools used for navigation, surveillance, and health promotion.
Referral directory updated and accessible.
Data privacy and confidentiality procedures are observed.

7.3.6 Continuous Quality Improvement (CQI)

CQI focal persons designated for Navigation, Surveillance, and Health Promotion.
Performance indicators are defined and monitored.
Quarterly CQI review meetings conducted.
Corrective actions are implemented based on CQI findings.
The annual CQI summary is presented to hospital management.

7.3.7 Linkages and Engagement

PHU collaborates with other hospital units (e.g., HEDMU, laboratories, and clinical departments).
PHU provides technical support to LGU health promotion activities upon request.
Stakeholder engagement records are maintained.

7.4 Functionality Scoring

The assessment tool uses a checklist format. Each indicator is rated as:

Yes Indicator met
No Indicator not met

The overall functionality rating is based on the percentage of indicators achieved:

Functional PHU ≥ 80% of indicators met
Partially Functional PHU 50–79% of indicators met
Non-Functional PHU < 50% of indicators met

7.5 Assessment Process

1. Self-Assessment Conducted internally by the PHU team to monitor functionality.
1. Hospital Management Review Results presented during hospital management meetings for validation and corrective action planning.
1. Follow-up Monitoring Corrective measures tracked and documented during the next review cycle.

7.6 Use of Results

The results of the PHU functionality assessment shall be used to:

Identify strengths and areas for improvement in PHU performance.
Inform staff of training and development plans.
Guide resource allocation and infrastructure support.
Strengthen integration of PHU services within the hospital system.

APPENDIX A. PATIENT FLOW IN THE HEALTH CARE PROVIDER NETWORK

Reference: AO No. 2020-0019, Guidelines on the Service Delivery Design of Health Care Provider Networks

APPENDIX B: REFERRAL ALGORITHM

Reference: AO No. 2020-0019, Guidelines on the Service Delivery Design of Health Care Provider Networks

^*The steps inside the yellow box are to be completed by the receiving facility.

APPENDIX C. REFERRAL FORM TEMPLATE

NAME OF HEALTH CARE PROVIDER NETWORK REFERRAL FORM

Name of Referring Facility:		Contact Number:
Address
Date of Referral		Time Called (for emergency cases)
Name of Receiving Facility		Receiving Personnel
Address		Response
Referral Category Working Impression	Emergency	Outpatient
Reason for Referral	Consultation
	Diagnostics
	Treatment / Procedure
	Others
Name of Patient		Identity Number
Age		Sex	Male Female
Address
Chief Complaint
Clinical History
Findings
Vital Signs	BP:	HR:	RR:
	O2 sats:	Temp:	Weight:
(Attach laboratory results)
Treatment Given (Attach treatment cards)
	Signature over Printed Name of Health Professional
	Date and Time

Reference: AO No. 2020-0019, Guidelines on the Service Delivery Design of Health Care Provider Networks

APPENDIX D: STANDARD COMMUNICATION PROTOCOLS

	Chandard Communication Dust and
Standard Communication Protocols For Emergency and Non-Emergency Cases via Phone
Total Emergency and Herricagency dates via Findite
S	Situation I am (name), (position) of (initiating facility) I am calling about an emergency referral Who am I talking with? [Wait for response 1] Patient is a (age), (sex), with chief complaint/problem: (state chief complaint), present working impression is: (Working impression), Reason for referral is: (state reason), Current vital signs are: (BP, HR, RR, O2 Sats, Temp)
В	Background (Name of patient) has a (Clinical History) Findings are: (state findings) Treatment given: (state treatment)
A	Assessment I think the problem/concern is: (describe) (state issues for the referral)
R	Recommendation We would like to transfer the patient immediately. Are you okay with the plan? Is there anything I need to do in the meantime? [Wait for response 2]
	Response
1	Name of receiver and position
2	Yes, please transfer to our facility immediately. No, our facility's capacity is full. Please transfer to (specify another facility) Other instructions: (e.g. medicines on the way)

Reference: AO No. 2020-0019, Guidelines on the Service Delivery Design of Health Care Provider Networks

APPENDIX E: TRIAGE CLASSIFICATION

Triage Category	Primary Care / Level 1	Level 2 / Level 3	Response Time	Description
1	Emergent	Resuscitation	Immediate	Immediately life-threatening
2		Emergent	10 minutes	Immediately life-threatening
3	Urgent	Urgent	30 minutes	Potentially life-threatening
4		Semi-Urgent /Acute	60 minutes	Potentially serious
5	Non-Urgent	Non–Urgent	120 minutes	Less urgent

Reference: Manual of Standards and Guidelines on the Management of the Hospital Emergency Department, Second Edition, 2022

Category	Clinical Description
	OR
	Very Severe Pain
	Humane practice mandates the relief of
	very severe pain or distress within 10
3 (30 minutes)	minutes. Potentially Life-Threatening
A - patent B - mild respiratory distress C - mild hemodynamic compromise D - GCS >12	The patient's condition may progress to life or limb threatening, or may lead to significant morbidity, if assessment and treatment are not commenced within 30 minutes of arrival.
	OR Situational Urgency There is potential for adverse outcome if time-critical treatment is not commenced within 30 minutes
	OR Severe Pain Humane practice mandates the relief of severe discomfort or distress within 30 minutes
4 (60 minutes) A - patent B - no respiratory distress C - no hemodynamic compromise D - normal GCS	Potentially Serious The patient's condition may deteriorate, or adverse outcomes may result, if assessment and treatment is not commenced within one hour of arrival in ED. Symptoms are moderate or prolonged.
	OR Situational Urgency There is potential for adverse outcomes if time-critical treatment is not commenced within 60 minutes
	OR Significant Complexity or Severity Likely to require complex work-up and consultation and/or inpatient management OR Humane practice mandates the relief of discomfort or distress within 60 minutes.

Category	Clinical Description
5 (120 minutes)	Less Urgent
A - patent	The patient's condition is chronic or
B - no respiratory distress	minor enough that symptoms or clinical
C - no hemodynamic compromise	outcome will not be significantly affected
D - normal GCS	if assessment and treatment are delayed up to 120 minutes from arrival.

	OR
	Clinico-Administrative Problems
	Results review, medical certificates,
	prescriptions only.

PHU Manual of Operations, 2025

Document Info

Public Health Unit

PUBLIC HEALTH UNIT MANUAL OF OPERATIONS

Department of Health

PRODUCTION CREDITS

MESSAGE OF THE ASSISTANT SECRETARY OF HEALTH

FOREWORD

PREFACE

ACKNOWLEDGEMENT

The TWG includes representatives from:

LIST OF ABBREVIATIONS AND ACRONYMS

Laws, Executive Orders, and Other Issuances

Department of Health Issuances

Others

DEFINITION OF TERMS

TABLE OF CONTENTS

CHAPTER 1. INTRODUCTION

The Public Health Unit within the Context of Universal Health Care

Legal Mandate and General Functions of the Public Health Unit

CHAPTER 2. PUBLIC HEALTH UNIT SERVICES

1. Patient Navigation and Referral

2. Epidemiology, Surveillance, and Health Statistics

a. Surveillance of Notifiable Diseases and Health Events of Public Health Concern

b. Surveillance of Non-communicable Diseases (NCDs) and Injuries

c. Health Statistics

3. Health Promotion

CHAPTER 3. GOVERNANCE: LEADERSHIP AND MANAGEMENT

General Overview

Organizational Structure and Staffing Pattern

3. Proposed Organizational Structure for Level 1 Hospitals

4. Proposed Organizational Structure for Level 2 Hospitals

5. Proposed Organizational Structure for Level 3 Hospitals

Roles, Responsibilities, and Qualifications of the Public Health Unit Staff

1. PHU Head

1.1. Roles and Responsibilities of the PHU Head

A. Overall Operations

B. Patient Navigation and Referral

C. Epidemiology, Surveillance, and Health Statistics

D. Health Promotion

1.2. Qualifications of the PHU Head

2. Assistant PHU Head

2.1. Roles and Responsibilities of the Assistant PHU Head

A. Overall Operations

B. Patient Navigation and Referral

C. Epidemiology, Surveillance, and Health Statistics

D. Health Promotion

2.2. Qualifications of the Assistant PHU Head

3. Patient Navigator

3.1. Roles and Responsibilities of the Patient Navigator

3.2. Qualifications of the Patient Navigator

4. Disease Surveillance Coordinator (DSC)

4.1. Roles and Responsibilities of the DSC

4.2. Qualifications of the DSC

5. Disease Surveillance Officer (DSO)

5.1. Roles and Responsibilities of the DSO

5.2. Qualifications of the DSO

6. HSS Data Encoder

6.1. Roles and Responsibilities of the HSS Data Encoder

6.2. Qualifications of the HSS Data Encoder

7. Senior Health Education and Promotion Officer (HEPO)

7.1. Roles and Responsibilities of the Senior HEPO

7.2. Qualifications of the Senior HEPO

8. Junior Health Education and Promotion Officer (HEPO)

8.1. Roles and Responsibilities of the Junior HEPO

8.2. Qualifications of the Junior HEPO

9. Administrative Staff

9.1. Roles and Responsibilities of the Administrative Staff

9.2. Qualifications of the Administrative Staff

Other Considerations

CHAPTER 4. OFFICE SPACE AND EQUIPMENT NEEDS

Physical Space

Workstations and IT Equipment

Software and Subscriptions

CHAPTER 5: SYSTEMS AND PROCEDURES

Operating Hours of the Public Health Unit

5.1 Patient Navigation and Referral

Activity 1: Patient Navigation and Referral

A. Initial Patient Assessment and Triage

B. Evaluation for Admission or Higher-Level Referral