CHN - White Book

-
FOREWORD
The Philippine health system is now at the throes of major reforms as it tries to
confront old and emerging health challenges. While the health of all Filipinos and
communities is still threatened by our lingering problems like major infectious killers
and the wide dispari~es that exist between the rich and the poor in terms of access to
health care, we as public health workers are compelled to face the more daunting
challenges on the field: double burden of disease, rising costs of health care, a
fragmented health system, increasing demands for quality but affordable services
and the impact of increasing globalization on health.
Amid the changing landscape of public health in our country, we must absolutely
rise to the challenge as the primary drivers in the" health sector in pushing for better
health care delivery and in bringing good health outcomes for all.
The Department of Health today remains steadfast in its mandate to provide the
leadership in reducing health disparities and empowering the Filipino people
through better targeting of services, better health education and promotion and
more equitable distribution of health benefits particularly for our poorest people.
With this vision in mind, we have thus launched the FOURmula One for Health as
the vehicle that will bring about our primary goals of better health outcomes, a more
responsive health system and equitable health care financing. These end goals,
however, cannot be achieved without the commitment and dedication of our most
precious resource ---- our public health workers who have a direct hand in caring for
our communities and families in diverse and difficult settings.
Hence, it is in the spirit of collaboration in the health sector that we welcome the
publication of this book, Public Health Nursing in the Philippines, and extol the
valuable role of our public health nurses as innovators, leaders, health providers
, and members of the health care team. Today, amid the unprecedented wave of
health worker migration to other countries, they choose to stay and serve and nurse
the health of the people's health needs. With their complex and ever expanding
roles in the Philippine health care setting, public health nurses provide evidence
that service truly has no limits. ·
We are optimistic that public health nurses shall continue to improve the well being
of all Filipinos in the next years to come as we transform the
health system into an engine for real social development. With
our joint efforts in the field of public health, there is indeed
great promise that we can fulfill our quest for better Health for
All.
QUE Ill, MD, MSc.

Se
PREFACE
The public health system in the Philippines has undergone several transformations
since established by the Americans more than a century ago. The concepts and
principles may still be the same, but the face and the structure have to change in
order to address the changing needs of the society.
And so must the face and the structure of this book have to change. For this book
essays the workings of the public health system in the Philippines. This book has
stood the test of time. It was first published in 1961 in response to the clamor of
government nurses for a community and family care nursing manual that could
guide their practice in the field of public health. The book, Community Health
Nursing Services in the Philippines, was initiated by Miss Annie Sand, then Nursing
Consultant of the Department of Health. She was also the founder and first
President of the National League of Philippine Government Nurses, Inc.
Today, it is not only the public health nurse who uses this. This has become a
textbook from which nursing students and other paramedical courses students draw
their first impression of the public health system in the country.
Periodic revisions were done in order to keep the book current and relevant.
However, this 10th edition marks a major change in the way the book is presented.
It is no longer just a collection of the Department of Health's public health programs'
operational manuals, but it revolves around a central focus: the Public Health
Nurse. It also brings realism to the work the Public Health Nurse does in the public
health setting as defined by the newly developed Standards of Public Health
Nursing (NLPGN, 2006). Thus the change in its title: PUBLIC HEALTH NURSING
IN THE PHILIPPINES.
The objective of the book is to inform the reader on the following:
1. What is public health nursing in the context of the Philippine setting? 2. Who is
the public health nurse? What are her functions, qualifications, competencies?
3. What kind of a health system is the public health nurse working in? 4. What are
the public health problems facing the country today and the public health
interventions needed to address them?
5. What is the role of the Public Health Nurse in implementing these public
health interventions?
With this objective in mind, the book is developed as follows:
Unit I Public Health Nursing in the Philippine Context
Chapter 1 Overview of Public Health Nursing in the Philippines Discusses the

global and health imperatives which influences the work of the PHN, general
concepts of health, public health, and the evolution of public health nursing in the
Philippines.
Chapter 2 The Philippine Health Care Delivery System

Discusses the public health system in the Philippines. It essays the organizational
development of the Department of Health and the present agency that it has
become now in the midst of devolution and health sector reform. It also discusses· the
mechanisms of local health systems and its influences.
Chapter 3 The Public Health Nurse

Discusses who the Public Health Nurse is in the context of the Standards of Public Health
Nursing in the Philippines and the public health system of the country. It discusses the
qualifications, settings of work, functions and competencies of the Public Health Nurse.
Chapter 4 Public Health Nursing in School and Work Settings Discusses other settings where
Public Health Nurses are at work: the school and work settings.
Unit II Public Health Programs
This Unit included the various programs developed and promoted by the Department of Health as
intervention packages for major public health problem. It also emphasizes the responsibilities of
the Public Health Nurse in the implementation of these programs.
Chapter 5 discusses programs for Family Health.
Chapter 6 discusses programs for Non-Communicable Disease Prevention and Control.
Chapter 7 discusses programs for Communicable Disease Prevention and Control.

Chapter 8 discusses Environmental Health and Sanitation Program.
Chapter 9 discusses other nationally driven programs designed to assist local government units
to deliver public health services effectively and efficiently.
Chapter 1 0 provides a summary of various laws that affect public health in general and public
in particular.
health nursing '
It is our hope that the book will serve as a "one stop shop" tool for Public Health Nurses that will
remind them of who they are and what they are supposed to be doing, thus becoming more
efficient and effective.
We also hope that nursing schools will continue to utilize this book as reference material for
faculty and stlJdents alike.
Most of all, we hope that the public may know and appreciate the contributions being made by
our Public Health Nurses to the overall positive health outcomes of the country.
MS. FR CES PRESCILLA L. CUEVAS, RN MAN

Editor i Chief
Prepared and Published by the Publications Committee,
National League of Philippine Government Nurses, Incorporated
EDITORIAL BOARD
FRANCES PRESCILLA L. CUEVAS, RN, MAN

Editor in Chief
Members
JEAN P. REYALA, RN, RM, MPH, MGM
ROSALINDA CRUZ-EARNSHAW, RN, MPH, MPA
SHIELA BONITO, RN,/MAN
JEAN M. SITIOCO, RN, MAN
LORENZA C. SERAFICA, RN, MAN
1Oth Edition
Copyright 2007
Printed 2007
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by means, electronic, mechanical, photocopying,
recording or otherwise, without prior permission from the publishers.
. 65241 Senal No.: .............................. .

ISBN No.: 978-971-91593-2-2
LIST OF CONTRIBUTORS
FRANCES PRESCILLA L. CUEVAS, RN, MAN
Chief Health Program Officer, Degenerative Disease Office National Center for Disease Prevention and
Control, Department of Health
JEAN P. REYALA, RN, MPH
Executive Director
National League of Philippine Government Nurses, Inc.
VICENTA E. BORJA, RN, MPH
Supervising Health Program Officer
National Center for Disease Prevention and Control
Department of Health
LORENZA C. SERAFICA, RN, MAN
Nurse V
Center for Health Development No. IV
Project 4, Quezon City
JEAN M. SITIOCO, RN, MAN
Nurse VI
Manila Health Department
CRESENCIA B. MANLANGIT, RN, MPH, Ed. D.
Chief Nurse
Quezon City Health Department
MA. TERESA B- MENDOZA. RN, MAN, COHN, Frinsg National Center for Health Facility Development
LOIDA B. RAMOS, RN, MPH
Senior Health Program Officer
Head, Nursing Service, Health and Nutrition Center
Department ol Education
CAROLINA A. RUZOL, RN, MPH
Nurse VI
National Center for Health Facility Development Department of Health
REBECCA T. SOLIMAN, RN, DTN
Nurse Ill
Jose R. Reyes Memorial Medical Center
JOSEPH ARICHETA, MD, MPH, 'RN
Medical Specialist IV
ANNA MARIE CELINA G. GARFIN, MD, MM
Medical Specialist IV
REMEDIOS NIOLA, BSN, RN
Nurse VI
National Center for Disease Prevention and Control
MELINDA B. BOCOBO, RN, MPH, MAN
Chief Nurse
Pasay City Health Office
HILDEGARDA C. HIPOLITO, RN, MPH
Clinical Coordinator, Cagayan Colleges
Tuguegarao
ACKNOWLEDGEMENT
The Committee on Book Revision acknowledges the following without whose support this book
would not have happened:
Dr. Francisco T. Duque, Secretary of Health, for believing in us, nurses.
The Department of Health's different Offices and Program Managers who generously provided
documents, handouts and monographs which we liberally and freely used for this book;
The former contributors of the Community Health Nursing Services in the Philippines whose work
inspired the contributors of this 1Oth Edition, now entitled PUBLIC HEALTH NURSING IN THE
PHILIPPINES. We give respect to the following personages; Mrs. Lydia M. Venzon, Mrs. Zenaida
P. Nisce, Mrs. Florida R. Martinez, Mrs. Nelia F. Hizon, Mrs. Remy B. Dequina, Mrs. Azucena P.
Alcantara, Mrs. Thelma B. de Leon and Ms. Gilda R. Estipona;
Our consultant, Mrs Rosalinda Cruz-Earnshaw who gave direction to the contributors in the
writing ofthis book;
Ms. Shi.ela Bonito for guidance in styling, fine tuning and "flow" of this book.
Dean Carlita Balita for the beautiful design and concept, and Mr. Jay G. Olle for the artwork of
this book cover;
To the staff of the National League of Philippine Government Nurses Office, Mrs. Analyn
Medrano-Rigero, Ms. Araceli S. Montales for their tireless effort's in typing the manuscripts, and
Nadine Guillermo for the nourishing food prepared f.or the committee;
To all the contributors and editorial board who spent sleepless nights during the fine-tuning of
their pieces;
To our families for their kind understanding when we were away from our homes while writing the
book;
To all our "bosses" who allowed us to soar to greater heights;
To many unnamed friends, they know who they are for their support and inspiration;
And above all, to our Almighty God whose infinite wisdom gave us the capability to come up with
a book that our nursing colleagues could use.
To all of you our deepest appreciation and gratefulness.
__________________ __j#
TABLE OF CONTENTS
Page
Unit I
Public Health Nursing .in the Philippine Context 1
2
Chapter I
Overview
of Public
Health
Nursing in
the
Philippines
19
The Philippine Health Care Delivery System
II
37
Ill
The Public Health Nurse
89
Public Health Nursing in the Schools and Work Settings IV
Unit II
Public Health Programs 117
V Family Health 118 VI Non-Communicable Disease Prevention and Control 177 VII
Communicable Disease Prevention and Control 239 VIII Environmental Health and
Sanitation 309 IX Other Priority Health Programs 321 X Laws Affecting Practice of Public
Health Nursing 341
'
361
Annex A Standards of Public Health Nursing in the Philippines
373
Magna Carta of Public Health workers
B
c
Blood Pressure Measurement Checklist
D
Community Diagnosis
/
383 385
UNIT I
PUBLIC HEALTH NURSING

IN THE PHILIPPINE CONTEXT
INTRODUCTION:
P ublic Health Nurses in the (PHNs) Philippines have made great
contributions to the improvement of the health of the people for more than a century now. They
have been leaders in providing qui:llity health services to communities. They are among the first
level of health workers to be knowledgeable about new public health technologies and
methodologies. They are usually the first ones to be trained to implement new programs and
apply new technologies.
PHNs have a good understanding of the workings of the current health system and its political
infrastructure and are sensitive to the political and·social implications of the dynamics involved.
They are adept in public relations and can relate with anybody across the social, political,
religious and economic spectrum. They also have a comprehensive grasp of current situations
that impact on the health of the people.
In order for new PHNs and soon-to-be public health nurses to continue the legacy of their
pioneers, it is important for them to appreciate how public health nursing in the Philippines came
about; understand the current global and country health imperatives that dictate public health
priorities and actions; and have a clear picture of the nature of public health nursing in the context
of the ·Philippine health care delivery system.
''i'J/'C?JI\~;o,/..., i/W¥?1 '€'J/WlY>i'tiiV,'i1 \f;'!i'f!l \;'1/'1;~ 'o:t~l\ ;rl 'd'i!f'<Ji \-:;.l\;f!ly!{y;t\:;f'r;l'fitl'A'!/Wiil"iiriV!JJI \"l! \?!i.'R<i 'vr/!1 V;{V;il Public Health Nursing 1
CI Ir\PTER I
OVERVIEW OF PUBLIC HEALTH NURSING IN THE
PHILIPPINES
INTRODUCTION:
In the same manner that the Department of Health and the public health system have evolved
into what it is now in response to the challenges of the times, so has Public Health Nursing
practice been influenced by the changing global and local health trends. These global and
country health imperatives brought public health nursing into new frontiers and have positioned
n~~ ~r.gfUi.§J~a<;i
~~~l!h_pmmotion and ad'lOCacy.
This perception has been validated by a WHO report acknowledging the significant contribution
of the nursing workforce to the achievement of health outcomes, particularly that of the Millenium
Development Goals.
Public Health Nursing in the Philippines evolved alongside the institutional development of the
Department of Health, the government agency mandated to protect and promote people's health
and the biggest employer of health workers including public health nurses. Historical accounts
show that as far back as the
· 1900s, nurses working in the communities were already given the title Public Health Nurses.
In the light of the changing national and global health situation and the acknowledgment that
nursing is a significant contributor to health, the Public Health Nurse is strategically positioned to
make a difference in the health outcomes of individuals, families and communities cared for.
GLOBAL AND COUNTRY HEALTH IMPERATIVES

Public health systems are operating within a context of ongoing changes, which exert a number
of pressures on the public health system.
These changes include:
1 . Shifts in demographic and epidemiological trends in diseases, including the emergence and
re-emergence of new diseases and in the prevalence of risk and protective factors;
2. New technologies for health care, communication and information; 3. Existing and emerging
environmental hazards some associated with globa lization;
4. Health reforms.
In response to above trends, the global community, represented by the~ Nations Gen~~~ ~~§~rnbJy,
decided to adopt a common vision of poverty reduction and sustainable development in
September 2000. This vision is exemplified by
\rfl \r)/ "(:::,1 V7!lV
~~~ \;:! \r,rl\? :1 \ "1!'11 \t: il \('!t/V:,:il ¥!':! \ til V;,)i\f?[ V.?:'i \r;zl\ ?1 \7:"':,(\:;7!1 \tr'ffl t\;~ttl
J~. f- :-7 /\ii\:;:r;¢
l\ .. 7!,'fi !l\";,:i'"'ii l\~il ~)/V(~;f \;(p
·· ;!. 2 Public Health Nursing
OVERVIEW OF PUBLIC HEALTH NURSING IN THE PHILIPPINES
the Millenium Development Goals (MDGs) which are based on the fundamental values of
freedom, equality, solidarity, tolerance, health, respect for nature, and shared responsibility. The
ejg!lt Millenium Development Goals are as follows: 1. Eradicate extreme poverty and hunger
2. Achieve universal primary education 1 rton -i~\l't 3. Promote gender equality and
empowerwomenY
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
~Except for
goals 2 and 3, all the MDGs are health or health-related. Health is essential to the
achievement of these goals and is a major contributor to the overarching goal of poverty
reduction.
In order to achieve these goals, the participation of all members of the society from both
developing and developed countries is required. Achievement of these goals by 2015 is now a
priority of the global community and dictates the priority public health programs that should be
implemented.
At the country level, the Philippines has experienced considerable improvements in its health
status for the past 50 years, yet it has also in recent years experienced decline as shown in its
poor performance in reducing infant and maternal mortality rates. The Philippines is also
experiencing an epidemiologic shift, which means that while it is still contending with the burden
of communicable diseases, it is also at same time contending with the devastation brought about
by non
communicable, chronic lifestyle-related diseases. Currently, the country is being threatened with
the devastating effect of a "triple whammy" which will be brought about not only by this
epidemiologic shift but also by the emergence of plague like infectious diseases such as Severe
Acure Respiratory Syndrome(SARS) and Avian Flu. With this scenario, the need to strengthen
the capability of the public health infrastructure including the public helath nurse to adequately
respond is imperative.
Currently there are various country initiatives to implement a more cost-effective health care
services. The Health Sector Reform Agenda (l:l~) implemented through FOURmula ONE and
operationalized in the National Objectives for Health 2005 to 2010 spells out the program
imperatives of the health sector. All these are in line with the Millenium Development Goals and
the Medium-Term Development Plan of the country.
EVOLUTION OF PUBLIC HEALTH NURSING IN THE PHILIPPINES
For the public health nurse to have a better understanding of how public health nursing came
about in the Philippines, there are certain concepts that must be understood and should serve as
a point of reference in the foregoing discussions.
v. .. ·ti Y)/ \ ;5/''f):J ·"":;,-i\ri V~if \:o~ \;tJi \NI \7?1 \rpf.<o,;-r;i V:i ;)l\(•i t?l\-~pl\~ ;~ \?i\R.:~i "rv \:~1 \ti 'f:;J\:r'i
>,;i:!{"':JI-"c:::/\:~Y ,;: ~;;/ '-:ri ~rrl \:?if \ ".ii v-4 Public Health Nursing 3
vflealth
The World Health Organization defines health as a "~~ate of complete physical, IT!ental, and social
well being, not merelytb~ bs~m~e p(dlseas ·: Qr]nfirmity." . -.•. ~- .
.
./ Determinants of health
The health of individuals and communities are, to a large extent, affected by a combination of
many factors. A person's health is determined by his circumstances and environment. It is
inappropriate therefore to blame or credit the person's state of health to himself alone because he
is unlikely able to directly control many of these factors however, knowledge of these factors is
important in order to effectively promote health and prevent illnesses. It is also important to note
that in understanding the multidimensional nature of health, the public health nurse will now be in
better position to plan1 and implement health promoting interventions for individuals and
communities.'
These factors or things that make people healthy or not, known as determinants of health are
listed by the World Health Organization to include: 1. lncom_JL3nd social st§llis. Higher income
and social status are linked to better health.
2. Edup)ltiQn. Low education levels are linked with poor health, more stress and rower
selfeonfidence. .
3. Physical environment. Safe water and clean air, healthy workplaces, safe hoiJSes,
communitieS and roads all contribute to good health. . 4. ,Fm~!.QY.me~~· People in employment
a~e healthier, particularly those who have more control over their working conditions. 5. .§.Qcial
support networks. Greater support from families, friends and communities is linked to better
health.
6. 9Jltl!re. Customs and traditions, and the beliefs of the family and community all affect health.
7. Genetics. Inheritance plays a part in determining lifespan, healthiness and the lrkelihood of
developing certain illnesses.
8. P_ersanal behavior and co in skills. Balanced eating, keeping active, smok ing, drinking, and
how we deal with life's stresses and challenges all affect health
9. He~s. Access and use of services that prevent and treat disease ihtluence health.
10. Gender. Men and women suffer from different types of diseases at different
..._ ages.
The determinants of health as a concept can be further explained in Figure I. ../ This framework
refers to an Optimum Level of Functioning (OLOF) of individuals, families and communities being
influenced by several factors in the eco-system.
Public Health
The classic definition of public health comes from Dr. C.E. Winslow. He defines public health as
the "science and art of preventing disease, prolonging life, promoting health and efficiency
through organized community effort for the
4 Public Health
Nursing
sanitation of the environment, control of communicable diseases, the education of individuals in

personal hygiene, the organization of medical and nursing services for the early diagnosis and
preventive treatment of disease, and the development of the socigl machinery to ensure
everyone a standard of living adequate for the maintenance of health, so organizing these
benefits as to enable every citizen to realize his birthright of health and longevity."
POLITICAL
Safety
··
Oppression
People Empowerment
Employment
Education
Housing
'
Culture Habits
Mores
Ethnic Customs
HEALTH CARE
DELIVERY SYS
TEM
Promotive
Preventive
Figure 1
ECO-SYSTEM INFLUENCES ON OPTIMUM
LEVEL OF FUNCTIONING (OLOF)
Modified from (Blum 1974:3) Further modified by the Community Health Nursing Committee,
NLPGN, 2000
Half a century later, the essence of public health as defined by Winslow remains essentially the
same when applied in the context of the current events. In a recent three-country study on
essential public health functions in the Western Pacific Region, public health is defined by W~O as
the "art of applying science in the context of pOlitics so as to reduce inequalities in health while
ensuring the 2.,est hea~h for the greatest num~_r". It points to the fact that public health is a core
element of governments' attempts to improve and promote the health and welfare of their
citizens.
Public Health
Nursing 5
{
,/further presented the core business of public health as:
1 . Disease control
2. Injury prevention
3. Health protection
4. Healthy public policy including those in relation to environmental hazards such as in the
workplace, housing, food, water, etc.
5. Promotion of health and equitable health gain.
The core business of public health cannot be achieved without the proper delivery of essential
public health functions which Yach described as "a set of fundamental activities that address the
determinants of health, protect a population's health and treat disease. These public health
functions represent public goods, and in this respect governments would need to ensure the
provision of these
; essential functions, but would not necessarily have to implement and finance them. They
prevent and manage the major contributors to the burden of disease by using effective technical,
legislative, administrative, and behavior-modifying interventions or deterrents, and thereby
provide an approach for intersectoral action for health. This approach stresses the importance of
numerous different public health partners. Moreover, the need for flexible, competent state
institutions to oversee these cost-effective initiatives suggests that the institutional capacity of
states must be reinforced."
~e following are the essential public health functions:

1 . Health situation monitoring and analysis
2. Epidemiological surveillance/disease prevention and control 3. Development of policies and
planning in public health
4. Strategic management of health systems and services for population health gain
5. Regulation and enforcement to protect public health
6. Human resources development and planning in public health 7. H~alth promotion, social
participation and empowerment
8. Ensuring the quality of personal and population based health services 9. Research,
development and implementation of innovative public health so lutions
For these public health functions to be adequately delivered, a well defined, coordinated public
health system or infrastructure must be put in place. Governments need to ensure these
essential functions are provided, but do not necessarily have to implement or finance them
themselves. Implementation may be achieved through other governmental agencies, community
and non
governmental organizations, or the private sector, among others.
Public Health Nursing

The World Health Organization Expert Committee of Nursing defined public health nursing as a
"special field of nursing that combines the skills of nursing, public health and some phases of
social assistance and functions as part of the total public health programme for the promotion of
health, the improvement of
6 Public Health
Nursing
the conditions in the social and physical environment, rehabilitation of illness and
disability."
This definition is an apt description of the nature of Public Health Nursing in the
Philippines. The RUblic health nurses in this country are using their nursing skills in
the application of public health functions and social assistao_~_W._i!!lJn tl]e context of ~ublic
health programs designed to promote health and prevent
d~s. - -----
Public health nursing and community health nursing have often been
interchangeably used in the Philippines. This is not surprising though because
various authors, foreign and local, also used them interchangeably.
One of the more famous definitions of community health nursing comes from ~uth B.
F~. It refers to "a service rendered by a professional nurse with' communities,
groups, families, individuals at home, in health centers, in clinics, in schools, in
places of work for the promotion of health, prevention of illness, care of the sick at
home and rehabilitation." This definition is also true to public health nursing if one
goes back to the definition given by the WHO Expert Committee on Nursing.
''(P
1
• Other definition of community health nursing indicates the it is broader than public
health nursing because it encompasses "nursing practice in a wide variety of
community services and consumer advocate areas, and in a variety of roles, at times
including independent practice .... community nursing is certainly ~

not confined to public health nursing agencies." This was the definition given by
However, just to clarify the use of these titles a short historical accounting is in
A variety of titles has been used to describe the type of nursing provided
order. ' in the
community setting such as district nursing, health nurping, visiting nursing, public
health nursing and community health nursing. These titles were used to identify
nurses who work with populations as well as individuals and families. For example,
it is common for health departments or departments of health and human services
to use the term public health nursing to describe the population focused practice of
nurses employed by these agencies.
Public health nursing was coined byliJman w8Jj when she was director of the
Henry Street Settlement in New York City to denote a service that was available
tQ_all people. However, as federal, state and local governments increased their
involvement in the delivery of health services, the term public health nursing
became associated with "public" or government agencies and in turn with the care
of the poor people.
The phrase community health nursing emerged out of an interest in reaffirming the
original thrust of public health nursing: nursing for the health of the entire
public/community versus nursing only for the public who are poor.
Public Health Nursing 7

In a move to redefine the practice of public health nursing in the Philippines, the National League
of Philippine Government Nurses came up with the Standards of Public Health Nursing in the
Philippines 2005. The Standards differentiated public health nursing and community health
nursing only in one area: setting of work as dictated by funding. The government is the employer
of public health nurses both at the national and the local health agencies. Position title or de~ig_ll ~lQ!
l_given to these nurses by the Civil Service Commission working in these agencies is Public Health
Nurse.
Thus, in the standards of Public Health Nursing in the Philippines 2005, the following are defined:
Public Health Nurses (PHNs) refer to the nurses in the local/national health departments or public
schools whether their official position title is Public Health Nurse or Nurse or school nurse.
Public Health Nursing refers to the practice of nursing !n national and local government health
departments (which includes health centers and rural health units), and public schools. It is
community health nursing practiced in the public sector.
With the above definitions clearly stated, public health nursing and public health nurses will be
used all throughout the entire book, and clearly refers to the work these nurses are doing in the
public health arena.
Historical Background
The history of public health nursing in the Philippines is embedded in the history of the
Department of Health which was first established as the Department of Public Works, Education
and Hygiene in 1898. (In Chapter II of this book, a more detailed historical accounting of the
institutional development of the Department of Health is presented.)
Since then various laws were enacted to organize and establish the various structures and
activities of the health agency covering the entire country. The following milestones marked the
events when the nurses and nursing were particularly mentioned in historical accounts:
1912
The Fajardo Act (Act No. 2156) created Sanitary Divisions. The President of the Sanitary Division
(forerunners of the present Municipal Health Officers) took charge of two or three municipalities.
Where there were no physicians available, male nurses were assigned to perform the duties of
the President, Sanitary Divi
sion.
In the same year the Philippine General Hospital, then under the Bureau of Health sent four
nurses to Cebu to take care of mothers and their babies. The St. Paul's Hospital School of
Nursing in lntramuros, also assigned two nurses to do home
8 Public Health
Nursing
'----- --- - - - - - - - - - - --- --- - - -- OVERVIEW OF PUBLIC HEALTH NURSING IN THE PHILIPPINES
visiting in Manila and gave nursing care to mothers and newborn babies from the
outpatient obstetrical service of the Philippine General Hospital.
1914
School nursing was rendered by a nurse employed by the Bureau of Health in
Tacloban, Leyte. In the same year, Reorganization Act No. 2462 created the Office
of General Inspection. The Office of District Nursing was organized under this
Office. It was headed by a lady physician, Dr. Rosario Pastor who was also a nurse.
This Office was created due to increasing demands for nurses to work outside the
hospital, and the need for direction, supervision and guidance of public health
nurses.
· Two graduate Filipino nurses, Mrs. Casilang Eustaquio and Mrs. Matilde Azurin
were employed for Maternal and Child Health and Sanitation in Manila under an
American nurse, Mrs. G. D. Schudder.
1916-1918
Miss Perlita Clark took charge of the public health nursing work. Her staff was
composed of one American nurse supervisor, one American dietitian, 36 Filipino
nurses working in the provinces and one nurse and one dietitian assigned in two
Sanitary Divisions.
1917
Four graduate nurses paid by the City of Manila were employed to work in the City
Schools. Provinces that could afford to carry out school health services were
encouraged to employ a district nurse.
1918
The office of Miss Clark was abolished due to lack of funds.
'1919
The first Filipino nurse supervisor under the Bureau of Health, Miss Carmen del
Rosario was appointed. She succeeded Miss Mabel Dabbs.
She had a staff of 84 public health nurses assigned in five health stations. There
was a gradual increase of public health nurses and expansion of services.
1923
Two government Schools of Nursing were established: Zamboanga General
Hospital School of Nursing in Mindanao and Baguio General Hospital in Northern
Luzon. These schools were primarily intended to train non-Christian women and
prepare them to render service among their people. In later years, four more
government Schools of Nursing were established: one in southern Luzon (Quezon
Province} and three in the Visayan Islands of Cebu, Bohol and Leyte.
July 1, 1926
Miss Carmen Leogardo resigned and Miss Genara S. Manongdo, a ranking

OVERVIEW Of PUBLIC HEALTH NURSING IN THE PHILIPPINES
supervisor of the American Red Cross, Philippine Chapter was appointed in her place.
1927
The Office of District Nursing under the Office of General Inspection, Philippine Health Service
was abolished and supplanted by the Section of Public Health Nursing. Mrs. Genara de Guzman
acted as consultant to the Director of Health on nursing matters.
1928
The first convention of nurses was held followed by yearly conventions until the advent of World
War II. Pre-service training was initiated as a pre-requisite for appointment.
1930
The Section of Public Health Nursing was converted into Section of Nursing due to pressing need
for guidance not only in public nursing services but also in hospital nursing and nursing
education. The Section of Nursing was transferred from the Office of General Services to the
Division of Administration. This Office covered the supervision and guidance of nurses in the
provincial hospitals and the two government schools of nursing.
1933
Reorganization Act No. 4007 transferred the Division of Maternal and Child Health of the Office of
Public Welfare Commission to the Bureau of Health. Mrs. Soledad A. Buenafe, former Assistant
Superintendent of Nurses of the Public Welfare Commission was appointed as Assistant Chief
Nurse of the Section of Nursing, Bureau of Health.
1941
Activiti&s and personnel including six public health members of the Metropolitan Division, Bureau
of Health were transferred to the new department. Dr. Mariano lcasiano became the first City
Health Officer of Manila. An Office of Nursing was organized with Mrs. Vicenta C. Ponce as Chief
Nurse and Mrs. Rosario A. Ordiz as Assistant Chief Nurse. They occupied these positions until
their retirement.
Dec. 8, 1941
When World War II broke out, public health nurses in Manila were assigned to devastated areas
to attend to the sick and the wounded.
1942
A group of public health nurses, physicians and administrators from the Manila Health
Department went to the internment camp in Capas, Tarlac to receive sick prisoners of war
released by the Japanese army. They were confined at San Lazaro Hospital and sixty-eight
National Public Health Nurses were assigned to help the hospital staff take care of them.
10 Public
Health Nursing
July 1942
Thirty-one nurses who were taken prisoners of war by the Japanese army and
confined at the Bilibid Prison in Manila were released to the then Director of the
Bureau of Health, Dr. Eusebio Aguilar who acted as their guarantor.
Many public health nurses joined the guerillas or went to hide in the mountains
during World War II.
February 1946
Post war records of the Bureau of Health showed that there were 308 public health
nurses and 38 supervisors compared to pre-war when there were 556 public health
nurses and 38 supervisors. In the same year Mrs. Genera M. de Guzman,
Technical Assistant in Nursing of the Department of Health and concurrent
President of the Filipino Nurses Association recommended the creation of a Nursing
Office in the Department of Health.
Oct. 7, 1947
Executive Order No. 94 reorganized government offices and created the Division of
Nursing under the Office of the Secretary of Health. This was implemented on
December 16, 1947. Mrs. Genara de Guzman was appointed as Chief of the
Division, with three Assistants: Miss Annie Sand for Nursing Education; Mrs.
Magdalena C. Valenzuela for Public Health Nursing and Mrs. Patrocinio J.
Montellano for Staff Education.
The Nursing Division was placed directly under the Secretary of Health so that
nursing services can be availed of by the different bureaus and units to help carry
out their health programs.
At the Bureau of Health, the Section of Nursing Supervision took over the func tions
of the former Section of Nursing. Mrs. Soledad Buenafe was appointed Chief and
Miss Marcela Gabatin, Assistant Chief.
The newly created Section of Puericulture Center of the Bureau of Hospitals had
Mrs. Teresa Malgapo as Chief.
1948
The first training Center of the Bureau of Health was organized in cooperation with
the Pasay City Health Department. This was housed at the Tabon Health Center
located in a marginalized part of the city. It was later renamed as Dona Marta
Health Center. The original training staff of the Center had Dr. Trinidad A. Gomez
as Center Physician; Miss Marcela Gabatin as Nurse Supervisor; Miss Constancia
Tuazon, Mrs. Bugarin and Miss Ramos as Nurse Instructors. Miss Zenaida Y.
Panlilio, National Public Health Nurse, Bureau of Health, later joined the staff.
Physicians and nurses undergoing pre-service and in - service training in public

health/public health nursing as well as nursing students on affiliation were assigned
to the above training center.

1950
The Rural Health Demonstration and Training Center (RHDTC) was established by tpe
Department of Health through the initiative of Dr. Hilario Lara, Dean, Institute of Hygiene, now
College of Public Health, University of the Philippines. The WHO/UNICEF assisted project used
health centers of the Quezon City Health Department, which were located in the rural areas of
the city. The RHDTC was used as a laboratory for the field experiences of graduate and basic
students in medicine, nursing, health education, nutrition and social work.
Health workers from other countries also came to observe in the training center. Dr. Amansia S.
Mangay (Mrs. Andres Angara), a Doctor of Public Health graduate from Harvard was chosen to
be the Chief of the RHDTC. Dr Antonio N. Acosta, former Physician of the Manila Health
Department was Medical Training Officer.
The training staff of RHDTC were nurses and had a major role in the organization and
implementation of training activities. The first Supervising Training Nurse was Miss Marta Obana,
with Miss Jean Bactat, Mrs Mary Velono, and Mrs. Natividad B. Asuque as Nurse Instructors.
1953
The Office of Health Education and Personnel Training (forerunner of Health Manpower
Development and Training Service) was established with Dr. Trinidad Gomez as Chief. Four
nurse instructors were recruited, two from the Manila Health Department, Mrs. Venancia
Cabanos and Mrs. Damasa Torrejon and two from the Bureau of Health, Miss Zenaida Y. Panlilio
and Miss Leonora M. Liwanag, (the first graduates of the Bachelor of Science in Nursing degree
from the University of the Philippines, College of Nursing, to join the Bureau of Health).
Philippine Congress approved Republic Act No. 1082 or the Rural Health Law. It created the first
81 Rural Health Units. Each unit had a physician, a public health nurse, a midwife, a sanitary
inspector and a clerk driver. They were provided with transrfortation Ueep) by the UNICEF.
Among the first public health nurses to undergo pre-service training prior to assignment in the
Rural Health Units were. two graduates of Class 1952 of the Philippine General Hospital School
of Nursing, Miss Florida B. Ramos (Mrs. Martinez) and Miss Lydia Amurao (Mrs. Cabigao).
1957
Republic Act 1891 was approved amending Sections Two, Three, Four, Seven and Eight of A.A.
1082 "Strengthening Health and Dental Services in the Rural Areas and Providing Funds
thereto." This second Rural Health Act created 8 categories of rural health units based on
population. This resulted in additional number of positions for health workers including public
health nurses and midwives.
1958-1965
Republic Act 977 passed by Congress in 1954 was implemented. This abolished
12 Public
Health Nursing
the Division of Nursing. However, it created nursing positions at different levels in

the health organization. Miss Annie Sand was appointed Nursing Consultant under
the Office of the Secretary of Health.
Two nurses in the former Bureau of Hospitals worked closely with the Nursing
Consultant. They were Miss Rosita Furia for Hospital Nursing Service, and Miss
Eva Obsequio for Nursing Education. Mrs. Rosita Villanueva and Mrs. Juanita P.
Hernando were appointed Nursing Program Supervisors of the Bureau of Hospitals
vice Miss Furia and Miss Obsequio when they retired.
The Department of Health National League of Nurses, Inc. was founded by Miss
Annie Sand in 1961. She became its first President and Adviser.
The Reorganization Act with implementing details embodied in Executive Order
288, series of 1959 de-centralized and integrated health services. It created 8
Regional Health Offices in the country, which were later increased to eleven and
eventually seventeen.
At the Regional level two supervising positions for nurses were created: Regional
Nurse Supervisor and Regional Public Health Nurse. These Nurses had the same
salary grades and performed the same functions and responsibilities. In every
region, there were 3 to 4 Regional Nurse Supervisors and 1 or 2 Regional Public
Health Nurses. They were assigned to specific provinces and cities and supervised
both hospital and public health nurses. One of them w~s designated as Coordinator.
Simultaneously, each Regional Health Office had a Regional Training Center,
creating positions for Regional Training Nurses and Nurse Instructors who took
charge of training activities.
The Supervising Public Health Nurses (SPHN) at the Provincial Health once
supervised the Public Health Nurses assigned at the Rural Health Units as well as
the Chief Nurses of the District hospitals. A small province had one SPHN and 'big
provinces had two SPHNs.
The reorganization of 1959 also merged two Bureaus in the Department of Health.
The Bureau of Health (in charge of preventive programs- Maternal and Child
Health, Dental Health, Industrial or Occupational Health) was merged with the
Bureau of Hospitals (curative programs and regulatory/licensing functions) to form
the Bureau of Health and Medical Services.
In the merged Bureau of Health and Medical Services, Nursing Program

Supervisors were appointed for the different programs. In the Maternal and Child
Health Division, the nurses were Miss Saturnina Latorre, Mrs. Fe Bacalso and later
Mrs. Rosario Zaraspe, Mrs. Isabel Pascua and Mrs. Emilia Briones. They
monitored, MCH programs and activites in the regions. They also conducted
training activities for the Maternal and Child Health Service. In the Occupational
Health Division, Mrs. Felisa V. Chanco was the nurse in charge of Occupational
Health Nursing.
__________________________________________________
_____ /
1967
In the Bureau of Disease Control, Mrs. Zenaida Panlilio-Nisce was appointed as Nursing
Program Supervisor and served as consultant on the nursing aspects of the 5 special diseases:
TB, Leprosy, Venereal Disease, Cancer, Filariasis; and, Mental Health. She was involved in
program planning, monitoring, evaluation and research.
At the Office of Health Education and Personnel Training, the nurses were Mrs. Josefina A.
Mendoza, Supervising Nurse Instructor, Miss Carmen Panganiban, Miss Virginia Orais and later,
Mrs. Constancia Asinas. Nurse Instructors were involved in staff development and training of
foreign and local health workers. Their positions were later reclassified as Department Training
Nurses.
Nov. 1971
Mrs. Josefina A Mendoza, Supervising Nurse Instructor, Office of Health Educa tion and
Personnel Training, succeeded Miss Annie Sand as Nursing Consultant. A few years later, Mrs.
Nelida K. Castillo, former Nurse Instructor at San Lazaro Hospital and counterpart to Miss Helen
Fillmore, WHO Consultant on Pediatric Nursing was appointed Nursing Program Supervisor,
Office of the Secretary of Health.
1974
The Project Management Staff was organized as part of Population Loan II of the Philippine
Government with Dr. Francisco Aguilar as Project Manager. Experts on different fields of public
health were recruited and Mrs. Nelida Castilio joined the PMS staff. Her position as Nursing
Program Supervi~or, Office of the Secre
tary of Health was taken over by Mrs. Zenaida Nisce, Nursing Program Supervi sor, Bureau of
Disease Control. Miss Julita Yabes, faculty member of the then Institute of Hygiene (now College
of Public Health} University of the Philippines served as consultant on nursing matters in the
Project Management Staff.
1975
As a result of the restructuring of the health care delivery system based on find ings of the
Operations Research (WHO Assisted) conducted in the province of Rizal in the early 70's, the
functions of the health team members (Municipal Health Officer, Public Health Nurse, Rural
Health Midwife, and Rural Sanitary Inspector} were redefined. The roles of the public health
nurse and the midwife were expanded. Two thousand midwives were recruited and trained to
serve in the rural areas.
1976-1986
The Nursing Consultant and Nursing Program Supervisor of the Office of the Secretary of Health
were involved in the Rural Health Practice Program which re quired medical and nursing
graduates to serve for two months in the rural areas of the country before their licenses could be
issued by the Professional Regula tion Commission. When the number of nursing graduates
reached over 12,000 per year, the program was stopped. By then, the objectives of the program
that health services be made available in the rural areas of the country, and that the
14 Public
Health Nursing
young medical and nursing graduates develop a liking for working in these re mote underserved
areas were partially attained.
During the incumbency of President Ferdinand Marcos, Mrs. Josefina Mendoza as Nursing
Consultant strongly and repeatedly recommended the creation of a Bureau of Nursing but
unfortunately, the government was in the midst of stream lining its organization. The envisioned
Bureau of Nursing did not materialize even if the President endorsed it to Mr. Armand Fabella
who was in charge of the government reorganization.
Nonetheless, nursing was represented in the monthly staff meetings of the De~ partment of Health.
Communications and problems on nursing matters were referred to the Nursing Consultant. She
and the other nurses at the Central Of~ fice represented the Department of Health at regional,
national and international nursing conferences and seminars.
1986
of the Department of Health durin~~is p~riod pla?ed the po Sition of Nurs1ng Consultant at
-r:~e reorgani~ation
the Bureau of Health arilJPMed1cal Serv1ces. It was later abolished when Mrs. Mendoza retired.
Mrs. Zenaida Nisce remained as Nursing Program Supervisor of the Office of the Secretary of
Health. In addition to her duties she was made Secretary, Task Force on Mental Health.
The other nursing positions at the Central Office were at the National Family Planning Service
(NFPS). Among these nurses were Miss Leonora Liwanag, Miss Virginia Orais, Mrs. Vilma
Paner, Mrs. Sarah Austria and Mrs. Leticia Daga. Mrs. Nelia Hizon joined the NFPS when Miss
Liwanag retired.
1987-1989 ' . ; ' ' ' Executive Order No. 1 '19 reorganized the Department of Health and created
sev eral offices and services within the Department of Health. 't\ .
1990-1992
The number of positions of Nursing Program Supervisors (Nurse VI) was in creased as there were
three or more appointed in each service. In the Maternal and Child Health Services Mrs. Emilia
Briones and Mrs Ana Mallari were first appointed followed by Mrs Patria Billones, Mrs. Nilda
Silvera and Mrs Vicenta Borja. Mrs Azucena Alcantara and Mrs. Lucila Agripa later joined them.
Aside from the usual services for mothers and children, these nurses were involved in the
following programs: Expanded Program on Immunization, Control of Diar rheal Diseases and
Control of Acute Respiratory Infections.
In the NorH::ommunicable Disease Control Service (NCDCS), the first two Nurs ing Program
Supervisors (Nurse VI) were Mrs. Gloria Temelo and Miss Gilda Estipona who were with the
cardiovascular and cancer control programs respec tively.ln 1989, Mrs. Carmen
BuencaminojoinedtheOccupational Health Division as Nurse VI. When these three nurses retired
one after another, their positions
Public Health
Nursing 15'
were taken over by Miss Ma. Thelma. Bermudez, Miss Frances Prescilla Cue vas and Mrs. Ma.
Theresa Mendoza. They were involved in the development of public health programs for the
prevention and control of cardiovascular diseases, cancer, diabetes and disabilities such as
blindness and deafness, osteoporosis, asthma and smoking control.
The three nurses at the Communicable Disease Control Service, Mrs. Zenaida P. Nisce, Mrs.
Carolina A. Ruzol and Mrs. Zenaida Recidoro participated in the planning, training, monitoring,
supervision and evaluation of diseases as leprosy, sexually transmitted diseases, rabies, filariasis
and dengue hemorrhagic fever.
At the Community Health Service, the Nursing Program Supervisor was Mrs. Patrocinio Ferrera.
She was involved in the planning and monitoring of primary health care activities in the different
regions. At the Department of Health Ad ministrative Service there were four Public Health Nurses
and one Senior Public Health Nurse assigned at the Medical Examination Division and Infirmary
(MEDI) formerly called Physical Examination Division.
January 1999
Department Order No. 29 designated Mrs. Nelia F. Hizon, Nurse VI, then President of the
National League of Philippine Government Nurses, as Nursing Adviser. She was detailed at the
Office of Public Health Services. As Nursing Adviser, matters affecting nurses and nursing are
referred to her.
May 24, 1999 . Executive Order No. 1 02 was signed by President Joseph Ejercito Estrada,
redirecting the functions and operations of the Department of Health.
Based on this Executive Order, most of the nursing positions at the Central Office were either
transferred or devolved to other offices and services.
2005-2006
The development of the Rationalization Plan to streamline the bureaucracy further was started
and is in the last stages of finalization.
\ :-:j\<JI ··-.;, ~,/~:? \ J.I '("Ji \r j ' '"'Jt--..:-?1 VJ! \:::rfV:p{ V;-;;J .,'if'-!['<;_-:y fJ/-.'<;;_:1 Yf'lVii Vi."¥711 ··rni \01 {¥-~i ·y~ ,.
."'!.7 \>#\,::-:! \1-.:i"f!rl "'i;Y\:4 \j.y--..;y ~7:1 \;;)/ 16 Public Health
Nursing
References:
Department of Health (1999). Health Sector Reform Agenda Philippines, 1999-2004 HSRA
Monograph Services No. 2, Department of Health, Manila, Philippines.
Freeman, Ruth B. (1981). Community Health Nursing Practice. 2nd Ed., W.B. Saunders Co.,
Philadelphia
http://www .answers.com/topic/public-health-nursing
http://www .un.org/millenniumgoals/
http://www. who. int/hia/evidence/doh/enlindex.html
Jacobson, M.J. (1975) An introduction to community health nursing. In SA Archer and A.

Freshman (Eds.) Community Health Nursing. North Scituate: Duxbury Press.
NLPGN (2005) Standards of Public Health Nursing in the Philippines. National League of
Philippine Government Nurses, Manila, Philppines.
Reyala, Jean et. al. 2000.Community Health Nursing Services in the Philippines, 9th edition.
National League of Philippine Government Nurses, Manila, Philippines.
Winslow, CEA (1982). Man and Epidemics. Princeton University Press, Princeton, New Jersey.
World Health Organization (2002). Strategic Directions for Strengthening Nursing arid Midwifery
Services. Geneva, World Health Organization.
World Health Organization (2003). Essential Public Health Functions: a three country study in the
Western Pacific Region. Regional Office for the Western Pacific, World Health Organization.
\n/\;7:1 \ g.-..,_n;/ \r .. ;.:t' •r:'i ;l- t:: \- .,r~:i \'!(·i ·"cl \ ?I V::?:i 17/'\~ \r:i '>r;.?i -."r.-7!.,/ 'VJi Vfy : ;; \;,)i·v: JI Y:.y'\ -)1 V7!! \t;,l Y"Ji "t:-7!1
itl .. .. .. ,,~~i \. ?lv: fl \f?l Vi Public Health
Nursing 17
~----------------------------------- -----
,.;THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM
INTRODUCTION:
A Public Health Nurse does not function in a vacuum. She is a member of a team working within
a system. In order for the nurse to function effectively she has to understand the health care
delivery system wherein she is working because it influences her status and functions. She
needs to properly relate with the dynamics of the political, organizational structure surrounding
her position in the health care delivery system.
THE HEALTH CARE DELIVERY SYSTEM: MAJOR PLAYERS
The Philippine health care delivery system is composed of two sectors: (1) the public sector,
which is largely financed through a tax-based budgeting system at boff'filational and local levels
and where health care is generally given free at the point of service (although socialized user
fees have been introduced in recent years for certain types of services), and (2) the private sector
(for-profit and non
profit providers), which is largely market-orlenled and where health care is paid through user fees
at the point of service.
The public sector consists of the national and local government agencies p~oviding health services.
At the national level, the Department of Health (DOH) is mandated'as the lead agency in health. It
has a regional field office in every region and maintains specialty hospitals, regional hospitals and
medical centers. It also maintains provincial health teams made up of DOH representatives to the
local health boards and personnel involved in communicable disease control, specifically for
malaria and schistosomiasis. Other national government agencies providing health care services
such as the Philippine General Hospital are also part of this sector.
With the devolution of health services, the local health system is now run by Local Government
Units (LGUs). The provincial and district hospitals are under the provincial government while the
city/municipal government manages the health centers/rural health units (RHUs) and barangay
health stations (BHSs). In every province, city or municipality, there is a local health board
chaired by the local chief executive. Its function is mainly to serve as advisory body to the local
executive and the sanggunian or local legislative council on health-related matters.
\:(';;;/ V.J:i \f?l ~~~ \,cc,i\ 1 \:?,l •tJI. \; ~\~ 1 Y?i -'·(·,7!1
'i;~ ~.'! i, '.:'! n-l· i\ 'V ! \ '::::_l..,l!.'i!.t \ ?i'Y.tl \,:'}1 Y7f 7l
'l; '7!!f -- ~- 'II.~-;I. i-: 'i.: ~f \1::/ V')/ ''-"i'i-;(,.;{'1:-ii r:i\~ t \i,.o'Jti \:i.J.i \-:2l'•tzi Public Health Nursing 19
THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM
The private sector includes for-profit and non-profit health providers. Their involvement in
maintaining the people's health is enormous. This includes providing health services in clinics
and hospitals, health insurance, manufacture of medicines, vaccines, medical supplies,
equipment, and other health and nutrition products, research and development, human resource
development and other health-related services.
PHILIPPINE DEPARTMENT OF HEALTH
In order for the public health nurse to fully appreciate the public health system in this country, it is
important to have an understanding of the development of the government agency mandated to
protect the health of the people. The following historical account on the institutional development
of the Department of Health was referenced from the Souvenir Program published during the 1
OOth year anniversary of DOH.
Pre-Spanish and Spanish Periods (before 1898)
Traditional health care practices especially the use of herbs and rituals for healing were widely
practiced during these periods. T'le western concept of public health services in the country is
traced to the first dispensary for indigent patients of Manila ran by a Franciscan friar that was
began in 1577. In 1876, Medicos Titulares, equivalent to provincial health officers were already
existing. In 1888, a Superior Board of Health and Charity was created by the Spaniards which
established a hospital system and a board of vaccination, among others.
June 23, 1898

Shortly after the proclamation of the Philippine independence from Spain, the Department of
Public Works, Education and Hygiene was created by virtue of a decree signed by President
Emilio Aguinaldo. However, this was short lived beca111se the Americans took over and started a
military and subsequently a civil government in the islands.
September 29, 1898

With the primary objective of protecting the health of the American soldiers, General Orders No.
15 established the Board of Health for the City of Manila.
July 1, 1901
Because it was realized that it was impossible to protect the American soldiers without protecting
the natives, a Board of Health for the Philippine Islands was created through Act No. 157. This
also functioned as the local health board of Manila. It truly became an Insular Board of Health
when Act Nos. 307, 308 dated Dec. 2, 1901, established the Provincial and Municipal Boards
respectively completing the health organization in accordance with the territorial division of the
islands.
20 Public
Health Nursing
-- --- -
October 26, 1905

The Insular Board of Health proved to be inefficient operationally so it was abolished and was
replaced by the Bureau of Health under the Department of Interior through Act No. 1407. Act No.
1487 in 1906 replaced the provincial boards of health with district health officers.
1912
Act No. 2156 also known as the Fajardo Act, consolidated the municipalities into sanitary
divisions and established what is known as the Health Fund for travel and salaries.
1915
Act No. 2468 transformed the Bureau of Health into a commissioned service called the Philippine
Health Service. This introduced a systematic organization of personnel with corresponding civil
service grades, and a secure system of civil service entrance and promotion described as the
"semi-military system of public health administration".
August 2, 1916
The passage of the Jones Law also known as the Philippine Autonomy Act, provided the highlight
in the struggle of the Filipinos for independence from the American rule. The establishment of an
elective Philippine Senate completed an all Filipino Philippine Assembly that formed a bicameral
system of government. This ushered in a major reorganization which culminated in the
Administrative Code of 1917 (Act 2711), which included the Public Health Law of 1917.
1932
Because of the need to better coordinate public health and welfare services, Act No. 4007 known
as the Reorganization Act of 1932, reverted back the Philippine Service into the Bureau of
Health, and combined the Bureau of Public Welfare uhder the Office of the Commissioner of
Health and Public Welfare.
The Philippine Commonwealth and the Japanese Occupation (1935-1945)
May 31, 1939

Commonwealth Act No. 430 created the Department of Public Health and Welfare, but the full
implementation was only completed through Executive Order No. 317, January 7, 1941. Dr. Jose
Fabella became the first Department Secretary of Health and Public Welfare in 1941.
1942
During the period of the Japanese occupation, various reorganizations and issuances for the
health and welfare of the people were instituted and lasted until the Americans came in 1945 and
liberated the Philippines.
October 4, 1947
Executive Order No. 94 provided for the post war reorganization of the Department
Public Health
Nursing 21
of Health and Public Welfare. This resulted in the split of the Department with the transfer of the
Bureau of Public Welfare (which became the Social Welfare Administration) and the Philippine
General Hospital to the Office of the President. Another split was created between the curative
and preventive services through the creation of the Bureau of Hospitals which took over the
curative services. Preventive care services remained under the Bureau of Health. This order also
established the Nursing Service Division under the Office of the Secretary.
January 1 , 1951
The Office of the President of the Sanitary District was converted into a Rural Health Unit,
carrying out 7 basic health services: maternal and child health, environmental health,
communicable disease control, vital statistics, medical care, health education and public health
nursing. This was carried out in 81 selected provinces. The impact to the community was so
strong, it directly resulted in the passage of the Rural Health Act of 1954 (RA 1 082). This Act
created more rural health units and created posts for municipal health officers, among other
provisions.
February 20, 1958

Executive Order No. 288 provided for what is described as the "most sweeping" reorganization in
the history of the Department at that period. This came about in an effort to decentralize
governance of health services. An Office of the Regional Health Director was created in 8 regions
and all health services were decentral
ized to the regional, provincial and municipal levels. Bureaus were limited to staff functions such
as policy making and development of procedures. RHUs were made an integral part of the public
health care delivery system.
1970
The Restructured Health Care Delivery System was conceptualized. It classified health services
into primary , secondary and tertiary levels of care. This further expa'nded the reach of the rural
health units. Under this concept the public health nurse to population ratio was 1 :20,000. The
expanded role of the public health nurse were highlighted.
June 2, 1978
With the proclamation of martial law in the country, Presidential Decree 1397 renamed the
Department of Health to the Ministry of Health. Secretary Gatmaitan became the first Minister of
Health.
December 2, 1982
Executive Order No. 851 signed by President Ferdinand E. Marcos reorganized the Ministry of
Health as an integrated health care delivery system through the creation of the Integrated
Provincial Health Office which combines public health and hospital operations under the
Provincial Health Officers.
April 13, 1987

Executive Order No. 119, "Reorganizing the Ministry of Health" by President
22 Public
Health Nursing
Corazon C. Aquino saw a major change in the structure of the minist,Y. It transformed the
Ministry of Health back to the Department of Health. EO 119 clustered agencies and
programs under the Office for Public Health Services, Office for Hospital and Facilities
Services, Office for Standards and Regulations and Office of Management Services. The
Field Offices were composed of the Regional Health Offices and National Health Facilities.
The latter was composed of National Medical Centers, the Special Research Centers and
Hospital. Five deputy minister positions were also created.
October 1 0. 1991
'Republic Act 7160 lknown as the Local Government Code provided for the decentralization
of the entire government. This brought about a major shift in the role and functions of the
Department of Health. Under this law, all structures, personnel and budgetary allocations
from the provincial health level down to the barangays were devolved to the local
government units (LGUs) to facilitate health service delivery. As such, delivery of basic
health services is now the responsibility of the LGUs. The Department of Health changed its
role from one of implementation to one of governance.
May 24, 1999

Executive Order No. 1 02 "Redirecting the Functions and Operations of the Department of
Health" by President Joseph E. Estrada granted the DOH to proceed with its Rationalization
and Streamlining Plan which prescribed the current organizational, staffing and resource
structure consistent with its new mandate, roles and functions post devolution.
The shift in policy and functions is indicated in the de-emphasis from direct service provision
and program implementation, to an emphasis on policy formulation, standard setting and
quality assurance, technical leadership and rfisource assistance. The shift in policy direction
of the DOH is shown in its new role as the national authority on health providing technical
and other resource assistance to concerned groups.
E01 02 mandates the Department of Health to provide assistance to local government units,
people's organization, and other members of civic society in effectively implementing
programs, projects and services that will promote the health and well being of every Filipino;
prevent and control diseases among population at risks; protect individuals, families and
communities exposed to hazards and risks that could affect their health; and treat, manage
and rehabilitate individuals affected by diseases and disability.
1999-2004
Development of the Health Sector Reform Agenda which describes the major strategies,
organizational and policy changes and public investments needed to improve the way health
care is delivered, regulated and financed.
Public Health
Nursing 23
2005 ongoing
Development of a plan to rationalize the bureaucracy in an attempt to scale down including the
Roles and Functions

The Department of Health, in its new role as the national authority on health providing technical
and other resource assistance to concerned groups as man dated by Executive Order 1 02 has
identified the following general functions un der its three specific roles in the health sector:
--n Leadership in Health
,.JServe as the national policy and regulatory institution from which the local gov ernment units, non-
government organizations and other members of the health sector involved in social welfare and
development will anchor their thrusts and directions for health. ~
• Provide leadership in the formulation, monitoring and evaluation of national health policies,
plans and programs. The DOH shall spearhead sectoral plan ning and policy formulation and
assessment at the national and regional lev els.
• Serve as advocate in the adoption of health policies, plans and programs to address national
and sectoral concerns.
/ 2:-:enabler and Capacity Builder

\ ..., Innovate new strategies in health to improve the effectiveness of health pro grams, initiate
public discussion on health issues and undertaking and dissem inate policy research outputs to
ensure informed public participation in policy decision-making.
• Exercise oversight functions and monitoring and evaluation of national health plans, programs
and policies.
• Eqsure the highest achievable standards of quality health care, health promo tion and health
protection.
. 3_0dministrator of Specific Services

"- • Manage selected national health facilities and hospitals with modern and ad vanced facilities
that shall serve as national referral centers (i.e., special hos pitals); and, selected health facilities
at sub-national levels that are referral centers for local health systems (i.e., tertiary and special
hospital, reference laboratories, training centers, centers for health promotion, centers for
disease control and prevention, regulatory offices, among others).
• Administer direct services for emergent health concerns that require new com plicated
technologies that it deems necessary for public welfare; administer special components of
specific programs like tuberculosis, schistosomiasis, HIV-AIDS, in as much as it will benefit and
affect large segments of the popula tion.
• Administer health emergency response services, including referral and net working system for
trauma, injuries and catastrophic events, in cases of epi
24 Public
Health Nursing
. ·---- --------------
demic and other widespread public danger, upon the direction of the President and in
consultation with concerned LGU.
t--/ Vision
The DOH is the leader, staunch advocate and model in promoting Health for All in the
Philippines.
Mission
t/
Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall
lead the quest for excellence in health.
The DOH shall do this by seeking all ways to establish performance standards for health human
resources; health facilities and institutions; health products and health s~.rvices that will produce the
best health systems for the country. This, in pursuit of its constitutional mandate to safeguard and
promote health for all Filipinos regardless of creed, status or gender with special consideration for
the poor and the vulnerable who will require more assistance.
/
V Goal: Health Sector Reform Agenda (HSRA)

Health Sector reform is the overriding goal of the DOH. Support mechanisms will be through
sound organizational development, strong policies, systems and procedures, capable human
resources and adequate financial resources.
Rationale for Health Sector Reform

Although there has been a significant improvement in the health status of Fili pinos for the last 50
years, the following conditions are still seen among the population:
• Slowing down in the reduction in the Infant Mortality Rate (IMR) and the Mater nal Mortality Rate
(MMR).
• Persistence of large variations in health status across population groups and geographic areas.
• [iigh burden from infectious diseases.
• Rising burden from chronic and degenerative diseases.
• Unattended emerging health risks from environmental and work related fac tors.
• Burden of disease is heaviest on the poor.
The reasons why the above conditions are still seen among the population can be explained by
the following factors:
• Inappropriate health delivery system as shown by an inefficient and poorly targeted hospital
system, ineffective mechanism for providing public health programs on top of health human
resources maldistribution.
• Inadequate regulatory mechanisms for health services resulting to poor qual ity of health care,
high cost of privately provided health services, high cost of drugs and presence of low quality of
drugs in the market.
• Poor health care financing and inefficient sourcing or generation of funds for healthcare.
The following are the implications of the above situation:

• There is poor coverage of public health and primary care services. • There is inequitable access
(physical and financial) to personal health care services.
• There is low quality and high cost of both public and personal health care.
In order to address the problem in the way the Philippine health care system delivers and pays
tor health services, interrelated reforms in five areas have been identified as critical in
transforming the health system into one that ensures the delivery of cost effective services,
universal access to essential services and adequate and efficient financing.
Areas that needed to be reformed are on health financing, health regulation, local health
systems, public health programs and hospital systems.
Framework for Implementation of HSRA: FOURmula ONE for Health This is adopted as the
implementation framework tor health sector reforms under the current administration. It intends to
implement critical interventions as a single package-backed by effective management
infrastructure and financing arrangements following a sectorwide approach.
~oals of FOURmula ONE for Health

1. Better health outcomes
2. More responsive health systems
3. Equitable health care financing
The tour elements of the strategy are:

1 . Health financing-the goal of this health reform area is to foster greater, better and sustained
investments in health. The Philippine Health Insurance Corporation, through the National Health
Insurance Program and the Department of Health through sectorwide policy support will lead this
component jointly.
2. Health regulation - the goal is to ensure the quality and affordability of health goods and
services.
3. Health service delivery - the goal is to improve and ensure the accessibility and availability of
basic and essential health care in both public and private facilities and services.
4. Good governance - the goal is to enhance health system performance at the national and local
levels.
A key feature of the FOURmula ONE for Health implementation strategy is the engagement of
the National Health Insurance Program (NHIP) as the main lever to effect desired changes and
outcomes in each of the four implementation components. The NHIP supports each of the
elements in terms of:
• financing, as it reduces the financial burden placed on Filipinos by health care costs;
• governance, as it is a prudent purchaser of health care thereby influencing the health care
market and related institutions;
• regulation, as the NHIP's role in accreditation and payments based on quality
26 Public
Health Nursing
acts as a driver for improved performance in the health sector; and, • service delivery, as the
NHIP demands fair compensation for the costs of care directed at providing essential goods and
services in health.
Roadmap for All Stakeholders in Health:

National Objectives for Health 2005 to 2010
The NOH 2005-201 0 provides the road map for stakeholders in health and health-related sectors
to intensify and harmonize their efforts to attain its time honored vision of health for all Filipinos
and continue its avowed mission to ensure accessibility and quality of health care to improve the
quality of life of all Filipinos, especially the poor.
The NOH sets the targets and the critical indicators, current strategies based on field
experiences, and laying down new avenues for improved interventions. It provides concrete
handle that would guide policy makers, program managers, local government executives,
development partners, civil society and the communities in making crucial decisions for health.
Building on the initiatives under Health Sector Reform Agenda and as set forth in the NOH
1999-?004, an implementation is defined through FOURmula ONE for Health which strategically
focuses on interventions that create the most impact and generates buy-in from all partners.
FOURmula ONE for Health is an overarching philosophy to achieve the end goals of better health
outcomes, a responsive health system and equitable health care financing. It is directed towards
ensuring accessible, affordable quality health care especially for the more disadvantaged and
vulnerable sectors of the population.
Objectives of the Health Sector

a. Improve the general health status of the population
b. Reduce morbidity and mortality from certain diseases
c. Eliminate certain diseases as public health problems
c:!: Promote healthy lifestyle and environmental health
e. Protect vulnerable groups with special health and nutrition needs f. Strengthen national and
local health systems to ensure better health service delivery
g. Pursue public health and hospital reforms
h. Reduce the cost and ensure the quality of essential drugs i. Institute health regulatory reforms
to ensure quality and safety of health goods and ·services
j. Strengthen health governance and management support systems k. Institute safety nets for the
vulnerable and marginalized groups I. Expand the coverage of social health insurance
m. Mobilize more resources for health
n. Improve efficiency in the allocation, production and utilization of resources for health
Public Health
Nursing 27
LOCAL HEALTH SYSTEM
For over forty years after post war independence, the Philippine health care system was
administered by a central agency based in Manila. This control agency provided the singular
sources of resources, policy direction, technical and administrative supervision to all health
facilities nationwide.
However, a major shift took place in 1991 with the passage ofthe Local Government Code also
known as Republic Act 7160. Under this law, all structures, personnel and budgetary allocations
from the provincial health level down to the barangays were devolved to the local government
units to facilitate health service delivery.
Devolution made local government executives responsible to operate local health care services.
New centers of authority for local health services emerged. These consist of provincial, city,
municipal governments, including an autonomous regional government and a metropolitan
authority.
"'-
Each center controls a portion of the health care system as part of its political and administrative
mandate. Now, provincial governments operate the hospital system, Provincial and District
Hospitals, while city/municipal governments operate the Health Centers (HC)/Rural Health Units
(RHU) and Barangay Health Stations (BHS).
Objectives
With Local Government Units running the local health systems because of devolution, it is
important to institutionalize local health systems within the context of local autonomy and develop
mechanisms for inter - LGU cooperation. The following are the objectives for local health
systems:
1 . Establish local health systems for effective and efficient delivery of health care services.
2. Upgrade the health care management and service capabilities of local health facilities.
3. Promote inter- LGU linkages and cost sharing schemes including local health care financing
systems for better utilization of local health resources. 4. Foster participation of the private sector,
non-government organizations (NGOs) and communities in local health systems de,elopment. 5.
Ensure the quality of health service delivery at the loc llevel. \
Inter Local Health System
This system is being espoused by the Department of Health in order to ensure quality of health
care service at the local level. It is a system of health care similar to a district health system in
which individuals, communities and all other health care providers in a well- defined geographical
area participate together in providing quality equitable and accessible health care with Inter Local
Government Unit (ILGU) partnership as the basic framework.
28 Public
Health Nursing
---- · ·- - -- ·
The overall concept is the creation of an Inter Local Health System (ICHS) by
clustering municipalities into Inter Local Health Zone (ILHZ). Each Inter Local
Health Zone (ILHZ) has a defined population within a defined geographical area
and comprises a central referral hospital and a number of primary level facilities
such as Rural Health Units and Barangay Health Station.
The importance of establishing the Inter-Local Health System is important because

there is a need to re-integrate hospital and public health service for a holistic
delivery of health services. The Inter Local Health System will identify areas of
complementation of the stakeholders in the delivery of health services. These
stakeholders include: LGUs at all level, Department of Health, Philippine Health
Insurance Cooperation (PHIC), communities, Non-Government Organizations
(NGOs) private sector and others.
Expected Achievement of the Inter-Local health System:

1. Universal coverage of health insurance
2. Improved quality of hospital and Rural Health Units (RHU) service 3.
Effective referral system
4. Integrated planning
5. Appropriate health information system
6. Improved Drug Management System
7. Developed human resources
8. Effective leadership through lnter-LGU corporation
9. Financially visible or self sustaining hospitals
1 0. Integration of public health and curative hospital care
11. Strengthened cooperation between LGU and health sectors
Guiding Principles In Developing The Inter Local Health System 1. Financial and
Administrative autonomy of the provincial and municipal administrations (LGUs)
~- Strong political support
3. Strategic synergies and partnerships

4. Community participation
5. Equity of access to health services by the population, especially the poor 6.
Affordability of health services
7. Appropriateness of health programs
8. Decentralized management
9. Sustainability of health initiatives
10. Upholding of standards of quality-.l:lealth service
Composition of the Inter-Local Health Zone

1. People - the number of people may vary from zone to zone. Depending on the
number of LGUs who will decide to cooperate and cluster. According to WHO,
the ideal health district would have a population size between 1 00,000 and
500,000 for optimum efficiency and effectiveness.
2. Boundaries - clear boundaries between Inter Local Health Zones determine the
accountability and responsibility of health service providers, geographical
locations and access to referral facilities such as district hospitals are the

THE PHil-IPPINE HEALTH CARE DELIVERY SYSTEM
usual basic in forming the boundaries. However, flexibility regarding existing political social and
cultural borders would be best in order to ensure every persons a9cess to health service.
3. Health Facilities- district or provincial hospital (referral hospital for secondary level of health
care) a number of Rural Health Units (RHU) Barangay Health Stations (BHS) and other health
services deciding to work together as an integrated health system.
4. Health Workers - the right unit of health providers is needed to deliver comprehensive health
services. The groups of health providers include the Department of Health, District Hospital,
Rural Health Units, Barangay Health Stations, Private Clinic, volunteer health workers, non-
government Organization (NGO) and community-based organization. Together, they form the
ILHZ team to plan joint strategies for district health care.
/ PRIMARY HEALTH CARE AS AN APPROACH TO DELIVERY OF HEALTH CARE

SERVICES
WHO defines PHC as essential health care made universally accessible to individuals and
families in the community by means acceptable to them through their full participation and at a
cost that the community and country can afford at every stage of development.
Primary Health Care was declared during the First International Conference on Primary Health
Care held in Alma Ata, USSR on September 6-12, 1"978 by WHO. The goal was "Health tor All
by the year 2000". This was adopted in the Philippines through Letter of Instruction 949 signed by
President Marcos on October 19, 1979 and has an underlying theme of "Health in the Hands of
the People by 2020."
The concept of PHC is characterized by partnership and empowerment of the people that shall
permeate as the core strategy in the effective provision of essen\ial health services that are
community based, accessible, acceptable and sustainable at a cost which the community and the
government can afford.
It is a strategy, which focuses responsibility for health on the individual, his family and the
community. It includes the full participation and active involvement of the community towards the
development of self-reliant people, capable of achieving an acceptable level of health and well
being. It also recognizes the interrelationship between health and the overall political, socio-
cultural and economic development of society.
Although the goal of PHC of Health for All in the Year 2000 may have already been challenged
as unrealizable in the given time frame, the concept and processes has already taken root all
over the world and has shown progress in the lives of peoples in communities it has empowered.
The recent PHC Summit held on February 23-24, 2006 has showcased the various community
managed health activities that has successfully placed health in the
30 Public
Health Nursing
hands of the people in this country, and is a testimony that indeed the concepts of
Primary Health Care as an approach to health works and has virtually changed the
landscape for health services in the country.
1 Elements/Components of Primary Health Care

(jJ. Environmental Sanitation (adequate supply of safe water and good waste
disposal)
,2. Control of Communicable Diseases Y' _..3. Immunization C.. ft.
Health Education \ 5. Maternal and Child Health and Family Planning
't-1 ft
Adequate Food and Proper Nutrition
7. Provision of Medical Care and Emergency Treatment /". 8.
Treatment of Locally Endemic Diseases
9. Provision of Essential Drugs -·
)Strategies
1 . Reorientation and reorganization of the national health care system with the
establishment of functional support mechanism in support of the mandate of
devolution under the Local Government Code of 1991.
2. Effective preparation and enabling process for health action at all levels. 3.
Mobilization of the people to know their communities and identifying their basic
health needs with the end in view of providing appropriate solutions (including legal
measures) leading to self-reliance and self determination. 4. Development and
utilization of appropriate technology focusing on local indigenous resources
available in and acceptable to the community. z · 5. Organization of communities
arising from their expressed needs which they have decided to address and that this
is continually evolving in pursuit of their own development.
6. Increase opportunities for community participation in local level planning, '
management, monitoring and evaluation within the context of regional and national
objectives.
7. Development of intra-sectoral linkages with other government and private
agencies so that programs of the health sector is closely linked with those of
othersocio-economic sectors at the national, intermediate and community levels.
8. Emphasizing partnership so that the health workers and the community
leaders/members view each other as partners rather than merely providers and
receiver of health care respectively.
The framework for meeting the goal of primary health care is organizational
strategy, which calls for active and continuing partnership among the communities.
private and government agencies in health development.
v Four Cornerstones/Pillars in Primary Health Care

I. Active community participation
2. Intra and inter-sectoral linkages

3. Use of appropriate technology

4. Support mechanism made available
/TYPES OF PRIMARY HEALTH CARE WORKERS

Various categories of health workers make up the primary health care team. The types vary in
different communities depending upon:
• Available health manpower resources
• Local health needs and problems
• Political and financial feasibility
In general, the PHC team may consist of physician, nurses, midwives, nurse auxiliaries, locally
trained community health workers, traditional birth attendants and healers. The preparation of a
new kind of health worker is not often required. What is needed may only be a redefinition of
roles and functions of existing personnel. For instance, in the Philippines under the restructured
health care delivery system, a physician, a public health nurse and midwives compose the basic
primary health care team. Each is trained and oriented to assume his/her redefined roles and
functions.
I Two levels of primary health care workers have been identified

1. Village or Barangay Health Workers (V/BHWs). This refers to trained commu nity health
workers or health auxiliary volunteer or a traditional birth attendant or healer.
2. Intermediate level health workers. General medical practitioners or their assistants. Public
Health Nurse, Rural Sanitary Inspectors and Midwives may compose these groups.
ILEVELS OF HEALTH CARE AND REFERRAL SYSTEM
1. Primary Level of Care

Primary care is devolved to the cities and the municipalities. It is health care provided by center
physicians, public health nurses, rural health midwives, barangay health workers, traditional
healers and others at the barangay health stations and rural health units. The primary health
facility is usually the first contact between the community members and the other levels of health
facility.
2. Secondary Level of Care

Secondary care is given by physicians with basic health training. This is usually given in health
facilities either privately owned or government operated such as infirmaries, municipal and district
hospitals and out-patient departments of provincial hospitals. This serves as a referral center for
the primary health facilities. Secondary facilities are capable of performing minor surgeries and
perform some simple laboratory examinations.
3. Tertiary Level of Care

Tertiary care is rendered by specialists in health facilities including medical centers as well as
regional and provincial hospitals, and specialized hospitals
32 Public
Health Nursing
- - - - - - - --- - -
such as the Philippine Heart Center. The tertiary health facility is the referral center for the
secondary care facilities. Complicated cases and intensive care requires tertiary care and all
these can be provided by the tertiary care facility. See Figure 2.
LEVELS OF HEALTH CARE SERVICES

Health problems that are beyond the capability of PHC units and beyond the competence of PHC
workers are referred to an intermediate health facility, usually a Rural Health Unit (RHU) located
in a town or poblacion. The RHU team generally consists of the physician, dentist, public health
nurse, midwife, sanitarian and other health workers. The District Community Hospital attends to
cases needing hospitalization. Higher echelons of health services at the provincial, regional and
national levels, provide secondary or tertiary care to complete the health care given at district and
peripheral levels.
The higher the level, the more qualified the health personnel and the more sophisticated the
health equipment. Under this structure, health care is provided by the suitable health facility on
the basis of health need. There is better utilization of scarce health resources.
More than ever, primary health care puts the concept of teamwork to the fore. Team planning by
health personnel in the same level and the various health levels will be essential for the
effectiveness and efficiency of hea~th services. For example, as a nurse you will plan family health
care with the midwife and community health workers. Together, you will set common objective,
delineate task, allocate resources and evaluate family services. You may need to consult the
hospital nurse for referral of seriously ill patients or coordinate with the sanitary inspector for
basic sanitation problems. The Chief Nurse of a community hospital may need to plan with the
Chief Nurse of a public health agency regarding a home care program. Likewise, the Medical
Health Officer plans priority community
• health programs with the other members of the health
team.
Teamwork in primary health care entails joint planning, implementation, and evaluation of
community' activities by the team members with the community health needs/problems as bases
of action. Joint efforts in the implementation of health programs is demonstrated by the health
team in the expanded immunization program where the nurse as team leader works with the
midwife and other community health workers.
Public HealtH
Nursing 33
National
Health Services
Medical Centers
Teaching and
Training Hospitals
Regional Health Services

Regional Medical Centers
And Training Hospitals
Provincial I City Health Services

Provincial I City Hospitals
Emergency I District Hospitals
Rural Health Unit

Community Hospitals and Health Centers
Private Practitioners I Puericulture Centers
Barangay Health Stations
Figure 2. Levels of Health Care and Referral System

34
References:
Department of Health. The Guidebook for LCE's and LHB's, Responding to Questions in
Devolution, and R.A. 7160 -The LGC of 1991.
Department of Health (2005). National Objectives for Health, 2005-2010, Department of Health,
Manila, Philippines
Department of Health (1998). Malaya at Malusog na Pamayanan: A DOH Cen tennial Souvenir
Program, 1898-1998
Department of Health (2001 ). Reengineering for Reforms.

HSRA Monograph S. Manila, Philippines
Department of Health - Documents/Handouts

1. FOURmula ONE for Health
2. Local Health Systems
3. Primary Health Care
Public Health
Nursing 35 - --- - - - - - ___ _ ______ __,

-
Cli.\PTER Ill
THE PUBLIC HEALTH NURSE I .
INTRODUCTION:
Throughout history, nursing has responded to advances in medical sciences,

modern technology, changing health care delivery system, technological and social
forces.
With the changing health care landscape, comes new challenges to the practice of
public health nurses, accordingly functions of public health nurses have been
modified and expanded to meet these challenges. From the traditional role of
physician's assistant to that of a health advocate, program manager and leader in
planning, implementing and evaluating health programs.
Public health nurses are found in various health settings and occupying various
positions in the hierarchy. They are assigned in rural health units, city health
centers, provincial health offices, regional health offices, and even in the national
office of the Department of Health. They are also assigned in public -schools and in
the offices of government agencies providing health care services. They occupy a
range of positions from Public Health Nurse I to Nurse Program Super-visors to
Chief Nurse in public health settings.
Public Health Nurses have broad roles and functions. Emphasis given on specific
role and function is dependent on the position description of the public health nurse
in the hierarchy of the health care system.
'
The Public Health Nurse uses various tools and procedures necessary for her to
properly practice her profession and deliver basic health service. She uses nursing
process in her practice and is adept in documenting and reporting accomplishments
through records and reports. She is also technically competent in various nursing
procedures conducted in settings where she is assigned.
QUALIFICATIONS AND FUNCTIONS ( c..M~k -Af\'fl..t.#. 1 )

The Standards of Public Health Nursing in the Philippines developed by the
National League of Philippine Government Nurses in 2005 described the
qualification and functions of a Public Health Nurse. The full text of the standards is
attached as an Annex in this book to serve as reference to readers.
The Public Health Nurse must b~r()fes.sione~lly qualified and li<:;en§E}c:j tqpr?:c,ti e in
the arena of public health nursing just like any other professional health worker.
However, professional competence is not the only requirement to fit into
?f -:;,~_-;_,; "<::·:i "'?i\···-'i! 't :/ "" '-i\~ :j\,~ :-;;; \·)./ \;y \t;:_;;'\: i V)t'\:-)1 ·v _;·.{"(.•;i \• .!J!. \: :;/ / "fi
·~- .:, ~.T} ;{ \,~;,f ";-?_ \.~ .;;/ y "J:l"'t~il y·f.{\ ~i ~;::•'!{ 'if"ci:i ~..::;:;/ 'f f \~ j Viti Public Health Nursing 37
THE PUBLIC HEALTH NURSE
this practice. Since public health nursing involves engagements with people,' the
Public Health Nurse must possess personal qualities and "people skills" that would
allow her practice to make a difference in the lives of these people . This is where
her physical, mental and emotional strength will be needed; where her leadership,
resourcefulness, creativity, honesty and integrity will be tested. Her interest,
willingness and capacity to work with people will spell the difference between a
token performance and making a difference in the lives of people.
The Public Health Nurse functions in accordance with the dominant values of public
health nurses, within the ethico-legal framework of the nursing profession, and in
accordance with the needs of the clients and available resources for health care.
The functions of the PHN are consistent with the Nursing Law 2002 and program
policies formulated by the Department of Health and local government health
agencies. They are related to management, supervision, provision of nursing care,
collaboration and coordination, health promotion and education training and
research.
/Management function ( 'fOSt:'G \

The management function of the p6blic health nurse is inherent in her practice. The
nurse, in whatever setting and role has been trained to lead and manage. Obje~ves set
for work being done can only be achieved through the execution of the five
management functions of planning, organizing, staffing, directing and controlling.
This function is performed when she organizes the "nursing service" of the local
health agency. For example, in a small municipality, there is only one public health
nurse employed in the rural health unit. Even when she is alone, she still manages
the nursing service of the health unit by preparing and implementing the nursing
service plan as part of the overall municipal health plan. In areas where there are
more nurses, like in big municipalities and cities, the management function of the
nurse is more apparent in managing the nurses and their activities.
Another emerging and acknowledged management function of the public health

nurse is ~nt. This is a function where the PHN actually excels in. As a program
manager she is responsible for the delivery of the package of services provided by
the program to the target clientele. For example, the PHN is usually the program
manager of the National Tuberculosis Program. As such, she plans activities and
sets targets, organizes, directs and control activities and outputs, deploys needed
manpower such as midwives and budgets resources accordingly. Reports on
program accomplishments is a documentation of her management skills.
I Supervisory function
Generally, the public health nurse is the s..upervisor ot.lb._e midwives and other
auxiliary health workers in the catchment area. This is in accordance with agency's
policies and in a manner that improves performance and promotes job satisfaction.
38 Public Health Nursing

As a supervisor she formulates a supervisory plan and conducts supervisory visits to

implement the plan. She conducts supervisory visits using a supervisory checklist.
The Sentr"()~g $Jg!~ f:lr_o_g!am has developed a Supervi~~'}'_E'~ ka_ge complete with supervisory
_
checklists for various programs and proved to be useful to supervisors. During the
visit the PHN identifies together with the supervisee any issue or problem
encountered and addresses them accordingly. If it is a technical matter like a breach
in the procedure or established protocol, coaching is immediately instituted. If
problems or issues identified needs further capacity enhancement or training for the
supervisee, then the nurse arranges for the conduct of this training. A report of the
encounter is given to the supervisee and kept in her personal file for future
reference.
Nursing care function

Nursing care provision is an inherent function of the nurse. Her practice as a nurse
is bii~d on t~~ill!_art of c_9ring, in whatever setting she maybe or role she may have,
providing nursing care is at the heart of it. Public health nursing is caring for
individuals, families and communities toward health promotion and disease
prevention, as such PHNs are expected to provide nursing care.
In the provision of care, the PHN uses her knowledge and skill in the nursing
process. She doed!assess~nt, pla!1_ Elll.9 impLements care.___and.J:waluates outcomes.
She establishes rapportwith her-Cilent, may it be individual, family or community, in
order to ensure good quality data and to facilitate or enhance partnership in
addressing identified health needs and problems.
~orne visits are must activities of the PHN. It is a visible manifestation of her
··-- .. ---
-~ ---·· " .. . ---- - -- - -----.
'-- -· ..
caring function. This is especially true today when many chronically ill patients are
staying at home rather than in expensive hospitals. Home care should be an area
too.
where Public Health Nurses should be able to devote some of their time '
lUf3,eferral of__Q~tsJQj~QprOp @t.@~Vei~ Of care should be done when indicated.
From an assessment, the nurse may discover health problems that are outside the
scope of nursing practice but require attention. In such instances, the nurse refers
the client to other health care providers. For example, a client who is depressed
following childbirth might be referred to a mental health service provider; a client
who has rats, water and sewage disposal problem in the backyard might be referred
to environmental health; or a client who is out of work and has no source of income
might be referred to social services.
Collaborating and coordinating function

This function of the PHN bring activities or group of activities systematically into
proper relation or harmony with each other. Public Health Nurses are the care
coordinators for communities and their members. They are actively involved both
socially and politically to empower individuals, families and communities as an
entity to initiate and maintain health promoting environments.

She establishes linkages and collaborativ~_J~I~!~onships with other health professionals,

governmenfagencies, the private- sector, non-government organizations, people's
organizations to address health problems.
She identifies persons, groups, organizations, other agencies and communities

whose resources are available within and outside the community and which can be
tapped in the implementation of individuals, family and community health care. Her
established linkages enables her to appropriately refer patients to other health
personnel, health facility or government agency.
Health promotion and education function

The Public Health Nurse understands that in the performance of her function in
health promotion and education her activities goes beyond health teachings and
health information campaigns. She understands that health is determined by various
factors such as physical and political environment, socio-economic status, personal
coping skills and many other circumstances, and it is inappropriate to blame or
credit a person's health to himself alone because he is unlikely to control many of
these factors. Understanding the multidimensional nature of health will enable her to
plan and implement health promoting interventions for individuals and communities.
The PHN ~ber skiii§J!L~SY~l!f:?PE_':!iv [l vir:gll.m~nt through policies and reengineering of

_
the physical environment for healthier actions. For example, she can influence the
Sangguniang Bayan to ban· smoking in public places, or to build a biking or walking
lane in the community. With this policy and physical environment in place, exposure
of the population to smoking and sedentariness can be reduced. ·
As an educator, the nurse p~~Q~onJhat allows them to make healthier choices

and practices. Giving health education is a very important funOifon of lhe Liblrc heaitti nurse
lt is a basic health service. Health education activities is a major component of any
public health program. In order to improve individual, family and community health,
correct knowledge, attitude and skill should be taught and subsequently practiced.
Public Health Nurses in the community are expected to teach on a daily basis as part
of their practice. To do this, nurses must have a solid knowledge base, not only of
theories and models of the teaching/learning process but of general principles of
teaching/learning. Nurses ~!~O!fl ~~ ~~t
indicate a need to learn. When nurses ~to tb ~t cue, they are teaching. Teachlng-
may--68 simple or complex; it may take a short time or many days to complete.
Client teaching requires great involvement by both the nurse and the client. The
nurse's knowledge of teaching/learning principles will enhance the teaching
relationship established with each individual, family, or group.

Training function
The public health nurse initiates the formulatiol'}_of staff develo_Q!!1~1'}9Jral!ling programs for
midwives an~ other auxilia_ry__ worke1:s. She does trn_ining _n~eds ~ent for these
health workers, designs the training program and conducts them in collaboration
with other resource persons. She also does evaluation of training outcomes.
The public health nurse also participates in the training of nursing and midwifery
affiliates in coordination with the faculty of colleges of nursing and midwifery. She
participates in teaching, guidance and supervision of student affiliates for their
related learning experiences in the community setting.
Health promotion calls for the active participation of the community. As such one of
the activities performed by the nurse is to mobilize communities for health actions.
Community organizing is a means of mobilizing people to solve their own problems.
Through community organizing, people learn that their problems have social causes
and fighting back is a more reasonable, dignified approach than passive acceptance
and personal alienation.
Research function
The public health nurse participates in the conduct of research and utilizes research
findings in her practice.
One of the areas where a Public Health Nurse functions is _disease su!Y~lllance. Disease
surveillance is a research activity of the nurses. It is a continuous collection and
analysis of data of cases and deaths. The purposes of disease surveillance are,{'{)
to measure the magnitu~e of the problem and~) to measure the effect of the control
program. The data collected can be used to improve strategies and thus prevent
these diseases from occurring. Surveillance is an integral part of many programs. It
is Jrrlportant in _maoitoring...!lliLQrogre~_of the disease reduction init@Jiv.es: Poliomyelitis
Eradication, Neonatal Tetanus Elimlrlation, Measles Control, NCD risk factors, etc.
Illustration of an actual performance of function

of a Public Health Nurse in a City Health Office
The Public Health Nurse II works in a health center where she is the frontline
~orl<e ancfprTme Jllover for all health programs and activities.
She is the first contact of the patient in the health center, where she screens
cases according to established program protocol. She only refers cases to
physicians when it is not within her responsibilities to manage. She assists the
physician during consultation and examination and gives treatments to patients.
She provides health education to the public by giving ·pre and post clinic
lectures, reaching out to the community by conducting mother's classes and
organizing community assemblies for health promotion as well

as disease prevention and control. She performs home visits or follow-up cases
that requires nursing care and teaches the family members to give care to the
sick. Apart from the mentioned functions of the PHN, she has to prepare and
submit the necessary reports required of her, which are done weeki thly,
quarterly or annually.
Th HN Ill erforms the same functions but differs from the PHN II in the sense a
hen they are assigned in the same health center, the PHN Ill acts as the
n.urse:ifr~ge. She supervises, guides, coordinates and evaluates the work of her
nurses. She likewise interprets policies and participates in planning health
programs or activities that involves nursing service.
The N_l!rse V otherwise known as the "Supervising Public Health Nur~e", is

assigned in a health center with a lying-in clinic, and takes charge of the unit,
with several staff members, assuming a bigger responsibility than the rest. She
supervises and coordinates the work of nurses, midwives and other health
personnel and guides them in carrying out health related activities ensuring that
they use correct procedures and techniques. She participates in program
planning, provides training and guidance to in-service trainees and student
affiliates. She attends f!Leetings, conferences or se~ for her own career growth
and for the improvement of health serv1ces. Still part of her task is to evaluate
the performance of her staff and analyze records and reports.
As the PHN mo\/es.upJo a higher level, she then becomes a "~J?.[Q_gram

Supervis9r'' 01( Nurse v) who manages and oversees the performance of a
gTol:ipof nurses-assigned in a number of health centers covered by a particular
district or area. Her functions include performing consultations and objective
assessment and evaluation of nursing programs, problems and services. She
consolidates I evaluates and analyzes the necessary weekly, monthly, quarterly
and annual reports of the health center. She studies and evaluates thEl
performance ratings of nurses. She initiates meetings, discussions and
conferences to provide joint planning to stimulate activities among nurses and
other health personnel. She conducts program orientation to pre-service and in-
service nurse trainees and students and coordinates with other health disciplines
in the implementation of programs. She likewise acts as a nursing consultant on
technical matters.
COMPETENCIES SKILLS AND KNOWLEDGE

'There are specific competencies
and skills that the public health nurse should have. These are community health
nursing process, nursing procedures during clinic and home visits, community
organizing, health promotion and educatioh, surveillance, records and reports.
42
.;Community Health Nursing Process

Community health purposes and goals are realized through the application of a
series of steps that lead to desired results. The nursing process is central to all
nursing actions- it is the very essence of nursing, applicable in any setting, in any
frame of reference, and within any philosophy. Its uniqueness will depend on the
best application of nursing and public health skills to family and community
problems (see Fig. 3).
The nursing process is a systematic, scientific, dynamic, on-going interpersonal

process in which the nurses and the clients are viewed as a system with each
affecting the other and both being affected by the factors within the behavior. The
process is a series of actions that lead toward a particular result. This process of
decision-making results in the optimal health care for the clients to whom the nurse
applies the process.
I
n
i
t
i
a
t
e
Contact * Demonstrate
caring attitudes* Mutual trust &
confidence * Collect data from
all possible sources * Identify
health problems * Assess
coping ability * ~naly!?e and
interpretoata
* Care Outcomes * Prioritize Needs * Establish goal
* Performance Appraisal * Estimate based on needs & capabilities of
cost benefit ratio * Assessment of Staff * Construct action and Operation
problems * Identify needed alterations plan * Develop evaluation parameters
* Revise plan as needed
Figure 3 COMMUNITY HEALTH NURSING PROCESS

Assessment
Assessment provides an estimate of the degree to which a family, group or community is
achieving the level of health possible for them, identifies specific deficiencies or guidance needed
and estimates the possible effects of the nursing interventions.
The assessment process involves the following steps which are taken with the active participation
of the clients especially in decisions made:
of Data
~ollection
Relevant data are collected on the health status of the family, groups and community:
demographic data, vital health statistics, community dynamics including power structure, studies
of disease surveillance, economic, cultural and environmental characteristics, utilization of health
services by the population: and on individuals and families: health status, education, socio-
cultural, religious and occupational background, family dynamics, environment and patterns of
coping.
Various rPiethods are employed to collect data: community surveys: interview of individuals,
families, groups and significant others: observation of health related behaviors of individuals,
family groups and environmental factors: review of statistics, epidemiological and relevant
studies: individual and family health records: laboratory and screening tests and physical
examinations of individuals.
These data are collected systematically and continuously, then are recorded in appropriate forms
and kept systematically so that retrieval of information is facilitated. Collected data are treated
confidentially.
Categories of Health Problems

Health deficits, health threats and foreseeable crisis or stress points are categories of health
problems. The public health nurse analyzes the data in accordance with the nurse's conception of
the source of the client's problems and needs that can be met through nursing intervention. The
nursing diagnoses are interpreted and validated with individuals, members of the community and
family groups concerned. Their capabilities and limitations to cope are identified.
• A health deficit occurs when there is a gap between actual and achievable health status.
Exploration and evaluation of possible precursors of health deficits such as history of
repeated .infections or miscarriages are noted. No regular health check-up is another example.
threats are conditions that promote disease or injury and prevent people
• Health from realizing
their health potential. An example of a health threat is when the population is inadequately
immunized against preventable diseases. • Foreseeable crisis includes stressful occurrences
such as death or illness of a ·famili_i!i~ ger. · - . • A ~alth nee exists when there is a health problem that
can be alleviated with medical'. ial technology. · • A~ealth ~roble~ js a situation in which there is a
demonstrated health need
44 Public
Health Nursing
combined with actual or potential resources to apply remedial measures and a

commitment to act on the part of the provider or the client.
The process of assessment in community health nursing includes: intensive fact

finding, the application of professional judgment in estimating the meaning and
importance of these facts to the family and the community, the availability of nursing
resources that can be provided, and the degree of-change which nursing
intervention can be expected to effect.
Planning Nursing Actions/Care

The plan for nursing action or care is based on the actual and potential problems
that were identified and prioritized. Planning nursing actions include the following
steps:
Goal Setting
.AgOafiSa'declaration of purpose or intent that gives essential direction to action .
Specific objectives of care are made with the individual family in terms of activities
of daily living. and adaptive functioning based on remaining capabilities:resulting
from this condition and capability to cope with stress associated with his/her disease
condition or environment. These objectives are stated in behavioral terms: specific.
measurable, attainable, realistic and time bounded. The nurse prioritizes these
objectives.
Constructing a Plan of Action

The planning phase of community health nursing process is concerned with
choosing from among the possible courses of action. selecting the appropriate
types of nursing intervention, identifying appropriate and available resources for
care and developing an operational plan.
•A
T.he courses of action may have positive and/or negative effects. The positive
consequences must be weighed agamst those with negative aspects. The ability of
the family to cope or solve its own problems and make decisions on health matters
should be considered.
The most appropriate action is selected such as those that the clients could not
perform themselves, those that facilitate actions that remove barriers to care and
those that improve the capacity of the clients to act in their behalf.
The appropriate resources are identified which include the family, the neighborhood.
the schools. the industrial population: the whole medical system the hospitals.
clinics. public and private practitioners of medicine. health units of welfare
departments. voluntary health agencies. and other health related agencies: non-
health facilities such as social. educational and counseling agencies.
~~9Pe@!~!:lan
To develop an operational plan. the public health nurse must
establish priorities, Public Health Nursing 45

phase and coordinate activities. Plans of care are prioritized in order of urgency to determine
those that need the earliest action or attention such as those that actually threaten the health of
the client (individual, family or community). These plans are broken down to manageable units
and properly sequenced. Periodic evaluation and modification of the plan is necessary. The plan
and activities should be coordinated with the various services so that it would synchronize with
the total health program of the community.
Development of evaluation parameters is done in the planning stage and based on standards set
by the nursing services, problems identified, goals and priorities as reflected in the plan or
program of nursing care for the clients.
Implementation of Planned Care

In community health nursing, implementation involves various Nursing interventions which have
been determined by the goals/objectives that have been previously set. The public health nurses
carry out nursing procedures which are consistent with the nursing care plan, are adopted to
present situations which promote a safe and therapeutic environment.
Public health nurses involve the patient and his/her family in the care provided in order to
motivate them to assume responsibility for his/their care. and to be able to teach and maintain a
desired level of function. explaining and answering questions to clarify doubts, to maximize the
client's confidence and ability to care for himself/ themselves. Thus. the role of the community
health nurse shifts from direct care giver to that of a t eacher.
To maintain his/her optimum level of functioning, the client needs the support of his own
knowledge and that of those around him/her. The utilization of a support system provides a
harmonious, orderly care to enable client to function optimally. Through coordination initiated by
the public health nurses, the client is offered planned assistance. He/she becomes his/her own
best to get services for help. Frier'lds, neighbors, church members, community agencies,
organization both government and private are variO\.IS resources that can be tapped.
The public health nurses monitor the health services provided, make proper referrals as
necessary and supervise midwives and barangay health workers. The knowledge and skills of
the midwives and barangay health workers are continuously updated through planned education
programs.
Documentation is an important function of the public health nurses This provides data which is
needed to plan the client's care and ensure its continuity: serves as an important communication
tool for various team members: furnishes written evidence of the quality of care that the clients
received and their response to it: whether revisions were made in his/her plan of care and
whether such has been effective. They are legal records to protect the agency and the health
care providers or the client himself/herself. They also provide data for research and education.
46 Public
Health Nursing
Evaluation of Care and Services Provided

Evaluation is interwoven in every nursing activity and every step of the public health
nurses. There are three classic frameworks from which nursing care is delivered. An
improvement in a!:lY.QIJ.§l of these three tends to produce favorable change in the
other two. ------,
(t;structural elements include the physical settings, instrumentalities and conditions

through which nursing care is given such as philosophy, objectives, building,
organizational structure, financial resources such as budget, equipment and staff.
Processelements include the steps of the nursing process itself-assessing, planning,

implementing and evaluating: such as taking the family health data base: performing
physical examination: making a nursing diagnosis: determining nursing goals:
writing a nursing care plan: performing the necessary nursing interventions and
coordination of services and measuring success of nursing actions.
1,
-·· Outcome elements are changes in the client's health status that result from nursing
intervention. These changes include modification of symptom. signs, knowledge.
attitudes. satisfaction, skill level and compliance with treatment regimen.
Each of these frameworks permits more than one approach to quality assurance. For
example. structure can be examined from the standpoint of the total community . in
which the patient lives and the public health agencies from which he/she receives
his/her care. Process can be examined by focusing on the actions and decisions of
the public health nurse in providing care. Outcome elements refer to the results of
care provided and the clients served, changes in the knowledge, skills and attitudes
and satisfaction of those served/including members of the nursing and health team.
' Quality assurance efforts now recommend that evaluation of structure, process and
outcomes criteria be made. This will evaluate the effectiveness of nursing care done
or changes in behavior, condition, or compliance.
Evaluation based on professional practice include conformity With accepted

community and public health standards of practice, continued refinement and
enhancement of nursing skills through continued field experience and a program of
continuing education.
Evaluation of structure include cost-benefit ratio, qualifications and number of

members of the health team especially nurses in proportion to the populations
served and the material resources in terms of quantity and quality.
Evaluation based on information gathered is utilized to improve community health

nursing services as part of the total community health services.

NUf!S!NG PROCEDURES
/CLINICVISf-T ~"'lej"""ie -v> / }MC\)

The patient visits the Health Center/clinic to avail of the services thereto offered by
the facility primarily for consultation on matters that ailed them physically.
Nowadays, patients are becoming aware of the other services that the Health
Center offer such as Pre-natal and post partum care , well baby check up,
immunization, free medicines under DOTS and other health care.
Most often, patients utilized the facility mainly for the said purpose. But with the
changing time, close interaction between health care providers and patient have
been intensified with other health programs prior to the actual nurse-patient contact
such as enhanced health education and promotion on health care of the family in
totality. The nurse plays a very important role in building a closer ties with the
patient to gain their trust and confidence and particularly in the implementation and
promotion of health care.
Pre-consultation conference>
A pre-clinic lecture is usually conducted prior to the admission of patients, which is
one way of providing health education: ·· '/
Standard procedures performed during clinic visits

" I. Registration/Admission
'h Greet the client upon entry and establish rapport.
2. Prepare the family record of new patients or retrieve records of old clients. 3.
Elicit and record the client's chief complaint and clinical history. 4. Perform
physical examination on the client and record it accordingly.
II. Waiting time

1. Give priority numbers to ,clients.
policy except for emergency/urgent
2. Implement the "firstcome,J;ist servecf'1
'cases. ..,. .. .
-, ~
··-
Ill. Triaging
1. Manage program-based cases.
(Certain programs of the DOH like the IMCI.utilize an acceptable decision to
w.hich the nurse has to follow in the management of a simple case).
Example - for control of a diarrheal diseases (COD), assess if the child has
diarrhea
-- , - If he has, for how long- is there blood in the stool?
-Assess the child's general condition- sleepy, difficult to awaken, restless
and irritable
- Observe for sunken eyes
"--:: Offer fluid. Is he able to drink or is he drinking regularly, thirsty
~inch skin of the abdomen- does it go back very slowly?
2. Refer all non-program based cases to the physician. For all other cases which
has no potential danger, treatment/management is initiated by the nurse and
she decides to do her own nursing diagnosis and then refer to

the physician for medical management

-- 3. Provide first-aid treatment to emergency cases and refer when necessary to , the next level
of care. ·
' IV. Clinical Evaluation

1 . Validate clinical history and physical examination
2. The nurse arrives at evidence-based diagnosis and provides rational treatment based on DOH
programs.
a. identify the patient's problem
b. formulate/write the nursing diagnosis and validate
c. give/perform the nursing intervention
d. evaluate the intervention if it has enabled the patient to achieve the desired outcome
·. 3. Inform the client on the nature of the illness, the appropriate treatment and prevention and
control measures.
V Laboratory and other diagnostic examinations

1. Identify a designated referral laboratory when needed.
VI. Referral System / , /,. ~.\ .- ~

··· ..... 1. Refer the patient ~ he ~ds J~rther ~nagement follbwing the two-
way ·, referral system (BHS to RHU, RHU to RHU, RHU to Hospital) . . , 2. Accompany the
patient when an emergency referral is needed. ~
---w. Prescription/Dispensing ·
1. Give proper instructions on drug intake
VIti. Health Education

1. Conduct one-on-one counseling with the patient.
2. Reinforce health education and counseling messages
3. Give appointments for the next visit.
' . . ··•·· ·. ·~
1
. BLOOD PRESSURE MEASURE~/
~easuring and monitoring blood pressure is a very common procedure and yet, iS:Often
performed incorrectly. Errors in measurement may mean wrqng decisions in blood pressure
management, ·thus compromising care. Efforts were made to standardize the procedure using
the guidelines provided by the Philippine Soci
ety of Hypertension translated for nurses by UP College of Nursing.
Procedure
. I .. Pr~paratQ_ry_phase
. ..-rntroduce selflo Cli~nt. . • Make sure client is relaxed and has res1e£L~e3~\~itinutes and should
not have smoked or ing~§!~d_~~i~~ tes b~fore BP measurement. / ·· .... __. • Explain the procedure
to the client at his/her level of understanding. • Assist to seated or supine position.
Public Health
Nursing 49
ltApplying !he ~P cuff and steth_<:>~~o~

• Barechents-arrn. ·· --~ . .
• Apply cuff around the upper arm (3
cm)above the brachial artery. •
Apply cuff snugly with nocrea_ses:· ·
• Keep the manometer at eye leveL
• Keep armleverwtth his7ner heart by placing it on a table or a chair arm or by
supporting it with examiners hand. If client is in recumbent position, rest arm at
his/her side. __ .
• Palpate brachial pulse correctly just below or_Sligtltly- medial to the antecu
bital area.
Ill. Obtaining the BP readying by ausculation

• Place earpieces of stethoscope in ears and stethoscope head over the brachial
pul~
• Use the beiJ (or di~9!!L!Qr_ol:>~~ersons) of the stethoscope to auscultate p·ulse.
• Watching the manometer, inflate the cuff rapidly by pumping the bulb until the
column or needle reaches ~_mm. Hg. Above th~p~lpat~~P. • Deflate cuff slowly at a
~m. Hg/beat.
• While the cuff is deflating, listen for pulse sounds (Korotkoff sounds)
**Note the appec;~rance of the first clear tapping sound. Record this as l>YStolic
BP (Korotkoff Phase I)
**Note the diastolic BP which is the disappearance of sounds (Korotkoff

Phase V) unless sounds are still heard near 0 mm. Hg. In which case
softening/muffling of sounds is noted (Korotkoff Phase IV).
II. Recording BP and other guidelines

For every first visit of the client:
• Take the mean of 2 readings, obtained at least 2 minutes apart, and consider
this as the client's blood pressure. '
• If the f~~S mm. Hg. Or more, obtain a 3'd rea_Qing and include this in the
average. If firsfvlsit, repeat the procedure wittLtbaotb.er arm. Subsequently, !
3P re~ngs should then be performed onlb.aarm'l{ith aj)igher_BP. ~ ·
• Document Phases I, IV and V by following the format for recording BP:
systolic /muffling/disappearance (e.g. 120-80-76).
• Inform client of _!~_s_IJ!t__~nd J~.@y. for .<~_wl:!ila_ to answer _client'~ qu~stions/ concerns.
HOME VISIT
The home visit is a family-nurse contact which allows the health worker to assess
the home and family situations in order to provide the necessary nursing care and
health related activities. In performing this activity, it is essential to prepare a plan of
visit to meet the needs of the client and achieve the best results of de
sired outcomes.
5
Purpose of home visit

. 1. To give nursing care to the .sick, to a poslparjum mother and tmr_newborn with the view to
teach a responsible family member to give the subsequent care. 2. To as~~livi119 condition of the
patient and his family and their health practices in order to provide the appropriate health
teaching
3. To give health teachings regarding the pr~ventian and control of diseases 4. To e~~e_r~hip
between the health agencies and the public for the promotion of health
5. To make u~~ of the inter-referral ~~tem and to promote the utilization of community services.
Principles involved in preparing for a home visit

When we plan to go on a home visit, it is necessary to assemble the records of the patients and
list the names to be visited, study the case and have a written nursing care plan.
1. A home visit must have a purpose or objectiver / 2. Planning for a home visit should make 4se
of all_9~~!_111ation about the patient and his family through family records. /
3. In planning for a visit, we should consider and give ,Priority to the essential needs of the
individual and his family.
4. Planning and delivery of care should involve the individuC!_Larui..fglmily. v 5. The plan should
be ~le.
Guidelines to consider regarding the frequency of home visits There is ~~ rule !o __ b~ _
fpiiQwed on the freq_l,!ency of home visits. The schedule of the visit may vary according to the
need of the patient or family for nursing care, but one has to consider the following factors:
1. The physical needs, psychological needs and educational n.eeds of the indi vidual and family
2. The acceptance of the family for the services to be rendered, their interest and the willingne~s to
cooperate
3. The policy of a specific agency and the emphasis given towards their health programs
4. Take into account other health agencies and the number of health personnel already involved
in the care of a specific family
5. Careful evaluation of past services given to a family and how the family avail of the nursing
services
6. The ability of the patient and his family to recognize their own needs, their knowledge of
available resources and their ability to make use of their re sources for their benefits
/ steps in conducting home visits

1. Greet the patient and introduce yourself
2. State the purpose of the visit
3. Observe the patient and determine the health needs
4. Put the bag in a convenient place then proceed to perform the bag technique 5. Perform the
nursing care needed and give health teachings 6. Record all important data, observation and
care rendered
7. M2ke appointment f~ '!. ~urn visit
Public Health
Nursing 51
THE BAG TECHNIQUE

~e b~~~~nigye i?__E_tool by which the nurse, during her visit will enable her to peiform a
nursing procedure with ease and deftness, to save time and effort, with the end
view of rendering effective nursing care tQs;lients .
. Ib5l public health bag is a~ari~ mdispe.oS~Ie equipme~ a public

healtb..nurse which §he has to·cany along during b.~ home Visits~ns . __ basic
medications and articles~ecessary for gtving care. -- ---~
-- -- -~
--Prii.ciples of bag technique
d(.i. ~erforming the bag technique will_mJnimize, if nQLprevent the_wead of any '\.. .. -.::
~nfection . · .. .
' 2,:"')( sav~s time and effort in the performance of nursing procedures. f·1· T ba~
technique should show the effectivene~f!Qt§l care given to an individual .'> fam1ly. .
4. e bag technique can be performed in ~~ depending on the \ gency's policy, the
home situation, or as long as principleSof avoiding trans
fer of infection is always observed. Thermometers (oral and rectal)
Contents of the public health bag Paper lining

Extra paper for making waste bag Plastic/linen ~~'€ 7( z-J '( p rer1) \OJYi~ ·,'v -; ':_)
lining V\~d
Apron
Hand towel ~
Soap in a soap dish
2 pairs of sCissors ( surgical and bandage ) 2 pairs

of forceps (curved and straight ) Disposable
syringes with needles (g. 23 & 25) Hypodermic
needles g. 19,22,23,25
Sterile dressing
Cotton balls ( dry and with alcohol )
Cord clamp
Micropore plaster
Tape measure
1 pair of sterile gloves
Baby's scale
Alcohol lamp
2 test tubes
Test tube holders
Solutions of
Betadine 70% alcohol
Zephiran solution Spirit of ammonia Hydrogen peroxide Ophthalmic ointment
Acetic acid Benedict's solution
*Sphygmomanometer and stethoscope are .carried separately.

Important points to consider In the use of the bag

1. The bag should contain all the necessary articles, supplies and equipments that
will be used to answer emergency needs.
2. The bag and its contents should be cleaned very often, the supplies replaced,
and ready for use anytime .
.t3. The bag and its contents should be well protected from contact with any article in
the patient's home. Consider the bag and its contents clean and sterile, while
articles that belong to the patients as dirty and contaminated.
r4. The arrangement of the contents of the bag should be the one most conve nient
to the user, to facilitate efficiency and avoid confusion.
Steps In Performing the Rationale
Bag Technique Actions
1. Upon arrival at the patient's home, place the To protect the bag from getting bag
on the table lined with a clean paper. contaminated
The clean side must be out and the folded
part, touching the table.
2. Ask for a basin of water or a glass of drinking To be used for handwashing
water if tap water is not available.
3. Open the bag and take out the towel and To prepare for handwashing soap.
4. Wash hands using soap and water. wipe to To prevent infection from the dry.
care provider to the client
5. Take out the apron from the bag and put it on To protect the nurse's uniform
with the right side out
6. Put out all the necessary articles needed for To have them readily acces- ' the
specific care. sible
7. Close the bag and put it in one corner of the To prevent contamination
working area.
8. Proceed in performing the necessary nursing To give comfort and security care
and treatment and hasten recovery
9. After giving the treatment, clean all things To protect the caregiver and that were
used and perform handwashing prevent infection
10. Open the bag and return all things that were
used in their proper places after cleaning
them.
11. Remove apron, folding it away from the per

son, the soiled side in and the clean side
out. Place it in the bag
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·~ .. ;~-:~ l \;.w· \ ';'li V-Pi-\'-·;·ri \: ~t . 'V/·i\:·-,.t'",i:·...:t -, ... ~-d .\' .. ('·.:{\ 1 \; li/ -., _~JI >.:·-·.:-71/ \r·· i-\'i;-'1/ ~·;-
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{ l,::-:1/ _r:_:· 'tf/ ... ~

12. Fold the lining, place it inside the bag and

Close the bag.
13. Take the record and have a talk with the For reference in the next visit Mother.
Write down all the necessary data
that were gathered, observations, nursing
care and treatment rendered. Give instruc
tions for care of patients in the absence of
the nurse.
14. Make appointment for the next visit (either For follow-up care
home or clinic) taking note of the date and
time
/NURSING CARE IN THE HOME
Giving to the individual patient the nursing care required by his/her specific ill ness
or trauma to help him/her reach a level of functioning at which he/she can maintain
himself/herself, or die peacefully in dignity.
,. Principles in Nursing Care .•

1. Nursing care uijlizeS-a med!g~l plan )>f care and.treatment.
2. The performance of nursing "care"" E,fl~~~ s~iii~ that would give maximum comfort "
and security to the individual. "- ....... ~ . ..

3. Nursing care given at home should be used as a t~chiog opp£!!_lf nity to the patient or
to any responsible member of the family. ~, . .r ·
··
4. The performance of nursing care should recogniz~dange'1> in the patient's over-

prolonged acceptance of support and comfort .. ,
5. Nursing care is a good opportunity for detecting abnormal signs and symptoms,
observing patient's attitude towards care given and the progress exhibited by the
patient.
...-Isolation Technique in the Home

Generally, strict isolation technique is difficult to carry out in the homes where
houses are small and occupy a large number of people.
1 . All articles used by the patient should not be mixed with the articles used by the
rest of the members of the household.
2. Frequent washing and airing of beddings and other articles and disinfection of
room are imperative. Abundant use of soap, water, sunlight and some chemi cal
disinfectants is necessary.
3. The one caring for the sick member should be provided with a protected gown
that should be used only within the room of the sick.
4. All discharges, especially from the nose and throat of a communicable disease
patient, should be carefully discarded.
5. Articles soiled with discharges should first be boiled in water 30 minutes before
laundering. Those could be burned, should be burned.

/ COMMUNITYORGANIZING (~ w~~ C0P.AR J. Studies have underscored some key

elements of the community which may be reactivated to bring social and behavioral change.
These include social organizations (relationships, structure and resources), ideology (knowledge,
beliefs and attitudes) and change agents. This process of change is often termed as
"empowerment" or building the capability of people for future community action.
Five stages of Organizing: A Community Health Promotion Model The five stage model has
identified key elements/tasks to be performed in each step. However, it should be noted that
activities and tasks may be repeated in succeeding stages and that overlapping of stages is
common.
Stage 1: Community Analysis

"The process of assessing and defining needs, opportunities and resources involved in initiating
community health action program (Haglund)." This process may be referred to as "community
diagnosis," "community needs assessment," "health education planning" and "mapping."
This analysis has five components.

1. A demographic, social and economic profile of the community derived from secondary data.
2. Health risk profile (social, behavioral and environmental risks). Behavioral risk assessment
includes dietary habit and other lifestyle ccincerns like alcohol, tobacco, and drugs. Social
indicators of risk are studied because of its associations to health status and this may include
exposure to long-term unemployment, low education and isolation.
3. Health/wellness outcomes profile (morbidity/mortality data). 4. Survey of current health
promotion programs.
5. Studies conducted in certain target groups .
• Steps in community analysis
a) Define the Community. Determine the geographic boundaries of the target community. This is
usually done in consultation with representatives of the various sectors.
b) Collect data. As earlier mentioned, several types of data have to be collected and analyzed.
c) Assess community capacity. This entails an evaluation of the "driving forces" which may
facilitate or impede the advocated change. Current programs have to be assessed including the
potential of the various types of leaders/ influential, organization and programs.
d) Assess community barriers. Are there features of the new program which run counter to
existing customs and traditions? Is the community resilient to change?
e) Assess readiness for change. Data gathered will help in the assessment of community
interest, their perception on the importance of the problem. f) Synthesis data and set priorities.
This will provide a community profile of the needs and resources, and will become the basis for
designing prospective community interventions for health promotion.
Public Health
Nursing 55
Stage 2: Design and Initiation

In designing and initiating interventions the following should be done: a) Establish a ~group and
select a locai...Qrganizer. Five to eight committed members of the community may be selected
todo the planning and management of the program. The skill of the local organizer is vital to the
program success. In fact, his management skills -good listening and conflict resolution skills are
crucial in the selection of the local organizer. b) Choose an organizational structure. There are
several organization structures which can be utilized to activate community participation. These
include the following:
• Leadership board or council - existing local leaders working for a com mon cause.
• Coalition - linking organizations and groups to work on community is sues.
• "Lead" or official agency - a single agency takes the primary responsi bility of a liaison for health
promotion activities in the community. • Grass-roots - informal structures in the community like
the neighbor hood residents.
• Citizen panels- a group of citizens (5-10) emerge to form a partnership with a government
agency.
• Networks and consortia - Network develop because of certain con cerns.
c) Identify, select and recruit organizational members. As much as possible, different groups,
organizations sectors should be represented. Chosen representative have power for the groups
they represent.
d) Define the organization mission and goals. This will specify the what, who, where, when and
extent of the organizational objectives.-
e) Clarify roles and responsibilities of people involved in the organization. This is done to
establish a smooth working relationship and avoid overlapping of responsibilities.
f) Provide training and recognition. Active involvement in planning and manage m~nt of programs
may require skills development training. Recognition of the program's accomplishment and
individual's contribution to the success of the program and boost morale of the members.
Stage 3: Implementation
Implementation put design plans into action. To do so, the following must be done:
a) Generate broad citizen participation. There are several ways to generate citi zen participation.
One of them is organizing task force, who, with appropriate guidance can provide the necessary
support.
b) Develop a sequential work plan. Activities should be planned sequentially. Of tentimes, plan
has to be modified as events unfold. Community members may have to constantly monitor
implementation steps.
c) Use comprehensive, integrated strategies. Generally the program utilize more than one
strategies that must complement each other.
d) Integrate community values into the programs, materials and messages. The community
language, values and norms have to be incorporated into the program.
\(;_ri \~·7{ \>1 \(../\r.i/ \.:}i\7.7/1 -}l\·- ~4\t
,r:_ l! \;~{ •tJI \;'J.i-..,t?l ':.:?-i\r;:-?1 'W·tif\.•,·.:;.;·•,_r;·ii"f,ifi\:._:.;:tf \_:::;! "¥ i\·:~-/''(';l!f \'?l"'i-)l'*f1"7t("Crl v·:,'!fi \y)/ \: ·v:tl'(;:i Viil"F:i
:t1 56 Public
Health Nursing
Stage 4: Program Maintenance - Consolidation .

The program at this point has experienced some degree of success and has
weathered through implementation problems. The organization and program is
gaining acceptance in the com,munity.
To maintain and consolidate gains of the program, the following are esential: a)
Integrate !ntervention activities into community networks. This can be affected
through implementation problems. The organization and program is gaining
~
acceptance the community.
in
b) positive A~·environment is a
Establish a organizational culture.
critical element in maintaining cooperation and preventing fast turnover of
members. This is the result of good group process based on trust, respect, and
openness.
c) Establish an ongping recruitment plan. It should be expected that volunteers may
leave the organization. This requires a built in mechanism for continuous
recruitment and training of new members.
d) ~s. Continuous feedback to the community on results of activities enhances
visibility and acceptance of the organization. Dissemination of information is vital
to gain and maintain community support.
Stage 5: Dissemination - Reassessment

Continuous assessment is part of the monitoring aspect in the management of the
program. Formative evaluation is done to provide timely modification of strategies
and activities. However, before any programs reach its final step, evaluation is done
for future direction.
a) Update the community analysis. Is there is a change in leadership, resources
and participation? This may necessitate reorganization and new collaboration
with other organizations.
b) Assess effectiveness of interventions/programs. Quantitative and qualitative ,
methods of evaluation can be used to determine participation, support and behavior
change level of decision-making and other factors deemed important to the
program.
c) Chart future directories and modifications. This may mean revision of goals and
objectives and development of new strategies. Revitalization of collaboration
and networking may be vital in support of new ventures.
d) Summarize and disseminate results. Some organizations die because of
the ,.la9k of visibilitx. Thus, a dissemination plan maybe helpful in diffusion of
infor mation to further boost support to the organization's endeavor.
Among the more traditional roles of a public health nurse are those of a health
educator and community organizer. Inherent in health promotion and disease
prevention is the ability of the public health nurse to educate and organize people
so they can participate in building healthier communities. As such,a greater
understanding of the concepts of health promotion, health education,
communication process, and community organizing is a must for the public health
nurse.
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\till \·:·,.,;·'t?/ '•;:),, Public Health Nursing 57
HEALTH PROMOTION AND EDUCATION

The prominence of health promotion came about as a result of the changing patterns of health
and the corresponding emphasis on"life style" as a factor. Life style is a composite expression of
the social and cultural circumstances that condition and constrain behavior. Although health
education had been successful to change single-directed acts, many policy makers and health
officials were not confident that health education could bring about changes in life styles. Public
health education could have an impact on public health only if it joined other sectors and brought
multiple social forces to bear. The behavioral change that health education is able to effect can
only be maintained if supportive environment were provided through the effort of other sectors-
political, economic, social, bio
medical etc. (Green)
The first use of the term health promotion occurred in 1945 when Henry E. Sigerist, the great
medical historian defined the four major tasks of medicine as 1) the promotion of health; 2) the
prevention of illness; 3) the restoration of the sick and 4) rehabilitation. According to him, "health
is promoted by providing a decent standard of living, good labor conditions, education, physical
culture, means of rest and recreation". These concepts are found in the Ottawa Charter for
Health Promotion which occurred 40 years later.
IN 1986, the WHO, Health and Welfare Canada and the Canadian Public Health Association
organized an International Conference on Health Promotion. The Conference came out with what
is now popularly known as the Ottawa Charter for Health Promotion which was adopted by 212
participants from 38 countries. Since then various charters have been issued on health promotion
but the Ottawa Charter remained to be the guiding principle in heatlh promotion efforts currently.
The Ottawa Charter for a Health Promotion

The Ottawa charter defines health promotion broadly, as "the process of enabling people to
increase control over and to improve their health." To reach a state of complete physical, mental
and social well-being, an individual or group must be able to identify and to realize aspiration; to
satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a
resource for everyday life, not the objective of living. Health is a positive concept emphasizing
social and personal resources, as well as physical capacities. Therefore, health promotion is not
just the responsibility of the health sector, but goes beyond healthy life
styles to well-being.
~erequisite for Health

The fundamental conditions and resources for health are listed below. Improvement in health
requires a secure foundation in these basic prerequisites. • Peace,
·Shelter,
• Education,
·Food,
58 Public
Health Nursing
• Income, • Social justice and, ·Equity.

• A stable eco-system, • Sustainable resources, THE PUBLIC HEALTH NURSE
In order to operationalize the concept of health promotion the Charter

recommended the following action areas:
1. Build Healthy Public Policy

Health promotion goes beyond health care. It puts health on the agenda of policy
makers in all sectors and at all levels, directing them to be aware of the health
consequence of their decisions and to accept their responsibilities for health.
Health promotion policy combines diverse but complementary approaches including

legislation, fiscal measures, taxation, and organizational change. It is a coordinated
action that leads to health, income and social policies that foster greater equity.
Joint action contributes to ensuring safer and healthier goods and services ,
healthier public services, and clear, more enjoyable environments.
Health promotion policy requires the identification of obstacles to the adoption of

healthy public policies in non-health sectors, and ways of removing them. The aim
must be to make the healthier and easier choice for policy makers as well.
2. Create Supportive Environments

Our societies are complex and interrelated. Health cannot be separated from other
goals. The inextricable links between people and their environment constitutes the
basis for a socio-ecological approach to health. The overall guiding principle for the
world, nations, regions, and communities alike, is the need to encourage reciprocal
maintenance - to take care of each other, our communities and our natural
environment. The conservation of natural resources throughout the world should be
emphasized as a global responsibility.
Changing patterns of life, work and leisure have a significant impact on health.
Work and leisure should be a source of health for people. The way society
organizes work should help create a society. Health promotion generates living and
working conditions that are safe, stimulating, satisfying and enjoyable.
Systematic assessment of health impact of a rapidly changing environment -

particularly in areas of technology, works, energy production and urbanization - is
essential and must be followed by actions to ensure positive benefit to health of the
public. The protection of the natural and built environments and the conservation of
natural resources must be addressed in any health promotion strategy.

3. Strengthen Community Action

Health promotion works through concrete and effective community action in setting
priorities, making decisions, planning strategies and implementing them to achieve
better health. At the heart of this process is the empowerment of communities - their
ownership and control of their own endeavors and destinies.
Community development draws on existing human and material resources in the

community to enhance self-help and social support, and to develop flexible system
for strengthening public participation in and direction of health matters. This
requires full and continuous access to Information, learning opportunities for health,
as well as funding support.
4. Develop Personal Skills

Health promotion supports personal and social development through providing
information, education for health, and enhancing life skills. By so doing, it increase
the options available to people to exercise more control over their own health and
over their environments and to make choices conducive to health.
Enabling people to learn throughout life, to prepare themselves for all of its stage
and to cope with chronic illness and injuries is essential. This has to be facilitated in
school, home, work, and community settings. Action is required through
educational, professional, commercial, and voluntary bodies, and within the
institution themselves.
5. Reorient Health Services

The responsibility for health promotion in health services is shared among
individual; community groups, health professionals, health service institutions and
governments. They must work together towards a health care system which
contributes to the pursuit of health.
The role of the health sector must move increasingly in a health promotion direction,
beyond its responsibility for providing clinical and curative services. Health services
need to embrace an expanded mandate which is sensitive and respects cultural
needs. This mandate should support the needs of individuals and communities for a
healthier life, and open channels between the health sector and broader social,
political, economic, and physical environment components.
Reorienting health services also requires stronger attention to health research as
well as changes in professional education and training. This must lead to a change
of attitude and organization of health services which refocuses on the total needs of
the individual as a whole prerson.
The WHO cites the following principles of health promotion: 1. Health

promotion involves the population as a whole in the context of their everyday life,
rather than focusing on people at risk from specific diseases. 2. Health promotion is
directed towards action on the determinants or cause health. This requires a close
cooperation between sectors beyond health care reflecting the diversity of
conditions which influence health.
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-.~ tl "~ v:,:qtl ~"·,.,· \~j ;·vt \·_:':1 v·.,if \'"JI".·:''ili \::·} v:~,'f v~r'l \t"l \:'w/\~·'1\: .·:. // '; ~i\-··: tl -. .. ··:7( 60 Public
Health Nursing
3. Health promotion combines diverse, but complementary methods or approaches, including

communication, education, legislation, fiscal development and spontaneous local activities
against health hazards.
4. Health promotion aims particularly at effective and concrete public participation. This requires
the further development of problem-defining and decision-making life skills, both individually and
collectively, and the promotion of effective participation mechanisms.
5. Health promotion is primarily a societal and political venture and not a medical service,
although health professionals have an Important role in advocating and enabling health
promotion. (WHO Health Promotion Glossary 1990)
Although health promotion has enjoyed a lot of attention and more than a decade, there still exist
a number of disagreements of what the definition and significance is. A review of the different
ways in which it is being implemented in different countries shows the variety of interpretation
given to it. Some countries tend to equate health promotion with intervention aimed only at
promotion in terms of social action and community intervention. Health promotions need to
reflect both perspectives, including organizational, economic and environmental strategies
together with individual knowledge, attitudes and skills. The WHO adopts an ecologic view of
health promotion and state that it is a "mediating strategy between people and their
environments, synthesizing personal choice and social responsibility in health."
Health promotion has lately assumed prominence because of the emerging public health
problems. While in the past the umbrella was health education with health promotion as only one
of its ribs, some authors have proposed to treat health promotion as a broader endeavor and
subsumes health education within its boundaries. Others do not make too much distinction
between the two and use them intecrhangeably.
H'ealth Education
Green defined health education as "any combination of learning experience designed to facilitate
voluntary adoptions of behaviors conducive to health." (Green et al1980)
The National Task Force on the Preparation and Practice of Health Educators (1983) defined
health education as "the process of assisting individuals, acting separately or collectively, to
make informed decisions about matters affecting the personal health and that of others."
The Scope of Health Education

Health education covers the continuum of what Leavell calls the levels of prevention; from health
promotion, specific health protection, early diagnosis and treatment, disability limitation to
rehabilitation. In all levels of prevention. Health education plays an important role. All the program
thrusts of the health care delivery system have corresponding health education/promotion
components.
The various labels used for health education programs and activities such as dissemination of
health information, communication, social marketing, motivation programs, behavior modification,
health counseling, etc. illustrate the scope, diversity and boundaries of educational application in
health.
Health education can take place in various settings, either formally or informally/ incidentally.
They take place in health care settings such as health centers, clinics, hospital, health
maintenance organizations where health education for patients, their families, the surrounding
communities can take place and where the training of health care providers have become part of
health care today; 2) schools where desirable health behaviors is installed from the grades up
through health teachings, supportive hygienic school environment, school health services,
teachers training and the training of health professionals; 3) communities, where through the
community organization approach, communities are able to identify their health problems, and
through group decision and action, find solutions to their problems; 4) the worksite such as
industries, offices, food establishment, entertainment establishment, hotels, etc. where one can
find captive groups with specific health problems that are common to each group.
/
vEPIDEMIOLOGY
Epidemiology is the study of occurences and distribution of diseases as well as the distribution
and determinants of health states or events in specified population, and the application of this
study to the control of health problems. This emphasizes that epidemiologist are concerned not
only with deaths, illness and disability, but also with more positive health states and with the
means to improve health.
Two main areas of investigation are concerned in the definition, the study of the distribution of
disease and the search for the determinants (causes) of the disease and its observed
distributions. The first area describes the distribution of health status in terms of age, gender,
race, geography, time and so on might be considered in an expansion of the discipline of
demography to health and diseases. The second area involves explanations of the patterns of
disease distribution in terms of causal factors. Many discipline seeks to learn about the causes
of the diseases; the special contribution of epidemiology are its search for concordance between
the known or suspected causes of the disease and the known patterns to investigate for possible
causal roles.
Consequently, we speak of the epidemiology of heart disease, measles or accidents because

each disease has the same element; the disease determinants, the human population in which
the disease occurs, and the distribution of the disease in the population.
hpidemiology, therefore is the backbone of the prevention of the disease.
In order to control a disease effectively, the conditions surrounding its occurrence and the factors
favoring the development of the disease must first be known.
62 Public
Health Nursing
Uses of Epidemiology:
According to Morris, epidemiology is used to:
• Study the history of the health population and the rise and fall of diseases and changes in their
character.
• Diagnose the health of the community and the condition of people to measure the distribution
and dimension of illness in terms of incidence, prevalence, disability and mortality, to set health
problems in perspective and to define their relative importance and to identify groups needing
special attention.
• Study the work of health services with a view of improving them. Operational research shows
how community expectations can result in the actual provisions of service.
• Estimate the risk of disease, accident, defects and the chances of avoiding them
• Identify syndromes by describing the distribution and association of clinical phenomena in the
population.
• Complete the clinical picture of chronic disease and describe their natural history
• Search for causes of health and disease by comparing the experience of groups that are clearly
defined by their composition, inheritance, experience, behavior and environments.
Figure 4- The
Epidemiologic Triangle
The Epidemiologic Triangle
The Epidemiologic Triangle consists of three component- host, environment and agent. The
model implies that each must be analyzed and understood for comprehensions and prediction of
patterns of a disease. A change in any of the component will alter an existing equilibrium to
increase or decrease the frequency of the disease.
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7
We focus on human and the forces within him and within the environment that
influence his state of health. From this viewpoint, the human is the host organism,
other organism like animals are considered only as they relate to the human health.
The hQ§! is any organism that harbors and provides nourishment for another
organism.
Awmt is the intrinsic property of microorganism to survive and multiply in the

environment to produce disease. Causative agent is the infectious agent or its toxic
component that is transmitted from the source of infection to the susceptible body.
The state of the host at any given time is a result of the interaction of genetic
endownment with environment over the entire lifespan. Environment is the sum total
of all external condition and influences that affects the development of an organism
which can be biological, social and physical. The environment affects both the
agents and the host. ·
Three component of the environment:.

1. Physical environment-is composed of the inanimate surroundings such as the
geophysical conditions of the climate.
2. Biological environment makes up the living things around us such as plants and
animal life.
3. Socio-economic environment which may be in the form of level of economic
development of the community, presence of social disruptions and the like.
Approach to Disease and its Determinants

The present epidemiology approach is based on the interaction of the host, the
causative agent, and the environment. Essentially, epidemiologic patterns depend
upon these factors which influence the probability of contact between an Infectious
agent and a susceptible host.
' The presence of infectious materials varies with the duration and the extent of its
excretion from an infected person the climactic conditions affecting survival of the
agent, route of entry into the host and the existence of alternative reservoirs or host
of the agent. The availability of susceptible host depends upon the extent mobility
and interpersonal contact within the population group, and the degree and duration
of immunity from previous infection with the same or related agents.
Classification of Agents, Host and Environmental Factors which determine the

occurrence of Disease in Human Population
1. Agents of Disease Etiological factors: Examples
A. Nutritive elements
Excess B. Chemical agents
Deficiencies Cholesterol
Vitamins, Proteins
Poisons Carbon monoxide, drugs
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1
V7/'r!lfl 64 Public Health Nursing
Allergens
C. Physical agents
D. Infectious agents Metazoa

Protozoa
Bacteria
Fungi
Rickettsia
Viruses
Ragweeds, poison ivy

Heat, light, ionizing radiation .
Hookworm, schistosomiasis
Amoeba Malaria
Rheumatic fever, lobar
Pneumonia, typhoid
Histoplasmosis, athlete's foot
Rocky mountain, spotted fever
Measles, mumps, chicken pox
Poliomyelitis, rabies
2. Host Factors (Intrinsic Factors) - influences exposure, susceptibility or re sponse to agents

A. Genetic
B. Age
C. Sex
D. Ethnic group
E. Physiologic
F. Immunologic
Experience
Active
Passive
G. Inter-current or pre-existing disease
H. Human Behavior
Sickle cell disease
Fatigue, pregnancy, puberty, stress
Hypersensitivity
Prior infection, immunization Maternal antibodies, gammaglobulin
Personal hygiene, food handling
3. Environmental factors (Extrinsic Factors)- influences existence of the agent, exposure, or

susceptibility to agent
A. Physical environment B. Biologic Environment Human population Flora

Geology, climate
Density
Sources of food, influence on Vertebrates & anthropod as source of agent
C. Socio-economic environment
Occupation Exposure to chemical agents Urbanization Urban crowding, tension and Pressures
Disruption Wars, disasters
Disease Distribution
The methods and technique of epidemiology are desired to detect the cause of a disease in
relation to the characteristic of the person who has it or to a factor present in his environment.
Since neither population and environment of different times or places are similar, these
characteristics and factors are called
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"~ .t "~'"'ul!i\;; ~ Public Health
Nursing 65
epidemiology variables. These variables are studied since they determine the individuals and
populations at greatest risks of acquiring particular disease, and knowledge of these associations
may have predictive value.
For the purpose of analyzing epidemiology data, it has been found helpful to organize that data
according to the variables of time, person and place;
Time refers both to the period during which the cases of the disease being studied were exposed
to the source of infection and the period during which the illness occurred. The common practice
is to record the temporal occurrence of disease according to date, when appropriate, the hour of
onset of symptoms. Subsequently, all similar cases are grouped or examined for various span of
time: an epidemic period, a year, or a number of consecutive years. This analysis of cases by
time enables the formulation of hypotheses concerning time and source of infection, mode of
transmission, and causative agent.
Epidemic period: a period during which the reported number of cases of a disease exceed the
expected, or usual number for that period. • Year: For many diseases the incidence (Frequency
of occurrence) is not uni form during each of 12 consecutive months. Instead, the frequency is
greater in one season the any of the others. This seasonal variation is associated with variations
in the risk of exposure of susceptible to the source of infection. • Period of Consecutive years:
recording the reported cases of a disease over a period of years-by weeks, months or year of
occurrence-useful in predicting the probable future incidence of the disease and in planning
appropriate prevention and control programs.
Persons refers to the characteristics of the individual who were exposed and who contacted the
infection or the disease in question. Person can be described in terms of their inherent or their
acquired characteristics (such as age, race, sex, immune status, and marital status); their
activities (form of work, play, religious practfces, customs); and the circumstances under which
they live (social, economic and environmental condition).
• Age: for most diseases, there is more variation in disease frequency by age than any other
variable-and for this reason age is considered the single most useful variable associated in
describing the occurrence and distribution of disease. This usefulness is largely a consequence
of the association between a person's age and their:
a) Potential for exposure to a source of infection
b) Level of immunity or resistance
c) Physiologic activity at the tissue level (which sects the manifestation of a disease subsequent
to infection)
• Sex and occupation: In general, males experience higher mortality rates than female for a wide
range of diseases. It is the female however who have higher morbidity rates. This is also because
of differing pattern of behavior between sexes or activities as recreation, travel, occupation which
results in different opportunities for exposure to a source of infection.
66 Public
Health Nursing
Place refers to the features, factor or conditions which existed in or described the
environment in which the disease occurred. It is the geographic area described in
terms of street, address, city, municipality, province, region or country. The
association of a disease with a place implies that the factors of greatest etiologic
importance are present either in the inhabitants or in the environment or both.
• Urban I Rural Differences: in general, disease spreads more rapidly in urban
areas than in rural areas primarily because of the greater population density of
urban area provides more opportunities for susceptible individual to come into
contact with a source of infection.
• Socio-economic areas: different communities can be usually divided into geo
graphic areas which are relatively homogenous with respect to the socio-eco
nomic circumstances of the residents. It commonly has been observed that the
incidence rate of many diseases, both communicable and chronic, varies
inversely with differences in large geographic areas within a country; geo graphic
variations in the incidence of infectious diseases commonly results from
variations in the geographic distribution of the reservoirs or vectors of the
disease or in the ecological requirement of the disease agent.
Patterns of Occurrence and Distribution

The variables of disease as to person, time and place are reflected in distinct
patterns of ocurence and distribution in a given community. Distinct patterns are
recognized as: sporadic, endemic and epidemic occurences. The following are the
characteristic features of those patterns of disease occurrence;
1. Spofapic occurrence is the intermittent occurrence of a few isolated and

unrelated cases in a given locality. The cases are few and scattered, so that
there is no apparent relationship between them and they occur on and off,
intermittently, through a period of time.
Rabies occurs sporadically in the Philippines. In a given year, there are few
cases during certain weeks of the year, while there are no cases at all during the
other weeks. During the weeks when the few cases are occurring, the cases are
scattered throughout the country, so that the cases are not related at all to the
cases in other area.
2. Endemic occurrence is the continuous occurrence throughout a period of time, of

the usual number of cases in a given locality. The disease is therefore always
occurring in the locality and the level of occurrence is more or less constant
through a period of time. The level of occurrence maybe low or high, when the
given level is continuously maintained, then the pattern maybe low endemic or
high endemic as the case maybe. The disease is more or less inherent in that
locality, it is in a way already identifiable with the locality itself. For example:
Schistosomiasis is endemic in Leyte and Samar, Filariasis is endemic in
Sorsogon, Tuberculosis is endemic practically in all specific areas of the country.

3. Epidemic occurrence is of unusually large number of cases in a relatively short

period of time. There is a disproportionate relationship between the number of
cases and the period of occurrence, the more acute is the disproportion, the
more urgent and serious is the problem. The number of cases is not in itself
necessarily big or large, but such number of cases when compared with the
usual number of cases may constitute an epidemic in a given locality, as long as
that number is so much more than the usual number in that locality. It is
therefore not the absolute largeness of the number of cases but its relative
largeness in comparison with the usual number of cases which determines an
epidemic occurrence. For example, there has been no case of bird's flu in any
area of the country, so that the occurrence of few cases in a given area in a
given time would constitute a bird's flu epidemic.
4. Pandemic is the simultaneous occurrence of epidemic of the same disease in

several countries. It is another pattern of occurrence from an international
perspective.
Epidemics
Of the pattern of occurrence of disease, epidemic is the most interesting and
meaningful as it demands immediate effective action which includes
epidemiological investigation - emergency epidemiology as well as control. Factor's
Contributory to Epidemic Occurrence:
• Agent Factor - the result of the introduction of new disease agents into the
population. It may also result from changes in the number of living
microorganisms in the immediate environment or from their growth in some
favorable culture medium.
• Host Factors- are related to lower resistance as a result of exposure to the
elements during floods or other disaster, to relaxed supervision of water and milk
supply or sewage disposal, or to changed habit of eating. Further, the host factor
may be related to change in immunity and susceptibility to population density
and movement, crowding, to sexual habits, personal hygiene or to changes in
motivation as a result of health education. ·
• Environmental Factors - changes in the physical environment; temperature,
humidity, rainfall may directly or indirectly influence equilibrium of agent and
host.
Outline of Plan for Epidemiological Investigation

1. Establish fact of presence of epidemic
• Verify Diagnosis - do clinical and laboratory studies to confirm the data • Is
the disease that which is reported to be?
• Are all the cases due to the same disease?
• Reporting
• Is it reasonably complete?
• Is it prompt enough so that cases reported to date represent a fairly
accurate picture of the present situation?
• Is there an unusual prevalence of the disease?
• Past experience of a given community

• Relation to nature of disease

• Which cases may be considered epidemic and which are endemic?
2. Establish time and space relationship of the disease

• Are the cases limited to or concentrated in any particular geographical subdivision of the
affected community?
• Relation of cases by days of onset to onset of the first known cases- maybe done by days,
week or months.
3. Relations to characteristic of the group of community
• Relation of cases to age, group, sex, color, occupation, school attendance, past immunization,
etc.
• Relation of sanitary facilities, especially water supply, sewerage disposal, general sanitation of
homes, relation to animal or insect vectors. • Relation to milk and food supply
• Relation of cases and known carriers if any
4. Correlation of all data obtained

• Summarize the data clearly with the aid of such tables and charts which are necessary to give a
clear picture of the situation
• Build up the case for the final conclusion carefully utilizing all the evidence available.
• Establish the source of the epidemic and the manner of the spread, if possible.
• Make suggestion as to the control, if disease is still present in community and as to prevention
of future outbreaks.
Epidemiology and Surveillance Units

Epidemiology and Surveillance units have been established in regional and some local office as
support to the public health system. As an epidemiologic information service, the unit is mainly
responsible for providing timely and accurate information on diseases in the locality. Such
information will be used mainly as basis for identifying health problems, allocation of resources
and other discussions in health care.
Among its responsibilities includes:

a. Surveillance of infectious diseases with outbreak potential b. Assisting local government units
in investigation of outbreak and their control
c. Developing information package on public health
d. Providing technical assistance related to epidemiology
For the team to carry out their duties and responsibilities, it is imperative that they have the
knowledge and skills in infectious disease epidemiology and surveillance.
Public Health
Nursing 69
Public Health Surveillance

Public Health Surveillance is an on-going systematic collection, analysis,
interpretation and dissemination of health data.
Surveillance system is often considered information loops or cycles involving health

care providers, public health agencies and the public.
The cycle begins when cases of diseases occur and are reported by health care
providers to the public health agencies. Information about cases are relayed to
those responsible for disease prevention and control and others "who need to
know". Because health providers, health agencies and the public have responsibility
on disease prevention and control, they should be included among those who
receive feedback of surveillance information. Others who need to know may include
other government agencies, potentially exposed individuals, employers, vaccine
manufacturers, private voluntary organization. (See Figure 5)
::D
HEALTH
AGENCIES
Figure 5
m
-u
0
~
en
HEALTH
CARE
PROVIDERS
Information loop involving health care providers, public health agencies and the
public
ROLE OF THE NURSE IN SURVEILLANCE

One of the areas where public health nurse function as researcher is disease
surveillance. Surveillance is a continuous collection and analysis of data of cases
and death. It is also important in monitoring the progress of the disease reduction
initiatives and an integral part of many programs.

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QUE Ill, MD, MSc.

The objective of the book is to inform the reader on the following:

With this objective in mind, the book is developed as follows:

Unit I Public Health Nursing in the Philippine Context

Chapter 1 Overview of Public Health Nursing in the Philippines Discusses the

Chapter 2 The Philippine Health Care Delivery System

Chapter 3 The Public Health Nurse

Unit II Public Health Programs

Chapter 5 discusses programs for Family Health.

Chapter 6 discusses programs for Non-Communicable Disease Prevention and Control.

Chapter 7 discusses programs for Communicable Disease Prevention and Control.

MS. FR CES PRESCILLA L. CUEVAS, RN MAN

FRANCES PRESCILLA L. CUEVAS, RN, MAN

JEAN P. REYALA, RN, RM, MPH, MGM

ROSALINDA CRUZ-EARNSHAW, RN, MPH, MPA

SHIELA BONITO, RN,/MAN

JEAN M. SITIOCO, RN, MAN

LORENZA C. SERAFICA, RN, MAN

. 65241 Senal No.: .............................. .

Dr. Francisco T. Duque, Secretary of Health, for believing in us, nurses.

To all our "bosses" who allowed us to soar to greater heights;

To all of you our deepest appreciation and gratefulness.

PUBLIC HEALTH NURSING

P ublic Health Nurses in the (PHNs) Philippines have made great

GLOBAL AND COUNTRY HEALTH IMPERATIVES

EVOLUTION OF PUBLIC HEALTH NURSING IN THE PHILIPPINES

sanitation of the environment, control of communicable diseases, the education of individuals in

~e following are the essential public health functions:

Public Health Nursing

including independent practice .... community nursing is certainly ~

Public Health Nursing 7

Public Health Nursing 9

Physicians and nurses undergoing pre-service and in - service training in public

Public Health Nursing 11

the Division of Nursing. However, it created nursing positions at different levels in

In the merged Bureau of Health and Medical Services, Nursing Program

Public Health Nursing 13

http://www. who. int/hia/evidence/doh/enlindex.html

Jacobson, M.J. (1975) An introduction to community health nursing. In SA Archer and A.

,.;THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM

THE HEALTH CARE DELIVERY SYSTEM: MAJOR PLAYERS

PHILIPPINE DEPARTMENT OF HEALTH

June 23, 1898

September 29, 1898

October 26, 1905

The Philippine Commonwealth and the Japanese Occupation (1935-1945)

May 31, 1939

February 20, 1958

April 13, 1987

May 24, 1999

Roles and Functions

/ 2:-:enabler and Capacity Builder

. 3_0dministrator of Specific Services

V Goal: Health Sector Reform Agenda (HSRA)

Rationale for Health Sector Reform

Public Health Nursing

THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM

The following are the implications of the above situation:

Nursing 35 - --- - - - - - ___ _ ____ ,