Health Governance Resource Center
MANUAL ON THE FAMILY PLANNING CLIENT REFERRAL SYSTEM FOR THE
PUBLIC SECTOR
May 2006
This publication was made possible through the support provided by the United States Agency for International Development (USAID) under the terms of contract No. 492-C-00-03-00024-00. The opinions expressed herein are those of the author(s)' and do not necessarily reflect the views of USAID.
TABLE OF CONTENTS
Page
Acknowledgements 1
List of Abbreviations 2
INTRODUCTION 3
I. Purpose of the FP Client Referral System 4
II. Scope of the FP Client Referral System 5
III. Elements of a Functional FP Client Referral System 6
IV. Organizing the Public Sector FP Client Referral System 7
V. Referral Procedures
A. Referrals for FP Contraceptives & Pills 9 B. Referrals for BTL and NSV 13 C. Referrals for Consultation and Technical Evaluation 17
VI. Recording and Reporting 22
A. Referrror B. Receiving Provider
VII. Monitoring and Evaluation 24
Annexes 25
A. Levels of Public Health Care and Service Capability for Family Planning B. Criteria for Selection of Private Providers C. Synopsis of Department of Health Administrative Order 158 D. Memorandum of Understanding E. Addendum Contract of services F. Referral slip for dispensing commodities G. Informed consent form for surgical sterilization H. Referral form for consultation/technical intervention I. Reporting tables for referror J. Reporting tables for receiving providers
ACKNOWLEDGEMENTS
The development and production of this manual was made possible through the support and invaluable inputs of the following resource persons for which deep gratitude is extended by the authors:
• The Provincial Population Office of Pangasinan under the stewardship of Ms. Luz Muego and her staff, Ms. Loida Episcope, Ms. Vicky Banez for their help in improving the systems content of this manual so that they may be as relevant and as useful for the users of this manual in the province of Pangasinan. The same is also acknowledged for the selection of the municipalities/cities for the pilot implementation of this referral system
• The Municipalities/Cities of Mangaldan, Binalonan and Urdaneta under the stewardship of Dr. Ophelia Rivera, Dr. Larry Patawaran and Dr. Bernard Macaraeg implementation of this referral system even if it meant adding to the already voluminous tasks and activities in their respective offices.
• Dr. Babes Perez, Ms. Lynn Almario, Ms. Risa Yapchiongco, Mr. Fidel Bautista, Mr. Delbert Marquez of the PRISM Project and their consultants Dr. Melchor Lucas, Jr. and Ariel Canaveral, likewise under the funding assistance of USAID for the collaboration in the design and development of this referral system and manual especially in the clinical procedures presented herein.
• Ms. RoseAnn Gaffud (Field Coordinator, LEAD for Health Pangasinan) and Mr. Ed Joel Carlos , Ms. Ailene Nitor and Mr. Daniel Culili (PLCPD - LEAD for Health Pangasinan Partner) for providing the logistical arrangements in the conduct of coordination meetings with the pilot areas.
• Mr. Verne Quiazon and Ms. Ida Cayetano for the relentless faith and support to the authors of this manual that it may come to fruition and final completion for the benefit of use in the various LGUs who may adopt the referral system for family planning services from the public to the private sector towards achieving the market development goals ultimately leading to the attainment of Contraceptive Self-Reliance in the country.
Once again, our heartfelt gratitude and acknowledgement for all the assistance.
1 LIST OF ABBREVIATIONS
AO Administrative Order BHS Barangay Health Station BHW Barangay Health Worker BTL Bilateral Tubal Ligation CBDO Community-Based Drug Outlet CBMIS Community-Based Monitoring and Information System CII Contraceptive Independence Initiative CSR Contraceptive Self-Reliance DOH Department of Health FP Family Planning HC Health Center IUD Intra-Uterine Device LGU Local Government Unit LHS Local Health System (Sector) MHO Municipal Health Office MWRA Married Women of Reproductive Age NGO Non-Government Organization NSV Non-Scalpel Vasectomy PhilHealth Philippine Health Insurance Corporation PhP Philippine Peso PHO Provincial Health Office POPCOM Population Commission RHU Rural Health Unit SES Socio Economic Status STD Sexually Transmitted Disease USAID United States Agency for International Development USD US Dollar
2 INTRODUCTION
For the last 30 years, the country’s Family Planning Program has relied primarily on foreign donations for the supply of contraceptives. Specifically, the United States Agency for International Development (USAID) has been providing 80% of the country’s contraceptive supply – pills, condoms, IUDs and injectables, amounting to around USD 3 million yearly.
In 1999, the national government of the Philippines produced a draft of the Contraceptive Independence Initiative (CII) to launch the country’s bid to be more self-reliant in securing its own contraceptive supply. This was spearheaded by the Department of Health followed through by a multi-sectoral task force convened by the POPCOM that led to the issuance by the DOH of a National Family Planning Program Policy in September 2001. Overall, this policy states that the Philippine Government will now assume greater responsibility for the Family Planning (FP) program of the Philippines.
In response to this development, USAID initiated the program for the phase-down of its contraceptive assistance to the Philippine government. The continuing support of USAID shall now be focused on the country’s poorest and the neediest coming from the socio- economic brackets D1 (earning roughly PhP 5,209 to PhP 7,291 per month) and E (PhP 5,208 and below per month). After several meetings with key stakeholders in this industry, USAID officially announced its phase-down plan to the public in September 2002. Phasedown of pills began in 2004, and will be completely phased out by 2007. Injectables shall begin in 2005 and will be completely phased-out by 2008. IUD’s is planned for a later date because of the lack of availability of other brands and sources in the country.
Since then, preparations have been underway to ensure that family planning services will continue to be given to both current and future potential users. Many initiatives have been undertaken in the national government level towards the direction of contraceptive self reliance. However, in the local government level, the LGU’s capacity to completely cover the current as well as future demands may be constrained by its limited funds.
While this might be the case, several studies already show that many contraceptive users are actually willing to pay for their supplies, that is, of 4.6 million women who use contraceptives, 1/3 or 3.22 million come from middle and high income classes who can afford and are willing to pay for their supplies. As such, one of the approaches being explored is the setting up of a client referral network whose aim is to direct public sector clients to the appropriate provider in the private sector and also higher level public sector providers. Once the referral networks is in place, the public and private FP providers shall have covered both the non-paying and paying clients respectively and contribute to the elimination of “unmet needs” for family planning.
3 PURPOSE OF THE FP CLIENT REFERRAL SYSTEM
The health care delivery system typically involves different geographic units, departments, and levels—including central, regional, and community. Thinking about the way work is organized helps managers and providers throughout the system to see their organization as a collection of interdependent resources (including infrastructure, supplies, and referral sites) and processes (such as client scheduling and information management) that change and evolve in response to both clients’ and staff needs.
In the public health sector, there are different levels of health care providers. The most basic unit is the barangay health station followed by the rural health unit, municipal health hospital, district hospital and provincial health hospital. Each of these has a different service capability for family planning services (Attachment A). For cases beyond its capability level, the health care provider sends its patient to another provider as a referral. The health provider from whom the patient/client is being transferred is called the referring provider or referror while the health provider to whom the patient/client is being transferred is called the receiving provider.
This manual is written to guide the health care providers in setting up a Family Planning Referral System that will standardize the referral procedures among participating FP service providers and/or commodity dispensers to help ensure a safe and efficient transfer of services in the network As necessary, the municipality may also improve the systems or procedures contained herein so that it may respond to other conditions existing in the locality.
4 SCOPE OF THE FP REFERRAL SYSTEM
The local health landscape consists of the private sector and the public health sector. To date, the bulk of family planning services are still availed of from the public sector. With the phase-down of donated contraceptives, the private sector will now have a more active involvement in the effort to address the challenges of the national family planning program. One of the ways this can be done is through organizing a referral network. Broadly speaking, the referral network can be established along the following types:
1. Referrals from Public Sector Facilities/Providers to other Public Sector Facilities/Providers 2. Referrals from Public Sector Facilities/Providers to Private Sector Facilities/Providers 3. Referrals from Private Sector Facilities/Providers to Public Sector Facilities/Providers 4. Referrals from Private Sector Facilities/Providers to other Private Sector Facilities/Providers
This manual will focus on the second referral type (i.e. from Public to Private) although much of the procedures may be applicable to any of the other three sectors.
In addition, within each sector, there are different geographic levels of health service delivery such as:
1. Barangay 2. Municipality 3. Inter-local Health Zone 4. Provincial
These guidelines herein address the inter-provider referral of family planning clients at the municipality level to cover FP referrals made for any of the following reasons:
1. Directing paying patients to the private sector and non-paying to the public sector for FP services and commodities. 2. Accessing services not available in a particular FP facility (i.e. BTL, Vasectomy, diagnostics) 3. Consulting for an expert opinion (e.g. consultation with a specialist for clients with medical conditions) 4. Accessing a technical intervention (e.g. referring complications arising from contraceptive use)
These guidelines do not include inter-facility transfers of acutely ill patients due to medical conditions. This is already covered by existing policies & guidelines in the health system.
5 ELEMENTS OF A FUNCTIONAL REFERRAL SYSTEM
Good referral systems help family planning and other clinics offer clients the right care at the right place. Linking services with delivery sites offers clients access to appropriate care at every level of the health care system—from community facilities for basic care to district, regional, or higher-level facilities for specialized care. Referral systems can give clients access to a complete range of services without inconvenience and unnecessary repetition of diagnosis or treatment. They also enable health centers to offer services which are not cost-efficient to offer elsewhere because the demand for the service is only a handful.
A referral system is essentially a relationship between two or more health providers. This relationship is formalized through an agreement indicating the elements and the mechanics behind such a relationship. These providers help each other complete the treatment of their patients through a referral. They provide feedback of the results of the referral and regularly update each other on the effectiveness of the system.
Thus, the important elements needed to ensure a functional referral system are:
1. Providers’ consent to participate in the referral system 2. An agreement to formalize the referral relationships 3. Set of guidelines to detail the elements of the referral system (what, when, and how to refer, and a fee schedule) 4. An administrative mechanism to oversee/coordinate the system 5. Monitoring/evaluation/feedback system
In this referral model, the suggested elements to operationalize these five elements in the referral system are:
1. Memorandum of Agreement for participating providers 2. Referral Manual that contains specific guidelines to govern the referral system 3. The MHO as the central organization and the PHO as the provincial consolidator of information
6 ORGANIZING THE PUBLIC HEALTH SECTOR REFERRAL SYSTEM
In 1991, with the passage of the Local Government Code, the responsibility for the provision of basic services, including family planning, was devolved to the local government units. This is specifically provided for in section 17, of Republic Act 7160 otherwise known as the Local Government Code of 1991. Thus Family Planning Services form part of the basic services that local government units now provide (source D.O.H. Administrative Order 158). In preparation for the phase out period, the Municipal Health Office (MHO) will need to engage other health providers and dispensers to share in the provision and dispensing of FP services and commodities. The most logical way is to keep the clients who are unable to pay for FP services and commodities in the public sector and refer clients with the capacity to pay to the private sector. To build up this system, the Municipal Health Office may follow the following steps in organizing its FP Client referral system:
1. The Municipal Health Office convenes existing FP providers around its catchment area. A criteria for selection of private providers is herewith provided. (Attachment B)
2. The Municipal Health Office gives an orientation on the following topics for better decision-making of the providers in joining the referral network:
a. Key points of the D.O.H. A.O. 158 (Attachment C) b. The referral system guidelines contained in this manual c. Benefits of executing a Memorandum of Understanding (Attachment D) in consonance with the Referral System guidelines.
3. The Municipal Health Office then formally recruits the FP providers who have updated Licenses To Operate or Business Permits to join the network by signing the MOA.
4. All participating providers submit their complete contact information and service capabilities to be entered in a directory. Copies of this directory are later distributed to the members of the network.
5. As applicable, Municipal Health Office prepares an addendum contract (Attachment E) for providers who opt to cover arrangements not included in the MOU with specific referral partners. Some of these arrangements may typically include the fee structure, terms of payment, the clinic hours, and other special instruction to clients.
6. The Municipal Health Office monitors the referral activities and submits reports to the Provincial Head Office.
7 7. Trainings in family planning are organized as appropriate in the network. These may be organized with the help of the Provincial Health Office, Provincial Population Office and other Project Offices who offer technical assistance for free or for a nominal fee.
8 REFERRAL PROCEDURES
A. Referral for FP contraceptives and pills
Referror:
1. The client enters any FP provider in the public health system. If the provider has the capability, he/she provides counseling. If the provider does not have capability to do counseling he/she provides basic information and makes appropriate referral to the next higher level (Attachment A) of public health sector FP service provider.
2. After counseling has been done, the client together with the FP provider makes a decision on the type of FP method (i.e. pills or injection) to avail of.
3. Next, the FP Provider determines the client’s ability to pay based on existing systems or criteria for client classification in the local health center.
4. Clients who have the ability to pay are given the following choices:
a. Advise the client that because of the phasing out of the free contraceptive supplies, the introduction of fees and charges for commodities is now underway. Explain the details of fess and charges.
OR
b. There are existing private service providers in the catchment area to whom they maybe referred to. Make sure that there is prior information as to what is available in the private service providers before making a referral to avoid client inconvenience. A referral slip/prescription (Attachment F) is prepared (in duplicate copies). The original copy is given to the client together with directions to the nearest provider/dispenser of FP contraceptive. The client shall present this to the seller of the contraceptive every time a purchase is made. This slip will be valid for a limited period of time (example three months only) so that a follow-through examination can be performed by the service provider to monitor on the client’s condition. The second copy is kept for filing as basis for follow-up and report preparation later on.
5. Those who have no capacity to pay are retained in the government facility and are given free FP contraceptives.
Receiving Provider:
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1. The dispenser asks for the referral slip/prescription from the client.
2. The client presents the referral slip/prescription for each purchase of pills or injections. The referral slip/prescription will be valid for 3 to 6 months as explained earlier by the referror.
3. The FP commodity is dispensed.
4. The dispenser signs at the appropriate space in the referral slip/prescription indicating the items and number of times the commodities were dispensed. Same time, it shall list down the client’s name and purchase details in the Report on Referrals form.
5. Every month, the Report on Referrals will be furnished to the MHO so that this may be shared with the respective Referrors.
6. At the end of the validity of the referral slip, the dispenser shall advise the client to get another referral slip.
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11 12
B. Referral procedure for BTL/NSV
Referror
1. Conducts counseling to the client
2. If the client decides on surgical sterilization, the FP service provider explains the elements of the Informed Consent form (Attachment G) which the client is to sign afterwards to confirm acceptance/agreement to avail of the procedure.
3. Evaluates client’s ability to pay. Non-paying clients are referred to the nearest government facilities while paying clients are referred to private facilities pre-certified for this particular service.
4. Fills up the referral form (in duplicate copy), gives pre-operative instructions to the client. For those referred to a private provider, informs them of the fee schedule and other relevant instructions contained in the Addendum Contract signed by the receiving provider.
5. Coordinates with the receiving provider for the schedule of the procedure.
6. Gives one copy of the referral form to the client and files the duplicate copy which will serves as basis for follow-up and report preparation later on.
7. Makes arrangements for transportation if requested by the client. If not, directions on the receiving provider’s location are given.
8. Calls the client or the receiving provider to determine the status of the referral and resolves problems that may arise.
Receiving Provider:
1. Upon the referral call of the referror, the designated person in the receiving facility reserves an operating room schedule for the client.
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2. Informs the surgeon of the operating time slot.
3. When the surgeon and operating schedule are confirmed available, accepts the referral.
4. Upon the arrival of the client on the day of surgery, examines the records, evaluates the client.
5. The client is asked to sign an Informed Consent Form to ensure his/her confirmation or acceptance of the procedure.
6. When all requirements are in order, performs the procedure.
7. Files the referral form.
8. Every month, the Report on Referrals is furnished to the MHO so that this may be shared with the respective Referrers.
14 15 16 C. Referral procedure for consultation or technical evaluation.
Referror: 1. Evaluates the client’s condition.
2. If needed, she orders laboratory tests to confirm his/her assessment.
3. If a condition is beyond her expertise, a referral is made.
4. Explains to the client the reason for referral.
5. If the referral requires a technical intervention, informs the receiving provider of the referral. Upon consent to accept the referral, proceeds in referring the client.
6. Fills up the referral form (in duplicate) (Attachment H) has the client sign the consent statement of the form and provides the following information:
a. Patients name b. Impression or diagnosis c. Time of referral d. The name of the referring provider e. The requested service
7. Gives the referral form and instructs the client on the fee schedule (if there is any) and directions on the receiving provider’s location.
8. Retains the management of the patient under her/his care in transit.
9. Keeps the duplicate copy for filing which will serve as basis for follow-up and report preparation later on.
17 10. Follows up the client or the receiving provider to determine the status of the referral.
Receiving Provider: 1. Receives the client and studies the referral note.
2. If the condition is within the provider’s capability level, accepts the referral and proceeds in treating the client. If beyond, refers the client to the appropriate provider.
3. Files the referral form.
4. Every month, the Report on Referrals is furnished to the MHO so that this may be shared with the respective Referrers.
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20 21 RECORDING AND REPORTING
Referror:
A. Recording Procedures
a. The referror always fills up a referral slip/form in duplicate copies.
b. The original copy is given to the client to be presented to the receiving provider.
c. The duplicate copy is kept on file.
d. Daily, the duplicate copies are segregated as: a) referral for dispensing, b) for surgical sterilization, c) for consultation and technical evaluation.
e. Based on the duplicate copies, the following tables are filled up at the end of the day (Attachment I)
i. Table for dispensing referrals ii. Table for surgical sterilization, consultation and technical evaluation
B. Reporting Procedures
a. Every month end, the tables are sent to the Municipal Health Office via fastest means possible.
b. The Municipal Health Office summarizes the report for the municipalities covered and submits this to the Provincial Head Office.
Receiving Provider
A. Recording Procedures
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a. Receives the referral slip/form and files.
b. Daily segregates the referral forms as: a) referral for dispensing, b) for surgical sterilization, c) for consultation and technical evaluation. The following tables are filled up (Attachment J)
i. Table for dispensing referrals ii. Table for surgical sterilization, consultation and technical evaluation
B. Reporting Procedures
a. Every month end, the tables are sent to the Municipal Health Office via fastest means possible.
b. The Municipal Health Office summarizes the report for the municipalities covered and submits this to the Provincial Head Office.
Collation of information is done at the provincial level. The data is summarized and the indicators are assessed. A report is generated and distributed in the referral network.
23 MONITORING AND EVALUATION
The referral system needs to be monitored and evaluated to find out if it addressed the objectives for which it was established.
Monitoring is checking something at regular intervals in order to find out how it is progressing or developing while evaluation is the act of considering or examining something in order to judge its value, quality, extent, or condition. Monitoring therefore involves the regular collection of data and arranging these data elements in a manner where periodic comparison of the level of performance can be made. Once a certain benchmark of performance is reached, evaluation of that specific aspect is performed and remedial action is designed and instituted.
The following table shows the suggested data elements, their sources, purpose and suggested thresholds and steps to follow if thresholds are reached. Source Purpose Benchmark Actions Number of out going To determine level of participation Trend must be maintained or increasing Examine cases that may be inappropriately referrals by type of providers treated Number of referrals received To determine level of acceptance Number of out going referrals must match Determine reason for non-acceptance by providers received referrals by 100% Number of serviced referrals To determine effectiveness 95% of received referrals must be serviced Determine reason for inability to service client For clinical referrals, reason To determine specific areas of No unjustified referral upon evaluation Determine the cause of unjustified referrals for referral concern Number of participating To determine the status of the Must not be decreasing in number Determine reason for withdrawal of providers system providers from the system Complaints from providers To determine areas for Must be 0% Examine the system improvement Complaints from clients To determine areas for Must be 0% Examine the system improvement
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ANNEXES
25 LEVELS OF PUBLIC HEALTH CARE AND SERVICE CAPABILITY FOR FAMILY PLANNING
HEALTH FACILITY / FP SERVICE PERSON POOR NON-POOR* BHWs and BSPOs Pill re-supply
BHS Pill initial and re-supply Pill initial and re-supply IUD insertion (case to case basis) & check- IUD insertion (case to case basis) & check-up up Injectables Injectables
RHUs Pills Pills IUD insertion IUD insertion Injectables Injectables
MUNICIPAL Pills Pills HOSPITAL IUD IUD Injectables Injectables Venue for VSS procedures of itinerant teams Venue for VSS procedures of itinerant teams
DISTRICT AND Pills Pills PROVINCIAL IUD IUD HOSPITAL Injectables Injectables Surgical sterilizations Surgical sterilizations Provides resources for itinerant teams Provides resources for itinerant teams Mgt. Of complications Mgt. Of complications
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CRITERIA FOR SELECTION OF PRIVATE PROVIDERS
Types of Private Providers:
Private Doctors – Obstetrician-Gynecologist Family Medicine / Family Physician Private Midwives Drugstores/Pharmacies Hospitals
General Criteria:
The important considerations in choosing a private provider are -
1. Accessibility to your paying clientele. Check the geographic clustering of your paying clients to be able pinpoint which areas private providers are most suitably needed. Decide on a ratio of paying clients to private providers to be able to decide how many providers are essential. An oversupply of private providers may also result in unnecessary competition in turn leading to disinterest in joining the network.
2. Willingness/ Capability/ Competence to provide quality Family Planning service/contraceptives. Some private providers are not automatically willing to provide the modern methods of family planning which this program is promoting. Therefore, this should be clarified early on to ensure non-coercion in joining the network. Subsequently, you need to determine if the skills in providing this service is still up-to-date. First and foremost is that the private provider should have undergone DOH-prescribed FP training. Moreover, there may be a need to enroll in some refresher courses for family planning service that are available from a number of training suppliers. Finally, please check if the private provider has the basic clinical equipment and facility as stipulated by the Department of Health to render family planning service.
27 3. Track record of outstanding medical practice – it is important that the integrity of the network is protected especially since some sectors of society might associate the family planning program with some illegal medical practice (e.g. abortion. ) resulting in rejection of family planning.
4. Active Membership in a Professional Organization – preferably the private provider is a member of a relevant professional organization such as Philippine Obstetrics and Gynecology Society (P.O.G.S), Philippine Academy of Family Physicians (P.A.F.P.), Integrated Midwives Associated of the Philippines (IMAP), Philippine League of Government and Private Midwives (PLGPMI), and Drugstore Association of the Philippines (D.S.A.P.). Membership in such organization helps ensure that the private provider has the basic qualifications as a medical practitioner. On occasion, the organization provides access to relevant training programs for family planning and access to supplies necessary for family planning services.
Additional Criteria:
For those providing Contraceptives / temporary Methods -
1. Maintains affordable and continuous supply of contraceptives including variety of types and brands prescribed by the provider to the client. 2. Compliant to the practice of requiring client to show a prescription from a private provider before selling a contraceptive
For those providing Permanent Methods -
1. Available service time for family planning surgical procedures 2. Preferably Philhealth-accredited so that clients may have the option to apply for reimbursement for VSS services obtained from the private provider. 3. Preferably Hospital-based or hospital-affiliated to ensure access to complete facilities in providing quality family planning services, as well as, handling of complications that may arise after the procedure is performed.
28 MEMORANDUM OF UNDERSTANDING
KNOW ALL MEN BY THESE PRESENTS :
The undersigned PARTIES, all Filipinos, of legal ages, residents of the municipalities/city as specified hereunder within the Province of Pangasinan, in their capacities or as representatives of the Local Government Units or entities for which they have been legally and duly authorized to act as such, hereby agree to enter into a Memorandum of Understanding to establish a CLIENT REFERRAL SYSTEM wherein the PARTIES may, alternately be referred to as REFERROR or as RECEIVING PARTY;
WITNESSETH, That:
WHEREAS, the Government of the Philippines embarked on the Contraceptive Independence Initiative last 1999 to launch the country’s bid to be more self-reliant in securing its own contraceptive supply due to the phase-down of donated contraceptives starting 2004 and ending in 2008;
WHEREAS, in response to this phase-out plan of donated contraceptive supplies, the Department of Health issued Administrative Order. 158 entitled “______” provided that Local Government Units shall act as the ultimate guarantor of the availability of contraceptive supplies for current and future users;
WHEREAS, the provincial government of Pangasinan initiated the Contraceptive Self-Reliance Initiative in 2002 to prepare the province for the eventual phase-out of donor support to Family Planning commodities;
WHEREAS, the province and its component cities and municipalities, realizing their own budgetary limitations in providing for all the needs of current and future FP users adopted a contraceptive self-reliance policy promoting and engaging the partnership and active participation of the private sector;
29 WHEREAS, all the PARTIES concerned are operating a health service facility/health service facilities and/or commodity facility either on a pay for services or free of charge and are willing to accept client referrals from other service or commodity providers;
WHEREAS. The PARTIES participating in the CLIENT REFERRAL SYSTEM maybe both REFERROR and RECEIVING PARTY and agree to provide the first family planning service or commodity to a family planning client before making a referral to another FP service and/or commodity providers;
WHEREFORE, the above premises considered, the PARTIES agree as they hereby agree to be guided by the FAMILY PLANNING REFERRAL MANUAL as an integral part of the CLIENT REFERRAL SYSTEM in providing for family planning services and/or commodities;
This MEMORANDUM of UNDERSTANDING shall take effect upon signing hereof and shall be in force unless the parties or any PARTY signify/signifies withdrawal or termination of their participation.
IN WITNESS WHEREOF, the PARTIES have hereunto set their hands on the ______of ______2006 in the Municipality of ______, Province of Pangasinan.
NAME OF REFERROR NAME OF RECEIVING PARTY
______NAME OF AUTHORIZED REPRESENTATIVE NAME OF AUTHORIZED REPRESENTATIVE Title Title
30 ADDENDUM CONTRACT
Municipal Health Center Municipality of ______, Province of ______
Date
Name Receiving Provider Address
Dear ______:
In connection with our Memorandum of Understanding executed last ______covering the participation in the Family Planning Client Referral Network in the Municipality of ______, we shall also be guided by the following guidelines for the referral of the client for family planning services/ commodities:
1. Fees & Charges – (specify exact fees / charges as reference of referror when advising the client for a referral) 2. Special Procedures – (specify any special instructions that the referror should advise to the client not yet covered in the referral system manual provided these do not pose any conflict of instructions.) 3. Others
For both our guidance and reference:
______Signatory Referror
Conforme:
______Signatory Receiving Provider
31 REFERRAL SLIP FOR FP CONTRACEPTIVES
FAMILY PLANNING CLIENT REFERRAL SYSTEM MUNICIPAL HEALTH OFFICE OF ______PROVINCE OF ______Tel. No.______
REFERRAL SLIP FOR CONTRACEPTIVES
Patient : ______Date Issued Valid thru: Please fill up below:
Name of Dispenser Date of (Drugstore, Item and Quantity Signature of Purchase Pharmacy, etc.) Dispensed Dispenser 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Referred by : ______
32 INFORMED CONSENT FORM FOR VOLUNTARY SURGICAL STERILIZATION
I ______, the undersigned, request that (Client’s Name) sterilization via ______be performed on me. (specify the procedure)
I make this request on my own free will, without having been forced or given any special inducement after understanding the following:
1. There are temporary methods of contraception available to me and my partner. 2. The procedure to be performed on me is a surgical procedure, the details of which have been explained to me. 3. The surgical procedure has benefits as well as risks, both of which have been explained to me. . I have been informed of the possible complications that may arise from this procedure and I do not bind the doctor for any legal responsibility for this situation 4. If the procedure is successful, I will be unable to have any more children. 5. The effect of this procedure is permanent. 6. I can decide against the procedure at any time before the operation is performed.
______Signature or thumbmark of client Date
______Signature of attending physician or Date delegated assistant
If the client cannot read, a witness of his/her choice speaking the same language must sign the following declaration:
I, the undersigned, attest to the fact that the client has affixed his/ her thumbprint or signature in my presence.
______Signature of Witness
33 FAMILY PLANNING CLIENT REFERRAL SYSTEM REFERRAL FORM FOR C ONSULTATION/ TECHNICAL INTERVENTION Name of Referring Provider: Telephone number: Date and Time of Consultation: Date and Time of Referral:
Referred to: Address & Tel #:
Name of patient: Age: Sex: Address:
Main reason/s for referral: Clinical notes: Treatment given:
I consent to be referred to ______for the
reason stated above.Patient’s/Relative’s Signature Signature of Over Printed Name ReturnReferring Slip (detach here and return to Referror) Diagnosis:Provider Treatment/s given: Instructions to the referror: Follow up visit on:
Date:
Signature of Receiving Provider 34 Summary/Reporting Table for Referror
Table 1 Consultation, Technical advice, and surgical sterilization
C. Reason for referral A. NAME B. Date C. Name D. client of Return OF PATIENT Receiving slips was Seek technical Surgical Consultation Provider received referred advice sterilization (FP complications)
TOTAL
Table 2 Family Planning Commodities and supplies Report for Month of ______Year 200__ Date Number referred Old Clients New Clients 1. 2. 3 Total
35 Summary/ Reporting table for the Receiving Provider
Table 1Consultation, Technical advice, and surgical sterilization
C. Reason for Referral D. Action Taken A. NAME F. Name OF PATIENT B. Date client of Refused Referring was seen Seek technical Surgical Consultation Accepted (state Provider advice sterilization reason) (FP complications)
TOTAL
Table 2Family Planning Commodities and supplies Report for Month of ______Year 200_ _ Date Number Received Old Clients New Clients 1. 2. 3 Total
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