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DOH AO 2012-0029
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Karlo QuezonCopyright
© © All Rights Reserved
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/ 15
Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
ADMINISTRATIVE ORDER
No. 2012- 0024 DEC 04 2012
SUBJECT: IMPLEMENTING GUIDELINES ON THE
INSTITUTIONALIZATION OF PHILIPPINE PACKAGE OF
ESSENTIAL NCD INTERVENTIONS (PHIL PEN) ON THE
INTEGRATED MANAGEMENT OF HYPERTENSION AND.
DIABETES FOR PRIMARY HEALTH CARE FACILITIES
I BACKGROUND AND RATIONALE
‘The National Policy on Strengthening the Prevention and Control of Chronic Lifestyle
Related Non Communicable Diseases (Administrative Order No. 2011-0003 dated April 14
2011) prescribes the strategy or comprehensive approach the country has adopted in reducing
the morbidity, mortality and disability rates due to chronic lifestyle-related non
‘communicable diseases (NCDs). The policy also clearly defines the Action Framework for
the Prevention and Control of the NCDs which consists of areas for intervention at three
levels, i.e, environmental, lifestyle and clinical. To support the changes in these three levels
of interventions, additional actions should be instituted in the areas of: 1) advocacy; 2)
research, surveillance, monitoring and evaluation; 3) networking and coalition building
across all sectors of the government and society, and 4) health system strengthening through
primary health care to make it more responsive to chronic care. Moreover, service packages
for clinical interventions of diabetes, cardiovascular diseases, cancers and chronic respiratory
diseases must be provided in these settings.
Currently, the main focus of clinical health care for NCDs in the Philippines is
hospital-centered acute care. Patients with NCDs usually seek treatment at the hospitals when
cardiovascular disease, cancer, diabetes and chronic respiratory disease have reached the
point of acute events or long-term complications. This is a very expensive approach that will
not contribute to a significant reduction of the NCD burden. It also denies people the health
benefits of taking care of their conditions at an early stage. A strategic objective in the fight
against the NCD epidemic is the early detection and care using cost-effective and sustainable
health-care interventions that are integrated in the primary health care facilities such as
barangay health stations, rural health units, community health centers and the like.
The World Health Organization has endorsed a set of low-cost individual treatment
protocol consisting of early screening and timely treatment in a primary health care setting
(WHO PEN, Geneva 2010). The approach involves the financing and the strengthening of
health care in order to improve access by high-risk individuals and by people with NCDs to
essential technologies and medicines. These set of interventions are cost effective especially
when compared to costly procedures that may be necessary when detection and treatment are
late and the patient reaches advanced stages of the disease.
Bulding , San Lazaro Compound, fal Avenue ta. Cruz, 1003 Manila Trunk Une 651-7200 Direct Line: 733-9503
Fax: 749-1829; 743-1786 © UR: htt://wonwdoh.gox.h; e-mail: osec@doh.co1.9h
if In consideration of the commitment to a 2% yearly reduction in mortality due to
NCDs in the country and to contribute to the global reduction of 25% by 2025, the
Philippines adapted the WHO PEN. It shall be called the Philippine Package of Essential
Noncommunicable Disease Interventions (Phil PEN). The protocol for the Integrated
‘Management of Hypertension and Diabetes (APPENDIX 1) will be institutionalized in primary
health care settings all over the country.
I POLICY STATEMENT
The provision of quality clinical interventions and services for lifestyle related non-
communicable diseases in the country follows the policy statements espoused by the National
Policy on Strengthening the Prevention and Control of Chronic Lifestyle Related Non
Communicable Diseases (Administrative Order No. 2011-0003 dated April 14, 2011).
This states that the country shall adopt an integrated, comprehensive and community
based response for the prevention and control of chronic, and lifestyle related NCDs,
intensifying health promotion strategies to effect changes in lifestyle, environmental support,
and delivery of health care services while fostering complementary accountabilities of all
stakeholders
III GOAL AND OBJECTIVES
This policy and guide aims to ensure the appropriate provision of quality clinical
interventions and services for lifestyle-related NCDs in the country: Specifically, it aims to:
1. Guide health workers and providers at primary health care facilities in
implementing the Phil PEN to identified population groups and client needs
2. Define the roles and responsibilities of the different DOH offices, the Philippine
Health Insurance Corporation, the LGUs and other agencies in the implementation
of the Phil PEN, including higher level referral facilities.
3. Generate the support of various stakeholders in implementing the Phil PEN policy
and guidelines in the country.
IV SCOPE AND COVERAGE
This policy applies to all units and instrumentalities including attached agencies of the
DOH and local government units (LGUs). It also applies to non-government organizations,
professional organizations, private sector, and other relevant partners in the health sector. V DEFINITION OF TERMS
1
Diabetes mellitus — a group of metabolic disorders characterized by high blood sugar
levels, ic. a fasting plasma glucose concentration above 7.0 mmol/l (126 mg/dl) or a
postprandial (approximately 2hours after a main meal) plasma glucose concentration
above 11.0 mmol// (200mg/l) on two separate occasions.
Phil PEN Protocol on the Integrated Management of Hypertension and Diabetes.
‘The Philippine Package of Essential Noncommunicable Disease Interventions
Protococol on the Integrated Management of Hypertension and Diabetes adopted from
the WHO PEN and adopted for country use.
Protocol on the Integrated Management of Hypertension and Diabetes. The first
clinical protocol developed under WHO PEN that makes use of the total risk approach
using hypertension, diabetes and tobacco use as the entry points. It specifically
involves the use of the WHO/ISH risk prediction charts to determine the risk of
developing a cardiovascular event, i.e. heart attack or stroke over a ten period and
‘management guidelines for risk reduction appropriate referral, regular follow-up, core
set of technologies and essential medicines.
Risk Factor Assessment is the key process of evaluating individuals for the presence
‘or absence of common risk factors that expose them to increased likelihood of
developing NCDs.
Risk Screening is the presumptive identification of unrecognized disease or the
presence intermediate risk factors by the application of test and procedures which can
be applied rapidly.
Risk Stratification estimating the level of risks of individuals for a fatal or non-fatal
cardiovascular event in 10 years.
Total Risk Approach is a structured method to identifying, assessing and managing
the major risk factors shared by cardiovascular diseases (CVD), cancer, diabetes and
chronic respiratory disease.
WHO PEN World Health Organization Package of Essential Noncommunicable
Disease Intervention provides a minimum set of interventions for detection ,
prevention, treatment and care of CVD and risk factors (heart disease, stroke,
hypertension), diabates, chronic respiratory disease (asthma and COPD) and cancer
deemed feasible for implementation even in low resource settings with a modest
increase in investment , that can be delivered by primary care physicians and non-
physician health workers in primary health care settings. Vi: GENERAL GUIDELINES:
1. The Phil PEN Protocol on the Integrated Management of Hypertension and Diabetes
shall be used in all primary health care facilities in the country, i.e. barangay health
stations, rural health centers, community health centers, and the like.
2, All relevant health care providers shall undergo training on the use of the protocol to
be provided by the DOH-NCDPC in coordination with NCPAM and PhilHealth,
3. The National Center for Pharmaceutical Access Management shall support the
implementation of the Phil PEN by providing the complete treatment packs for
lifestyle related diseases pursuant to Administrative Order 2011-0013 dated
September 12, 2011 (Implementing Guidelines on the DOH Complete Treatment Pack
(COMPACK) to Ensure Sustainable Access to Essential Drugs and Medicines for the
Marginalized Sector) until such time that the PhilHealth benefit packages shall have
been fully instituted.
4, The PhilHealth benefit packages shall be provided for the long term support of the
implementation of the Phil PEN Protocol on Integrated Management of Hypertension
and Diabetes.
5. The referral system must be established and duly guided, while higher referral centers
must be properly equipped to deal with referrals coming from the primary care level
facilities.
6. All primary health care facilities in the country should be reorganized to address
chronic long term care of patients taking into account patient load, logistical
requirements and recording and reporting accountabilities.
VII SPECIFIC GUIDELINES AND PROCEDURES:
These specific guidelines and procedures shall be instituted at the primary health care level
facilities all over the country, i.e. barangay health stations, rural health units, community
health centers and the like, whatever is appropriate. A manual of operation will be issued
containing more details.
1, Target Population
All individuals aged 25 years old and above with no established cardiovascular disease
(angina pectoris, coronary heart disease, myocardial infarction and transient ischemic
attacks), cerebrovascular disease (CeVD) or peripheral vascular disease (PVD) or have
not undergone coronary revascularization or carotid endarterectomy will undergo Risk
Factor Assessment. (WHO 2007) 2. Flow of Activities or Service Pathway
‘The flow of activities (service pathway) in the assessment, screening and management of
potential clients at risk of NCD shall follow the algorithm illustrated in APPENDIX 2.
3. List of Essential Devices
The following equipment, devices and supplies are needed in the implementation of the
Phil PEN protocol on the management of hypertension and diabetes and should be made
available at the health care facility:
* Stethoscope
* Blood Pressure measurement device, non-mercurial
‘* Measuring Tape, non-extensible
* Height Board
© Weighing Scale
. Glucometer with test strips*
* Cholesterol Meter with test strips
* Test tube or glass container for the urine
‘* Tests strips for checking urine ketones and protein
List of Essential Drugs/Medicines
‘The following drugs and medicines are needed in the implementation of the Phil PEN
protocol on the management of hypertension and diabetes and should be made available
at the health care facility:
© Thiazide diuretics
* Beta blockers
‘* Angiotensin converting enzyme inhibitors
* Calcium Channel blockers (sustained release formulations)
© Aspirin
© Metformin
© Glibenclamide
. Gliclazide
. Simvastatin
5. Risk Assessment and Screening
Risk Factor Assessment is the key process of evaluating individuals for the presence or
absence of common risk factors that expose them to increased likelihood of developing
NCDs. Risk factor assessment involves asking specific questions to determine the
individual’s age, sex, family history of diseases associated with NCDs among first degree
relatives, the use of alcohol and tobacco, physical inactivity and diet. Risk Screening is
the presumptive identification of unrecognized disease or the presence of intermediate
risk factors by the application of tests and procedures which can be applied rapidly. The
primary goal of risk screening is to detect a disease in its early stages to be able to treat it
and prevent its further development. It must be understood that screening is not a
diagnostic measure but it is a preliminary step in the assessment of the individual's
chances of becoming unhealthy. (DOH, 2009) This involves tests to measure central
5 adiposity and obesity, raised blood pressure, raised blood glucose and raised blood
cholesterol.
Following the service pathway in APPENDIX 2, risk assessment will be performed on
individuals 25 years old and above. Only those with any of the following will undergo
risk screening:
© Age greater than 40 years
© Tobacco/Cigarette Smoking
© Central Adiposity
‘* Raised Blood Pressure
* Diabetes
«Family History of Hypertension, Stroke or Heart Attack
* Family History of Diabetes or Kidney Disease
‘At the primary health care facilities, the NCD Risk Assessment and Screening Form
(refer to APPENDIX 3) will be used to record the results of the risk assessment and
screening. The questionnaire to determine probable angina, heart attack, stroke & TIA
(WHO, 2002) and the tests to determine the presence of urine protein and urine ketones
are incorporated in this form in order to determine individuals who need to be referred to
a higher level of care for further diagnosis and management.
In filling-out the NCD Risk Assessment and Screening Form, an individual is considered
at risk if he or she:
‘© has a first degree relative with any of the following conditions: hypertension, stroke,
heart attack, diabetes and kidney disease.
* currently smokes or stopped smoking for less than a year or is exposed to cigarette
smoke (passive smoker)
* consumes excessive alcohol. Excessive alcohol intake is defined as having more than
2 drinks for males and more than 1 drink in females or having 5 drinks in one
occasion.
‘consumes high fat/high salt food frequently
«consumes less than 3 servings of vegetables and 2 servings of fruits daily
has less than 2 % hours of moderate intensity physical activity weekly
‘© has a body mass index (BMI) equal to or more than 23
© has a waist circumference equal to or more than 90 centimeters in males or 80
centimeters in females
‘© has a blood pressure reading above 120 mmig systolic or 80 mmHg diastolic, taken
as the mean of two readings on each of two occasions
+ has a fasting blood glucose concentration above 7.0 mmol/I or 126 mg/dl or a random
blood glucose concentration above 11.0 mmol/l or 200 mg/dl
# has a total blood cholesterol concentration above 5.3 mmol/l or 200 mg/dl
6
Hi 6.
Referral
Coordination mechanisms with the next referral level should be established for clients
who need specialist or hospital care. Following Action 3 of the WHO PEN Protocol for
the Integrated Management of Hypertension and Diabetes, individuals with any of the
conditions below will be referred to a higher level facility
* Blood Pressure of >140 (systole) or >90 mmHg (diastole) in people below 40 years
old (to exclude secondary hypertension)
* Known heart disease, stroke, TIA, DM, kidney disease (for assessment as necessary)
Angina, claudication
© Worsening heart failure
* Raised Blood Pressure >140/90 (in DM above 130/80 mmlg) in spite of treatment
with 2 or 3 agents
© Any proteinuria
‘© Newly diagnosed diabetes with urine ketones 2+ or in lean person of below 30 years
old
© DM with fasting blood glucose >14 mmol/l despite maximal metformin with or
without sulphonylurea
‘* DM with severe infection and/or foot ulcers
Risk Stratification
Following risk assessment and screening, the level of risks of individuals who are not
referred to a higher level facility will be estimated using the WHO/ISH Risk Prediction
Charts for the Western Pacific Region (refer to Appendix 3).
Classification of the 10-Year Risk of Fatal or Non-fatal Cardiovascular Event:
Risk Level Percentage of Risk | _ Color of the Cell
Low <10% Green _
fild 10% to < 20% Yellow
Medium 20% to < 30% Orange
High 30% t0 < 40% Red
Very High 240% Deep Red
Charts are not necessary for making treatment decisions in individuals who are at high
cardiovascular risk because they have established cardiovascular disease or very high
levels of individual risk factors. All of them need intensive lifestyle interventions and
appropriate drug therapy. They include people:
* with established cardiovascular disease
+ without established CVD who have a total cholesterol > 8 mmol/l (320 mg/dl) or low-
density lipoprotein (LDL) cholesterol > 6 mmol/l (240 mg/dl) or TC/HDL-C (total
cholesterol/high density lipoprotein cholesterol) ratio >8
* without established CVD who have persistent raised blood pressure (>160-170/100-
105 mmHg) + with type 1 or 2 diabetes, with overt nephropathy or other significant renal disease
© with renal failure or renal impairment.
8. Risk Management
Management guidelines for risk reduction will follow Action 5 of the WHO PEN
Protocol for the Integrated Management of Hypertension and Diabetes (WHO 2010) and
the Pocket Guidelines for Assessment and Management of Cardiovascular Risk (WHO
2007).
VIII IMPLEMENTATION ARRANGEMENT
The oversight in the implementation of the Phil PEN lies with the National Center for
Disease Prevention and Control, Degenerative Disease Office in collaboration with the
National Center for Pharmaceutical Access Management and the Philippine Health Insurance
Corporation.
IX ROLES AND RESPONSIBILITIES
‘The following offices and institutions shall provide support to LGUs in the adoption of Phil
PEN:
1. Department of Health
‘The DOH shall provide leadership in the adoption of Phil PEN by (1) promoting Phil PEN for
nationwide adoption and formation of partnership among several stakeholders; (2) providing,
of technical support, logistics and financial assistance to LGUs; and (3) monitoring progress
of nationwide implementation of Phil PEN.
National Center for Disease Prevention and Control (NCDPC)
‘The NCDPC shall be the over-all coordinator for the adoption of Phil PEN among LGUs. It
shall:
* Provide policy directions in the adoption and institutionalization of Phil PEN for
LGUs.
Provide technical support to the CHDs in extending support to the LGUs.
In collaboration with the CHDs, provide logistics and financial assistance to the
LGUs.
© Develop a reporting and monitoring system in the adoption of Phil PEN among
LGUs in collaboration with the National Epidemiology Center.
© Coordinate with other national centers and bureaus in the central office in the
adoption of Phil PEN such as:
© Development of IEC plans and materials with the National Center for
Health Promotion (NCHP);
© Coordinate with the National Center for Pharmaceutical Access and
Management (NCPAM) in ensuring access and availability of affordable
quality generic non-communicable disease medicines. National Center for Pharmaceutical Access and Management (NCPAM)
The NCPAM in collaboration with the NCDPC and Centers for Health Development (CHD)
shall:
* Set the policy direction in the provision of affordable quality generic non-
communicable disease medicines particularly for the poor.
* Oversee and supervise the provision of affordable quality generic non-
communicable disease medicines including the pre and post procurement
activities.
National Center for Health Promotion (NCHP)
The NCHP shall:
© Provide the necessary IECs that will advocate the adoption of Phil PEN among
LGUs as well as development of behavioral change communication schemes
targeting various stakeholders in the community.
* Advocate with other govemment agencies, non-government, private sector,
development partners and other relevant stakeholders for support on policy
development and funding in the creation of an environment that will encourage
healthy lifestyle.
Health Policy Development and Planning Bureau (HPDPB)
‘The HPDPB shall support the development of relevant policies in the adoption of Phil PEN
as well as the facilitation of program evaluation studies and researches.
National Epidemiology Center
‘The National Epidemiology Center shall support the development of the indicators and
possible sources
Centers for Health Development (CHD)
The DOH CHD shall serve as local coordinator in the adoption of Phil PEN. The roles of the
CHDs shall be as follows:
‘* Ensure that the health systems at the local level are supportive and responsive to
the essential elements required in the adoption of Phil PEN.
* Build local coalitions composed of local government, civil society, academe,
private sector and other relevant partners in the health sector that would support
adoption of Phil PEN.
* Promote the adoption of Phil PEN among LGUs in the region.
«Provide technical support to LGUs in the adoption of Phil PEN.
«Assist LGUs in accessing available financial grants and support of the DOH,
development partners and donors. 2. PHILIPPINE HEALTH INSURANCE CORPORATION (PHIC)
In order to ensure the adoption of Phil PEN, the PHIC shall:
‘© Develop and implement an insurance package for individuals at risk and afflicted
with lifestyle related disease
* Advocate the adoption of Phil PEN in the health facilities nationwide by linking to
financial incentives.
3. Local Government Units (LGUs)
The Local Government Units shall adopt and implement the PHIL PEN and provide services
and products in primary health care facilities and hospitals in their localities as well as
provide the training needs for personnel at peripheral health units , district hospitals and
laboratories.
4, Referral Centers
Higher level facilities such as district, provincial hospitals, medical centers, regional hospitals,
and specialty hospitals must be equipped to handle referral for lower level facilities and
provide the necessary support to the implementation of the PHIL PEN.
X FUNDING
‘The Department of Health Central Office and Centers for Health Development shall
provide funds for technical assistance, monitoring and health promotion campaigns to ensure
the operationalization of this Order. Local Government Units shall provide funds to provide
products and services in their respective communities. Other government agencies, non-
government organizations and other stakeholders shall provide counterpart funds and
technical assistance as appropriate to ensure the effective implementation of the PHIL PEN
Protocol in the country.
XI REPEALING CLAUSE
All previous Orders and other related issuances inconsistent or contrary to the
provisions of this Administrative Order are hereby repealed, amended or modified
accordingly. All other provisions of existing issuances which are not affected by this Order
shall remain valid and in effect.
‘XI EFFECTIVITY
This Order shall take effect immediately.
CTO.
ENRIQUE T. ONA, MD, FPCS, FACS
Secretary of Health 1
Cad
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(Foe prevention of bean anacks,svoes, renal aoe, ampazins and bine)
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Protocol : 1P (continued)
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van anhyperanstve rastmont
su All patients wrth astabtnhod iabstos and eardiwrascslar dissass
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SPSEiccreous ontints tev romance stray precast snd Bo
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1) shell Be give tyla advise and saline
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a,
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rok 10 << 20M follow up avery 3 minnie nl targets atu rat,
hi 6-9 mons dora
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ae Foto wp at hat ovory 3 meets
Irrasourcee tow gpvo m satin to
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Tak 200 om
Coyne on dit, py actiiy, sok ingcomatian Pecicots 3
1 Porsisan BP 2 140/90 mratig dn DM 2 130/20 samy camaider &
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een Say, 100 me day we Aspe:
follow up oriey 1.6 month.
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@Betst — [Wo Pacape ftsental HOD [PEN meventons
Protocol : 1P (continued)
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‘SECOND VISIT
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8 nse ei
and aP)
physial stv, smoking cosssion (Protrals 30
TF Uf risk i 20 to Ss fer 345 months of prescribed interventions
fist ii, refer to neat eel
1 Avo able sal and reduce sal foods such as icles, sly fish, fastfood, processed fod, canned oad an stek cubes
1 Have your blood goss level, Hood pressure and urine eheckod regulary
Avie spevife for diabetes
1 Ifyou areon any diabetes medication that mas cause your blood ghicose lvl 1 go
1 I oasble,bave so
1 Avoid walking baefot or without socks
{Was fet in akewvarw water and
1 Do nn cat calluses a cons, nor use chemical agents am them
eyes checked every year
nv cary sup oF sweets with you
pllespeially Detwean the toes
1 Look t your feet everyday andi you so problem or an injury goo your health worker Appendix 2. Flow of Activities or Service Pathway
ear
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14 Appendix 3. NCD Risk Assessment and Screening Form
NCD HIGH-RISK ASSESSMENT
DN. {Facility Form)
Dated Assesment Trahbater Wee
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som cow lM F
Tare Contaet Namba
apa cational ARTE
Fam Hstory ing (abeco/ Cette)
Doespatenthave 1*depee ewer smoked [| stopsed> ayear
reat Curenteroker Ll stopped
