icht 3/12/2013

2013

The iCHT The Marikina CityExperience and Quick Guide to the iCHT System

Health Policy Development Program

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Content Guide Click on the section of interest A. Introduction B. iCHT Concept and Software Development C. iCHT Pilot Implementation in Marikina City D. Quick Guide to iCHT ImplementationAnnexes

HPDP and Marikina City Memorandum of Understanding A. Algorithms B. Marikina Training Design C. Commodatum D. Cost Benefit Analysis Paper and Presentation E. iCHT Application Manual F. iCHT Videos Pretest Results G. Pop-up and Video Messages H.

Access Level for iCHT Administrators Panel I.

The iCHT System

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Introduction The Department of Health (DOH) Department Order 2011 0188 entitled Kalusugan Pangkalahatan (KP) Implementation and Execution Plan provides a clear path in the achievement of Universal Health care through its three strategic thrusts: (1) Financial Risk Protection; (2) Access to Quality Health Services; and (3) Attainment of Health-related Millennium Development Goals (MDGs).

In particular, the attainment of health related MDGs strategy applies additional effort and resources in localities with high concentration of families who are unable to receive critical health services by using the approach of Community Health Teams (CHT). This approach was supported by the results of the Family Health Book (FHB) Operations Research done in Compostela Valley wherein the increase in use of FP/MNCHN services such as Antenatal Care (ANC), Facility Based Delivery (FBD), Immunization and Modern Family Planning (MFP) among families was influenced by the health navigators. They visited low-income, poorly educated families and provided them health messages through the FHB and assisted them in health use planning and adherence.

Based on the DO 2011-0188 issuance, for the Scale-up Phase (CY 2012 to 2013), the mobilization of at least 100,000 CHTs should be organized and trained in identifying clients with health needs on FP/MNCHN by profiling and health risk assessment, guiding clients in the formulation of health plans, linking clients to health providers and facilities and providing information to families on their entitlements as PhilHealth members. By this time, they should already be partnered to the 5.2 million poorest families listed in the National Household Targeting System-Poverty Reduction (NHTS-PR) and eventually to 10.8 million families by 2016.

However, with the implementation of CHT nationwide, there are certain bottlenecks that have been identified. These include: (1) high cost of printing for the various paper forms and materials, (2) high transaction cost for the validation of profiles of household members, (3) time consumed in the consolidation of data (barangay to regional level), (4) error-prone manual reporting system, (5) time consumed in updating the central database of NHTS and PhilHealth membership list, and (6) inability to relay real time information to health facilities to help them estimate resources for health needs of clients.

These identified bottlenecks in the implementation of CHT activities may be addressed by the use of iCHT, a computer based application which is an automated version of the CHT tools specifically designed for the profiling of families, provision of critical health information and development of Health Use Plans (HUP). This development was led by Health Policy Development Program (HPDP), a USAID-funded project, in cooperation with the DOH-NCR and City Government of Marikina as the main pilot site of implementation.

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iCHT Concept and Software Development

Concept The general concept (Figure 1) of the iCHT system is to deploy CHT partners using a tablet-based application which serves as a substitute of the CHT forms. In this case, the paper-based forms are translated into an automated version wherein it can perform profiling of families, formulation of specific health plans with standardized multimedia health messages, referral to facility, monitoring of utilization and follow-up.

Figure 1: General Concept of iCHT

On the other hand, the CHT deployment shall also be monitored by the CHT supervisors, health center staff and health managers. With the current consolidation and reporting scheme of the pen and paper CHT approach (Figure 2) which is time consuming and error-prone, the iCHT system, through a web-based application, will be used to generate reports using its cloud computing capability. This shall sort the CHT reports to their required classification.

Figure 2: Pen and Paper CHT Reporting Flow

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From the data collected during the home visits and follow-ups of CHT partners, when synced via wireless internet to the admin server, this will already be accessible to the health providers, LGU health staff and DOH (Figure 3).

Figure 3: iCHT Reporting Flow

The iCHT Tablet Application The features of the tablet application are the following:

a. Each CHT partner will be provided by a tablet installed with an iCHT android application wherein

a username and password is provided to access the application.

Figure 4: iCHT Log-in Page

b. The assigned head of households for the CHT partner will be accessed upon the login. Initial details such as NHTS number, birth date, sex and address of the head of household are uploaded in the system.

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Figure 5: Household Search Page

This shall be validated and updated by the CHT partner during the home visit. During the profiling, the PhilHealth membership and NHTS category are also asked in the application.

Figure 6: Profiling Page

Adding household members are also facilitated by the application wherein the birth date, sex, relationship with the head of household and PhilHealth membership are also determined.

Figure 7: Adding Household Members

c. Automatic identification of health risks from the profiling will initiate the HUP development. The criteria used for HUP eligibility are seen in Table 1. For HUP A/B, C, and F, these will be automatically developed when the household member meets the conditions of age and/or sex. While for HUP D, E and G, screening questions shall be asked by the system to proceed in the profiling. For example in HUP D, the system will ask if the female member aged >15 years old is pregnant (Figure 8).

Table 1: Criteria for HUP Eligibility

Criteria for HUP Eligibility Health Use Plans Male or Female Age < 1 years old HUP A/B Male or Female Age 1 to 15 years old, Pregnant HUP D Female, >15 years old , < 6 weeks post-partum HUP E Female, aged 15-49 years old HUP F Male or Female, Aged 10 onwards, with cough for > 2 weeks. HUP G

Figure 8: HUP Eligibility Qualifier

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d. HUP development for newborn, infant, child aged 1 to 5 years old, pregnant, postpartum, family planning and cough of more than two weeks. When a member has already been profiled and screened for health risks, the CHT partner may now start assisting the client in health use planning. A set of questions patterned from the paper-based form were translated to easily navigate the CHT partner in determining referrals. Most of the HUPs except for HUP G and F have two components in planning: (1) Identification of Danger Signs which is usually located on the first part and (2) Assessment of needed health services.

For example in HUP D, the pregnant is screened first with Danger Signs (Figure 9). If there are items that are selected in the list of signs and symptoms, the system will automatically refer the client to a hospital. While, if there are no danger signs, the planning will proceed to the maternal profile, identification of prenatal check-ups and screening for high risk pregnancies (Figure 10).

Figure 9: Pregnancy Danger Signs

Figure 10: Risk Assessment

e. Every HUP has a standardized pop-out and video health messages to provide health education and awareness among the families. For example in HUP D, when the question for prenatal check-up is asked and answered by Oo or Hindi, a pop-out message will appear for every answer (Figure 11 & 12). While there are video health messages such as Newborn Screening and Exclusive Breastfeeding campaign embedded in the HUP that should be played and shown to the client (Figure 13).

Figure 11: Pop-up message for Oo

Figure 12: Pop-up message for Hindi

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Figure 13: Video screenshot on messages for newborn screening and exclusive breast feeding

For the full list of pop-out and video health messages, see Annex H.

f. Referral of clients to health facilities is also integrated in the HUP development. This feature customizes the type of health facility based on the health service needed by the client (Table 2).

Table 2: Service Delivery Network by type of Referral

HUP Health Center Lying-in

Government Hospital

Private Hospital

HUP AB Danger signs Others

HUP C Danger signs Others

HUP D Danger signs Antenatal care Facility for NSD Facility for CS

HUP E Danger signs Postnatal care

HUP F FP consultation

HUP G Cough consultation

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For example in HUP D, dangers signs are referred only to government and private hospitals since that this needing immediate intervention. The lists of hospitals are not only those in the situated in the municipality or city but also those who are adjacent or near the location of the client. Moreover, for the antenatal care, the pregnant may be referred to the health center, private lying-ins and hospitals since that these facilities can accommodate the health services needed by the client.

g. Generation of notifications which prompts the follow-up of households through syncing and

updating with the web server. For this feature, the data inputted by the CHT partner during the field visit shall be transferred to the web server/admin panel through wireless internet connection. The admin panel will generate the notifications and update the android application. For example in HUP D, if a pregnant women has no antenatal check-up and she has been referred by the CHT partner to the health center, the admin panel will generate notification in the tablet application to follow-up if the client went to the facility for health services (Figure 14).

Figure 14: Notifications Page

The iCHT Administrator Application Features of the Admin Panel Application:

a. Accessibility level of users (see Annex I) b. Adding CHT members c. Generation of essential reports d. Prompting the generation of notifications for android application e. Health Risk Assessments f. HUP Development

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iCHT Pilot Implementation in Marikina City Marikina City was chosen as the pilot site for iCHT implementation due to the presence of Pantawid Pamilyang Pilipino Program or (4Ps), number of trained CHT partners, and existing IT infrastructure (availability of internet connections and servers). HPDP expressed its interest to Marikina City as a pilot site last May 22, 2012 through a meeting with Marikina City Health Office (CHO) and representatives from the Marikina Information System (MIS) office. The iCHT concept, proposed times and counterparts expected from the LGU was presented. The CHO agreed that the implementation of CHT strategy in their city experiences difficulty due to the (1) downloading of forms, (2) data consolidation since their midwives are flooded with various tasks, and (3) delay in the transfer of TEVs of the CHT volunteers which ensure commitment.

They also agreed that the use of an Information and Communication Technology (ICT) will greatly affect the CHT implementation. However, they raised some concerns in the security of tablets as this may post risks. The CHO suggested that the Barangay Hall may be involved with the barangay tanods in the field work of the CHTs. Moreover, the suggested procurement of tablet PCs as part

of their counterpart of the LGU may not be provided since that the annual budget allocation for health has already been programmed for this year. It was also agreed that the tablets will be under the ownership of the Marikina CHO after the turnover of the iCHT system.

To formalize the iCHT project development and pilot testing in Marikina City, the CHO requested formalization of roles between the stakeholders of the project by drafting a Memorandum of Understanding (MOU) signed by the City Mayor and Chief of Party of HPDP. The MOU indicates the roles and functions of each party in the roll-out of the iCHT system (see Annex A).

Development of the iCHT software for Marikina City The iCHT system was developed over a period of five (5) months, from August to December 2012. The software development was contracted out to AppLabs Digital Studios., an IT application developer. Last August 1, 2012, a formal meeting was conducted between AppLabs, Marikina CHO and HPDP. This was a venue for the CHO to provide an orientation of the current CHT implementation of the city as well as the possible sites for the pilot. While on the part of AppLabs, they presented their iCHT concept presentation which includes digitizing and creation of a paperless CHT tool and the ability to sync reports collected via wireless connection towards the server. Marikina CHO was also expected to prepare data sets of NHTS and health facilities which shall be uploaded in the system.

During the development of the applications, the following activities were done: a. Procurement of Tablet PCs based on the number of CHTs. b. Review and streamlining of the paper-based CHT forms (both Form 1 and 2A-G), referral and

monitoring tools which were translated into algorithms (see Annex B). Additional questions based on the reviewed forms were also accommodated to simplify the health planning.

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c. Health messages integrated in the CHT forms were executed as pop-out messages while existing DOH health videos was also included to provide standardized presentation of messages for FP/MNCHN and TB. This was also presented with Marikina CHO.

d. Formulation of systematic referral of FP/MNCHN and TB services to health facilities. e. Debugging and Beta Testing of both android and admin panel applications

Preparing the IT Infrastructure of Marikina City In preparing the IT infrastructure of the iCHT System in Marikina, the developers assessed the existing server of the city in coordination with MIS. After this, the developers installed the web-based software in Marikina system based on its configuration, available memory space and compatibility issues. Since that Barangay Tumana was the target pilot site, the health center was provided with a desktop computer and internet connection through the citys local area network and wireless router. This served as the access point for the tablets to communicate with the iCHT admin panel wherein designated data for a specific CHT will be fetched from the system.

Training HPDP conducted a three-day orientation-training on the use of the iCHT application for the navigational duties of the CHTs (see Annex C). The CHO organized the CHTs that will be trained. There was a turnout of 78 CHT members from the selected site. The first day of training was devoted to the familiarization of the CHTs to their roles and functions in the delivery of health services in the barangay. The orientation was conducted by the CHD KP nurse assigned to Marikina City. It was a venue to familiarize them with the iCHT application, wherein a hands-on manipulation of the application using the PC tablet was experienced. Alongside the CHT sessions, a separate orientation for the health providers in Barangay Tumana and Marikina City Health Officers was conducted on the use of the iCHT Administration Panel. The third day was divided into three (3) parts, in the morning the CHTs were provided with a refresher on the discussions made on the first two (2) days of the training, the afternoon was devoted to a practicum for the use of the iCHT application to an actual household and finally, to evaluate the effectiveness of the training. A plenary discussion was held regarding the benefits, issues and challenges experienced with the actual use of the iCHT application.

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Deployment & Roll-out in Marikina Sixty CHT members, who were assigned a total of 2,515 households or around 40 families for each, were provided with tablets installed with the iCHT application and deployed. Prior to deployment, each CHT member was provided a commodatum as a way to secure the tablets (see Annex D). CHT members who were having difficulties in using the iCHT application were paired with those advance users. In order to not overcrowd the health center, the CHT members were grouped and assigned a specific schedule when they will get the tablets from the health center and do their home visits.

HPDP team preparing the tablets prior to deployment (left) and members of the CHT

check their household assignments (right)

Monitoring & Troubleshooting During the initial deployment, a number of setbacks were documented. Some of the iCHT application crashes while being used. This was resolved by customizing the android operating system of the tablet. The customization removed unnecessary preinstalled applications in the tablet and made the iCHT application more stable. Problems in fetching and syncing of data, development of health use plans were common since the application was still in its infancy. Versions after versions of the application were developed, resolving every new glitch that was found during testing. Some of the problems were with the server and the connection from the health center.

Some members of the Community Health Team in Marikina City pose with their electronic tablet containing the android-based iCHT application during the turnover ceremony of the iCHT system in Marikina City on December 10, 2012.

iCHT Timeline August and September 2012 Finalization of the iCHT concept and requirements Presentation to key stakeholders, the Department of Health and the

Marikina City Government (local health board) and Marikina City Health Office

Procurement of the PC tablets Start of software development October 2012 End of software development and debugging Installation of the iCHT system in the Tumana Health Center Training of 57 CHTs of Barangay Tumana November 2012 Random selection of 18 CHTs involved in a time and motion study Presentation of the cost benefit analysis of the iCHT system to the

Department of Health Completion of monitoring of iCHT implementation in Tumana December 2012 Turn over ceremony

Feedback and Results The potential of the iCHT system in improving CHT tasks was determined by randomly selecting eighteen (18) CHT members who assessed the ease of using iCHT and were subjected to a time and motion analysis to determine the length of time needed to profile families and develop HUPs. In addition, the relative cost of the iCHT system versus the use of paper-based forms and materials for a five-year period and the amount of savings that may be derived for each CHT member in a year were also estimated.

Feedback from the CHT members who have used the iCHT system reveals the following: 1. The CHTs validated the user-friendliness of the application and the portability and convenience of

bringing a tablet instead of a set of forms and booklets; 2. The delivery of health messages did not miss out on health messages to be delivered. The

multimedia format was found to be more interesting by the families; and 3. The data gathered by the CHTs seamlessly synced to the iCHT administration panel that is

accessible to the health center midwife, thus providing instant report consolidation.

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The key findings in using the iCHT system versus the paper-based approach are the following: 1. There is no difference in the training cost between the two methods; 2. The cost of materials for the iCHT is lower than that of the paper-based approach; 3. The cost of household visits is lower when using the iCHT because of the shorter time spent in

profiling, developing health use plans, and delivering health messages; 4. Data processing and reporting is significantly quicker and less expensive when using the iCHT; and 5. Considering all the costs involved in the two methods, using the iCHT system is less expensive and

can generate savings by around PhP 9,000 per CHT annually.

Using the tablets with the iCHT makes our work easier and faster. We just need to press buttons and show the families the health messages.

-Luchi Lamac, CHT member trained on iCHT

The iCHT system was shown to be more advantageous than the traditional paper-based approach because of the lower cost of materials and the lesser time spent in performing CHT functions. Using the iCHT system is nearly half as expensive over a five-year period. The difference in cost between the two methods translates to a savings of PhP 9,314 for each CHT member per year when using the iCHT system.

Luchi Lamac, Marikina CHT member, assisting a family in developing health use plans using the tablet-based iCHT application.

Quick Guide to iCHT Implementation As a reference for the roll-out of the iCHT technology to the other regions, a guide was developed to assist the CHDs and LGUs in the implementation. This was based from the preparatory and implementation activities done in Marikina City pilot experience.

Download the video at: https://dl.dropbox.com/u/32411870/Quick%20Guide%20To%20iCHT.mp4

A. Preparatory Phase In the preparatory phase, assessment of areas for implementation, resources, software development and pre-deployment activities are expected to be accomplished. In this section, the agreements made by both CHD and LGUs are expected to support the implementation.

1) Targeting Areas for Implementation With the benefits of iCHT in the reduction of cost in the CHT deployment, ease in reporting, among others, it is ideal to implement such technology in all areas. However, with several constraints in the implementation, it is essential to note basic considerations in selecting sites. This may determine if the area selected will meet the basic requirement of the system. These are as follows: a. Are there existing IT resources in the area such as internet connection or Local Area

Networks? b. What is the current NHTS household target for iCHT implementation (Q1, Q2 or CCT

Households)? c. With regards to the geographical orientation of the areas, is there an internet or 3G

connection provider?

2) Determining the Resource Requirement and Costs After a site has already been selected, the resources needed for the implementation should be identified basing on the scale of implementation. This may vary depending on the targeted areas

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if province-wide or selected municipalities/cities only. To determine the required resources, the CHD should have already identified which LGUs to be covered and number of NHTS households to be targeted.

Android Application The android application will be primarily be used by the CHT partners in the field. This requires the following:

a. Determine the number of Tablet PCs to be procured by the identifying the number of CHT partners needed in the deployment. The recommended ratio in determining the number of CHT partners is 1 CHT Partner: 20 Households based from the DO 2011-0188.

b. Customize the software application based on the needs of the LGU. This is optional for the implementing CHDs and LGUs.

c. Conduct of trainings for CHT partners and health staff. d. Preparation of logistics for deployment

Admin Panel Application The requirements in setting-up the admin panel/ web server application are the following:

a. Provision of server where the application shall be installed. b. Establish an internet connection or Wireless Local Area Connection (WLAN) if internet is

not available c. Computers to be installed at the health centers. d. Preparation of required data sets that will be uploaded in the admin panel. e. Training of Health Staffs in using the both the tablet application and admin panel.

Preparing the iCHT Database Prepare the following for integration in the iCHT database in excel format: NHTS or CCT Database with the following details

NHTS ID number Name of head of household Age/Birthdate Sex Complete address Name of dependents and their age, sex, and relation to head of household

List of CHT members and their assigned households List of all health facilities with the following information

Name of the facility Contact Details Address PhilHealth Accreditation Services Available

List of users for the admin panel with their corresponding access authorization level

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3) Engaging with LGUs A video material was developed especially design for local chief executives (LCE) to secure their support. It was designed to give an idea on what the iCHT system is and how it can potentially improve the performance of CHT functions. It is available in two languages: English and Filipino.

Filipino Version

http://youtu.be/UCjOoPHM2o4

Download the videos at: Filipino version: https://dl.dropbox.com/u/32411870/iCHT%20LCE%20Filipino.mp4 English version: https://dl.dropbox.com/u/32411870/iCHT%20LCE%20English.mp4

Agreements between the CHD and LGUs are important in the execution and sustainability of the iCHT. With the identified areas for implementation, the CHD should secure commitment of the LCEs and its staff through a Memorandum of Understanding (MOU). This shall contain the agreements of each party on their functions, duties, and responsibility in the implementation of iCHT.

4) Setting-up the IT Infrastructure When the agreements have been made between the CHD and LGU and the resources are already available (i.e. tablets, servers, routers, etc.), it is now ready to set up the IT infrastructure suited for the iCHT system. Note that the setup for both android and admin panel application can be simultaneously done to maximize the time spent for the preparation. For the android application, tablet PCs should already be procured and customized before the installation of the software application. Customization of the tablet PCs entails that this should only be used for the iCHT application and not for other purposes. Customization of the android application depends on the discretion of the CHD and LGU if they want to. This includes modification of language, health messages, and other components that is more suitable in the area of roll-out. With the experience in Marikina City, the health messages, language, and other parts of the android application were presented to the City Health Office to

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at least provide feedback from them if the features of the application compliment their current health programs. Customization may be outsourced with IT Company specializing application development, however, it important to consider the time of development. This may lengthen the process of development based on the degree of changes in the software which may delay the training and deployment of the CHT partners. When the customization of iCHT application has already been completed, this should be installed to the tablet PCs for beta testing. To proceed on the beta testing, the admin panel should be ready by this time. To setup the admin panel application, the server, internet connection/WLAN and computers should be already in place. The server, where the application will be accessed to by the users, will be managed by a primary administrator. In this case, the CHD and LGU should identify who will manage the server. This includes tasks on uploading of data sets of the targeted areas which contains the list of households and service delivery network; identification of access level among the users of the application; and maintains the web server.

Internet connection or WLAN should be established to sync and update the data from the web server to the tablet. Make sure that the routers and computers are already functional in the area. It is recommended to install the equipment at the health centers.

The data sets that will be used for the deployment should be submitted by the LGU staff for uploading in the system. These include, the list of names of NHTS households matched with the CHT partners and the Service Delivery Network. The list of NHTS households may be obtained from the regional or local DSWD. This list should be matched with the number of CHT partners that will be trained. The recommended ratio for CHT partner to its assigned household is 1:20. However, this may vary depending on the availability of the CHT volunteers in the area. In the case of Marikina City, 2515 households of Barangay Tumana were accommodated by 60 CHT partners. In assigning households to the CHT partner, it should take into consideration if the volunteer is a Parent Leader (PL). In this case, the covered CCT households may already be assigned to the PL. Another factor would be designation of households should be at least accessible with the CHT partner. It is also important to arrange the grouping of households according to their address and proximity.

While in determining the Service Delivery Network that will be used for the referral of patients, the LGUs should prepare a list of health facilities (health centers, private lying-ins, private hospitals and government hospitals). Information such as the name of the facility, address,

contact person, contact number, and PhilHealth Accreditation should be also contained in the list.

5) Conduct iCHT Training The planner should ensure that the tablets are ready for use before training the CHTs. This means that the customized application has already been developed and functional especially in the syncing and updating capability with the admin server application through beta testing. In addition, training materials should be prepared by the trainers. This includes the training design, modules and forms used in the deployment. An instructional manual (see Annex F) and an instructional video (see disk 2) on the use of the iCHT application were developed to assist in the conduct of training.

The conduct of iCHT training for CHT partners may take three days of training. With the experience in Marikina, the first day of training was dedicated in the orientation of roles, process and tools of the CHT volunteer. While the remaining two days, this shall be focused on the discussions of the iCHT actual demonstration of profiling, HUP development, notifications, field practicum and arrangements for the deployment.

6) Preparing for the deployment and monitoring of CHT partners Before the deployment of the trained CHT partners, the commodatum or the agreement between the LGU and CHT in using the iCHT Tablet should be signed. Moreover, the logistics should be prepared. First, the CHT partners should be provided with the list of assigned NHTS households at hand. This will serve as an opportunity for them to locate the households before the home visit. Second, the referral forms should be readily given to family members who are referred to the health facilities. Third, the schedule of services in the health center as well as the point persons should be oriented to the CHT partners since they should also providing them the a list of referred clients by using a summary call sheet or customized form.

Maintaining the integrity of the tablet PC should be oriented among the CHT partners not only in the iCHT training but also during the deployment. The health staff should identify storage cabinets where the tablet PCs will be stored when not in use. Policies in charging the equipment as well as the monitoring of ins and outs of the tablet should also be formulated.

At least one staff of the health center should be familiar in troubleshooting the tablet PCs and web server application.

Another important aspect that should be look into would be the anticipation that demands for health services for FP/MNCHN and TB will increase. Like what happened in Tumana Health Center, the midwife verbalized that during the deployment of CHTs in the area, patients for immunization and FP services increased. In this case, the Municipal/City Health Officer should at least prepare the health facilities for supplies and other resources to accommodate its clients.

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Annexes

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Annex A. HPDP and Marikina City Memorandum of Understanding

MEMORANDUM OF UNDERSTANDING

ON THE SETUP, PROMOTION, AND MAINTENANCE OF THE INTELLIGENT COMMUNITY HEALTH TOOL (iCHT)

IN MARIKINA CITY

The City Government of Marikina and the UPecon Foundation Inc.-Health Policy Development Program (HPDP), hereafter referred to as the Parties, COGNIZANT of the fact that Marikina City is responsible for the timely delivery of basic health services to the people; RECOGNIZING the provision of the Local Government Code that mandates Marikina City to ensure and promote the health and safety of its constituents; AWARE of the value of information regarding affordable and accessible quality health care services and products, together with their costs; REALIZING the value of the latest mobile communication technology to promote, disseminate, and share relevant information to end users; DESIROUS of the promotion of informed choice that leads to better health seeking behavior of Marikina City families, especially those with limited financing sources for health care needs; REAFFIRMING the Parties resolve to develop and further enhance a functional referral system that considers the respective capacities of health care providers in Marikina City; COMMITTED to the realization of potential benefits through multilateral policy formulation and decision-making among stakeholders; Accordingly, the Parties, operating under this MOU agree as follows:

ARTICLE 1

The Parties hereby employ the Intelligent Community Health Tool (iCHT), which will automate the process and tools employed by Community Health Teams in helping poor families access critical health services through development of and adherence to health use plans. The iCHT shall be an Android-based application that will facilitate a more efficient way of collecting and updating relevant database, create and track adherence to health use plans by target families, and deliver standardized health messages.

ARTICLE 2

The Parties agree to undertake the following functions, duties, and responsibilities for this MOU, with each Party providing its own resources in implementing its activities:

A. Marikina City shall: 1.) Provide HPDP with the roster, including all pertinent data, of Marikina City households that are

identified as poor by the National Household Targeting System for Poverty Reduction (NHTS-PR) or are beneficiaries of the Pantawid Pamilyang Pilipino Program (4P), with an assurance that all information

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shall be used solely in the development of iCHT and accessed only by authorized Community Health Teams and by designated staff from the City Health Office;

2.) Provide HPDP with a list of names of Community Health Teams and their corresponding assigned households that are beneficiaries of the Pantawid Pamilyang Pilipino Program (4P);

3.) Provide HPDP with a list of names, addresses, contact details, services provided, and corresponding fees (if available) of all PhilHealth-accredited health care facilities in the city, from both public and private sectors, from all its available databases, such as those from the Business Permit and Licensing Office;

4.) Mobilize instrumentalities, officers, and staff for the implementation of an Executive Order that will support the setup, promotion, and maintenance of iCHT;

5.) Organize designated representatives from the City Health Office and the systems administrator of the Marikina City website to execute tasks related to the operations of iCHT, including but not limited to approving new registrants in the network, reviewing all information reflected in the CHT reports and in the health provider profiles and ensuring their correctness, and monitoring the network for potential user abuse;

6.) Issue the necessary executive fiat and recommend to its Local Health Board the enactment of appropriate local legislative acts related to the iCHT activities, such as but not limited to establishing an inter-agency committee that will promote and maintain iCHT and defining annual budgetary allocations for its promotion and maintenance;

7.) Provide logistics and administrative support to activities, strategies, and materials related to the setup, promotion, and maintenance of iCHT application and website to ensure sustainability from launching onwards;

8.) Allow HPDP to access to Marikinas existing systems for the setup and hosting of the iCHT website; 9.) Ensure the protection of the tablets by defining a clear protocol on its handling, storage and

maintenance, which may include employing the services of Barangay Service Point Officers (BSPOs) or other individuals who may be able to escort the CHTs during their family visits and physically secure the units; and

10.) Cooperate with HPDP in validating the functionality of the application and the website and the accuracy of all reports produced by the package.

B. HPDP shall provide technical assistance to Marikina City in the:

1.) Conduct of consultative meeting with the Office of the City Mayor, the City Health Office, and the Marikina City Local Health Board for the development of iCHT;

2.) Formulation, development, and setup of the Android-based and user-friendly iCHT application that will introduce efficiency into the processes and tools of the Community Health Teams, potentially generating demand for health services in the city;

3.) Setup of the iCHT website, which shall contain information on NHTS-PR poor and 4Ps households, health status of families, and health care providers in the city and shall generate CHT reports and statistics, such as the number of health use plans developed and complied;

4.) Provision of tablets that shall contain the iCHT application and shall solely be used for pertinent activities by the Community Health Teams; and

5.) Conduct of technical assistance and capacity-building activities for Marikina City and other partners in relation to their functions and responsibilities in implementing all the tasks contained therein, especially in training for the use of and maintaining the iCHT application and website.

ARTICLE 3

Unless otherwise agreed, each Party will be accountable for the cost resulting from its own participation

in the activities contained in this MOU.

ARTICLE 4

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A Working Committee shall be created for the implementation of the provisions in this MOU. The Working Committee shall organize meetings, consultations, and workshops and shall meet at least once a month or whenever deemed appropriate. It will be responsible for developing the agendas, presentations, and minutes of each activity. Action items will be clearly identified and tracked in the minutes. Moreover, the working committee will monitor and evaluate the outputs, progress, and accomplishments of the iCHT initiative in relation to its objectives.

ARTICLE 5

This MOU may be amended upon mutual agreement of the Parties.

ARTICLE 6

This MOU shall remain in force for three months effective on the date of the final signature and may be extended for a similar period unless one Party officially notifies the other of its desire to suspend or terminate this MOU one month prior to its intended date of expiration. Either Party may terminate this MOU at any time, to take effect one month from receipt of the notice by the other Party.

Signed in Marikina City, Metropolitan Manila this __th day of September 2012.

For the City Government of Marikina: ________________________________ Hon. DEL R. DE GUZMAN Mayor, Marikina City

For the Health Policy Development Program: ________________________________ ORVILLE JOSE C. SOLON, PhD Chief of Party, UPecon Foundation, Inc. Health Policy Development Program

Annex B. Algorithms See file Alogorithms.rar

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Annex C. Marikina Training Design

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TRAINING DESIGN

ACTIVITY: Orientation/Training of Community Health Teams in Marikina City in the use of iCHT

DATES: October 4-5 & 8, 2012

VENUE: Marikina City Health Office Building, Marikina City

FUNDING AGENCY: Marikina City Health Office

RATIONALE: The organization and mobilization of Community Health Teams (CHT) is the main strategy to generate demand for

health services among the targeted poor. This is espoused in the MNCHN Manual of Operations (DM 2011-0177)

and the Kalusugan Pangkalahatan Execution Plan and Implementation Arrangement (DO 2011-0188.), being

formally implemented in the year 2011. Although a number of issuances have been disseminated, operational

issues have been raised from its nationwide implementation. Among others the implementation of CHT is faced

with the following concerns and bottlenecks, (1) expenses of monthly printing of various paper forms, (2) high

transaction cost in validating of information from individual CCT/ NHTS PR HHs, (3) difficulty in updating critical

databases (e.g. CCT/NHTS list, PHIC membership list), (4) time consuming manual consolidation of reports, (5)

error-prone manual reporting system, and (6) providing real time info to health facilities to help them estimate

resources for clients referred to them. These bottlenecks in the implementation of CHTs with its very nature need

an efficient, compact tool which is easily upgradable and modifiable for the dynamic needs of its implementation.

In this age of robust development in the field of Information Communication Technology (ICT), it will be

advantageous to integrate such to eliminate the issues bought by the current pen and paper approach of the CHT

implementation, thus the development of an Internet Community Health Team or iCHT.

The iCHT is an automated version of the CHT tools specifically the profiling form and the six (6) Health Use Plans

(HUPs), packaged into a user-friendly application embedded in a PC tablet, which when synchronized via internet

to a server and then received by an Administration Panel, can generate reports on vital indicators monitored by

the CHTs inherent in its navigational functions.

Marikina City has 11,997 NHTS PR poor household, Barangay Tumana in particular, is a known melting pot

Barangay, with 3,940 NHTS poor households (33% of Marikina), among which 1,956 are CCT beneficiaries was

chosen as the pilot testing site of the iCHT due to its diverse profile of poor families.

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TRAINING OBJECTIVES: The training will provide a venue for the Community Health Teams, CHT Supervisors, Marikina City Health Officers

and partner private health providers in familiarizing themselves with the iCHT application and to discuss changes in

the CHT forms bought by the automation of the CHT tools in paper format. At the end of the training, the

participants will be able to do the following:

a. Understand the navigational function of the Community Health Team

b. Understand the various concepts in delivering the CHT tasks through the use of the iCHT application

c. Maneuver through the Profiling and Health Use Plans in the iCHT application

d. Learn the basic handling and maintenance of the PC tablet as platform for the iCHT application

DESCRIPTION:

This will be a three-day orientation/training on the use of the iCHT application for the navigational duties of the

CHTs of Marikina City particularly in Barangay Tumana. The first two (2) days of the training will be devoted to the

familiarization of the CHTs to their roles and functions in the delivery of health services in the Barangay. It will also

be a venue to familiarize them with the iCHT application, where in a hands-on manipulation of the application

using the PC tablet will be experienced. Alongside the CHT sessions, a separate orientation for the health providers

in Barangay Tumana and Marikina City Health Officers will be conducted for the use of the iCHT Administration

Panel. The third day will be divided into three (3) parts, in the morning the CHT will be provided with a refresher on

the discussions made on the first two (2) days of the training, the afternoon, will be devoted to a practicum for the

use of the iCHT application to an actual household and finally, to evaluate the effectiveness of the training a

plenary discussion will be held regarding the benefits, issues and challenges experienced with the actual use of the

iCHT application.

TRAINING GOALS:

At the end of the three day activity, it is expected that:

The Community Health Teams are oriented on their roles and functions such as: Profiling of Assigned households Health Risk Assessment Relaying Health Messages Development of Health Use Plans with assigned household Follow-up on Health Use Plan adherence

The Community Health Teams are familiar in the use of the iCHT application City Health Officers and Health Managers/Providers are familiar in the use of the iCHT Administration Panel Community Health Teams, Barangay Officials, Health Providers are aware of the proper handling and

maintenance of the PC tablet. Agreements on monitoring the pilot implementation of the iCHT in Barangay Tumana have been identified

PREPARATION FOR THE TRAINING

The following are preparation work for the iCHT orientation/training for CHTs of Barangay Tumana;

Consultative meeting with Marikina CHO for the training design of the iCHT training

Venue: Marikina City Health Office c/o Dr. Cristy Sy Technical Chief

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o Use of projector(s) and sound system

o Meals and snacks of participants

o Transportation arrangements

Invitation of Participants c/o Mr. Brian Mascarina DOH KP Nurse & Dr. Cristy Sy Technical

Chief

Transportation of participants c/o Mr. Ziffred Anchetta Barangay Captain of Tumana

Mass reproduction of iCHT Administration Panel & Application module c/o HPDP Team &

AppLabs Team

Presentations c/o HPDP Team, Marikina CHO & AppLabs

THE TRAINING

DAY 1: OVERVIEW OF COMMUNITY HEALTH TEAMS ROLES, FUNCTIONS AND

TOOLS

Expected Participants:

60 CHT members in Barangay Tumana, Marikina City 3 representatives from Brgy. Tumana Health Center 2 representatives from Brgy. Tumana Hall Marikina CHO

o Dr. Cristy Sy o Engr. Melody Bibat

DOH CHD NCR o Mr. Brian Mascarina

Trainers/Facilitators:

8 representatives from HPDP UPecon 4 representatives from AppLabs Digital Studios

= 80 Participants

The morning session of the first day of training begin with the opening/welcome remarks from the City Health

Officer Dr. Alberto Herrera and the Barangay Captain of Tumana, Mr. Ziffred Anchetta, followed by setting up

expectations between participants and trainers and presentation of the training program. A short introduction on

iCHT will be presented by the HPDP team as a prelude to day 2 of the training. After which is the discussion of the

two modules namely:

Local Implementation of KP through CHTs

The Processes and tools of the CHT

This will be facilitated by the Marikina CHO and a DOH partner, included in the module is the overview of the CHT

functions as a navigator, the CHT tools such as the profiling form and the health use plans. A group activity is

included in module 2, where in the CHTs can practice on the CHT tools in paper form. The activity will be ended by

the closing remarks from the Marikina CHO, which would also mention activities for day 2 of the training.

The expected outputs are as follows:

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Clear understanding of the roles and functions of the Community

Health Teams

Understanding the benefits of an automated CHT tool

Understanding and mastery of the CHT tools in paper format

DAY 1 ACTIVITY OUTLINE:

Dates Time Activity Activity Description Facilitator

Day 1 October 4,

2012 Thursday

8:00 8:15 am

8:15 8:25 am

8:25 8:35 am

8:35 9:00 am

9:00 11:30 am

11:30 12:00 pm

1:00 4:30 pm

4:30 5:00 pm

Opening Ceremonies

Welcome/Opening remarks from Marikina CHO

Presentation of program activities for the three day orientation/training

Local implementation of KP through CHTs Module 1

Overview of iCHT

Processes and tools of the CHT Module 2

Closing remarks and introduction to day 2

leveling of expectations, presentation of participants

Overview on the roles and functions of the Community Health Team, navigational roles, reporting process, etc.

Bottlenecks & Issues from current CHT, Rationale & benefits of iCHT as compared to the current pen & paper approach

Discussion on the

processes of the CHT, such as Phase 1: Preparation, Phase 2: Household visits, Phase 3: Follow-up & Reporting. A group activity as a practice, will follow

Dr. Cristy Sy, Technical Division Chief, Marikina CHO

Dr. Alberto Herrera, City

Health Officer, Marikina City

Barangay Tumana Captain

Mr. Ziffred Anchetta Dr. Cristy Sy, Technical

Division Chief, Marikina CHO

Marikina CHO & DOH

partner HPDP Team Marikina CHO & DOH

partner Marikina CHO & DOH

partner

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activities

DAY 2: FAMILIARIZATION TO THE ICHT APPLICATION







= 80 Participants

The second day of activities will be devoted to the familiarization of CHTs to the iCHT application. The HPDP team alongside developers from AppLabs will discuss each health use plans, the questions and sequences within the forms and the proper handling and maintenance of the PC tablet. Before discussions the plenary will be divided into 8 groups with 7-8 members each and will be co-facilitated by a member from the HPDP team listed below:

1. Dr. Yosef Laudencia 2. Dr. Faith Obach 3. Mr. Karlo Paredes 4. Ms. Kristine Romorosa 5. Mr. Chamuel Santiago 6. Ms. Crisna Surmienda 7. Ms. Bonna Villagen 8. Mr. Lindsley Jeremiah Villarante

The seating arrangement will be based on the grouping identified. The first topic will be regarding the proper use of the PC tablet, a member from AppLabs will discuss the basic operations of the PC tablet such as turning on and off, locking and unlocking the screen, proper holding, cleaning etc. This topic is discussed prior to the manipulation of the tablet to ensure that the CHTs gain confidence on the handling of the PC tablet. To demonstrate effectively group facilitators will show his/her group the actual operations of the PC tablet with an actual unit. This will be followed by the distribution of the PC tablets to CHTs, and the reading of the Commedatum by Dr. Yosef Laudencia. Upon signing the Commedatum, it will thus be collected and kept by the Marikina CHO. Next will be the actual discussions on the iCHT application, each co-facilitator will guide his/her group in learning the HUPs while being discussed by a lead facilitator depending on the health plan, which are as follows:

1. Form 1 & HUP 2A & 2B Mr. Karlo Paredes & Dr. Faith Obach 2. HUP 2C -2D Mr. Kristine Romorosa 3. HUP 2E Mr. Chamuel Santiago 4. HUP 2F Mr. Lindsley Jeremiah Villarante 5. HUP 2G Dr. Yosef Laudencia

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Each lead facilitator will be accompanied by a developer from AppLabs namely:

1. Mr. Darwin Toledo Developer for the iCHT application 2. Mr. Brian Urfano Developer for the Administration Panel

Each HUPs will be discussed given a time allotment of 30 minutes each, after each HUP is discussed a simulation exercise will follow. The simulation exercises are two to three (2-3) sample cases that will be read by the lead facilitator for the CHTs to simulate on using the PC tablet. The groups will be given 5 minutes to practice using the tablet and another 5 minutes for the lead facilitator to demonstrate the answers. After the discussions and simulation exercises from the plenary, the PC tablets will be collected back for safe keeping of the Marikina CHO. The practicum will be discussed and the day two activity for the CHTs will thus end by the closing remarks of Dr. Cristy Sy of Marikina CHO. Given that there is still time at least an hour, the Marikina CHO, Barangay Tumana health providers and Barangay officials, will convene to discuss about the iCHT administrative panel, which includes the web base counterpart of the iCHT application, features such as adding administrators in the group, database updates from the field work of the CHTs, monitored health indicators of the software and the reports that can be generated by the iCHT administration panel. This will be facilitated by the HPDP team with their respective HUPs and assisted by the developer of the Administrative panel from AppLabs.


Familiarized in maneuvering through the iCHT version of the profiling

form and forms 2a-2g

Familiarized with the content, sequence of questioning and health

messages in the iCHT application

CHT supervisors, CHO representative and health providers

familiarized with the iCHT Administration Panel

Learned about the responsibility and accountability of the CHT and

health providers regarding the handling and safe keeping of the PC

tablet

Learned the basic maintenance of the PC tablet



Day 2 October 5,

2012 Friday

8:00 8:15 am

8:15 9:30 am

9:30 10:00 am

Opening of the activity and announcement of groupings

Discussion on the proper handling and maintenance of the PC tablets

Reading of the iCHT

Presentation of the 2nd

day activities

Discussion on manual

operations of the tablet such as power on & off, screen lock and unlock, proper handling, cleaning, battery reading and charging etc.

The commedatum, a


Mr. Darwin Toledo, AppLabs

Dr. Yosef Laudencia, HPDP

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10:00 10:15 am

10:15 10:45 am

10:45 11:05 am

11:05 11:35 am

11:35 11:55 am

1:00 1:30 pm

1:30 1:50 pm

1:50 2:20 pm

2:20 2:40pm

2:40 3:10 pm

3:10 3:30 pm

3:30 4:00 pm

Commedatum

Distribution of the PC tablet

Discussion of the iCHT version of the profiling form and HUP 2a &2b

2 Case Studies each for the profiling form and HUPs 2a & 2b

Discussion of the iCHT version of HUP 2c &2d

2 Case Studies each for the profiling form and HUPs 2c & 2d

Discussion of the iCHT version of HUP 2e

2 Case Study for the profiling form and HUPs 2e

Discussion of the iCHT version of HUP 2f

2 Case Study for the profiling form and HUPs 2f

Discussion of the iCHT version of HUP 2g

2 Case Study for the profiling form and HUPs 2f

1 random case study per each HUPs

Closing remarks and

contract ensuring the responsibility of the CHT to the PC tablet will be discussed, signed by the CHT and collected for safe keeping of the Marikina CHO

Dr. Cristy Sy, Marikina CHO Mr. Karlo Paredes, HPDP &

Mr. Darwin Toledo, AppLabs

Ms. Kristine Romorosa, HPDP & Mr. Darwin Toledo, AppLabs

Mr. Chamuel Santiago,

HPDP & Mr. Darwin Toledo, AppLabs

Mr. Lindsley Jeremiah

Villarante, HPDP & Mr. Darwin Toledo, AppLabs


& Mr. Darwin Toledo, AppLabs


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4:00 4:30 pm

4:30 5:30 pm

introduction to day 3 activities

Introduction to the iCHT Administration Panel

Super Admin functions

Profiling form HUPs 2a-2g Report synching

and consolidation HUP adherence &

non adherence Monitored health

indicators

Dr. Cristy Sy, Marikina CHO

HPDP team and Mr. Brian Urfano - AppLabs

DAY 3: REFRESHER DISCUSSION ON ICHT, FIELD PRACTICUM, PLENARY

DISCUSSION ON THE ACTUAL USE OF THE ICHT APPLICATION IN THE FIELD







= 80 Participants


Hands-on experience in using the iCHT application, with feedback on

the benefits and challenges with the automated tool

120 profiled households in Barangay Tumana with 120 or more

developed HUPs

Awareness of the deliverables of the pilot testing and schedule of

checkpoints from the HPDP team

The third and final day of training will be divided into three parts;

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1. The morning will be devoted to a refresher discussion on the iCHT specifically on the profiling form and HUPs 2a-2g and would be held in the Barangay Tumana Health Center, there will be simulated exercises similar to the day two activities. This will be followed by the actual field practicum of the CHTs

2. Following the groupings in the day 2 activities, the 8 groups with 7-8 CHT members and one (1) HPDP

facilitator will then proceed with the field practicum. The remaining time in the morning will be devoted to profiling at least one (1) assigned household, and another one (1) in the afternoon.

3. Finally they will be summoned back to the training site in the Marikina City Health Office, for plenary discussion, in the plenary discussion; one (1) CHT per group will be tasked to report on the experiences from the practicum, following the outline of report from the 3

rd module of the CHT facilitators guide or

Practicum to an Actual Household.

The closing will be led by Dr. Cristy Sy Technical Division Chief, she will explain the duration of the pilot testing that will be held from October 9-22, 2012, as well as the schedule of visit of the team to check on the progress of the implementation.



Day 3 October 8,

2012 Monday

8:00 9:15 am 9:15 10:00 am 10:00 12:00 pm

1:00 2:30 pm

Opening of the activity

Practicum to an actual household Module 3

Refresher discussion on the iCHT application

Field Practicum

Continuation of the Field Practicum

Presentation of the 3rd

day activities

Discussion of the guidelines for the practicum

The profiling form and HUPs 2a-2g will be discussed briefly to remind the CHTs of the important points to effectively and efficiently maneuver through the application, simulated exercises at least two (2) per HUP will also be included

60 CHT members will be divided into 8 groups, with 7-8 CHT members each


Marikina CHO

HPDP Team Groups to be led by HPDP

members (Dr. Yosef Laudencia, Karlo Paredes, Chamuel Santiago, Kristine Romorosa, Dr. Faith Obach, Lindsley Villarante, Bonna Villagen, Crisna Surmienda)

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2:30 3:00 pm 3:00 4:30 pm 4:30 5:00 pm

Travel back to Marikina City Health Office Buidling

Plenary discussion

Discussion on the pilot testing and formal closing of the training program

1Per group there will be at least one (1) CHT member that will report on the perceived benefits and challenges with the use of the iCHT application

Dr. Cristy Sy, Technical

Division Chief, Marikina CHO

Annex D. Commodatum

KASUNDUAN SA PAGGAMIT NG iCHT TABLET Ako, si ____________________________, ___ taong gulang at nakatira sa ___________ ____ _______ ____ ___ ___________________________, ay pinagkakatiwalaan ng City Health Office para pahiramin ng isang yunit ng SAMSUNG GALAXY TAB 2-7.0 [P3110] na tablet at may Serial Number na ___________________, kasama ang wall charger, USB cable, earphones, at User Manuals nito. Sa paggamit nito, alinsunod sa aking tungkulin bilang miyembro ng CHT, ako ay pumapayag at tutupad sa mga sumusunod na alituntunin:

1. Pananatilihin ko ang maganda at maayos na kalagayan ng mga kagamitang ipinagkatiwala sa akin. Iingatan ko ang mga ito, mula sa pagkuha ko nito sa umaga hanggang sa pagbalik ko nito sa pagtatapos ng araw sa Tumana Health Center, ang lugar na itinalaga ng City Health Office;

2. Pangangalagaan ko ang mga kagamitang ito sa pamamamagitan ng hindi pagbago, pagsira ng anyo, o pagtakip ng anumang numero, pagkakasulat, o iba pang mga tanda ng kagamitang ito;

3. Sisiguraduhin ko na ang paggamit ng mga ito ay para lamang sa iCHT, tulad ng itinakda ng City Health Office. Hindi ko dapat ito gagamitin para sa mga gawaing labag sa batas, para sa mga pansariling layunin, o para sa iba pang mga dahilan;

4. Pananagutan ko ang pagkawala o pagkasira ng mga kagamitang ito kapag ito ay naganap sa labas ng pangkaraniwang gawain, lugar, o oras ng aking mga tungkulin bilang miyembro ng CHT, o kapag ang sanhi ng pagkawala o pagkasira ng mga kagamitang ito ay mapatutunayan na dulot ng aking kapabayaan. Sa loob ng 24 oras pagkawala nito, ako ay tutungo sa pinakamalapit na himpilan ng pulisya upang magpa-blotter at magbigay ng ulat. Magbabayad ako ng makatwirang halaga para sa pagkawala o pagkasira ng mga kagamitang ito, batay sa halaga nito sa petsa ng pagkawala;

5. Kung ang kabuuan o anumang bahagi ng mga kagamitang ito ay nasira at hindi na maaaring magamit dulot ng sunog, baha, kidlat, lindol, bagyo, kaguluhan, giyera, o iba pang mga kadahilanang hindi inaasahan, ang kasunduang ito ay magwawakas nang walang kabayaran sa City Health Office o sa miyembro ng CHT sa pamamagitan ng pagsulat ng abiso sa isat-isa;

6. Papahintulutan ko at hindi ko kailanman tatanggihan ang City Health Office o ang sinumang inatasan nito na magsagawa ng inspeksyon sa mga kagamitang ito anumang oras; at

7. Hindi ko ibibigay o ipahihiram ang anumang bahagi ng mga kagamitang ito o ang mga datos na nilalaman nito sa mga taong hindi inatasan ng City Health Office.

Ang kasunduang ito ay katuparan ng ugnayan sa pagitan ko, bilang miyembro ng CHT, at ng City Health Office. Hindi ito maaaring baguhin o wakasan, maliban sa mga dahilang nakapaloob sa kasunduang ito o sa iba pang kasunduan na kaugnay nito. Nilalagdaan ko ang kasunduang ito ngayong ika-____ ng ________________, taong 2012 sa City Health Office, Lungsod ng Marikina. Pangalan: _________________________________ Lagda: _________________________________ Tirahan: _________________________________ Telepono: _________________________________ Para sa City Health Office, Lungsod na Marikina: Pangalan: _________________________________ Lagda: _________________________________

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Annex E. Cost Benefit Analysis Paper and Presentation

ECONOMIC EVALUATION OF USING THE iCHT SYSTEM VERSUS PAPER-BASED FORMS BY COMMUNITY HEALTH TEAMS: THE MARIKINA EXPERIENCE Laudencia Y, Paredes K, Romorosa K, Santiago C, Villarante L, Obach F, Ilagan J and Solon O Health Policy Development Program

Introduction Community Health Teams (CHTs) play a very important role in providing information to families on their health risks and needs. CHTs are also key to reaching poor households identified by the National Household Targeting System for Poverty Reduction (NHTS-PR) in providing them information on their benefits and responsibilities as PhilHealth members. In line with this, the Department of Health (DOH) mandated the deployment of 100,000 CHTs nationwide as a key strategy for universal health care.

However, resource constraints have largely delayed the implementation of the CHT strategy at scale. Among these is the unavailability of forms used by CHT members in profiling and developing Health Use Plans (HUPs). In addition, processing, consolidating, and transmitting all the information in these forms from the health centers up to the provincial level requires considerable time and resources from the LGU.

An electronic system called the iCHT was developed to address these challenges to CHT deployment. Essentially, the health information materials and forms used by CHTs were translated into an electronic format. The iCHT expedites the development of individual household profiles, the accomplishment of HUPs based on identified health risks, the delivery of health messages, the facilitation of referral to providers, the monitoring of adherence to HUPs, and the generation of reports from all collected information.

Objective This paper aims to determine the following:

1) The potential of the iCHT system to improve the performance of CHT tasksprofiling family members, developing HUPs, delivering health messages, and monitoring their adherence to HUPs; and

2) The relative cost of the iCHT system versus the use of paper-based forms and materials for a five-year period, and the amount of savings that may be derived for each CHT member in a year.

Methodology

Developing the application Developing the iCHT system first involved the review and streamlining of existing CHT information, processes, and forms. These were then integrated into the iCHT system, which is composed of two main parts: first is an Android-based application, which is installed in tablets and intended mainly for use by

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the CHTs as a substitute for the forms. In addition to electronically translating these forms, standardized health messages were included through pop-up messages and videos. Automatically facilitating the referral of families who need FP/MNCHN and TB services to health care facilities may also be accomplished, together with transmitting all collected information, by syncing the tablets to Marikina Citys servers. The other part is a web-based application installed in Marikina Citys servers and intended mainly for use by health managers. This consolidates and processes all the information gathered by the CHT members using the tablets.

Pilot testing the iCHT The pilot testing of the iCHT system was conducted in Barangay Tumana, Marikina City. Sixty CHT members, who were assigned a total of 2,515 households or around 40 families for each, were provided with tablets installed with the iCHT application.

Estimating costs The five year costs of using the iCHT system and paper-based forms were estimated based on the following parameters: 1) Training

The estimated cost of training for using the iCHT system and the paper-based approach, which includes meals and training materials, was determined based on the expenses incurred in training CHT members in Marikina City. The cost of training is the same for both the use of the iCHT system and paper-based forms. 2) Materials The estimated cost of using the iCHT system includes the one-time cost of the tablet and the reproduction of referral forms that will be issued to 40 families per CHT member per year. We did not include the cost of developing the system, which will be negligible since this may be installed and reinstalled to an unlimited number of tablets.

On the other hand, the estimated cost of using paper-based forms was based on the actual cost of reproducing the profiling forms, the HUPs, the Family Call Sheet, the Summary Call Sheet, the Family Health Guide, the PhilHealth Guide, referral forms, and a list of health care providers for 40 families per CHT member. 3) Household visits To determine the cost of household visits, 18 CHT members were randomly selected and subjected to a time and motion analysis (TMA). The TMA was done to document the length of time needed for a family of five to be profiled and assisted in the development of various HUPs. The selected CHT members were observed in engaging three families each. The cost in terms of the length of time engaging a family was valued in terms of its proportion to the current daily minimum wage of non-agricultural workers in the National Capital Region.

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The length of time for the paper-based approach was based on an estimate by an experienced panel on CHT deployment. A similar approach to estimating the cost of time spent by CHTs was used. 4) Data processing and reporting Processing the data gathered by the iCHT system to generate reports is done in real-time by syncing the tablets with the Marikina City server. This is done through a local connection that is already set up in Tumana Health Center. It is assumed that the CHT members, midwives, and the City Health Office member spend five hours for syncing per month. The cost of time spent for data processing and reporting was calculated by estimating its proportion to the current daily minimum wage of non-agricultural workers in the National Capital Region.

In using paper-based forms, processing the voluminous documents used in profiling and developing HUPs can take a total of 75 hours per month. The cost of time spent for data processing and reporting was calculated by estimating its proportion to the current daily minimum wage of non-agricultural workers in the National Capital Region.

Using the above parameters, the total costs of using both methods, expressed as cost for each CHT member and projected over a five-year period, were calculated and compared. The relative cost was then determined by dividing the cost of using the paper-based approach by the cost of using the iCHT system. Finally, the savings for each CHT per year was determined by calculating the difference between the estimated costs for both methods in a year.

Limitations of the Study This study is based on a small pilot involving 18 out of 60 CHTs engaging at least three families each. A larger sample size will increase the accuracy of time and motion analysis.

The study site, which is Barangay Tumana in Marikina City, is a highly-urbanized barangay with IT infrastructure already in place. This condition may not be present in other barangays in the country.

Results and Discussion The key findings in using the iCHT system versus the paper-based approach are the following:

1) There is no difference in the training cost between the two methods.

The training cost for each CHT member is estimated at PhP 1,050, based on a three-day training program that includes training materials and meals. The cost is the same for the iCHT and the paper-based approach.

2) The cost of materials for the iCHT is lower than that of the paper-based approach.

The cost of materials of using the iCHT for each CHT member over a five-year period is estimated at PhP 17,300. This represents a one-time cost for the purchase of the tablets (PhP

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12,500) and a recurrent cost totaling PhP 4,800 for the reproduction of referral forms that will be left with the families.

On the other hand, the cost of using paper-based forms for each CHT member over a five-year period is estimated at PhP 48,480 per year. This represents a one-time cost of PhP 5,280 for reproducing the Family Call Sheet, the Summary Call Sheet, the Family Health Guide, the PhilHealth Guide, referral forms, and a list of health care providers, and a recurrent cost of PhP 43,200 for the reproduction of forms used in profiling and HUPs.

3) The cost of household visits is lower when using the iCHT because of the shorter time spent in profiling, developing health use plans, and delivering health messages.

Based on the average time spent in performing CHT tasks as determined in the time and motion analysis, using the iCHT will take 30 hours per month to cover the 40 families assigned to each CHT member. Assuming that every hour spent in engaging households costs PhP 57 and that the CHT members engage each family four times in a year, the cost of using the iCHT for each CHT member over a five-year period is estimated at PhP 34,200.

On the other hand, using paper-based forms will take 40 hours per month to cover the 40 families assigned to each CHT member. Using the same assumptions as in using the iCHT, the cost of using paper-based forms for each CHT member over a five-year period is estimated at PhP 45,600.

We did not include the cost of TEVs as this would be the same across the two groups.

4) Data processing and reporting is significantly quicker and less expensive when using the iCHT.

Since the iCHT system can instantaneously generate reports once the information collected by the tablets are uploaded to the server through syncing, we assumed that five hours is spent for data processing and reporting. Using the same cost assumption as in engaging families, the cost of time for data processing and reporting using the iCHT for each year is estimated at PhP 3,420, or PhP 57 per CHT member. This translates to PhP 285 per CHT member over a five-year period.

For the paper-based forms, we assumed that the CHT member, midwife, and the CHO spend a total of 75 hours per month for data processing and reporting. Using the same cost assumption as in engaging families, the cost of time for data processing and reporting using paper-based forms for each year is estimated at PhP 51,300 or PhP 355 per CHT member. This translates to PhP 4,275 per CHT member over a five-year period.

5) Considering all the costs involved in the two methods, using the iCHT system is less expensive and can generate savings by around PhP 9,000 per CHT annually.

Based on the estimated costs as stated in the above findings, using the iCHT comes out much cheaper at PhP 52,835 per CHT member for five years. The cost of using the paper-based approach, on the other hand, is at PhP 99,405 per CHT member for five years.

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A summary of the costs involved in using the two methods is summarized below:

Comparison of the costs of using the iCHT system and the paper-based approach for each CHT member over five years. (in Philippine Peso)

Cost Parameters iCHT system Paper-based approach

Training 1,050 1,050

Materials 17,300 48,480

Household visits 34,200 45,600

Data processing and reporting 285 4,275

Estimated cost for five years 52,835 99,405

By dividing the cost of using the paper-based approach by the cost of using the iCHT system, a relative cost ratio of roughly 1: 2 is obtained. This implies that using the iCHT system is nearly half as expensive as using the paper-based approach over a five year period. The difference in cost between the two methods is PhP 46,570 per CHT over a five year period or PhP 9,314 for each CHT per year when using the iCHT system.

Conclusion and Recommendations Using the iCHT system is beneficial, in terms of lower cost of materials and lesser time spent in performing CHT-related tasks, relative to using paper-based forms. Given the rapid pace of technological advancements, it is recommended that the local government units (LGUs) consider investing in the iCHT system to assist in CHT deployment. Additional materials containing health messages and forms should also be developed for the iCHT depending on the needs of the area.

While other areas may not have the capacity to provide a server with a local connection, securing a third-party hosting for the database and providing internet connection in select areas, is not expected to impact significantly on costs.

The DOH should support the conduct of implementation research on the use of other electronic solutions that may be used in Kalusugan Pangkalahatan (KP) implementation. This may include the use of electronic medical records and telemedicine using PCs and tablet PCs as platform.

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ECONOMIC EVALUATION OF USING THEiCHT SYSTEM VERSUS PAPER-BASED

FORMS BY COMMUNITY HEALTH TEAMS:The Marikina Experience

Health Policy Development Program

INTRODUCTION

CHTs play an important role in informing families of their health risks and needs,

PhilHealth benefits and responsibilities

Deployment has been delayed due to lack of resources to reproduce forms and other

materials, time-consuming generation of

reports

HPDP developed the iCHT system to address this operational bottleneck

RESEARCH QUESTION

Will the iCHT be more beneficial

than using paper-based forms and

materials in performing CHT

functions?

OBJECTIVES

Determine the potential of the iCHTsystem to improve the performance of CHT tasks

Estimate the relative cost of the iCHTsystem versus the use of paper-based forms and materials for a five-year period, and the amount of savings that may be derived for each CHT member in a year

METHODOLOGY

iCHT system developed, pilot testing conducted in Barangay Tumana, Marikina

City

60 CHT members (assigned a total of 2,515 families or around 40 each) trained

in using iCHT

18 CHT members randomly selected, subjected to time and motion analysis

METHODOLOGY

Costs estimated in terms of:

Training

Materials

Household visits

Data processing and reporting

Total costs of using both methods calculated and compared, expressed as

cost for each CHT member and projected

over a five-year period

METHODOLOGY

Relative cost determined by dividing the cost of using the paper-based approach by

the cost of using the iCHT system

Savings for each CHT member per year determined by calculating the difference

between the estimated costs for both

methods in a year

RESULTS

Training cost equal at PhP 1,050/CHT member

Cost of materials for iCHT at PhP17,300/CHT member (vs. PhP 48,480)

Cost of household visits for iCHT at PhP34,200/CHT member (vs. PhP 45,600)

Data processing and reporting quicker and less expensive for iCHT at PhP 285/CHT

member (vs. PhP 4,275)

RESULTS

Cost

Parameters

iCHT

system

Paper-

based

approach

Training 1,050 1,050

Materials 17,300 48,480

Household

visits34,200 45,600

Data

processing

and

reporting

285 4,275

Estimated

cost per

CHT for five

years

52,835 99,405

Using the iCHTsystem nearly half

as expensive over

a five year period

(cost ratio=1:2)

iCHT can save around PhP

9,000/CHT

member annually

CONCLUSION

The iCHT system is beneficial, in

terms of lower costs and the lesser

time spent in performing CHT-

related tasks

RECOMMENDATIONS

LGUs to invest in installing the iCHTsystem as part of CHT deployment

DOH to help develop additional materials that can be included in the iCHT

Conduct implementation research on the use of other tablet PC based applications

for use in KP/UHC (e.g., electronic

medical records, telemedicine)

Annex F. iCHT Application Manual

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2013

Department of Health

March 2013

Gabay sa Paggamit ng iCHT Para sa mga miyembro ng Community Health Team (CHT)

1

Contents

Panimula ....................................................................................................................................................... 2

Mga Pangunahing Hakbang sa Paggamit ng iCHT ......................................................................................... 3

Paggawa ng Profile sa mga Miyembro ng Sambahayan ............................................................................... 8

Mga Planong Pangkalusugan ...................................................................................................................... 17

Planong Pangkalusugan Para Sa Bagong Silang (Edad 0-28 Araw) At Sanggol (Edad 1-11 Buwan) ..... 18

Planong Pangkalusugan Para Sa Bata (Edad 1-5 Taon) ........................................................................ 26

Planong Pangkalusugan Para Sa Pagbubuntis ...................................................................................... 32

Planong Pangkalusugan Para Sa Bagong Panganak ............................................................................. 44

Planong Pangkalusugan Para Sa Pagpaplano Ng Pamilya .................................................................... 52

Planong Pangkalusugan Para Sa Paglunas Ng Matagalang Ubo ........................................................... 60

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PANIMULA

Ang pagbubuo at ang pagpapalaganap ng Community Health Teams (CHT) ay ang pangunahing

pamamaraan ng Kagawaran ng Kalusugan o Department of Health (DOH) sa pagtugon sa mga

pangangailangang pangkalusugan ng ating mga mahihirap na kababayan. Bagamat ito ay ipinatutupad

na sa ibat-ibang mga bayan at lungsod sa ating bansa, marami itong hinaharap na suliranin. Ang ilan sa

mga ito ay ang mga sumusunod:

1) Malaki ang nagagastos buwan-buwan sa pagpi-print ng mga dokumentong ginagamit ng mga

CHTs;

2) Mahirap matiyak na tama ang impormasyon na nakukuha mula sa mga sambahayan at sa mga

miyembro ng pamilya;

3) Mahirap ang pagdadagdag o pagtatanggal ng mga pamilya sa mga nakalista na mga household

beneficiaries na saklaw ng mga programa ng gobyerno (e.g. NHTS-PR list);

4) Maraming oras ang nagugugol sa pagbubuo ng mga data para sa paggawa ng mga report at iba

pang impormasyon, na maaari sanang gamitin para sa mga gawaing pambahay atpampamilya;

5) Madalas ang mga maaring maging pagkakamali sa pagkuha, pagtatala, at pagbuo ng mga

nakuhang impormasyon; at

6) Mahirap ang regular at madalas na pagbigay ng mga bagong ulat at iba pang impormasyon sa

mga health facilities na makatutulong sa mga pangangailangan ng mga miyembro ng pamilyang

kumokonsulta sa kanila.

Dahil sa mga nabanggit na problema, nagkaroon ng pangangailangan para sa isang paraan na hindi

lamang madaling magagamit ng miyembro ng CHT sa pagtupad ng kanilang mga tungkulin, kundi maaari

ring makipagsabayan sa mga makabagong teknolohiya sa panahon natin ngayon. Ang iCHT ay ginawa ng

DOH para sa layuning ito. Sa paggamit nito ay natutulungan ang mga miyembro ng CHT na mapadali ang

pagtupad ng kanilang mga tungkulin, nababawasan ang mga pagkakamali sa pagkuha, pagtatala, at

pagbuo ng mga datos na maaaring mas mapadali kung ikukumpara sa paggamit ng karaniwang papel at

panulat, at nabibigyan sila ng mas maraming panahon para sa mga gawaing pantahanan at pansarili.

Ang iCHT ay isang tablet applicationna ginawa para gawing automatic ang pagkuha ng profile sa mga

miyembro ng sambahayan, pati ang paggawa ng anim na Planong Pangkalusugan o Health Use Plans

(HUPs) sa pamamagitan ng isang computer tablet. Ang mga data,a ulat pangkalusugan, at iba pang

impormasyon na nakakalap ng mga miyembro ng CHT gamit ito ay madali ring naipapadala at nabubuo

sa City Health Office sa pamamagitan ng internet.

Layunin ng Gabay na ito na mabigyan ng kaalaman ang mga miyembro ng CHT tungkol sa pagsasanay sa

paggamit ng iCHT tablet na ipapahiram ng City Health Office. Ang mga sumusunod na nilalaman ng

Gabay na ito ay tumutukoy sa mga hakbang sa paggamit ng iCHT para sa pag-profile at paggawa ng mga

Planong Pangkalusugan.

3

MGA PANGUNAHING HAKBANG SA PAGGAMIT NG iCHT

Ang iCHT ay isang tablet application na makatutulong sa mga miyembro ng CHT na gumagamit ng

computer tablet na ipagkakatiwala ng City Health Office. Bago simulan ang pagbabahay-bahay sa mga

pamilyang naka-assign sa bawat miyembro ng CHT, kailangang pumunta sa lugar na itatalaga ng City

Health Office upang kunin at mag-log sa paggamit ng tablet at ibalik rin ito at mag sync sa pagtatapos

ng araw.

Ang mga sumusunod na hakbang ay naglalarawan sa mga mahahalagang hakbang sa paggamit ng iCHT

sa tablet.

I. Pagbubukas ng iCHT sa tablet

Mula sa tablet ay pindutin ang icon ng iCHT, tulad ng nakalarawan. Sa pagpindot nito

ay masisimulan ang programa ng iCHT.

II. Pag-sign in

Kapag nabuksan na ang iCHT, makikita ang pahina na nakalarawan sa ibaba:

Ang bawat miyembro ng CHT ay bibigyan ng City Health Office ng username at password. Mahalaga

na pag-ingatan ang mga ito at siguraduhing hindi ito ibibigay ito sa mga taong hindi

pinahihintulutan ng City Health Office. Ang mga data na nilalaman at makakalap sa paggamit ng

tablet application na ito ay maselan at maaaring magamit sa mga hindi tamang paraan.

Isulat lamang ang mga ito sa kani-kaniyang kahon at pindutin ang MAG-SIGN IN upang makapasok

sa programa ng iCHT at magamit ito sa pagkuha ng profile at paggawa ng mga Planong

Pangkalusugan.

4

III. Pangunahing Pahina

Kapag tama ang inilagay na username at password, makikita ang pahina na nakalarawan sa ibaba:

Sa pahinang ito, maaaring pindutin ang mga sumusunod:

HANAPIN. Dito maaaring hanapin at piliin ang mga nakalistang mga Puno ng Sambahayan (Head of Household o HOH) para maumpisahan ang pagkuha ng-profile at paggawa ng mga Planong Pangkalusugan.

NOTIFICATIONS. Dito maaaring makita ang mga miyembro ng sambahayan na nakatakdang kumonsulta sa mga health facilities (health center o ospital), pati ang mga dapat balikan (follow-up visits) upang maituloy ang paggawa ng mga Planong Pangkalusugan.

FILE. Dito ay maaaring makita ang mga data at mga impormasyon na mabubuo mula sa mga impormasyong makakalap ng miyembro ng CHT.

C

5

I-SYNC. Mahalaga ang pag-sync upang masigurado na bago ang mga datos na nilalaman ng iCHT. Dapat itong gawin ng miyembro ng CHT pagkakuha ng tablet sa umaga bago magsimulang magbahay-bahay, at sa hapon bago ibalik ang tablet sa lugar na itinalaga ng City Health Office. Kapag pinindot ito, lalabas ang mensaheng tulad ng nakalarawan sa ibab

icht 3/12/2013

Documents

health messages

health facilities

health providers

health navigators

health needs of clients

health use planning

quality health services

critical health services