EMERGENCY CARE SYSTEM ASSESSMENT

AND CONSENSUS-BASED ACTION PRIORITIES:

PHILIPPINES
 TABLE OF CONTENTS
Table of Contents
Contributors
Abbrevia ons
Execu ve Summary
Ac on Priori es

1. Introduc on to the WHO Emergency Care System Assessment (ECSA)

2. Emergency care and ECSA in Philippines
3. Results from the ECSA and output form the working group
3.1. System Organiza on, Governance and Finance
3.2. Emergency Care Data and Quality Improvement
3.3. Scene Care, Transport and Transfer
3.4. Facility-Based Care
3.5 Emergency Preparedness and Security
4. Next steps
5. References
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CONTRIBUTORS
The following individuals contributed signi cantly to the emergency care system
assessment and par cipated in the working group (in alphabe cal order by last name):

World Health Organiza on

Dr Pauline Convocar, Philippines College of Emergency Medicine
Dr Jojo Go, WHO Country O ce, Philippines
Dr Pryanka Relan, WHO Consultant
Prof Lee Wallis, WHO Consultant

The following addi onal individuals are acknowledged for their work in WHO ECSA
planning, compiling response data and/or preparing mee ng materials (in alphabe cal
order by last name):
Dr Harveen Bergquist, WHO Consultant
Dr Teri Reynolds, WHO Headquarters
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 LIST OF ABBREVIATIONS

AO Administra ve Order

BLS Basic Life Support

ECS Emergency Care Systems

ECSA WHO Emergency Care System Assessment

EMR Electronic Medical Record

ED Emergency Department

EO Execu ve Order

DILG Department of the Interior and Local Government

DOH Department of Health

HTAC Health Technology and Assessment Council

LGU Local Government Unit

NHIP Na onal Health Insurance Program

PCEM Philippines College of Emergency Medicine

PhilHealth Philippine Health Insurance Corpora on

QI Quality Improvement

RA Republic Act

WHO World Health Organiza on

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 EXECUTIVE SUMMARY
Emergency care systems address a wide-range of common medical, surgical, and obstetric
condi ons, including injury, complica ons of pregnancy, exacerba ons of non-communicable
diseases (e.g. asthma, heart a acks, strokes), and acute infec ons (e.g. sepsis, malaria). With
sound planning and organiza on, emergency care systems have the poten al to address nearly
half of deaths and more than a third of disability in low- and middle-income countries.

Given the poten al to reduce death and disability in Philippines through improvements in
emergency care, the Philippines Department of Health, in collabora on with the World Health
Organiza on (WHO) and Philippines College of Emergency Medicine (PCEM) undertook a
system-level assessment using the WHO Emergency Care System Assessment (WHO ECSA) tool
and organized a working group comprised predominantly of local emergency care experts.

Key stakeholders were asked to complete the WHO ECSA, an instrument designed to help
policymakers and planners assess a na onal emergency care system and iden fy country speci c
ac on priori es for high-impact improvements of the emergency care system. A working group
was convened on 23-24 July 2019 to review results. During the mee ng, each ques on and the
aggregated answer was discussed among the stakeholders un l a consensus answer was
obtained. Based on the discussions, ac on priori es were recorded by domain. At the end of
the mee ng, ac on priori es were arranged as a priority list as a group.

Representa ves from the major groups dealing with emergency care in Philippines were
represented, including:

• Department of Health • Private Hospitals

• Philippines College of Emergency • Bloomberg Ini a ve
Medicine • Philippines General Hospital
• WHO Country O ce for the • Experts in emergency care
Philippines
• Private EMS service

Emergency care has long been a priority in Philippines and signi cant developments in both
prehospital and facility-based care have been made. However, there are s ll a range of
opportuni es for improvement in: ambulance and emergency unit services, coordina on
between prehospital and hospital-based services, standardiza on of emergency unit processes,
and implemen ng systema c data collec on to support quality improvement e orts.

The government’s con nued commitment to strengthening the delivery of emergency care in
Philippines is re ected in its recent na onal strategies for the health sector, which call for further
strengthening of the emergency care system.

Speci c ac on priori es for each component of the emergency care system proposed by the
working group are listed below, and details of the discussion on each topic are described in the
main document.
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 ACTION PRIORITIES
System Organisa on, Governance and Finance
▪ Establish a dedicated lead government agency at the na onal level with the authority to
coordinate prehospital and facility-based emergency care
▪ Introduce legisla on manda ng universal access to emergency care without regard to
ability to pay
▪ Develop na onal status report on emergency care
▪ Establish a new dedicated revenue genera on scheme speci cally for emergency care
▪ Introduce a dedicated na onal budget alloca on speci cally for prehospital care
(separate from disaster preparedness and response) and speci cally for facility-based
emergency care
▪ Develop and incorporate a speci c package of prehospital services into current universal
health coverage package

Emergency Care Data and Quality improvement

▪ Introduce standardized data collec on in both prehospital and facility-based se ngs
▪ Strengthen linkage of emergency care data across all sources
▪ Ensure regular use of data for system planning at na onal level

▪ Strengthen con nuous quality improvement ini a ves in prehospital and facility-based
emergency care se ngs

Scene Care, Transport and Transfer

▪ Implement newly passed legisla ons and enforce all exis ng legisla on rela ng to the
emergency care system (including Execu ve Order 56 on ins tu onalizing the
emergency 911 number in Local Government Units, ambulance service provider
licensing, ambulance provider cer ca on and related regula ons)
▪ Expand popula on awareness of universal access number through public educa on
campaigns
▪ Introduce a bystander protec on law (Good Samaritan law)
▪ Formalize and expand a community rst aid responder program
▪ Create standardized na onal prehospital protocols and enforce use across private and
public sectors in a uni ed system
▪ Ensure clear delinea on of ambulances used for acute events from emergency inter-
facility transport vehicles
▪ Set na onal response me targets for highest priority ambulance calls
▪ Develop, implement and monitor na onal system wide inter-facility transfer criteria

Facility-based care
▪ Develop and implement na onal triage tool for all emergency units
▪ WHO/ICRC/MSF Interagency Integrated Triage Tool available
▪ Introduce minimum set of norms and standards for emergency units (infrastructure,
equipment, medica ons, sta , services)
▪ WHO essen al resource standards available
▪ Conduct na onwide hospital emergency unit assessments
▪ WHO Hospital Emergency Unit Assessment Tool available
▪ Introduce accredita on system for emergency units at all levels of facili es
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 ▪ Introduce undergraduate and postgraduate educa on programs speci c for emergency
care for nurses
▪ Introduce medical school training speci c for emergency care
▪ Develop a set of core na onally standardized clinical protocols for emergency unit care

Emergency Preparedness and Security

▪ Ins tute security plans for emergency unit and prehospital services including strategies
for protec on of sta and infrastructure from violence
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 1. INTRODUCTION
Emergency care systems (ECS) address a wide-range of medical, surgical, and obstetric
condi ons, including injury, complica ons of pregnancy, exacerba ons of non-communicable
diseases (e.g. asthma, heart a acks, strokes), and acute infec ons (e.g. sepsis, malaria). 1 The
emergency care system is o en the rst point of contact with the health system, par cularly in
areas where there are barriers to access.2 With sound planning and organiza on, emergency
care systems have the poten al to address half of deaths and more than a third of disability
annually in low- and middle-income countries (LMICs). 3,4

Despite the poten al bene t of an organized emergency care system, it remains underdeveloped
in many countries.5 As a result, emergency care delivery is o en compromised due to a lack of
suppor ve legisla on, governance and regula on, gaps in funding, and insu cient human and
physical resources.6

The WHO Emergency Care Systems Assessment (ECSA) is a WHO tool designed for internal
systema c assessment of essen al components of a country’s emergency care system. The main
goal of the ECSA is to iden fy country speci c ac on priori es for high impact improvements of
emergency care system processes and outcomes. The following components of a na onal
emergency care system are assessed via the ECSA: system organiza on; governance; nancing;
emergency care data; quality improvement; scene care; transport and transfer; facility-based
care; rehabilita on; and emergency preparedness.

Answers to the ECSA are aggregated and presented to a working group consis ng of at least a
core set of respondents at a two-day in country consensus mee ng. Each ECSA ques on is
discussed and a nal answer to each ques on is determined. At the end of an ECSA consensus
mee ng, policymakers and planners discuss and gain consensus on ac on priori es for
emergency care system strengthening. A given country’s par cipants may choose to create a
strategy for implementa on of iden ed ac on priori es together at the end of the ECSA
consensus mee ng or choose to convene a separate mee ng to discuss implementa on steps
with key stakeholders.

2. EMERGENCY CARE AND ECSA IN PHILIPPINES

This is a par cularly transforma ve me for health policy in the Philippines. Several policies
rela ng to health care delivery, including emergency care, are currently being developed and
deliberated by na onal policymakers, while others such as the Universal Health Coverage bill
have recently been launched and are being implemented. Addi onally, the recent transi on
from a centralized to a decentralized government structure has led to fragmenta on in the
delivery of health services. See Sec on 3.1 on System Organiza on and Governance for more
informa on.

As with any emergency care system, there are s ll many opportuni es for improvement. Among
the leading causes of death in Philippines are road injury, complica ons of cardiovascular
diseases, and complica ons of respiratory infec ons. Given the poten al to reduce death and
disability from these and many other me-sensi ve condi ons through improvements in
emergency care, the Philippines Department of Health (DOH), in collabora on with the World
Health Organiza on (WHO) undertook a system-level assessment using the WHO Emergency
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 Care System Assessment (ECSA) tool and organized a working group composed predominantly of
local emergency care experts.

The WHO ECSA is a survey instrument developed to help policy-makers and planners assess a
na onal emergency care system and iden fy gaps in order to set priori es for system
development. Stakeholders iden ed by DOH and WHO were approached, and the respondent
group included representa on from:
• Department of Health
• Philippines College of Emergency Medicine
• WHO Country O ce for the Philippines
• Private EMS service
• Private Hospitals
• Bloomberg Ini a ve
• University Hospitals (Philippines General Hospital)
• Experts in emergency care

Stakeholders were asked to complete the WHO ECSA, with the goal of using the ndings to
inform development of ac on priori es for strengthening the Philippines emergency care
system. The ECSA is a survey tool assessing the following components of a na onal emergency
care system: organisa on and governance; nancing; emergency care data; quality
improvement; scene care; transport and transfer; facility-based care; and emergency
preparedness. Fi y-one stakeholders completed the WHO ECSA survey. The surveys were
compiled, and the results analysed. On 23-24 July 2019, DOH hosted a working group mee ng
that aimed to: i) review the WHO ECSA results and establish consensus on divergent responses;
ii) iden fy gaps in the emergency care system; iii) develop consensus-based ac on priori es for
system development. The following sec ons summarise the ECSA results and the discussions and
conclusions of the WHO ECSA working group. Ac on priori es are listed together in the
execu ve summary above and are listed by sec on with discussion highlights below.

3. RESULTS FROM THE WHO ECSA AND DISCUSSION

3.1. SYSTEM ORGANISATION, GOVERNANCE AND FINANCE

SYSTEM ORGANISATION AND GOVERNANCE

Emergency care services are provided by several ers of government as well as by private
agencies. In the public sector, the na onal Department of Health (DOH) oversees all health care
in the country. Its governance over emergency care is divided between the Health Emergency
Management Service (HEMS) unit (which primarily coordinates disaster preparedness and
response, which includes all of prehospital care) and the Violence and Injury unit. Local
Government Units (LGUs), independent en es from DOH, also have the authority to coordinate
emergency care in their regions. There is no designated lead o ce within the government that
is responsible for the coordina on of these dis nct en es or for the overall provision of
emergency care. Par cipants stated that during a disaster or mass casualty incident these units
do collaborate on the response e orts, but that they do not communicate regarding regular day-
to-day opera ons. All par cipants agreed that establishing a dedicated lead government agency
at the na onal level with the authority to coordinate prehospital and facility-based emergency
care is a priority. Par cipants also felt that crea ng a mechanism for more e ec ve coordina on
of emergency care ac vi es between DOH and other major health service delivery providers,
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 including universi es and the private sector, is cri cal for improving emergency care in
Philippines. Improved coordina on will increase e ec veness and e ciency in the delivery of
emergency care to all.

In general, the distribu on of emergency care services is quite dispersed throughout the
country. Ter ary level hospitals in some urban areas o er highly specialized care while some
rural areas lack access to basic health services. Par cipants stated that generally, in urban areas,
there is inadequate availability of emergency care, and in rural areas, there is minimal or no
emergency care available. In some regions of the country, LGUs and volunteer groups are more
ac ve than others; but overall, the number and level of emergency care facili es is inadequate
or not well distributed to meet the popula ons needs. Par cipants noted that over 90% of
physicians work in urban areas.

During the mee ng, par cipants referenced several pieces of legisla on rela ng to mandatory
access to emergency services, health services and payment requirements. Speci c legisla ons
reviewed were: Republic Act of 83447, which calls for provision of emergency medical treatment
without regard for ability to pay prior to receiving life-saving treatment; Republic Act 112238,
also known as the Universal Health Coverage bill; and Senate Bill #889, also known as Emergency
Medical Services System (EMSS) bill. More details on these are below:

❖ Republic Act of 8344 (approved August 1997) states that “In emergency or serious cases,
it shall be unlawful for any proprietor, president, director, manager or any other o cer,
and/or medical prac oner or employee of a hospital or medical clinic to request,
solicit, demand or accept any deposit or any other form of advance payment as a
prerequisite for con nement or medical treatment of a pa ent in such hospital or
medical clinic or to refuse to administer medical treatment and support as dictated by
good prac ce of medicine to prevent death or permanent disability: Provided, That by
reason of inadequacy of the medical capabili es of the hospital or medical clinic, the
a ending physician may transfer the pa ent to a facility where the appropriate care can
be given, a er the pa ent or his next of kin consents to said transfer and a er the
receiving hospital or medical clinic agrees to the transfer: Provided, however, That when
the pa ent is unconscious, incapable of giving consent and/ or unaccompanied, the
physician can transfer the pa ent even without his consent: Provided, further, That such
transfer shall be done only a er necessary emergency treatment and support have been
administered to stabilize the pa ent and a er it has been established that such transfer
entails less risks than the pa ent's con nued con nement: Provided, furthermore, That
no hospital or clinic, a er being informed of the medical indica ons for such transfer,
shall refuse to receive the pa ent nor demand from the pa ent or his next of kin any
deposit or advance payment: Provided, nally, That strict compliance with the foregoing
procedure on transfer shall not be construed as a refusal made punishable by this Act."

❖ Republic Act (RA) 11223, the UHC bill signed by President Rodrigo Duterte in March
2019, automa cally enrols all Filipino ci zens in the Na onal Health Insurance Program.
This law states that “Every Filipino shall be granted immediate eligibility and access to
preventa ve, promo ve, cura ve, rehabilita ve, and pallia ve care for medical, dental,
mental and emergency health services, delivered either as popula on-based or
individual-based health services, Provided, That the goods and services to be included
shall be determined through a fair and transparent Health Technology Assessment
process.” The term Emergency as used in RA 11223 has been de ned as “a condi on or
state of a pa ent wherein based on the objec ve ndings of a prudent medical o cer
on duty, there is immediate danger and where delay in ini al support and treatment
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 may cause loss of life or permanent disability to the pa ent, or in the case of a pregnant
woman, permanent injury or loss of her unborn child, or non-ins tu onal delivery.”
Health Technology Assessment refers to “the systema c evalua on of proper es, e ects,
or impact of health-related technologies devices, medicines, vaccines, procedures and
all other health-related systems developed to solve a health problem and improve
quality of lives and health outcomes, u lizing a mul disciplinary process to evaluate the
social, economic, organiza onal and ethical issues of a health interven on or health
technology.” Several par cipants noted that HTA assessments are a DOH driven process
and may take months to years to complete. Implemen ng Rules and Regula ons (IRR)
of RA 11223 are s ll being dra ed by DOH, PhilHealth and experts and concerned
agencies.

❖ Senate Bill #88, awai ng approval at the me of this report, was also speci cally
discussed. This bill, also known as Emergency Medical Services System (EMSS) bill, calls
for an “ins tu onaliza on of 24/7 well-coordinated na onwide emergency medical
services system that can respond to medical emergencies at any place and any me.” A
similar Bill was also reported to be si ng in the House oor (House Bill #173)10.

There is no explicit legisla on governing the availability of emergency care services for migrants
and refugees. Par cipants stated that all pa ents, regardless of ci zenship status receive the
same services.

There are currently no comprehensive na onal status reports on road safety or emergency or
trauma care. The DOH Violence and Injury unit’s report on injury preven on o en includes
injury surveillance data from hospitals, with no speci c data rela ng to care of the injured. The
Philippine road safety ac on plan11 discusses policies rela ng to road safety and the ve Pillars
of the Decade of Ac on of Road Safety, but does not include epidemiology or list of available
services. All par cipants felt that the development of a na onal status report on emergency and
trauma care, possibly coordinated by DOH, should be a key priority.

The Na onal Objec ves for Health 2017-202212 produced by DOH do not explicitly address
prehospital care. Emergency health care provision is listed as a limita on in health service
packages and facili es standards. Regarding surgical care, the document states: “Current
standards require hospitals to provide surgical and ancillary services to qualify as at least a Level
1 facility.” See more regarding the levels of facili es in Sec on 3.4 on Facility-based care.

FINANCE
As men oned above, as of March 2019, RA 11223 automa cally enrols all Filipino ci zens in the
Na onal Health Insurance Program, called PhilHealth. PhilHealth, or the Philippine Health
Insurance Corpora on, was created in 1995 to implement universal health coverage in the
Philippines13. It is government-owned and is an a ached agency of the Department of Health.
RA 11223 s pulates immediate eligibility for the na onal health bene t package. Par cipants
discussed a speci c Resuscita on Package14 embedded within PhilHealth which covers also
claims “for con nement of less than 24 hours if the pa ent expired even if beyond the service
capability of the health care ins tu on.”

There is one na onal budget for health. Alloca ons for speci c areas of health, such as
hospitals, are designated by DOH. While facili es receive funding directly from the government,
there is no protected amount speci cally for emergency care. Budgets for facility based
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 emergency care services are determined by each facility’s administrators. LGUs receive funding
for “disaster preparedness”, and more speci c alloca on to prehospital care is completed by
individual LGUs. There is no funding for emergency care services that speci cally comes from
vehicle registra on. All par cipants agreed that funding for facility-based emergency care is not
adequate and that including a dedicated funding stream for emergency units (EUs) within
hospital budgets should be a priority. Addi onally, par cipants felt that funding for prehospital
care is not adequate and should be made separate from disaster preparedness budgets. A
separate UHC package for prehospital care was also suggested as a priority ac on.

There is a worker-compensa on scheme called the Employees' Compensa on Program (ECP)15,

which covers the cost of care for those who are injured or become ill as a result of condi ons at
work. Pa ents must pay upfront and there is a maximum of how much is reimbursed.
Par cipants also noted that this system is not widely known. Per the ECP guide, certain groups
such as registered government sector employees and registered private sector employees have
access to this programme.

ACTION PRIORITIES: SYSTEM ORGANIZATION, GOVERNANCE AND FINANCE

▪ Establish a dedicated lead government agency at the na onal level with the authority to
coordinate prehospital and facility-based emergency care
▪ Introduce legisla on manda ng universal access to emergency care without regard to
ability to pay
▪ Develop na onal status report on emergency care
▪ Establish a new dedicated revenue genera on scheme speci cally for emergency care
▪ Introduce a dedicated na onal budget alloca on speci cally for prehospital care
(separate from disaster preparedness and response) and speci cally for facility-based
emergency care
▪ Develop and incorporate a speci c package of prehospital services into current universal
health coverage package

3.2. EMERGENCY CARE DATA AND QUALITY IMPROVEMENT

Emergency care data, including data on emergency condi ons, management and outcomes, is
not systema cally gathered for use by policy makers at either the prehospital or facility based
level. There are disparate sources of some data from LGUs (for example, rela ng to road safety
planning and injury preven on), private ambulances and even facili es, but the type of data
collected and its remains unclear. Some private facili es have an electronic medical record
(EMR) that allows them to gather emergency care data, but public hospitals primarily use paper-
based medical records.

There is no clear linkage of data between sources. Data are not analysed for emergency care
system planning purposes. The crea on of a na onal strategy for the monitoring and evalua on
of care delivered in all se ngs and developing a mechanism for integra on of emergency care
data into system planning was felt to be a top priority by all par cipants.

Records rela ng to presenta ons and management of acute pa ents are documented by some
providers in prehospital and facility-based se ngs, but not in a standardized way. All
par cipants agreed that the implementa on of standardized clinical documenta on in both the
prehospital and facility-based emergency unit se ng (whether this data is collected
electronically or on paper) should be a top priority, poten ally using the WHO templates that are
available, which could also be integrated into electronic systems.
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 Within individual health facili es, clinical data are some mes used for quality improvement.
There are no na onwide quality improvement programs. Par cipants from university hospitals
indicated that various quality improvement techniques were used including morbidity and
mortality conferences, preventable death panels, and equipment and infrastructure quality
checks. All par cipants agreed that it is important to develop simple quality improvement
programmes at all levels of the emergency care system.

ACTION PRIORITIES: EMERGENCY CARE DATA AND QUALITY IMPROVEMENT

▪ Introduce standardized data collec on in both prehospital and facility-based se ngs
▪ Strengthen linkage of emergency care data across all sources

▪ Ensure regular use of data for system planning at na onal level

▪ Strengthen con nuous quality improvement ini a ves in prehospital and facility-based
emergency care se ngs

3.3. SCENE CARE, TRANSFER AND TRANSPORT

As of May 2019, respondents stated that 911 is the main access number for emergency care
services across the en re country. Execu ve order (EO) 56, signed by President Duterte in May
2019, ins tu onalizes the use of 911 as the Na onwide Emergency Hotline Number, replacing
the prior number “117”16. EO 56 also establishes the Emergency 911 Commission which serves
as the policy making body and overseer of the Emergency 911 Na onal Program. The
Emergency 911 Commission is mandated to ensure that all calls made to the Emergency 911
Hotline be free of charge.

Calls placed to 911 or 117 go to a central dispatch governed by the Department of the Interior
and Local Government (DILG). Par cipants noted that some LGUs s ll have their own emergency
numbers (for example, 168 in Maka ). Addi onally, there are parts of the country that have no
coverage. Par cipants felt that less than 25% of the popula on knows and can properly use an
emergency care services access number by memory.

When reached, 911 or 117 operators can dispatch providers to the scene, provide basic clinical
advice to bystanders and provide medical direc on to prehospital providers (via an Emergency
Medical Technician (EMT) on call). Field to facility communica ons occur through the central
dispatch system, not directly from ambulance providers to facili es. Automated tracking of
caller loca on via phone is limited to private ambulance companies only.

There are no ‘Good Samaritan’ laws in the Philippines to protect bystanders who provide help to
the acutely ill or injured. There are some community-based basic rst aid training courses for lay
people through both public and private sectors, but they are not widely available nor are they
uniformly regulated. In the public sector, these courses are typically provided through the DOH,
LGUs, Philippine Heart Associa on (PHA), Philippine Na onal Red Cross (PNRC), American Heart
Associa on, and other private companies. Republic Act 10871 mandates basic educa on
students to undergo age-appropriate basic life support training, including cardiopulmonary
resuscita on (CPR)17. RA 10871 states that training should “include programs which have been
developed by the PHA or PNRC using na onally-recognized, evidence-based guidelines for
emergency cardiovascular care” and that the DOH must “accredit nongovernment organiza ons
competent to provide basic life support instruc ons.” All par cipants agreed that developing a
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 centrally coordinated process to agree upon both quality standards for the content of rst aid
training courses and on the trainer cer ca on process should be a priority.

Lay-persons are not universally formally designated as emergency care responders; however, a
Na onal Disaster Risk Reduc on and Management and Civil Defense Educa on and Training
Programs Catalogue describes the background, objec ves, modules and content of a formal 6-
day community rst aid responder (CFAR) course as a na onal mandate from Republic Act
1012118. Though there is no explicit terminology of such in the text of RA 10121, the catalogue
describes “mobiliza on of individuals or organized volunteers to augment personnel
complement and logis cal requirement in the delivery of disaster risk reduc on programs and
ac vi es” to be a mandate of Local Disaster Risk Reduc on and Management O ce in every
province, city and municipality. Par cipants were unaware of the status of execu on of these
courses. No basic emergency provider kits are provided. No training is integrated into formal
administra ve or creden aling structures. All par cipants agreed that coordinated rst aid
training and coordinated implementa on of the exis ng wri en CFAR structure are top priori es
for ac on.

Within the prehospital system, there are personnel who are trained and cer ed speci cally as
ambulance providers, but this is not a mandated, centralized or standardized process.
Cer ca on to become a trained EMT is provided by select private groups and content of
cer ca on varies. Par cipants noted that most of those who seek EMT cer ca ons aim for
interna onal job placements. The Technical Educa on and Skills Development Authority, or
TESDA, a government agency under the Department of Labour, also has a cer ca on pathway
available for those who wish to stay in country, however the process is not regulated centrally by
DOH. All par cipants agreed that developing a standardized training and cer ca on pathway
for ambulance providers is a top priority.

Some standardized prehospital care protocols exist (in the private sector); however, these are
not system-wide nor reliably monitored. Some protocols have been adapted for Philippines use
from the United States, United Kingdom or Australian protocols; inputs from experts are
sporadic. There is no component of regular clinical prac ce review. There is no reliable back-up
advisory system to provide extra clinical support to all providers na onwide. Medical direc on is
provided inconsistently throughout public and private sectors.

There are no des na on triage protocols or system. The decision regarding which facility a
pa ent goes to from the prehospital se ng is made based on provider or pa ent preference.

Respondents es mated that few (<25%) of the country’s popula on has reliable access to a
formal prehospital ambulance system that can provide mely on-scene emergency care as well
as transport with a trained provider, both in the urban and rural se ngs. Respondents
es mated the country has about 35,000 ambulances which can be called in an emergency and
have at least one trained provider and one driver onboard.

Current ambulance regula ons apply to all licensed ambulances. All ambulances are mandated
to be licensed; however, par cipants reported that several ambulances operate without a
license.
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 TRANSPORT AND TRANSFER
There are facility designa ons for some speci c emergency condi ons (trauma centres, stroke
centres and cardiac centres). Trauma centre criteria is s ll being dra ed in conjunc on with the
Philippine college of surgeons and is divided into two categories: trauma capable hospitals and
trauma receiving hospitals. There are also designa ons for “orthopaedic” hospitals, “lung”
hospitals and “kidney” hospitals, though explicit criteria for these designa ons are not
documented.

Ambulances carry pa ents from the scene to a facility and are also used for interfacility
transfers. Hospitals have the responsibility to contract with ambulance providers to provide an
interfacility transfer service. This service also encompasses “procedural runs” in which pa ents
are transferred to another facility speci cally for a diagnos c test or a procedure and then
brought back. Par cipants noted that most ambulances are not used e ciently for this service
and instead remain sta oned at hospitals. These hospital ambulances are not connected to the
na onal 911 emergency system and thus cannot be dispatched in the event of an acute need at
a nearby scene. Very rarely, centralized dispatch may dispatch a private ambulance company to
the scene of an emergency.

Communica on about interfacility transfers occurs in an uncoordinated manner based on

individual decisions. Transfer criteria are employed in some regions of the country, although not
all healthcare facili es or regions use the same criteria. There are no protocols for prehospital
provider handovers to facili es. Par cipants felt that this communica on could poten ally be
improved through the implementa on of standardized clinical forms for prehospital providers,
possibly using the WHO template as a guide.

Par cipants noted that the number of ambulances is grossly inadequate for the needs of the
popula on. There are no na onally agreed me targets for responding to priority emergency
calls. Legisla on governing the use of ambulances exists and is enforced unreliably. For
example, there is a mandatory policy requiring a driver and two care providers for ambulance
transport. There are na onal regula ons and policies about prehospital equipment but they are
minimally enforced.

ACTION PRIORITIES: SCENE CARE, TRANSPORT AND TRANSFER

▪ Implement newly passed legisla ons and enforce all exis ng legisla on rela ng to the
emergency care system (including Execu ve Order 56 on ins tu onalizing the
emergency 911 number in Local Government Units, ambulance service provider
licensing, ambulance provider cer ca on and related regula ons)
▪ Expand popula on awareness of universal access number through public educa on
campaigns
▪ Introduce a bystander protec on law (Good Samaritan law)
▪ Formalize and expand a community rst aid responder program
▪ Create standardized na onal prehospital protocols and enforce use across private and
public sectors in a uni ed system
▪ Ensure clear delinea on of ambulances used for acute events from emergency inter-
facility transport vehicles
▪ Set na onal response me targets for highest priority ambulance calls
▪ Develop, implement and monitor na onal system wide inter-facility transfer criteria
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 3.4. FACILITY-BASED CARE
There are approximately 995 private hospitals and 463 government hospitals. Health facili es
are divided into three levels (Levels 1, 2 and 3) and all have emergency units. There are also
occasional free-standing emergency units, which are not counted in the preceding numbers.

Respondents es mated that in urban areas 51-75% of the popula on in Philippines theore cally
has 24-hour access to facility-based emergency care, de ned as a dedicated EU with
independent, non-rota ng providers trained in emergency care, without a requirement for
payment prior to care. However, in rural areas, this percentage drops down to about 25-50%.
Par cipants also es mated that few (<25%) pa ents with an injury requiring emergent surgery
have access to appropriate surgical care within two hours of injury.

The na onal assessment and accredita on scheme for most hospitals in the country exists as a
tool to search for the “best” hospital. The accredita on process does not include assessment of
capacity to deliver emergency care. Accredita on of facili es as trauma capable or trauma
receiving by DOH (in conjunc on with the Philippines College of Surgeons) is underway. All
par cipants felt that minimum standards for emergency care should be integrated into the
hospital accredita on process.

Respondents stated that rst level-hospitals and ter ary level hospitals have EUs accessible 24
hours per day, but pa ents are not triaged by acuity (seen in order of arrival). Sta ng in these
units consists of non-rota ng providers that permanently sta the EU. Mid-level providers do
not exist in the Philippines.

Respondents es mated that many (51-75%) ter ary-level EUs have adequate func onal
equipment necessary for airway management (including intuba on), breathing interven ons
(including oxygen and bag-valve mask ven la on) and vasoac ve medica ons, almost all (>95%)
have IV uids, and few (<25%) have oxygen satura on or cardiac monitoring. Few (<25%) rst
level EUs have adequate func onal equipment. Few rst level hospitals and many ter ary level
hospitals have adequate access to diagnos c and radiology services (to allow for pa ent care
decisions to be made in a mely fashion).

The majority of ter ary care hospitals (76-95%) have designated triage personnel. Time targets
for speci c triage designa ons exist and are facility-based. Many (51-75%) have me targets for
certain triage designa ons, but only a few (<25%) track compliance for these me targets. Few
(<25%) rst level facili es u lise a formal triage protocol for pa ents on arrival. Par cipants
emphasized the development of a system-wide strategy for triage and the expansion of formal
triage (via standardised tool with me targets) in EUs at all levels as a top priority. The WHO/
ICRC/MSF Interagency Integrated Triage Tool was proposed as a possible triage tool model for
the country.

There are no na onal regula ons and/or protocols manda ng that acutely ill or injured pa ents
be clinically triaged prior to being required to register; these are ins tu on speci c guidelines.
Par cipants stated that while in prac ce, most cri cally ill pa ents are triaged prior to being
registered, developing appropriate regula on for EU triage and registra on ow should be a
priority. Par cipants also agreed that uni ed requirements for EU infrastructure should be
developed through a review of exis ng and WHO standards.

There are no emergency medicine speci c post-graduate degree courses (e.g. master’s degree)
for nurses. DOH does o er some training courses in speci c areas such as wound care, but this
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 is not a formal degree. Nurses can obtain a master’s level degree in cri cal care and many of
these nurses do go on to work in the EU, but there is no degree program speci c for emergency
medicine or trauma.

Emergency care educa on pathways have been developing quite rapidly since the formal
recogni on of emergency medicine as an independent sub-speciality in 1988. The rst residency
program was developed in 1991 and since then training opportuni es have con nued to expand
across the country. There are fully cer ed specialist programs for physicians in emergency
medicine, anaesthesia, cri cal care and trauma surgery. There are no speci c requirements for
nurses or doctors at rst-level hospitals to undergo injury-speci c training as part of their ini al
or on-going cer ca on. First aid, basic life support and IV placement trainings are mandatory
for nurses, but there is no speci c training on trauma or emergency care. Par cipants noted that
doctors do receive this as part of their general training program, and that there is an emergency
medicine specialty elec ve available for medical students.

Standardized protocols for management of key emergency condi ons exist in some EUs, but they
are not consistently used or externally validated. Par cipants stated that while there are no
government protocols, there are some developed by PhilHealth, PCEM and other groups.
Guidelines for use are facility-speci c. Representa ves from university hospitals stated that they
do have mechanisms in place for internal tracking and audi ng to ensure compliance with some
parts of their protocols. All par cipants felt that system-wide protocols for emergency care
(including clinical and process guidance protocols) should be developed.

There are few ini a ves to screen emergency pa ents for diabetes mellitus, domes c violence/
child abuse, HIV, TB or substance abuse, but these are not widely known to clinicians. DOH does
have guidelines for infec on control that governs screening of emergency pa ents for highly
contagious condi ons during mes of concern for outbreak (e.g. Ebola, SARS, MERS, etc.).

There is no formal protocol for communica on with pa ents regarding disposi on or discharge.
All par cipants agreed that it would be bene cial to develop a standardized format for
communica on with pa ents upon discharge from the EU.

ACTION PRIORITIES: FACILITY-BASED CARE

▪ Develop and implement na onal triage tool for all emergency units
▪ WHO/ICRC/MSF Interagency Integrated Triage Tool available
▪ Introduce minimum set of norms and standards for emergency units (infrastructure,
equipment, medica ons, sta , services)
▪ WHO essen al resource standards available
▪ Conduct na onwide hospital emergency unit assessments
▪ WHO Hospital Emergency Unit Assessment Tool available
▪ Introduce accredita on system for emergency units at all levels of facili es
▪ Introduce undergraduate and postgraduate educa on programs speci c for emergency
care for nurses
▪ Introduce medical school training speci c for emergency care
▪ Develop a set of core na onally standardized clinical protocols for emergency unit care
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 3.5. EMERGENCY AND DISASTER PREPAREDNESS AND SECURITY
There is a mul -agency emergency response plan centrally coordinated by DOH which is
periodically evaluated through running of simula on drills. There is no single, regular,
na onwide assessment of the ability of the emergency care system to mobilize resources to
respond to disaster, outbreaks or other large-scale emergencies. Some par cipants noted that
LGUs conduct an annual assessment for emergency response and that this includes assessments
of equipment, workforce, budgets, and running simula on drills.

Par cipants stated that most hospitals have facility-level plans for extraordinary events, but that
they are not regularly prac ced or reviewed, and that the details may not be known by most
sta (beyond the hospital directors).

Violence against emergency care sta and prehospital providers does occur intermi ently. There
are no security plans in place to protect sta , pa ents or infrastructure from violence at either
the facility or the prehospital level. Par cipants stated that many hospitals have police/security
to protect sta but there are no formal security protocols. All par cipants agreed that it is
necessary to develop facility and prehospital security plans. These plans should be based upon
an assessment of the security situa on for facility and prehospital providers.

3.6. ACTION PRIORITIES: EMERGENCY AND DISASTER PREPAREDNESS AND SECURITY

▪ Ins tute ins tu on-based security plans for emergency unit and prehospital services
including violence strategies

4. NEXT STEPS
As outlined in this report, stakeholders used the WHO ECSA results to iden fy cri cal gaps in the
emergency care system of the Philippines and agreed on a set of ac ons for development of
each component of the system. To facilitate further discussion on priority-se ng within DOH
and implemen ng partners, mul ple parameters of the ac on priori es were discussed (cost,
impact, poli cal will, urgency and me to execute). At the conclusion of the ECSA mee ng, all
par cipants expressed enthusiasm and commitment for taking part in next steps, which will be
to convene implementa on partners to create a roadmap for ac on on these priori es.

Some of these ac on priori es can be implemented without substan al new resources by

partners already working within the emergency care system. With engagement and
coordina on of the government, exis ng partners could provide much of the technical
assistance, program development and pilo ng needed to the opera onalize the agreed upon
priori es.

These priori es represent reasonable and feasible next steps in the development of the na onal
emergency care system. Each of the ac on priori es above has the poten al to signi cantly
improve the emergency care system and the outcomes of acutely ill and injured persons
countrywide.
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 REFERENCES

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