“Cebu Institute of Medicine PBL 1 and 2 students’ knowledge and attitude
towards the current status and future outlook of the Philippine health care
referral system”
Submitted by:
PBL 3 Group 9
Cabahug, Kurt Raymond
Israel, Goldameir
Kho, Rachelle
Layese, Charcel Lex
Sales, Gene Robert
Talili, Pauline Julia
Urgel, Mary Angeli
Valmoria, Tiaramaria Rosary
Ymbong, Au Bain Marie
June 12, 2020
ABSTRACT
Introduction: The healthcare referral system is an important part of any health care’s
professional’s work in the country. Current health care professionals have to be aware
of it and how legislation such as the Universal Health Care Law will affect it. Awareness
also needs to be significantly existent in medical students, as future health care
professionals, also known as medical students.
Objective: To assess the knowledge & attitudes of PBL 1 & 2 students of the Cebu
Institute of Medicine towards the current status & future outlook of the Philippine health
care referral system.
Methodology: The study utilized a descriptive cross-sectional study design. A
knowledge & attitude questionnaire was developed and the proposal was submitted
to the Cebu Institute of Medicine Ethics Review Board. Upon approval, messages
along with the informed consent forms and questionnaire were sent to the 1st & 2nd
year students. The respondents were given a week to answer the questionnaires
online.
Data Analysis: Responses from the different questionnaires were tallied, grouped,
and interpreted.
Results & Discussion: The results showed that the sample respondents possessed
moderate or fair knowledge of the referral system and of the Universal Health Care
law. The overall grade was 61.5%, as 177 of the 219 respondents scored
moderately/fairly. The scores for each batch were also similar to the overall moderate
score. Attitude-wise, the majority of respondents were positive towards the potential
benefits of the referral system and were receptive towards the Universal Health Care
Law. The respondents registered more negative feelings towards the current state of
the healthcare system and the enforcement of current policies.
Conclusion: The majority of PBL I & II students of CIM possess moderate knowledge
and positive attitudes positive towards the referral system & UHC Law in principle and
on paper. Thus they are knowledgeable and have room for more growth in becoming
well-versed in matters of the current status & future outlook of our public health system.
While attitudes do lean negatively concerning the enforcement and awareness of the
system, there is certainly promise in the awareness, knowledge, and attitudes of the
PBL 1 and 2 students of CIM towards these relevant topics of public health.
Keywords: public health, referrals, Universal Health Care Law
Corresponding contact details: cimpbl3group9@gmail.com
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Table of Contents
I.
Introduction……………………………………………………………...….4
II.
Review of Literature………………………...……………………………..7
III.
Methodology
Study Setting………………………………......................................19
Study Population……………………………………………………...19
Data Collection Process…………………......................................20
Data Collection Tool………………………………………………….21
IV.
Ethical Considerations…………………………………………………..21
V.
Analysis…………………………………………………………………….22
VI.
Results & Discussion………………………………………………...….24
VII.
Conclusion………………………………………………………………...40
VIII.
Recommendations……………………………………………………….41
IX.
References………………………………………………………………...42
X.
Appendices………………………………………………………………..44
3
I.
INTRODUCTION
Background
The Philippine healthcare system exists for the primary purpose to address the
general and specific health needs of the Filipino people whether they be individual or
population-based. The core of this system lies in the people employed and the
services they provide. Physicians in particular can offer different services based on
their levels of training and expertise, while physical institutions can offer different
facilities based on accommodations and what they can offer. Different individuals with
their own needs require different levels of service and facilities to make sure their
welfare is attended to. This is where the referral system comes into place.
A health referral system refers to practices and protocols put into place in order
to maintain the continuity of health services. It encompasses health services and
facilities across the entire spectrum, from the lowest to the highest level. These levels
are manifested in barangay health stations and municipal hospitals all the way to core
district hospitals and tertiary hospitals as the need arises. The Department of Health
has produced protocols in order to preserve such a system, as manifested in manuals
and guidelines.
Despite these measures put into place, inefficiencies and inadequacies exist in
the system. These inefficiencies include but are not limited to the primary levels of
service being understaffed and underutilized, along with the dependence of many
Filipinos on specialty-level healthcare without going through the different levels of the
system. These inefficiencies have existed for years without dramatic intervention from
healthcare and bureaucratic officials alike, leading to these practices being entrenched
4
in the status quo. What actually exists as inadequacies have now been accepted by
the population at large.
In response to this, measures have been put into place in order to enforce and
integrate a proper referral system for the benefit of the Filipino people. These include
programs to promote the awareness and importance of primary health services, as
well as encouraging health professionals to give their services at the community and
barangay levels.
The recently passed Universal Health Care Law also seeks to improve the
visibility and effectiveness of the referral system in comparison as to how it exists
today. Specifically it seeks to enforce the routing of patients through primary services
and physicians before consults with specialists can be made.
The knowledge of such a system is an important part of any health care’s
professional’s work in the country. Current health care professionals have to be aware
of what they can do and cannot do regarding healthcare decisions of their patients.
This awareness also needs to be significantly existent in future health care
professionals, also known as medical students. While their current knowledge on the
referral system may revolve around the status quo as we know it, the researchers
believe such knowledge needs to be expanded to include the implications of
government policies on the future of the Philippine healthcare referral system. With
the aforementioned situation, the researchers aim to evaluate and assess student
knowledge towards the current status & future outlook of the Philippine health care
referral system
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General Objective
To assess the knowledge & attitudes of PBL 2 & 3 students of the Cebu Institute
of Medicine towards the current status & future outlook of the Philippine health care
referral system.
Specific Objectives
Specifically, the study will accomplish the following objectives:
1.) To examine CIM students' current knowledge on the different aspects of the
Philippine health care referral system such as
A. Its background and nature
B. Scope and limitations of the current system with regards to medical
professionals and patient stakeholders
2.) To gauge CIM students' attitudes towards the legislative outlook of the Philippine
health care referral system such as
A. How the passage of current legislation in the form of the Universal Health
Care Act will affect their future careers and the country’s healthcare referral
system
B. Their different positive and negative perceptions towards said law, and
specifically which provisions do they feel positive/negative about
6
II.
REVIEW OF RELATED LITERATURE
Overview on the Philippine Healthcare System
The Philippine healthcare system serves as a reflection of the Philippine political
and sociodemographic landscape.
(1)
It is tailored to address the general and specific
needs of the Filipino people, often being influenced by biophysical profiles and disease
prevalence states of the collective populace, and also being plagued by inherent
problems that arise from political and economic origin.
The Philippines can be economically described as a low middle-income
developing country, with the distribution of wealth being markedly unequal among the
different income classes. These financial inequities are reflected in the difficulty in
access to quality health care for millions of Filipinos. In a city, one may find Filipinos
comfortably paying for any services their conditions may entail, almost regardless of
cost. In the same said city, one may also find Filipinos who cannot even afford basic,
essential health care services. One can imagine the economic burden of having to
shoulder fees for more complex and specialized health care services. The high costs
for services, medicines, and various other fees, coupled with the financial
inadequacies of many Filipinos have led to unsustainable out of pocket payment
practices. Long-term, these practices cannot be called viable. (2)
Inequality is not just reflected in classes, but also on a much larger scale as can
be seen across different cities and provinces. A number of highly urbanized cities exist,
the majority of which are centered in Metro Manila, a conglomerate of several
metropolitan areas. Places like these have a number of hospitals, both private and
public, to tend to the needs of the people. On the other end of the spectrum, places
7
distant from the hyper metropolitan hub that is Metro Manila can be severely lacking
in facilities such as hospitals or even satellite health centers.
The financial aspect is the most commonly cited difficulty of Filipinos regarding
challenges in healthcare access. Financial challenges are often linked to the
prevalence of out of pocket payments. Although different financial sourcing bodies
exist such as allocated government spending, donors, and public & private insurance
services, out of pocket payments from patients make up the largest share of the total
health expenditure, having increased from 47% in 1997 to 57% in 2007, while national
government health spending decreased in that same period.
(2)
These payments are
the major source of financing for public and private inpatient cases alike, being notably
higher in those admitted to public facilities. Financial debt and impoverishment can
result from the high level of out of pocket payments. Medicine makes up more than
half of medical expenditures and is higher in poor Filipinos when compared to higherearning members of society. Contraceptive spending is also higher among poor
households.
Financial woes are not limited to patients but extend to the healthcare workforce
as well. Lacking compensation, underemployment, scarcity and the limiting of salary
opportunities to highly urbanized cities & the private sector has led to inability of health
workers to cope up with patient needs in many parts of the country. This is especially
true for rural areas. A lack in the workforce subsequently leads to inefficiencies in
delivery of healthcare services. It goes without saying that human resources are the
main drivers of the health care system and are essential for its efficient management
and operation. The Philippines’ large population coupled with its labor-ready youth
8
demographic expand the potential of human resources even further. The irony lies in
the uneven distribution as most are concentrated in urban areas such as Metro Manila.
The scope of health facilities in the Philippines include hospitals both
government and private in administration, and primary health care facilities. The
number of hospital beds is a good indicator of health service availability. Per WHO
recommendation, there should be 20 hospital beds per 10,000 population (2017), and
almost all regions fall short of this ratio.
(2)
The high costs, workforce shortages, and inadequacies in transport & physical
resources can make health care access very, very challenging for many Filipinos.
Although the Philippine government has made significant investments and advances
to aid the health care system aided by the boost in economic growth, the World Health
Organization (WHO) still refers to the Philippine healthcare system as “fragmented”
due to the fact that most of the benefits of this growth have not reached the most
vulnerable groups of the Filipino society
(2)
. It has been stated that in order to correct
these problems in the system, two factors would have to be acknowledged and
addressed head-on: a decentralized health system structure and the need for a strong
referral system. These two factors have a hand in the fragmentation and inequality of
service provision across the nation.
A decentralized structure is a function of the organization and administrative
levels of the health system.
(2)
Prior to 1991, the system then saw the Department of
Health (DOH) possess the following primary functions: 1) control and supervision over
personnel and facilities, 2) operation of local facilities such as provincial hospitals, 3)
delivery of health programs and services, and 4) the promulgation and enforcement of
ordinances related to health concerns. The 1991 date is important as it saw the
9
enactment of the Local Government Code of 1991. Since then, the devolved or
decentralized state entails the DOH providing national policy NS guidelines while
providing technical standards and assistance. The 1991 provisions see local
government units (LGUs) possess autonomy in decision-making and wield
considerable responsibility in managing their respective health care resources. These
LGUs are now responsible for the primary functions formerly belonging to the DOH.
This autonomy can often become political in nature, with local officials having strong
influence in health care policies as a result. This political dependency also contributes
to the varying levels of health care quality in the Philippines. (3)
The importance of local health facilities cannot be understated as according to
a 2008 health survey, rural health units (RHUs) and barangay health centers were the
most visited health facilities in all the regions except for NCR and CAR, where most
visited private hospitals and clinics for health needs.
The Health Referral System
Health referrals refer to activities undertaken by a provider or facility in response
to an inability to provide the necessary intervention for a patient. Referrals start from
the community level.
(4)
First contact with a patient begins in the barangay health
station. Next, the primary referral center of the barangay is the RHU, then next from
the RHU to the district hospital. From the district hospital, referrals are forwarded to a
provincial hospital and in some cases, a private tertiary hospital. Within the hospital,
referrals now navigate through the hospital internal system and policies. A progression
from a primary to a tertiary level of health care can be appreciated, with each level
offering a succeedingly wider variety of health services.
10
A change in the personnel involved in the care of the patient can also be seen
in a referral. This scope of personnel extends from the barangay health workers
serving as first contact with the patients to the general physicians to hospital/clinicbased specialists. The ideal application of the referral system sees the patient being
managed among progressively higher levels of the health care system. This is
reflected in the DOH guiding principle, “To refer the Right Patient, to the Right Facility,
at the Right Time all the Time.”
The ideal application of the referral system is often not seen in reality, as
barangay health centers and other forms of primary health care facilities are often
bypassed by patients. In the Philippines, it is the norm for people from all social classes
to go directly to secondary and tertiary hospitals even if manifesting with primary health
concerns. This bypassing leads to several patients seeking consultation for conditions
which could have been treated at the primary level.
This health-seeking behavior also makes patients usually seek out admissions
first rather than primary care. Based on a 2006 survey, most Filipinos, especially the
low income households, prefer to seek treatment in government hospitals if family
members need confinement. Affordability is the main reason for going to a government
medical facility, while excellent service is the main reason for going to a private medical
facility. In a 2006 study by Social Weather Stations, excellent service and affordability
are the main reasons for being satisfied whereas poor service is the main reason for
being dissatisfied with the services given by government hospitals. People with
PhilHealth insurance are more likely to be confined in a private hospital (56 percent),
than those without Philhealth insurance (28 percent)
(5)
.
11
The Universal Health Care Act
The aforementioned contributing factors have been recognized by the
administration and action has been taken in order to start reform efforts. Several
approaches to mitigate the fragmentation of the health care system have come and
gone and one of this was the drafting of the Universal Health Care (UHC) Act.
(6)
The
UHC attempts to solve this fragmentation issue through the integration at the provincelevel of continuity of care and improved access to services; incentivizing public and
private linkages; and rationalizing multiple payers for health at the province-level by
the establishment of a Special Health Fund. Parliamentarians and health stakeholders
have made drastic efforts to pass a UHC bill for the past two years, but in reality, the
Philippines has already experienced a 50-year process of health reform, under
different names. The UHC Act is the culmination of decades of progress, and two
years of dedicated political and technical work.
The Universal Health Care Act is an act that guarantees equitable access to
quality and affordable healthcare to all Filipinos.
It will also automatically enroll
Filipinos into the National Health Insurance Program and expand PhilHealth coverage
to include free medical consultations and laboratory tests. It was officially signed into
law by President Rodrigo R. Duterte on Wednesday February 20, 2019. Aside from
the automatic enrollment of all Filipinos to PhilHealth, other significant reforms that will
be implemented over time include:
(7,8)
1. Designating PhilHealth as the national purchaser for health goods and services
for individuals, such as medicines
2. Improvement of health facilities especially in underserved areas
3. Responding to the gap in health workers throughout the country
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4. Strategic engagement of the private sector
5. The creation of new functions in the Department of Health (DOH) to improve
the delivery of health services
The bill seeks to utilize ICT to deliver health care services which have the
potential to be profitable, improve quality, change the conditions of practice, and
improve access to healthcare, especially in rural and other medically underserved
areas. With the approval of the National Health System and Services Act and the
Universal Health Act being signed into law, the Philippines has a monumental task of
delivering accessible, quality healthcare services to all its 105 million citizens. It will
shift the health system’s current treatment-oriented approach towards a more
balanced approach emphasizing prevention and health promotion.
One of the aspects that makes the Act remarkable is that it is the first act of its
type in the Western Pacific; this is remarkable considering the strong presence of the
private sector in the Filipino health system existing in parallel with a fragmented and
devolved government health service. The Act prescribes system reforms in
accordance with the multiple financing and service delivery mechanisms at work in the
Philippines.
It is notable that WHO officials were instrumental in the formulation of the act,
as national, regional and headquarters representatives shared detailed knowledge
about the coordination of service delivery, financial flows and health systems
governance, acting as a guide in the background. WHO also produced a formal
position paper which proved instrumental in guiding the bill’s redrafting process.
13
Medical Students and Healthcare
Measuring the level of awareness of medical students regarding various
concerns in the healthcare system has been a topic of interest for research for many
years now. There was a previous on University Students’ Knowledge and Awareness
of Human Papilloma Virus.
(9)
The students in the university located in Florida were
selected from a sampling frame provided by the registrar’s office as their target
population. The researchers sent out a 54-item self-administered questionnaire and
this was mailed with a cover letter explaining the purpose and importance of the study.
Questions were formulated based on previous sexually transmitted infection studies
and references. Health survey experts also assessed all questions for validity and
were in a forced-choice format. In measuring the overall knowledge of the respondents
about HPV, the number of correct responses to knowledge items were combined to
form a knowledge scale. The final scale consisted of the number of correct responses
to 14 knowledge questions ranging from 0–14.
The knowledge scores from the study that were compared among the
respondents who indicated they had no prior knowledge about HPV, those who
indicated they knew a little about HPV and those who indicated they knew a lot about
HPV assessed the validity of this scale. Another three questions were developed to
compare the respondents’ knowledge and attitudes about HPV with those of other
sexually transmitted infections: HPV, HIV, chlamydia, syphilis, gonorrhea, hepatitis B,
and herpes using a 3-point ordinal scale (1= no knowledge, 2= know a little, 3= know
a lot). The respondents were also asked to rate how well they think the university
students have been educated about HPV and other STIs that were listed. A 4-point
14
ordinal scale was used (1= not educated at all, 2= a little educated, 3= moderately
educated, 4= very educated).
Another research article had a self-administered questionnaire to assess the
knowledge and attitudes regarding HIV/AIDS among Pre-clinical Medical Students in
Israel.
(10)
The questions were derived from previously validated questionnaires that
were administered as part of relevant previous studies. The validity of the
questionnaire was also assessed by medical doctors who specialized in the field of
infectious diseases, with a specialty in HIV/AIDs. HIV/AIDS knowledge was measured
with a 17-item questionnaire covering awareness of transmission and nontransmission routes of HIV and basic knowledge of HIV/AIDS treatment. The
respondents only answered using one of three possible responses to each statement
in the knowledge portion: yes, no or don’t know. The attitudes portion of the
questionnaire consisted of 33 items that were measured on a four-point Likert-type
scale ranging from 1 = strongly agree to 4 strongly disagree.
The importance of social media as a tool for awareness cannot be understated
as it is a tool used not only to share ideas or information but also discussions on health
care issues. It provides an interface where users can interact. Nowadays, social media
occupies an increasing rate in both the daily lives of people and the world. There are
about 2.46 billion users of social media worldwide during 2017, it is estimated that
~12% rise will occur by 2019. Over 80% of the Philippine Internet population uses
social media. In Universal McCann’s 2008 Wave 3 study on social media, the
Philippines has the highest penetration of social networking among Internet users at
83%, compared with the global average of 58%.There are many online websites
providing information on health and let patient or the public communicate with health
15
experts online, leading to a change in behaviors and habits of people, especially the
youth. One-third of medical faculties use Facebook and other social media for
teaching, while about 50% of the faculties are planning to use social media in the near
future. The infectious disease surveillance plays an important role in the management
of public health that can be done through social media. Online habits may have an
effect on the mental health and behavior of the people that can have potential health
care challenges. Social media use can be a leverage to drive people engagement,
grow a practice, or influence in a particular field. An easy example of where social
media is useful is simply getting the word out about a device or treatment that patients
may not know about otherwise, or to share research with colleagues. Patients most
likely accept the presence of social media as means for health issues and the
healthcare industry can use social media to create a human and trustworthy image. It
can be used to teach, such as via Youtube video or Facebook live, and provide
education to the public.
In the study The Impact of Online Social Networks on Health and Health
Systems: A Scoping Review and Case Studies by Griffiths et al.
(11)
the researchers
aimed to find out the impact of social networking on an individual’s health seeking
behavior and how it could collate to form a mass movement that would enable a
general political activity for health promotions. This particular study suggests that
different social interactions in four social networking sites could help spread
awareness and information among people with specific health experiences and
common people. At the end of the study, the researchers observed that most people
on the sites seek support and knowledge on how to live with their condition. As a result
of this interaction, two new sites and various organizations have been established with
a goal of supporting individuals with specific conditions; one in particular was “My Pro16
Ana” which supports people with anorexia and helps in spreading awareness about
the condition. Three out of the four social networking sites have evidence that they are
aiming to change the health systems by spreading information and by gaining
supporters to fund and support various campaigns. These campaigns in return post to
the different networking sites about the events and successes of the campaign and
thus spreading more awareness. In conclusion, this observational study of social
networking sites has a direct effect on an individual’s health and health seeking
behaviors and explain that these virtual social interactions have an indirect impact on
the overall health promotion in a larger and national context.
Medical students are expected not only to have knowledge and skills, but also
character in having the drive to familiarize themselves with several regulations and
laws that would concern their future practice. This period of medical education is a
critical time for students to be aware of the law that could improve the quality of patient
care through understanding the problems in the health care system and utilizing the
UHC as a guide to ensure that all Filipino citizens have access to a comprehensive
set of health services. (12)
Law propagation can come in many ways, either formal or informal. One of the
formal strategies in law dissemination is taking courses about the law and its
specifications. In medicine, every student is mandated by the Philippine law to take
units in this subject. The Republic Act No. 2382 (The Medical Act of 1959) Article II,
Section 6 states that the medical course should consist of at least five years consisting
of fourteen subjects, one of which is Legal Medicine & Medical Jurisprudence. Through
this course, students of medicine are introduced to the knowledge of medicine
pertaining to the law. In Cebu City, the majority of the medical schools take up Legal
17
Medicine the year preceding clerkship. Specifically, the medical students of Cebu
Institute of Medicine take up this course during the first semester of their third year.
18
III. METHODOLOGY
Study Design:
The study utilized a descriptive cross-sectional study design.
Study Setting:
Initially, the study was to be done at Cebu Institute of Medicine F. Ramos St.
Cebu City, Philippines. However, due to the current health and social circumstances,
the study was done online through Google forms instead.
Study Population:
A. Inclusion Criteria:
-
First -year students enrolled in Cebu Institute of Medicine for AY 2019-2020.
-
Second- year students enrolled in Cebu Institute of Medicine for AY 2019-2020.
B. Exclusion Criteria:
-
Third- year students enrolled in Cebu Institute of Medicine for AY 2019-2020
that are proponents to the study.
-
Fourth- year students enrolled in Cebu Institute of Medicine for AY 2019-2020
Sampling Size Calculation
Sample size calculations for a descriptive study with a population of 379 as shown
with the following formula (22):
SS = [Z2p(1-p)]/c^2 with a 95% confidence interval
SS = [(1.096)^2(0.5)(1-0.5)]/(0.08)^2
19
SS = 0.9604/0.0064
SS = 150.0625
Corrected sample size:
SS/{[1+(SS-1)/N]}, wherein N = 379
Corrected SS = 150.0625/{1+[(149.0625)/379]}
Corrected SS = 107.7 = 107.
Randomization
This study used simple random sampling.
Data collection process
An online questionnaire was developed by the researchers using information
derived from health referral manuals and their relevance to medical students. The
research proposal was then submitted to the Cebu Institute of Medicine Ethics Review
Board. Upon approval, letters were sent to the specific PBL I & II coordinators to obtain
permission to do the research.
With permission obtained, the research team messaged all 1st & 2nd year
students online and introduced themselves and the study with its purpose and
background. The students were given electronic letters of informed consent &
questionnaires. They were allowed to answer the questionnaires using the developed
Google Form at their own pace.
20
Data collection tool
Data was collected through an online 40-item questionnaire on Google Forms
distributed to CIM students through Facebook chat. The questionnaire was developed
by the researchers using information derived from health referral manuals and their
relevance to medical students.
The questionnaire was divided into 2 sections: knowledge and attitude. The
former had 20 questions while the latter had 20 questions as well. Knowledge
questions were noted and graded as to whether or not respondents arrived at the
correct answer(s) while in the attitude section answers were gauged on a scale
ranging from “strongly agree” to “strongly disagree.”
IV. ETHICAL CONSIDERATIONS
The research proposal and questionnaire will be submitted to the Cebu Institute
of Medicine Ethics Review Committee for thorough review and approval. Once
approved, letters of intent will be sent to individual year-level coordinators. At the start
of the data gathering process, the respondents will be fully informed about the
evaluation being conducted and how the findings will be used. To maintain
confidentiality, the filled-out questionnaires will be sorted into designated envelopes,
which will then be placed in a safety box, padlocked, in the researcher’s home. Lastly,
only relevant information will be used during the data collection, to avoid divulging
confidential data.
21
V. DATA ANALYSIS
Operational definition of terms
Independent variable - Student’s body of knowledge on the Philippine healthcare
referral system.
Dependent variable - Student’s perception on their knowledge & attitudes on the
subject matter.
Statistical Test
Knowledge and attitudes will be assessed using a questionnaire.
The
respondents will be scored based on their answers. For a yes or no question, a
negative response will be given a score of 0 points, while a positive response will be
given a score of 1 point. For questions with multiple choices ranging from a more
negative to a more positive response (attitude portion), the selected choice will
correspond to a set number of points. For objective questions, a correct answer will
correspond to 1 point, while a wrong answer will correspond to 0 points. The points
per section will then be totaled and a score of >75% will be considered good, 50-74%
will be considered moderate, and <50% will be considered poor.
22
Percentage
The results will be identified and sorted, and the data will be used to express the
prevalence of good/ moderate/ poor knowledge. The formula will be as follows:
Percentage (%)= f/N x 100
where: f= frequency of points gathered
N= total number of questions
23
VI. RESULTS & DISCUSSION
The purpose of this study was to assess the knowledge & attitudes of PBL 1 &
2 students of the Cebu Institute of Medicine towards the current status & future outlook
of the Philippine health care referral system.
There were 219 respondents in this study, consisting of 103 students from PBL
1 and 116 students from PBL 2. The number of respondents equated to roughly 58%
of the entire PBL 1 & 2 population.
Figure 1.0 shows the general distribution amongst the respondents.
Although the turnout was less than our expected target, there are a number of
reasons explaining this outcome. These reasons include multiple forms from multiple
groups being released at the same time period competing for the attention of
24
overlapping research populations. Additionally, there was a difficulty in encouraging
and monitoring compliance in answering the forms despite continuous follow ups done
by the researchers. The researchers believe that this is due to lack of physical
meetings with the respondents. There were also respondents who stated that they
were unable to answer our forms to their best efforts due to limited internet connectivity
or non-working links. The researchers did their best to address concerns whenever
they arose. These forces are deemed unfortunate and beyond the scope of control of
the researchers.
The knowledge section of the questionnaire was meant to assess the
respondents’ knowledge on the Philippine healthcare system through a series of
questions, emphasis placed on the background, mechanics, and scope behind the
referral system.
Table 1.0 provides an overall look at the responses to the knowledge portion of
the questionnaire, and key questions will be provided with more detailed figures as the
analysis goes on.
25
Table 1.0 Answers of the respondents for questions regarding knowledge of the
Philippine Healthcare Referral System (n=219)
26
Figure 1. Knowledge on the provision of a primary care provider under the
Universal Health Care Law.
As seen in Figure 1, questions #1 and #2 deal with Universal Health Care Law’s
provision of a primary health provider to address patient concerns. A majority of the
respondents (95.9%) were able to identify the primary caregiver as the assigned
healthcare worker and also identify the several possible duties a caregiver may carry
out. The primary care provider’s duty to be the first line in addressing citizen concerns
was also the most frequently chosen out of the choices. For question #3, 72.6% of the
respondents were able to correctly answer that municipal, city, and health services all
operated independently from each other. Upon re-examining the question, the
researchers realized that the question may have been more specific in wording to
define the context of “independently” in the question.
27
Figure 2. Knowledge on the best definition of a functional health referral system.
As shown in Figure 2, a majority (88.6%) of the respondents were able to
correctly answer what a functional referral health system is defined as. Being aware
of the key concept of the referral system as a means for continuity and
complementation is important in understanding it. Out of 219 respondents, 159
(72.6%) are aware of the standard referral flow direction which starts from the Brgy.
health station and ends in the Regional Center.
28
Figure 3. Knowledge on the direction of a patient referral.
Figure 3 shows that the majority of respondents are also aware that the referral
flow is bidirectional (69.9%) and that referrals are recorded by both the referring and
the receiving health facilities (94.1%). Additionally, the majority of the respondents do
recognize how both an internal (99.1%) and external (98.2%) referral take place.
Among the reasons for internal referrals, only one reason which was co-management
with a fellow health professional was chosen correctly by the majority (90.9%) while
the other reasons in the pool of choices were not as popular. Only 36.8% were able to
correctly identify all reasons for internal referrals. Also, among the respondents, only
33.3% were able to correctly identify all situations in which an external referral may
occur or be applicable. Despite this, 94.5% of the respondents’ were able to identify
that an external referral is needed when a patient requires technical intervention that
is beyond their capabilities and 91. 3% were able to identify the need for an external
referral when a patient requires a technical examination not available at the health
care center. These results show that respondents are aware of the importance of
internal and external referrals only in some situations but not all. Majority of the
29
respondents are knowledgeable about what horizontal (95.9%) and vertical (96.8%)
referrals are. These show that respondents are able to identify and differentiate the
two types of referrals in which vertical refers to a higher level facility from a lower level,
while horizontal is between same level facilities in different catchment areas.
For question #14 regarding the concept of inter-local health zone (ILHZ), only
15.1% answered correctly, defining it as the district hospitals within the closest
proximity to each other. This shows that most respondents are not aware of the ILHZ
concept. More than half (59.8%) of the respondents correctly chose “district or
provincial hospital” being the core referral hospital in charge of secondary care. This
shows that some but not all of the respondents are aware of the different levels of
healthcare and their corresponding hospitals. Therefore it is important to know the
referral system in correlation with the different levels of care within the country as well
as the type of service and facilities needed by the patient.
Regarding question #16 on when a referral back to the initial health center/site
should be done, only 28.3% answered correctly, which was to refer the patient as soon
as possible. The rest answered incorrectly with most of the respondents, 50.2%,
choosing to refer the patient only if the patient has any lingering issues or further
concerns. These results show that most of the respondents think it insignificant to
refer back to their patient’s initial health center/site, and only to do so when the patient
shows concerns or is still suffering from his or her symptoms. However it is important
to note that patients must be referred back immediately even though they no longer
present with symptoms, as monitoring and proper education of the patient is integral
to proper management.
On question #17 regarding which factors a well-functioning two-way referral
system should have, respondents were made to pick more than one choice and from
30
the data gathered only 9.58% of the respondents were able to correctly pick three out
of the 4 choices given which were that a two-way referral system must have defined
functions and responsibilities for each level of care, agreed roles and responsibilities
of key stakeholders, and that a trained personnel is a must at higher levels of care but
not necessary at centers of first contact.
Figure 4. Knowledge on course of action if no government hospital is present.
Figure 4, which concerns question #18, shows what should be best developed
for the sake of the referral system in an ILHZ where there is no government hospital,
55.7% of the respondents answered correctly choosing “networking with private
hospital facilities with available services“ as the best that should be developed in the
referral system. This highlights the fact that most of the respondents are aware that
most of the public hospitals and facilities in the country are ill equipped and out dated
as to the equipment and services they provide, compared with the more privately
owned institutions. Therefore communication and networking with private hospitals
should be given prime importance in order to best manage and serve patients
accordingly.
31
On the next question that identifies which is not a responsibility of the rural
health midwife, only 9.1% of the respondents were able to pick the correct answer
which was that the midwife’s responsibilities do not include contacting the city health
officer if the patient is outside the capabilities of the brgy. health station. Most of the
respondents, 76.7%, picked the choice “If capable, gives medication to patients”, as
not being part of the Midwife’s responsibilities in the rural health center. Regarding the
knowledge about which hospital is the end referral hospital in Cebu, 90.9% of the
respondents answered correctly choosing Vicente Sotto Memorial Medical Center as
the end referral hospital of the province of Cebu.
Using the methods stated in the data analysis section, the researchers were
able to compute the scores of each batch and the overall score of the entire sample
population. The PBL 1 students, totaling 103 out of 219 respondents, closely reflected
the overall score of the entire sample, with the students’ responses being 11 (10.7%)
having poor knowledge, 85 (82.5%) having moderate knowledge, and 7 (68%) having
good knowledge. The same trend was also noticed in the responses of the PBL 2,
totaling 116 out of 219, with the students’ responses being 15 (12.9%) having poor
knowledge, 92 (79.3%) having moderate knowledge, and 9 (78) having good
knowledge. Regarding the overall scoring of the knowledge section for the entire
sample population, 26 or 11.9% of the respondents had poor knowledge regarding
various aspects of the referral system, 177 or 80.8% of respondents had moderate
knowledge while only 16 or 7.3% had good knowledge. The final grade therefore was
61.5%, which would be graded by the researchers as moderate.
32
Figure 5. Knowledge of PBL 1 & 2 Students on the Health Care Referral
System.
In this study’s questionnaire, the attitude section speaks about the respondents’
opinions and viewpoints on the topic at hand. As seen in Figures 6, it can be inferred
from the data collected that despite the majority agreeing that the referral system is an
effective way to subject patients to the highest level of care (92.7%) and that the
guidelines/policies on making these referrals are adequate on paper (56.2%), a good
number (42.5%) believe that the government is doing a poor job at enforcing this
referral system. These beliefs would reflect a belief that most Filipinos are unable to
take full advantage of the potential benefits they would receive from the healthcare
system due to a lack of education & promotion. On a more positive note this also
reflects how the concept of the referral system is seen as a would-be benefit to those
in need.
33
Figure 6. Attitude on the referral system being an effective way to subject
patients to the highest level of care.
Figure 7. Attitude on public awareness of the referral system concept.
Majority of the respondents (68.0%) also believe that there is a lack of good
public awareness of the referral system concept which can be a result of the lack of
enforcement of this system by the government themselves. There is a close number
of respondents between those that agree (35.2%) that district hospitals have the
necessary facilities to accommodate referrals from lower levels and those that
34
disagree (36.5%) but despite this, majority (58.9%) believe that regardless of the
facilities, these district hospitals don’t have the necessary manpower to accommodate
referrals from lower levels. This may be due to the decentralization of the Philippine
health system leading to its fragmentation allowing local officials to have strong
influence on the health care policies. This autonomy causes a disruption in the
provision of quality health care services which includes the adequacy of the workforce
in local health units.(3) In line with this, most of the respondents agree (85.9%) that
provincial and district hospitals would benefit if patients are treated at lower levels
beforehand and think that public health systems should focus more on improving
barangay health stations (85.6%). In comparison to the results, the attitude of the
respondents towards the referral system contradicts the above statement.
Majority (54.8%) would rather go to a private practitioner of choice than to go
through the referral system. It also seems that 62.1% of the respondents find it more
efficient to consult private practitioners than going through the referral process. This
might be due to several factors such as a change in the personnel involved in the care
of the patient, health seeking behavior of individuals, and a need for excellent service
and affordability.(3) Additionally, most of the respondents would disagree (46.1%) that
the health care system delivery in the Philippines is satisfactory.
Majority of the respondents (51.1%) agree that the division between public and
private care enforces differences in health care quality provided to Filipinos and
believe that sticking to the status quo would not result in great improvements in health
care delivery.
As noted in Figure 8 regarding the Universal Health Care Law, most of the
respondents (47.8%) said that this will improve the referral system and would agree
35
(44.1%) that more Filipinos will benefit from the system if this is only to be implemented
well. The researchers believe this is due to the Universal Health Care Law prioritizing
measures to cater to the more dependent patients in order to equalize the playing field
between public & private health care systems. Thus, the majority (37.1%) believe that
a greater government focus on the referral system will lead to fewer patients referring
to private practitioners.
Figure 8. Attitude on whether the UHC Law will likely improve the referral
system.
Factors affecting their attitude towards the health care delivery system may
include (a) their level of education towards the ideal health care delivery system. As
medical students, the respondents are constantly given lectures, seminars, or reading
assignments about the ideal approach on how to provide a better system for health
care delivery. Another one would be (b) that the said respondents are constantly
exposed to health care institutions and this has helped them garner some ideas on the
current problems of the healthcare system (e.g. lack of education on the referral
system, lack of empowerment for public health, lack of medical personnels, and etc).
36
Lastly, the respondents (c) have an easy access to multiple news articles or posts
about the present health care delivery system; with one click, the respondents would
get a view on the complaints and the hearsay of the general population. Despite this
negative attitude towards the Philippine health care system, the respondents seem to
be satisfied (44.3%) with how the private health care delivery system runs and this
may be because they find direct consultation with specialists more efficient. In relation
to this, the respondents seem to be neutral or undecided on their satisfaction level on
the public health care delivery system. One factor that may have affected this is their
lack of exposure to community medicine, although they are given lectures on it, it is
not until their senior year that they are given the chance to fully immerse in the
community.
Figure 9. Attitude regarding considerations on going into public health.
Figure 9 addresses if the current knowledge, attitudes, and exposure of the
respondents to the referral system & the UHC Law has made them consider going into
public health. The majority of results were neutral, possibly because of a need for more
exposure to the medical field before such a decision could be made.
37
To summarize, the majority of the respondents do believe that the referral
system is an effective way to subject patients to the highest and most efficient level of
care, however they seem to lack faith in the public healthcare referral system and how
it is enforced among the Filipino citizens. This drives most of them to rather seek
private health facilities instead. Despite this, they believe that the Universal Health
Care Law will be able to improve the referral system allowing more Filipinos to benefit
from it (Figure 9).
Figure 10. Attitude of PBL 1 & 2 Students regarding the Philippine Healthcare
Referral System in relation to the Universal Health Care Law
The students of PBL 1 and 2 can be described as having a moderate
understanding when it comes to knowledge of our health care referral system. The
possible reasons include the notion that being a medical student in a medical
institution allows for an amount of exposure to these family and community medicine
concepts. This exposure is reflected in the lectures given pertaining to these topics. It
38
is important to note though, that the CIM family and community medicine curriculum
reaches its peak in the junior clerkship/PBL 3 program, which means that there is more
learning to be done, about family/community medicine as also specifically tackling the
referral system.
Attitude-wise, the PBL 1 and 2 students of CIM are positive and supportive
towards the concept and principles of the public health referral system and the
Universal Health Care Law’s efforts to further push the concept to society at large.
This is reflected in the general agreements with statements agreeing that referrals are
an effective way to subject patients to the highest level of care, especially on paper.
However, the sentiments lean more towards the negative side of the spectrum
when it comes to the enforcement and awareness of such endeavors. These feelings
towards the inadequacies of the system are also reflected in the admission that many
would prefer to consult with private doctors rather than go through the system. This
may reflect more widespread health beliefs in the country where private health care is
considered as being dragged down by less red tape and being more efficient overall.
Another purpose of this research was also to assess how knowledge of the Universal
Health Care Law may affect the considerations of PBL 1 and 2 students towards a
public health career in the future. Regarding this, the majority of responses were
neutral. This may reflect a need for students to be more informed about the UHC law
before seriously considering a career path. A shift in this thinking not only towards
public health careers but also toward the perception of public vs. private health care
would first require massive overhauls in the Philippine healthcare system.
39
VII. CONCLUSION
It is practically public knowledge at this point that the Philippine healthcare
environment is filled with inadequacies of the workforce, physical resources, and
an inability of well-meaning health policies and programs to live up to their full
potential. These inadequacies are magnified when juxtaposing public and private
healthcare in the country.
The researchers conclude that the average PBL 1 and 2 student possesses
moderate or fair knowledge of the Philippine healthcare referral system, in the
sense that they are at least aware of the intricacies of the system, although there
is still room for improvement which can be remedied by community medicine
lectures in the latter stages of curriculum and further exposure to the community
and health bureaucratic environments. The average PBL 1 and 2 student is also
positive towards the concept of public health referral system and the changes the
Universal Health Care Law would bring in favor of such a system especially to
Filipinos. However, reservations still exist regarding the realities of public health:
the enforcement, perception, and practicality in ensuring that the referral system
has the capability of delivering fair quality healthcare to Filipinos, especially those
who are in need of it the most. These realities are matters unavoidable to these
students as future healthcare professionals.
Changing not just perceptions but also the inconvenient realities of the nation’s
public health situation would require a paradigm shift in policies of bureaucracy and
education. While there is certainly promise in the awareness, knowledge, and
attitudes of the PBL 1 and 2 students of CIM towards bringing change, hopefully
40
the Universal Health Care Law will be the first tangible step into a new era of
change.
VIII. RECOMMENDATIONS
The proponents would like to make the following recommendations for further
studies regarding the matter:
The research questionnaire could be greater in scope by including questions
formulated around more topics relevant to the referral system. The knowledge and
attitude portions of the questionnaire could also be subdivided to promote organization
of the questions. The proponents would also recommend the vetting and validating of
the questionnaire by family and community medicine experts. Said experts in those
fields can
also
be
consulted
for
advice
regarding
the
formulation
and
comprehensiveness of the questionnaire.
It is also recommended that a greater scope of respondents be included such
as students of PBL 3. Not only would their inclusion allow for more data to work with,
but future researchers could also compare results between PBL 1 and 2 and PBL 3
responses to show any possible effect of family and community medicine lectures on
the knowledge and attitude of CIM students.
Sampling of future studies can also include a greater number of respondents
by including methods such as physical papers to be filled out in the presence of
proponents to guarantee a greater number of filled responses.
41
REFERENCES:
1. Health Referral and Minimum Packages of Services. DOH - Center of Health
Development Northern Mindanao. 2016.
2. World Health Organization. Philippines. Country Cooperation Strategy at a
Glance. Retrieved 2009-12-23, 2017.
3. Romualdez et. al. The Philippines Health System Review. Health Systems in
Transition. Vol. 1. No. 2. 2011.
4. Manual on Central Visayas Health Referral System. 1st ed. Regional Office VII:
Department of Health; 2015.
5. DOH. Chapter 1. In The Philippine Health System at a Glance (pp. 1-17).
Republic of the Philippines Department of Health. Retrieved September 23,
2017,
from
http://www.doh.gov.ph/sites/default/files/basic-page/chapter-
one.pdf
6. Dean Koh. “Universal Healthcare Act in the Philippines Signed into Law by
President
Duterte.”
Healthcare
IT
News,
26
Feb.
2019,
www.healthcareitnews.com/news/universal-healthcare-act-philippines-signedlaw-president-duterte.
7. Towards Better Health for All Filipinos. Universal Health Care Law Signed.
Department of Health Website.” February 2018. www.doh.gov.ph/pressrelease-towards-better-health-for-all-Filipinos-UHC-signed-into-law.
8. UHC Act in the Philippines: a new dawn for health care [Internet]. World Health
Organization.
2019
[cited
2019Sep10].
Available
from:
https://www.who.int/philippines/news/feature-stories/detail/uhc-act-in-thephilippines-a-new-dawn-for-health-care ss
42
9. Yacobi, E., Tennant, C., Ferrante, J., Pal, N., & Roetzheim, R. (1999).
University Students’ Knowledge and Awareness of HPV. Preventive Medicine,
28(6), 535–541
10. Baytner-Zamir R, Lorber M, Hermoni D. Assessment of the knowledge and
attitudes regarding HIV/AIDS among pre-clinical medical students in Israel.
BMC Res Notes. 2014;7:168. Published 2014 Mar 20. doi:10.1186/1756-05007-168
11. The Impact of Online Social Networks on Health and Health Systems: A
Scoping Review and Case Studies (Griffiths et al., 2015)
12. Tomacruz S. EXPLAINER: What Filipinos can expect from the Universal Health
Care Law. Rappler [Internet]. 2019Apr1 [cited 2019Oct10]; Available from:
https://www.rappler.com/newsbreak/iq/226810-explanation-what-filipinos-canexpect-universal-health-care-law
13. Arab, M., Zareiee, A., & Hosseini, M. (2010). Awareness about patient's Bill of
Rights from patient impression in Tehran, Iran. School of Hygiene and Public
Health Research Institute, 8(2), 77-86.
14. Tripathi M. Effect of Social Media on Human Health. Virology & Immunology
Journal
[Internet].
2018Feb13;
Available
from:
https://www.researchgate.net/publication/323486379_Effect_of_Social_Media
_on_Human_Health
15. Sharma R. et al. (2002) Patient Attitudes, Insurance, and Other Determinants
of Self-Referral to Medical and Chiropractic Physicians. American Journal of
Public Health 93, no 12. Dec. 1, 2003.
43
APPENDIX A
DATA COLLECTION FORM
44
APPENDIX B
DUMMY TABLES
RESPONSES
TALLY
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
Question
Wrong
Correct
45
APPENDIX C
QUESTIONNAIRE
Year Level:
o PBL 1
o PBL 2
Pre-med Course: ____________
Part I. Knowledge
General instructions: encircle your answer/s to the questions below. Choose
the best answer
1. According to the 2018 Universal Health Care Law, each Filipino will be
provided with a _______ to address their health needs.
a. individualized doctor
b. primary care provider
c. social worker
d. barangay midwife
2. The primary health care provider is capable of fulfilling the following duties:
(you make choose more than 1 answer)
46
a. Be the first line in addressing citizen health concerns
b. Properly refer the patient through the referral system
c. Coordinate with other health centers if the patient needs further treatment
d. Set up meetings with private specialists as soon as patients manifest disease.
3. Municipal, city, and provincial hospital/health services operate
independently from each other.
a. True
b. False
4. What best defines a functional health referral system?
a. A system consisting of all the activities & programs of the different barangay
health centers.
b. A system connecting doctors of different specialties and their patients in the
tertiary hospital environment.
c. A system ensuring the continuity and complementation of health and medical
services involving all health facilities from the lowest to highest level.
5. Which best describes the direction of the standard referral flow:
a. Brgy. health station - Rural health unit – District hospital – Provincial
Hospital – Regional Center
b. Brgy. health station - Rural health unit – District hospital – Provincial
Hospital – Private hospital
47
c. Birthing & midwife center - Brgy. health station – District hospital –
Provincial Hospital – Regional Center
6. The direction of a patient referral is best described as:
a. Unidirectional: from center of first contact to the center of final contact.
b. Bidirectional, from center of first contact to the center of final contact and back
again, following completion of hospital intervention
7. All referrals shall be recorded by:
a. the referring facility
b. the receiving facility
c. both
8. What best describes an internal referral?
a. It takes place within the health facility and from one health personnel to another.
b. It directs patients from one health facility to another.
9. What best describes an external referral?
a. It takes place within the health facility and from one health personnel to another.
b. It directs patients from one health facility to another.
10. Which of the following can be possible reasons for internal referrals?
You may choose more than one answer.
o Opinion or suggestion
48
o Co-management with a fellow health professional
o Further management or specialty care.
11. An external referral can occur in which of the following situations? You
may choose more than one answer.
a. Patient needs expert advice.
b. Patient needs a technical examination not available at the health centers.
c. Patient requires technical intervention that is beyond the capabilities of the health
center.
12. What is a vertical referral?
a. A patient referral from a lower to a higher level of health facility and vice versa.
b. A patient referral that is between similar facilities in different areas.
13. What is a horizontal referral?
a. A patient referral from a lower to a higher level of health facility and vice
versa.
b. A patient referral that is between similar facilities in different catchment areas.
14. In the concept of the Inter-Local Health Zone, or ILHZ, the referral system is
two-tiered as it would primarily involve:
a. 2 neighboring barangay health stations.
b. The barangay health station and its corresponding district hospital.
49
c. The provincial hospital and a partner tertiary private hospital.
15. The core referral hospital in charge of secondary care is
a. private hospital in the nearest vicinity
b. municipal hospital
c. district/provincial hospital
d. city health center
16. After the reason for referral to the hospital has been addressed, when
should a referral back to the initial health center/site of referral be done, if
ever?
a. None.
b. If the patient has any lingering issues or further concerns.
c. As soon as possible.
d. Within a span of 1 year from hospital discharge.
17. Encircle the choices of the different factors a well-functioning
comprehensive two-way referral system should have.
o Defined functions and responsibilities for each level of care
o Agreed roles and responsibilities of key stakeholders
o Trained personnel is a must at higher levels of care but not necessary at
centers of first contact.
50
o Barangay health station should have birthing, minor surgery, and laboratory
services available.
18. In an area or ILHZ where there is no government hospital, what should be
BEST developed for the sake of the referral system?
a. networking with private hospital facilities with available services
b. strengthening the relationship with the other nearest barangay health
station
c. establish specialized surgical, ob-gyne, and internal medicine facilities in
the barangay health station for self-sufficiency
d. request the city health office to fast-track the development of a provincial
hospital
19. At the barangay level, the ff. are responsibilities of the rural health midwife
EXCEPT.
a. If capable, gives medication to patient.
b. Contacts city health officer if patient is outside the capabilities of the brgy. health
station.
c. Refers patients to Rural Health Unit if further evaluation is needed.
d. Registers patient in Client Registry and obtains vital signs.
20. In the province of Cebu, the end referral hospital is:
a. Vicente Sotto Memorial Medical Center
51
b. Cebu City Health Department
c. Chong Hua Hospital
d. Cebu Velez General Hospital
Part II: Attitude
General Instructions: Please place a check in the column on your answer.
Question
Strongly
Agree
Agree
Neutral /
Undecide
Disagree
Strongly
Disagree
d
1. The referral system is
an effective way to
subject patients to the
highest level of care.
2. The guidelines and
policies on making
referrals are adequate
on paper.
3. The government has
done a good job of
enforcing the referral
system.
52
4. There is good public
awareness of the
referral system concept.
5. Provincial & district
hospitals have the
necessary facilities to
accommodate the
referrals from lower
levels.
6. Provincial & district
hospitals have the
necessary manpower to
accommodate the
referrals from lower
levels.
7. Provincial and district
hospitals would benefit if
patients could be
treated be at lower
levels beforehand.
8. The barangay health
station should be the
53
key focus of the public
health system.
9. I would choose to go
through the referral
system rather than go to
a private practitioner of
my choice right away.
10. Consulting with private
practitioners is more
efficient than going
through the referral
process.
11. The divide between
public and private care
enforces differences in
health care quality
provided to Filipinos.
12. Sticking to the status
quo would result in great
improvements in health
care delivery.
54
13. The Universal Health
Care Law will likely
improve the referral
system.
14. More Filipinos will
benefit from the different
referral system levels
because of the
Universal Health Care
Law.
15. A greater gov’t. focus on
the referral system will
lead to less patients
referring to private
practitioners.
16. The referral system and
Universal Health Care
Act has made me
consider going into
public health.
17. It is better for everyone
if all private practitioners
55
participated in public
practice.
18. The ability of the overall
Phil. health care system
to deliver services is
good.
19. The ability of the private
Phil. health care system
to deliver services is
good.
20. The ability of the public
Phil. health care system
to deliver services is
good.
56
APPENDIX D
Invitation to Participate and Informed Consent
Good day!
We, the members of PBL 3 Group 9 are conducting a study entitled, “Cebu Institute
of Medicine 1st & 2nd year students’ knowledge & attitude towards the current
status & future outlook of the Philippine health care referral system.” The study
aims to assess the knowledge of CIM students about referral system of the Philippines.
The group is using a 40-item questionnaire tackling knowledge and attitudes towards
the referral system. The initial 20-point half regarding knowledge is a multiple choice
portion while the latter 20-point half regarding attitudes is a 5-point Likert scale ranging
from STRONGLY AGREE (1) to STRONGLY DISAGREE (5). Respondent data will
be collected by year level and pre-med course.
Your participation is purely voluntary with no anticipated risks or inconveniences to
yourself. We will not require you to write your names to preserve confidentiality and
anonymity. This study protocol has been approved by the Institutional Review Board
(IRB) of the Cebu Institute of Medicine, school year 2019-2020. Thank you.
If you agree to participate in this project, please answer the questions on the online
questionnaire as best as you can.
You may also contact Kurt Cabahug at 09338631420 for further inquiries regarding
the study.
This study protocol has been approved by the Institutional Review Board (IRB) of the
Cebu Institute of Medicine, school year 2019-2020.
57
Institutional Review Board Contact Number: 416-2764
58
APPENDIX E
Tabulated Knowledge Results
59
APPENDIX F
MEASURES OF CENTRAL TENDENCY
Group
Mean
Median
Mode
SD
Variance
PBL 1
11.7
12
11
1.85
3.43
PBL 2
11.7
12
13
1.96
3.85
Total
11.7
12
11
1.91
3.64
APPENDIX G
BUDGET
Item
Price
No. of Pieces
Total
Paper
200 php/50 pcs.
100
400 php
Printing
1 php/pg.
100
100 php
Sum total
2800 php
60
APPENDIX H
GANTT CHART
Oct
Nov
Dec
April
May
May
June
2019
2019
2019
2020
2020
2020
2020
Proposal
Data
Collectio
n
Data
Analysis
Final
Paper
61
APPENDIX I
CURRICULUM VITAE
Name: Kurt Raymond Y. Cabahug
Age: 24
Address: Royale Cebu Homes, Consolacion
Hometown: Cebu
Mobile No.: 09338631420
E-mail address: kurtcabahug3@gmail.com
PERSONAL INFORMATION
Place of birth: Cebu City
Date of birth: July 28, 1995
Citizenship: Filipino
Civil status: Single
Gender: Male
EDUCATIONAL BACKGROUND:
Tertiary:
2013 -2017
City
Velez College
F. Ramos Street Cebu
Course: Bachelor of Science in Medical
Technology
Secondary:
School
2009 - 2013
Primary:
2003-2009
PAREF-Springdale
Lahug Cebu City
PAREF-Springdale School
Lahug Cebu
City
62
Name
Address
Cell. #
Email
: Goldameir C. Israel
: Pooc Occidental, Tubigon Bohol
: 09206729695
: goldiiegold7@gmail.com
_______________________________________________________________
PERSONAL DATA
Nickname
Age
Gender
Date of Birth
Place of Birth
Nationality
Religion
Civil Status
Father’s Name
Mother’s Name
: Golda
: 22
: Female
: December 7, 1996
: Cebu City
: Filipino
: Roman Catholic
: Single
: Dionisio C. Israel
: Rosario C. Israel
EDUCATIONAL BACKGROUND
TERTIARY (2013-2017)
: Velez College
Bachelor of Science in Medical Technology
Cebu City
SECONDARY (2009-2013): University of San Carlos - North Campus
Cebu City
PRIMARY (2003-2009)
: Holy Family of Nazareth School
Tubigon, Bohol
63
Name: Rachelle Lerias Kho
Age: 24
Address: Urgello St. Sambag 1, Cebu City
Hometown: Naval, Biliran, Leyte
Mobile no.: 09052300581
E-mail address: rachellekho95@gmail.com
PERSONAL INFORMATION:
Place of Birth: Cebu City
Date of Birth: July 28, 1995
Citizenship: Filipino
Civil Status: Single
Gender: Female
EDUCATIONAL BACKGROUND :
Tertiary:
2012 -2016
Velez College
F. Ramos Street Cebu City
Course: Bachelor of Science in
Nursing
Secondary:
Naval
2008 - 2012
Primary:
School
2002 - 2008
Biliran
Cathedral School of La
Castin Street. Naval, Biliran
Naval SPED Center
Garcia Street Naval,
64
NAME: Charcel Lex T. Layese
AGE: 22
ADDRESS: Banawa, Guadalupe, Cebu City
CELLPHONE NUMBER: +63 916 344 2505
EMAIL ADDRESS: lexlayese@gmail.com
PERSONAL INFORMATION
DATE OF BIRTH: November 3, 1996
PLACE OF BIRTH: Cebu City, Cebu
CITIZENSHIP: Filipino
CIVIL STATUS: Single
SEX: Male
EDUCATIONAL BACKGROUND
TERTIARY: Velez College – College of Nursing
F. Ramos St., Cebu City
2013 – Present
SECONDARY: Saint Paul Academy
Bantayan Cebu
2009 – 2013
PRIMARY:
Harrison, Pomona County
California, USA
2003 – 2009
65
Name: Gene Robert Revilles Sales
Age: 23
Address: 84 B. Lopezjaena St. Cebu City
Hometown: Cebu City, Cebu
Mobile No.: 0917 327 9747
E-mail address: generobert45@yahoo.com
PERSONAL INFORMATION
Place of birth: Cebu City
Date of birth: July 17, 1996
Citizenship: Filipino
Civil status: Single
Gender: Male
EDUCATIONAL BACKGROUND:
Tertiary:
2013 -2017
City
Velez College
F. Ramos Street Cebu
Course: Bachelor of Science in Medical
Technology
Secondary:
Incorporated
2009 - 2013
Cebu City
Childlink Learning Center Highschool
Primary:
Incorporated 2003-2009
Rama Cebu
City
Childlink Learning Center Highschool
530 Zodiacville, V.
530 Zodiacville, V. Rama
66
NAME: Pauline Julia Corcuera Talili
AGE: 22
ADDRESS: 27 Tambuli St., Villa del Rio-Mactan, Babag II, LapuLapu City
CELLPHONE NUMBER: +639173025271
EMAIL ADDRESS: ptalili16@gmail.com
PERSONAL INFORMATION
DATE OF BIRTH: April 16, 1997
PLACE OF BIRTH: Cebu City, Cebu
CITIZENSHIP: Filipino
CIVIL STATUS: Single
SEX: Female
EDUCATIONAL BACKGROUND
TERTIARY: Velez College – College of Medical Technology
F. Ramos St., Cebu City
2013-2017
SECONDARY:
Sacred Heart School – Ateneo de Cebu
H. Abellana St., Canduman, Mandaue City
2009 – 2013
PRIMARY:
Woodridge School - Cebu
Banilad, Cebu City
2003 – 2009
67
Name: Mary Angeli G. Urgel
Age: 23
Address: 888 Mt. Mayon St., Singson Village, Subangdaku,
Mandaue City
Hometown: Cebu City, Cebu
Mobile No.: 09432047787
E-mail address: maryangeli.urgel@yahoo.com
PERSONAL INFORMATION
Place of birth: Cebu City
Date of birth: December 2, 1995
Citizenship: Filipino
Civil status: Single
Gender: Female
EDUCATIONAL BACKGROUND:
Tertiary ( 2013 -2017) : Velez College
Bachelor of Science in Medical Technology
F. Ramos Street Cebu City
Secondary (2008- 2012): Cebu City National Science High School
Labangon, Cebu City
Primary ( 2002 - 2008): St. Theresa’s College
Cebu City
68
Name: Tiaramaria Rosary Q. Valmoria
Age: 25
Address: Forest Hills, Banawa, Cebu City
Hometown: Cebu City, Cebu
Mobile No.: 09568476758
E-mail address: tiara_valmoria@yahoo.com
PERSONAL INFORMATION
Place of birth: Cebu City
Date of birth: December 3, 1994
Citizenship: Filipino
Civil status: Single
Gender: Female
EDUCATIONAL BACKGROUND:
Tertiary ( 2011-2015) : Velez College
Bachelor of Science in Medical Technology
F. Ramos Street Cebu City
Secondary (2007- 2011): Saint Theresa’s Cebu City
Primary ( 2001 - 2007): St. Theresa’s College
Cebu City
69
NAME: Au Bain Marie M. Ymbong
AGE: 24
ADDRESS: Ceres Street, Gun-ob, Lapu-Lapu City
CELLPHONE NUMBER: +9154801986
EMAIL ADDRESS: aubainymbong@gmail.com
PERSONAL INFORMATION
DATE OF BIRTH: May 9, 1995
PLACE OF BIRTH: Cebu City, Cebu
CITIZENSHIP: Filipino
CIVIL STATUS: Single
SEX: Female
EDUCATIONAL BACKGROUND
TERTIARY: Velez College – College of Occupational Therapy
F. Ramos St., Cebu City
2012-2016
SECONDARY:
Saint Theresa’s College
Cebu City
2007 – 2012
PRIMARY:
Saint Theresa’s College
Cebu City
2003 – 2004
70