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I.    RATIONALE

Antimicrobial resistance is currently a public health problem in many countries. One major driver in the emergence of drug-resistance is the “selective pressure”
 
brought about by the irrational and irresponsible use of antimicrobials by health care professionals. In an effort to ensure that only reliable quality microbiology laboratory test results are used to guide rational antimicrobial use, PhilHealth partnered with the Antimicrobial Resistance Surveillance Reference Laboratory for antimicrobial resistance (DO 393-E s 2000) for the implementation of a quality assurance scheme that allowed PhilHealth reimbursements for select restricted Philippine National Drug Formulary (PNDF) antibiotics only for hospitals with ARSP accredited laboratories.

To ensure that restricted antimicrobials are used rationally, DOH Administrative Order No. 2016-0034: The New Implementing Guidelines of the Philippine National Formulary System (PNFS) provided guidelines which include new requirements for the use of restricted antimicrobials in the latest PNDF for hospitals.

II.   OBJECTIVES

This circular aims to adopt and implement the DOH AO No. 2016-0034 Item VII.B.6 on the mandatory use of drugs in the Philippine National Formulary, specifically on the provisions on procurement of restricted antimicrobials in health facilities. This aligns PhilHealth claims reimbursement policy with the DOH AO to assure favorable health outcomes to members by preventing the irrational use of the restricted antimicrobials.

III.  SCOPE

All accredited infirmaries/primary care facilities and hospitals that utilize restricted antimicrobials.

IV.  DEFINITION OF TERMS

A.   Antimicrobial Resistance (AMR) - is the ability of organisms that cause disease to withstand attack by antimicrobials.

B.   Antimicrobial Resistance Surveillance Program (ARSP) - is a program of the DOH which aims to provide critical inputs to the DOH’s effort to promote rational drug use by determining the status and trends of antimicrobial resistance of selected bacteria to specific antibiotics.

C. Tertiary clinical laboratory - A clinical laboratory, regardless of its classification by ownership, function, and institutional character which provides minimum service capabilities for the following: routine and special hematology including coagulation procedures, qualitative and quantitative platelet determination, routine urinalysis and fecalysis, routine clinical and special chemistry, cross matching*, KOH*, blood typing*, immunology, and microbiology-culture and sensitivity. (* for hospital based only)

D.   AMS program - Antimicrobial Stewardship program is the program of the DOH tasked with concerted implementation of systematic, multi-disciplinary, multi-pronged interventions in both public and private hospitals in the Philippines to improve appropriate use of antimicrobials, which is essential for preventing the emergence and spread of AMR.

E.   Adverse Monitoring Findings - performance of health care providers that show deviations from PhilHealth policies and treatment protocols which may result  to  abuse  or  compromise  the  National  Health  Insurance  Program (NHIP).  These  are  identified  during  conduct  of  the  monitoring  activities prescribed by the Corporation. (source: PhilHealth Circular No. 2016-0026)

V.   GENERAL GUIDELINES

A.  Restricted antimicrobials shall only be utilized by institutions with tertiary clinical laboratories which have ARSP laboratory accreditation.

B.   The restricted antimicrobials as stated in the Philippine National Formulary 8th edition 2017 are listed in ANNEX A*.

C. All future DOH issuances identifying restricted antimicrobials shall automatically be adopted by PhilHealth. ANNEX A shall be updated accordingly through an Advisory posted in the PhilHealth website.

D. Transition period for hospitals to attain ARSP Laboratory Accreditation as a requirement for utilization of restricted antimicrobials:

1.   Compliance period  until  June  2019  will  be  implemented. The  list  of hospitals with provisional ARSP accreditation shall be provided by RITM- DOH to PhilHealth and shall be regularly updated. Use of restricted antimicrobials by facilities with no ARSP accredited laboratory shall not be an “adverse monitoring finding” during post-audit or monitoring activities if:

a.    They  will  present  either  of  the  following  documents  issued  by Antimicrobial Resistance Surveillance Reference Laboratory (ARSL) of Research Institute for Tropical Medicine: “Acknowledgment letter for Phase 1 ARSP Accreditation” (ANNEX-B*) or the Notification for compliance to Phase 2 ARSP accreditation (ANNEX-C*) containing the list of requirements for compliance identified during inspection; AND

b.    Relevant  cultures  are  taken  from  patients  for  whom  restricted antimicrobials are used with the results attached to medical charts and  should be  readily available during PhilHealth’s validation or post-audit activities.

2.   By July 2019, as imposed by the DOH issued Administrative Order No. 2016-0034 “The New Implementing Guidelines of the Philippine National Formulary System (PNFS)”, aside from the requirement for the microbiology  laboratory  to  be  ARSP  accredited,  all  secondary  and tertiary hospitals should have any of the following:

a.    A DOH AMS trained chairperson of either the hospital’s Infection Control Committee (ICC) or Antimicrobial Stewardship (AMS) Committee. The hospital shall provide a copy of the Certificate of Training on AMS of current personnel to their respective PhilHealth Regional Office (PRO); or

b. A board-certified infectious disease specialist that shall authorize the use of the restricted antimicrobials per patient.
c. For hospitals which will not attain ARSP accreditation after July 2019, may outsource with an ARSP Accredited Laboratory. A copy of a valid Memorandum of Agreement (MOA) shall be provided to the respective PRO
E.   Inappropriate or unauthorized use of restricted antimicrobials shall not result in denial of a claim but shall be considered as an “Adverse Monitoring Findings” during claims post-audit or any monitoring activity wherein cumulated offenses shall have bearing on a provider's accreditation renewal.

F.   For queries and accreditation applications on ARSP, the HCI may refer to the details below:

Antimicrobial Resistance Surveillance Program
Research Institute for Tropical Medicine - Department of Health
9002 Research Drive, Filinvest Corporate City, Alabang, Muntinlupa City 1781
Direct Line: (02) 809-9763 Trunk Line: (02) 807-2631 to 32 loc. 243
Email: secretariat@arsp.com.ph Website: www.arsp.com.ph

VI.  REPEALING CLAUSE

PhilHealth Circular Nos. 15 s.2006, 18 s.2006, 4 s.2007, 16 s.2007 and any other previous issuances, circulars, and directives that are inconsistent with any of the provisions  of   this   Circular,   are   hereby   amended,  modified   or   repealed accordingly.

VII. EFFECTIVITY

This Circular shall take effect after fifteen days following its publication in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.