ANNEX C.

Data Capture Form for use of CHDs (Municipalities and CCs)

Reporting Year 2022

LGU HEALTH SCORECARD

DATA CAPTURE FORM for Municipalities and Component Cities

Date Accomplished: ____________

Region: _________________________________

LGU Name: _________________________________

Instructions:

1. Fill-up the form with the required data (e.g., numerator, denominator). Round-off the final values into two
decimal points (e.g., xx.xx). In case an indicator is not applicable to the LGU, please put N.A and write a
brief explanation in the remarks portion.

2. Countersign any erasures on the DCF

3. For all indicators with accomplishment rate of at least 20% higher than the target, or at least 20%
lower than the baseline values, write a corresponding explanation on the remarks section including the
sources of initiative/efforts, whether from DOH or LGU, or both, as applicable. The information shall be
used to aid data analysis, and as evidence for national and local planning.

4. LGU report will be deemed official ONLY when submitted together with a signed certification page.
This is to establish accountability in the submission and review of LGU data reflected in this DCF.

ENSURE EQUITABLE HEALTH FINANCING

Sustainable investments to improve health, and the efficient and equitable use of resources

Indicator 1. Percentage of LGU budget allocated for health

For data collection but LGUs will not be rated

*refers to the proportion of LGU budget earmarked to health, nutrition & environment, expressed in percentage

A. Total LGU budget allocated for health, No

X 100 = Data
nutrition & environment
B. Total LGU budget

Expense Class LGU Budget for Health Total LGU Budget

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

(in PhP) (in PhP)

Personnel Service (PS)

Maintenance and Other

Operating Expenses (MOOE)

Capital Outlay (CO)

TOTAL:

Notes:

● LGU budget - refers to a financial plan embodying the estimates of income including NTA and other locally-
generated sources (including special funds) spent for Personnel Services, Maintenance & Other Operating
Expense (MOOE), and Capital Outlay for a given fiscal year

● LGU income includes PhilHealth payments

● Include the LGU budget allocated for health, nutrition & environment programs, activities, and projects (PAPs)
(including special funds allocated to health) whose primary purpose is to improve the health status of the
population. You may also refer to the list of PAPs in the Local Health Account (LHA) manual.

Remarks:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Indicator 2. With complete Local Investment Plan for Health (LIPH)

*DM 2021-0434 requires Provinces, Highly Urbanized Cities (HUC), Independent Component Cities (ICC),
Municipalities and Component Cities (CC) to develop their respective Local Investment Plans for Health for 2023-
2025.

With Municipal/CC (Mun/CC) 2023-2025 LIPH and 2023 AOP endorsed by the Mun/CC Health Office and/or
Mayor to the PHO:

YES NO

Criteria YES NO
2023-2025 Mun/CC LIPH endorsed

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

by the Mun/CC Health Office and/or

Mayor to the PHO
2023 AOP endorsed by the Mun/CC
Health Office and/or Mayor to the
PHO

Benchmark: Scoring System (external benchmark):

● 2022 National Target: 100% of
municipalities and component cities have
2023-2025 LIPH and 2023 AOP endorsed
by the Mun/CC Health Office and/or
Mayor to the PHO on or before December
31, 2022
 Green: With Mun/ CC 2023-2025 LIPH and 2023 AOP
endorsed by the Mun/CC Health Office and/or Mayor to
the PHO on or before December 31, 2022
 Red: Absence of Mun/CC 2023-2025 LIPH and/or 2023
AOP or with Mun/CC 2023-2025 LIPH and 2023 AOP
but was not endorsed by the Mun/CC Health Office
and/or Mayor to the PHO on or before December 31,
2022

Remarks (record any implementation issue encountered):

____________________________________________________________________________________________

____________________________________________________________________________________________

___________________________________________________________________________________________

Indicator 3. Provision of FULL hazard pay, subsistence, and laundry allowances to permanent public health
workers (Physician, Public Health Nurse & Midwife) in accordance with RA 7305 (Magna Carta of Public
Health Workers)

*Does the LGU provide full hazard pay, subsistence, and laundry allowances to its health workers (Physician,
Nurse & Midwife) in accordance with RA 7305 (Magna Carta of Public Health Workers)?

YES NO

Magna Carta Benefits Provided to PHWs YES NO

Hazard Pay

Subsistence

Laundry Allowance

Note: An LGU must have provided all the three incentives (hazard pay, subsistence, and laundry allowance)
following the provisions of RA 7305 (Magna Carta of Public Health Workers), computed using the current salary to

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

be able to answer YES. Otherwise, the target is not met

Remarks (any implementation issue encountered):

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

LOCAL HEALTH SYSTEMS INTEGRATED INTO PROVINCE-WIDE

AND CITY-WIDE HEALTH SYSTEMS

Accessible essential health services for all at the right place and time

Indicator 4. Functional Local Health Board (LHB)

* Refers to the extent wherein the LHB is able to meet the minimum required members including civil society
organization (CSO) representative. It is also able to perform its mandated functions.

YES NO

Criteria/ Means of Verification YES NO

1. EO on LHB organization. This shall contain the following among others:
a. Members of the LHB in compliance with RA 7160, RA 11223 and DILG
MC 2022-083
b. Functions and operations (e.g. schedule of meetings)
c. Sources of funds
d. Committees created, as applicable
2. Received copy of LHB resolution to the Sanggunian proposing the annual
health budget with evidence on the prioritization of LGU needs
3. LHB resolution to the Sanggunian recommending ordinance/ resolution on
matters pertaining to health
- At least 4 resolutions received by the SB
- With proof of meetings of committees and consultation with community/
CSO representatives outside the regular members of LHB
Remarks (any implementation issue encountered):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

IMPLEMENT COMPREHENSIVE DEVELOPMENT PLAN FOR SERVICE DELIVERY NETWORK

Accessible essential health services for all at the right place and time

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

Indicator 5. Rural Health Unit (RHU)/ Health Center (HC) to population ratio

* RHU/HC to Population Ratio refers to the number of RHU/HC for every 20,000 population

A. 2022 Projected Population of the LGU 1: No Data

B. Total Number of RHU/HC in the LGU

Notes:

● Municipal Health Center/City Health Center/Rural Health Unit a health facility which provides basic clinical,
preventive, promotive, curative, and rehabilitative services for the municipality/city. Barangay Health Stations
shall not be included in the count.

Benchmark: Scoring System (external benchmark):

National Baseline (2019): 1: 31,385 ● Green: 1 RHU/HC per 20,000 population or below
National Target: 1:20,000 ● Red: 1 RHU/HC per 20,001 population and above

Remarks (include a short explanation for accomplishments 20% or higher than the target, or 20% or lower than
the baseline values, or any implementation issue encountered):

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

LOCALIZE HIGH IMPACT HEALTH POLICY REFORMS

Indicator 6. Percentage of national health policies localized by LGUs

For baseline data collection. LGUs will not be rated

*refers to the number of local policies (i.e. ordinances or executive orders) issued by the LGUs among the total
number of national health policies identified by the DOH through A.O. No. 2021-0063 or “Health Promotion
Framework Strategy 2030” as needing local ordinances adaptation, expressed in percentage.

A. Number of priority health policies adapted as No Data

8 X 100 =
local policies (i.e. ordinances or executive orders)

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

B. Total number of priority health policies (8)

With local policy

List of Priority Health Policies (i.e. ordinances or executive orders)?
YES NO
1. Implementation of RA 11148 (Kalusugan at Nutrisyon ng Mag-
Nanay Act)
2. Implementation of PD No. 1569 (BNS Law; Strengthening the
Barangay Nutrition Program)

3. Tobacco and vape control

4. Restricted access of minors to alcoholic beverages

5. Hygiene and sanitation

6. Localization of the Mental Health Law

7. Gender-based violence, violence against women, and violence

against children

8. Empowering Barangay Health Workers

IMPROVE PERFORMANCE OF THE LGUs

Indicator 7. Percentage of LGU health budget utilized

*Utilization Rate refers to the proportion of budget allocated for health that was actually utilized for health,
expressed in percentage

Indicator 7.1. Obligation Rate

*Obligation Rate refers to the proportion of the budget that was earmarked/committed out of the total budget
allocated for health, expressed in percentage.

X 100 = No
A. Total health budget obligated
Data
B. Total LGU budget allocated for
health

Expense Class Total health budget Total LGU budget allocated for
obligated (in PhP) health (in PhP)

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

Personnel Service (PS)

Maintenance and Other

Operating Expenses (MOOE)

Capital Outlay (CO)

TOTAL

Note:

● Obligations are liabilities legally incurred and committed to be paid for by the government either
immediately or in the future (DBM).

● Budget Allocated to Health used to compute for this indicator includes budget that was apportioned
specifically to health (excludes budget attributions mentioned in Indicator 1)

● Report the obligation rate as of December 31, 2022.

Benchmark: Scoring System (external benchmark):

National Baseline: 83.71% (2019) ● Green: 95% and above
National Target: 95% ● Yellow: 83.71% to <95%
● Red: below 83.71%

Remarks (include a short explanation for accomplishments 20% or higher than the target, or 20% or lower than
the baseline values, or any implementation issue encountered):

____________________________________________________________________________________________

____________________________________________________________________________________________

___________________________________________________________________________________________

Indicator 7.2. Disbursement Rate

*Disbursement Rate refers to the proportion of budget that was spent out of the total budget obligated for health,
expressed in percentage.

A. Total health budget disbursed X 100 = No

B. Total health budget obligated Data

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

Expense Class Total health budget Total health budget

disbursed (in PhP) obligated (in PhP)

Personnel Service (PS)

Maintenance and Other

Operating Expenses (MOOE)

Capital Outlay (CO)

TOTAL:

Note:

● Disbursements refer to the actual withdrawal of cash from the Bureau of the Treasury due to the
encashment of checks issued by agencies and payment of budgetary obligations (DBM).

● Report the disbursement rate as of December 31, 2022.

Benchmark: Scoring System (external benchmark):

National Baseline: 95.11% (2019) ● Green: 100%
National Target: 100% ● Yellow: 95.11% to < 100%
● Red: < 95.11%

Remarks (any implementation issue encountered):

____________________________________________________________________________________________

____________________________________________________________________________________________

___________________________________________________________________________________________

Indicator 8. Health Service Coverage target met

Note: The official data source of the sub-indicators under Indicator 8 is the Field Health Services Information System (FHSIS)
except for Sub-indicator 8.7 which the official data source is National Nutrition Council .

Indicator 9. Percentage of facilities (e.g., RHU, MHC, HC) with no-stock out of the following commodities:

* No Stock-out means that the facility (e.g. RHU, MHC, HC) has at no time reached (0) stock of the tracer
commodities based on their average monthly consumption at any point during the reporting year

Tracer Commodity Number of facilities THAT

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

EXPERIENCED stock-out

a. Family Planning Pill (COC)

b. DPT-HiB-HepB Vaccine

c. Losartan

d. Metformin

e. TB Drugs (category 1)

A. Number of recipient public health facilities

(e.g., RHU, MHC, HC) within the LGU WITH
NO REPORT OF STOCK-OUTS of any of No Data
the specified tracer commodities X 100 =
B. Total number of recipient public health
facilities within the same LGU

Remarks (any implementation issue encountered):

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Indicator 10. With Organized Epidemiology Surveillance Unit (ESU)

* A functional ESU must have the 5/5 components.

YES NO

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

An Epidemiology and Surveillance Unit (ESU) is deemed organized if it meets the following criteria:

Criteria Means of Verification (MOV) Yes No

Policy/Issuance Refers to an ordinance or an executive order creating the Epidemiology

and Surveillance Unit.

Dedicated Staff The Epidemiology and Surveillance Unit shall have at least one (1)
and Training disease surveillance officer duly trained on applied/field epidemiology,
surveillance, and response, and one (1) epidemiology assistant of an allied
health profession.

Distinct To illustrate the reporting relationships and chains of command within the
Organogram Unit for an organized organization.

Dedicated Annual Work and Financial Plan with Allotment from the local budget.
budget/work
and financial
plan

Processes and This includes a Disease and Event Surveillance report submitted in the
generates prescribed timeline and released at least on a monthly basis to the Local
epidemiologic Health Board.
reports

Benchmark: Scoring System (external benchmark):

National Target: All LGUs have 5/5 ESU ● Green: with presence of 5 ESU components
Components ● Red: no ESU component is present or with
presence of less than 5 ESU components

Remarks (any implementation issue encountered):

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Indicator 11. With institutionalized Disaster Risk Reduction and Management in Health (DRRM-H) System

*Institutionalized DRRM-H system means the availability of ALL four criteria.

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

YES NO

Criteria Means of Verification (MOV) Yes No

1. Approved, The plan must be signed, approved and recommended by the

updated, authority of the office/ facility for inclusion in the LGU
integrated, budget.
disseminated and
tested DRRM-H
Plan The plan being up to date with the latest information on
DRRM-H, communicated and circulated within the level of
organization through conduct of meetings/ orientations, and
annually tested through drills, table top, program
implementation reviews, etc.

2. Organized and HERT (Health and Emergency Response Teams)

trained HERT on organized/created through an official issuance to provide
minimum required basic health services in emergency/ disaster. Further, for all
trainings: Basic HERT members to have Basic Life Support and Standard
Life Support and First Aid Training.
Standard First Aid

3. Available and Emergency commodities such as Anti-infectives, Analgesics,

accessible Antipyretics Fluids/Electrolytes, Respiratory Drugs,
essential health Dietary/Nutritional Products are available as evidenced by
emergency logistics inventory or MOA with partners/DRRMC or actual
commodities presence of commodities. Further, commodities must be
accessible within 24 hours post impact of emergency/ disaster

4. Health At a minimum, may present a designated or converted area

Operations (may be shared with DRRM) where a DRRM-H personnel
Center or and equipment are available in performing the functions of
Emergency the system on command and control, coordination and
Operations communication as evidenced by the following:
Center with
functional system
1. A policy establishing an Incident Command System
(ICS)
2. Notices of meetings, actual conduct of meetings,
documentation, or any formal agreement or arrangement
with DRRMC/ partners in incident response management
3. Equipment or tools utilized for communication such as
voice, print and electronic transmittal

Benchmark: Scoring System (external benchmark):

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

National Target: All LGUs have the 4/4 ● Green: with presence of 4 DRMM-H components
DRMM-H Components ● Red: no DRMM-H component is present or with
presence of less than 4 DRMM-H components

Remarks (any implementation issue encountered):

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________.

Certification Page

Part I. On Accomplishing the DCF (for Health Officers & Financial Officers)

LGU Name: _____________________ Date Accomplished: ______________

This is to certify that the data provided in the LGU Health Scorecard Data Capture Form are
final and correct to the best of our knowledge. We understand that the data we provided in the LGU
Health Scorecard Data Capture Form will be the basis in producing the LGU Health Report Card.

SIGNED:

(Note: Affix your signature above printed name. Indicate your office &position opposite your name.)

Name Office & Position

NOTED BY:

___________________________________

Mayor
(Signature over Printed Name)

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ANNEX C. Data Capture Form for use of CHDs (Municipalities and CCs)
Reporting Year 2022

Part II. On Review of DCF (For the DOH Representative)

This is to certify that the undersigned have reviewed the data provided in this LGU Health
Scorecard Data Capture Form.

Remarks: _________________________________________________________

_________________________________________________________

SIGNED:

(Note: Affix your signature above printed name.)

Validated by:

Municipal/Component City DOH

Representative

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