The following rules and regulations are hereby promulgated to implement Republic Act (R.A.) No. 9709, otherwise known as the Universal Newborn Hearing Screening and Intervention Act of 2009, an act establishing a Universal Newborn Hearing Screening (UNHSP) Program for the prevention, early diagnosis, and intervention of hearing loss.

RULE 1
  POLICY AND APPLICATIONS

SECTION 1. Purpose - These Implementing Rules and Regulations shall provide the concerned national government agencies, local government units, non-governmental organizations, people ™s organizations, other public and private institutions with guidelines for the implementation of a UNHSP to institutionalize measures for the prevention and early diagnosis of congenital hearing loss among newborns, the provision of referral, follow--up, recall, and early intervention services to infants with hearing loss, and counseling and other support services for families of newborns with hearing loss, to afford them all the opportunities to be productive members of the community.

SECTION 2. Declaration of Policy - It is the policy of the State to protect and promote the right to health of the people, including the rights of children to survival, full and healthy development as individuals, and a better quality of life. Recognizing the fact that newborns and children who are deaf or hard of hearing have unique language, learning and communication needs, the State shall formulate a comprehensive program for the prevention, early detection, and diagnosis of congenital hearing loss among newborns and infants based on applied research and consultations with the sectors concerned.

SECTION 3. Universal Newborn Hearing Screening Program - There is hereby established a Universal Newborn Hearing Screening Program (UNHSP) to institutionalize measures for the prevention and early diagnosis of congenital hearing loss among newborns, the provision of referral, follow up, recall and early intervention services to infants with hearing loss and counseling and other support services for families of newborns with hearing loss, to afford them all the opportunities to be productive members of the community.

The UNHSP shall refer to a program that includes but is not limited to the following:

a. Educating relevant stakeholders about the significance of Newborn Hearing Screening (NHS);
b. Conducting hearing loss screening on infants born in the country;
c. Tracking patients with congenital hearing loss for further evaluation;
d. Providing medical intervention to patients before the age of seven years, and
e. Monitoring and evaluating the UNHSP.

SECTION 4. The objectives of the UNHSP are:

a. To ensure that newborns have access to hearing loss screening and diagnostic services such as clinical, audiologic, radiologic, or other methods which have been shown effective through scientific studies;

b. To promote and establish a UNHSP in the country through a nationwide network of government and non-government agencies and other stakeholders who shall commit to the effective and efficient implementation of the program through appropriate policies, cost--effective procedures, regular monitoring and evaluation;

c. To provide continuing capacity building which includes training for healthcare practitioners, conducting applied research and other related activities to aid in the effective implementation of a universal newborn hearing screening program;

Specifically the following shall be done to attain this objective:

c. 1. To provide teaching, training, educational, and capacity building activities to healthcare practitioners to increase awareness and enhance their capabilities in diagnosing and screening and providing counseling, and the necessary interventions for the hearing impaired newborn, and

c.2. To initiate, implement, monitor, and evaluate research activities related to the diagnosis and management of newborn hearing impairment and to disseminate the results of research activities that will aid in the effective implementation of the program.

d. To promote, integrate, and coordinate research activities related to newborn hearing screening and intervention;

e. To establish and maintain a newborn hearing screening database which can serve as the foundation for decision-making and regulatory policies of health institutions and other national health policy-making bodies;

f. To develop public policy in early hearing detection diagnosis and intervention that is based on research and recognition that infants, toddlers and children who are deaf or hard-of--hearing have unique language, learning and communication needs. Consultation with pertinent public and private sector is encouraged;

g. To establish linkages and referral systems with a nationwide network of Newborn Hearing Screening Centers (NHSC) which are committed to providing appropriate screening to newborns, delivering appropriate and early intervention and counseling, implementing recall and follow--up programs for infants with hearing loss, giving other support services to infants with hearing loss, and contributing to the Newborn Hearing Screening database at the NHSRCs at the National Institutes of Health;

h. To formulate and implement quality standards to ensure effective and efficient implementation of the UNHSP, and

i. To promote, discover, develop, and recommend alternative methods, procedures or instruments for newborn hearing screening and intervention that may be used in areas where technologically-dependent instruments and procedures are not available or accessible. lt shall provide a system to validate the results of the alternative hearing screening procedures and initiate early intervention measures.

SECTION 5. Definition of terms - Under this Act, following terms shall mean the following:

a. Alternative methods, instruments, and procedures - shall refer to non-traditional, indigenous substitutes recommended technology-based and or evidence-based methods, instruments or procedures;

b. Audiologic diagnostic evaluation - shall refer to a service related to diagnosis of hearing loss administered by professionals or by NHSCs;

c. Certification - shall refer to a formal certification/accreditation issued by the Department of Health to newborn hearing screening centers;

d. Congenital hearing loss - shall refer to hearing impairment already present at birth;

e. DOH - refers to the Department of Health;

f. Follow--up - shall refer to the monitoring of an infant with possible hearing loss for the purpose of ensuring that the infant receives necessary diagnostic services and intervention or treatment;

g. Healthcare practitioner - shall refer to physicians, audiologists, nurses, midwives, nursing aides, traditional birth attendants, occupational therapists, speech therapists, and rehabilitation personnel;

h. Health institutions - shall refer to hospitals and other health facilities such as but not limited to, health centers, lying--in centers or puericulture centers with obstetrical and pediatric services, whether public or private;

i. Infant - refers to babies less than 12 months old;

j. Intervention - shall refer to any service rendered to an infant diagnosed with hearing loss ranging from counseling, diagnosis, and providing hearing aids as well as medical procedures for the correction of hearing loss;

k. IRR - refers to Implementing Rules and Regulation of R.A. 9709;

l. Newborn hearing screening database - shall refer to an organized body of information related to newborn hearing screening;

m. Newborn - shall refer to a baby from the time of complete delivery to twenty--eight days (28) old;

n. Newborn hearing screening (NHS) - shall refer to an objective, screening procedure performed on a newborn for the purpose of determining if the newborn has hearing impairment;

o. Newborn Hearing Screening Reference Center (NHSRC) - shall refer to the central facility at the National Institutes of Health that defines testing and follow--up protocols, maintains an external laboratory proficiency testing program, oversees the national testing database and case registries, assists in training activities in all aspects of the program, and oversees content of educational materials;

p. Newborn Hearing Screening Center (NHSC) - shall refer to a facility equipped with newborn hearing screening equipment that complies with the standards established by the NHSRC as recognized by the DOH. These centers also implement recall and follow--up programs for newborns that fail the initial screening;

q. NIH - shall refer to the National Institutes of Health;

r. Recall - shall refer to a procedure of locating an infant with a possible hearing loss for purposes of diagnosis, intervention, and/or treatment;

s. Refer - shall indicate a newborn hearing screening result that the ear being tested did not pass the newborn hearing screening;

t. Referral - shall refer to an act of sending a patient to another service provider within the network for continuation of care;

u. Universal Newborn Hearing Screening Program (UNHSP) - shall refer to the program developed to carry out hearing screening for all newborns in the Philippines and to provide adequate interventions for infants with congenital hearing loss;

RULE II
IMPLEMENTING MECHANISMS

SECTION 6. Obligation to inform - Any health practitioner who delivers or assists in the delivery of a newborn in the Philippines shall inform the parents or legal guardian of the newborn of the availability, nature, and benefits of newborn hearing screening among infants three months old and below which should be done during the prenatal period or prior to delivery.

The parent or guardian of newborns who, after undergoing newborn hearing screening, are suspected to have hearing loss or with œrefer  results shall be informed of the availability, nature, and benefits of further evaluation, intervention, treatment, and counseling.

The DOH shall, in coordination with the NHSRC and other stakeholders, undertake the preparation, production and dissemination of informational educational and communication materials on the nature, benefits and available medical interventions for hearing loss.

SECTION 7. Performance of NHS

a. All infants born in hospitals in the Philippines shall be made to undergo NHS before discharge, unless the parents or legal guardians of the newborn object to the procedure subject to Section 11 of this Implementing Rules and Regulations.

b. Infants not screened prior to discharge because of unavailability of instruments may seek hearing screening within the first three months after birth in the nearest facility doing hearing screening. In cases where the newborn is born at home, or outside birthing facilities, the healthcare practitioner attending the birth of the newborn or the health worker assigned in the community where the newborn is residing shall refer the newborn to the nearest hearing screening center.

c. In areas where these facilities are not accessible, the healthcare practitioner shall perform an alternative hearing screening procedure and thereafter encourage parents to seek validation of the test results within three months after birth in NHSCs whenever the results indicate a possible hearing loss.

d. NHS shall be performed by duly trained healthcare providers

e. Validation or confirmation of the NHS test shall only be performed by DOH certified NHSCs.

SECTION 8. Obligation to Perform NHS and Audiologic Evaluation

a. Compliance to NHS shall be the joint responsibility of the parent(s)/legal guardian, health practitioner, or any other individual attending to the newborn.

b. An appropriate informational brochure, prepared by the DOH and NHSRC shall be made available and distributed to all healthcare facilities.

SECTION 9. Recall - Any infant who has a œrefer  result in the screening shall be recalled immediately for further evaluation to confirm hearing loss and, as appropriate, to provide intervention. Parents of the affected child shall be informed of the availability, nature, and benefits of evaluation and treatment.

The local government units through their provincial/municipal/city health offices, district health offices and barangay health centers shall be actively involved in the recall process.

a. The NHSC shall immediately notify the participating health institutions about the results of the patient.

b. Participating health institutions shall locate and recall patients for immediate referral and management. To ensure that all newborns who fail screening are recalled, the institution should designate a person, section, or department in the health facility responsible for the recall.

c. The attending health practitioner shall also actively participate in locating and recalling the newborns with a œrefer  result. Prompt management should be initiated within three months after birth.

d. Once located, newborns with œrefer  results should be referred to the appropriate health care provider for further evaluation, management, and follow--up.

e. Parents with the assistance of the local government unit, shall have the responsibility to ensure that the newborns who had a œrefer  result shall receive the appropriate intervention needed.

SECTION 10. Referral and Management of newborns who had œrefer  results

a. A network of hospitals and health facilities shall be established for the referral and management of all patients who fail initial screening.

b. All referral hospitals shall follow a standard clinical protocol in the management of patients who fail initial screening. The protocol shall be developed by the DOH in consultation with the NHSRC.

SECTION 11. Refusal to be Tested - A parent or legal guardian may refuse hearing screening on the grounds of religious and/or cultural beliefs but shall acknowledge in writing that they have been informed of the availability of said screening, and of the implications of not having the NHS done on the newborn.

A copy of this waiver shall be made part of the newborn ™s medical record and shall be entered into the national newborn hearing screening database.

SECTION 12. Continuing Education, Re--education and Training of Health Personnel

a. Continuing education, re--education, and training programs shall be conducted for health care practitioners on the rationale, benefits and procedures involved in NHS

b. Informational materials on NHS shall be prepared, produced, and disseminated annually to all healthcare providers in the field of maternal and pediatric care.

c. Information about NHS shall be integrated in existing educational programs of the medical and paramedical professionals.

RULE III
IMPLEMENTING ARRANGEMENTS

SECTION 13. Lead Agency - the DOH shall be the lead agency in implementing the provisions of this Act. For this purpose, the DOH shall perform the following functions:

a. Develop a comprehensive program for prevention and management of hearing loss of children;

b. Appropriate, leverage, and mobilize resources of various offices within the DOH, NIH, PHIC, and other health related facilities, other external resources to fully implement the Law;

c. Enjoin local government, stakeholders, concerned health personnel and workers at all levels to fully implement the UNHS;

d. Coordinate with other national government agencies, Local government units, health professional organizations and societies, funding agencies, development partners, socio-civic organizations private sectors and others in the implementation of the UNHS;

e. Coordinate with the NIH and NHSRC for the following:

e.1 Certification of NHSCs;
e.2 Preparation of defined testing protocols and quality assurance programs;
e.3 Maintenance and improvement of the NHS registry;
e.4 Development of alternative hearing screening methods, instruments, and procedures, and
e.5 Definition of candidacy and the promulgation of selection criteria regarding appropriate treatment and/or rehabilitative interventions for the deaf or hearing-impaired child;

f. Preparation of advocacy campaign activities and dissemination of public information materials;

g. Formulate policies for the institutionalization of the program at all levels of implementation. Integrate the NHSP into the current health care delivery system. It should become part and parcel of a routine procedure for newborn in hospitals, public and private health institutions;

h. Ensure that a network for prompt recall of those with œrefer  results is established in collaboration with the LGUs, government agencies, and other non-government organizations;

i. Establish a network of hospitals, health facilities and diagnostic hearing centers for the referral and management of those newborns who had œrefer  result and for confirmatory test;

j. Coordinate with the following groups for their roles in the implementation of the =UNHSP:

j.1 Patients ™ support groups and service provider delivery groups involved in attending to the needs and concern of individuals who are deaf and hard-of-hearing and their families;
j.2 Qualified professional personnel who are proficient in deaf or hard-of-hearing children ™s language and who possess the specialized knowledge, skills and attributes needed to serve deaf and hard-of-hearing infants, toddlers, children and their families
j.3 Other health and education professionals and organizations

k. To monitor the extent to which hearing screening and evaluation are conducted in health institutions, and assist in the development of UNHSPs for hospitals, health institutions and diagnostic hearing centers. The DOH shall require these healthcare institutions to periodically submit data on newborns screened in their facility and include compliance to this function as a criterion for renewal of certification.

SECTION 14. Major Stakeholders -- To ensure the implementation of the UNHSP, the following organizations/agencies identified below shall have the following responsibilities:

a. Healthcare institutions (hospitals, birthing facilities, rural health units and health centers) shall:

1. Integrate newborn hearing screening in the delivery of health services in the respective healthcare institutions;

2. Institutionalize NHS services in healthcare facilities by ensuring that information, education, communication, screening, recall, referral, and management of newborns who had a œrefer  result are being provided in the healthcare facilities;

3. Ensure that all staff in the healthcare institutions is oriented about the benefits of NHS, the integration of the services in their current health services provided in the health facility and the roles and responsibilities of the staff in the institutionalization of the services;

4. Designate people who will be responsible for the following:

4.1 Educating expectant parents about the significance of NHS;
4.2 Conducting hearing screening;
4.3 Recalling high risk patients in need of further management, and
4.4 Referring newborns for further audiologic examination and management;

5. Establish a financial system that will ensure the effective and efficient collection of fees and services for the duly-certified Newborn Hearing Screening Center;

6. Monitor and evaluate the operations of Newborn Hearing Screening in the health facility, and

7. Define creative health financing packages to make NHS accessible, particularly to the economically deprived.

b. The Department of Interior Local Government (DILG) shall advocate and encourage the cooperation of LGUs to take active role in the implementation of RA 9709. Assist the DOH in the monitoring and evaluation of the program.

c. Local Government Units (LGUs) shall:

1. Develop the capabilities of health workers in the implementation of RA 9709. Public health physicians and other designated health workers should be trained to conduct hearing screening tests on all newborns in their locality;

2. Appropriate budget for the training of their public health workers on how to do newborn hearing screening;

3. Issue local ordinances and resolutions that integrate Newborn Hearing Screening in the local health delivery system and the appropriation of budget such as, but not limited to, the following:

3.1 Operation of R.A. 9709;
3.2 Training of personnel on how to conduct hearing screening;
3.3 Establishment of a hearing screening center in the locality;
3.4 Purchase of the hearing screening equipment, and
3.5 Referral of a newborn detected with hearing loss to a referral center for further evaluation and treatment;

4. Ensure that adequate and sustained newborn hearing screening services such as information, education, communication, screening, recall, and follow--up are being provided in all LGU Health facilities (Rural Health Unit/ City Health Unit, Lying-in clinics, City/Municipal/District/Provincial Hospitals);

5. Establish a functional case management for the recall and referral system with a strategically accessible NHS health facility referral center;

6. Establish coordination and networking among concerned agencies in the implementation of the law;

7. Monitor and evaluate the implementation of the law in their localities;

8. Explore/encourage creative health financing packages to make newborn hearing screening accessible particularly among the economically deprived populace, and

9. Perform other roles and responsibilities as deemed necessary for the implementation of this Act.

d. Academe, Health Professional Societies, National Organizations of Health Professionals shall:

1. Ensure that all its members are aware of the significance of newborn hearing screening to their clients, their families and the society at large;

2. Define mechanisms that will ensure and monitor that its members are doing their moral and social obligations to inform parents about the significance of Newborn Hearing Screening

3. Recommend the inclusion of NHS as part of the curricula of all allied health professions

e. Council for the Welfare of Children (CWC) shall:

1. Ensure NHS in the establishment of the system for early detection, prevention, referral and intervention of congenital hearing loss and disabilities in early childhood;

2. Promote NHS as an integral part of the Early Childhood and Care Development (ECCD) programs implemented at the national, regional and local levels;

3. Provide avenues in developing innovative advocacy and communication approaches and social mobilization in partnership with civil societies, non-government organizations and other groups;

4. Include NHS-related indicators in the monitoring and evaluation system of child advocacy programs.

RULE IV
  ADVISORY COMMITTEE ON NEWBORN HEARING SCREENING

SECTION 15. Advisory Committee on NHS - To ensure sustainable inter-agency collaboration, the Advisory Committee on NHS shall be created and made an integral part of the Office of the Secretary.

SECTION 16. Composition of the Advisory Committee - The composition of the Advisory Committee on NHS created under Section 11 of Republic Act No, 9288, œNewborn Screening Act of 2004  shall be expanded to include the representatives from the Philippine Society Otorhinolaryngology--Head and Neck Surgery (PSO--HNS) and the Philippine Society of Audiology (PSA). The committee shall be composed of:

1. Secretary of Health, who shall act as Chairperson;
2. Executive Director of the National Institutes of Health Philippines, who shall act as Vice Chairperson;
3. Undersecretary of the DILG;
4. Executive Director of the Council for the Welfare of Children;
5. Director of the NSRC;
6. Executive Director of the NHSRC
7. Representative of the Philippine Society of Otolaryngology-Head and Neck Surgery
8. Representative of the Philippine Society of Audiology
9. Three (3) representatives appointed by the Secretary of Health who shall either be a pediatrician, obstetrician-gynecologist, endocrinologist, family physician, nurse or midwife, from either the public or private sector. The three (3) representatives shall be appointed for a term of three (3) years, subject to their being reappointed for additional three (3) year periods for each extension.

SECTION 17. Functions of the Advisory Committee on Newborn Hearing Screening

a. Review and recommend risk factors to be included in the NHS;
b. Review and recommend the standard NHS hearing screening fees to be charged by NHSC for each newborn, and
c. Recommend corrective measures and strategic directions as deemed necessary.

SECTION 18. Meetings - The ACNBS shall meet at least twice a year. The National Institutes of Health shall serve as the Secretariat of the Committee.

RULE IV
  THE NEWBORN HEARING SCREENING REFERENCE CENTER

SECTION 19. Establishment of a NHSRC

The NHSRC shall be established at the NIH Philippines. NIH shall be responsible for establishing the NHSRC. The NHSRC shall have the following functions:

a. Establish standards for certification for newborn hearing screening centers;
b. Define the testing and follow--up protocols on hearing screening;
c. Maintain an external laboratory proficiency testing program;
d. Oversee the national testing database and case registries;
e. Assist in the training activities in all aspects of the program;
f. Oversee the content of all promotional and educational materials on newborn hearing screening program, and
g. Report to DOH any non-compliance committed by any NHSC or health facility in the implementation of this Act.

SECTION 20. Data Management

a. NHSRC shall coordinate with NHSC for the consolidation of all patients database. NHSRC together with DOH shall ensure that all NHSC and health facilities shall submit periodically copies of the results of the hearing screening test including a summarized tabulation of result to NHSRC. Compliance to these provisions shall be used as a criterion for renewal of certification of the involved institutions.
b. The NHSRC shall submit reports annually to DOH on the status of and relevant health information derived from the database.
c. NHSRC shall maintain a national database of all children tested and a registry of all children diagnosed to have hearing loss

A plan for long--term outcome evaluation of hearing screening utilizing the case registries shall be developed within one (1) year from the effectiveness of this Act by the NIH in consultation with various stakeholders. This plan may be amended as the need arises.

RULE V
  NEWBORN HEARING SCREENING CENTERS

SECTION 21. Establishment of Newborn Hearing Screening Center - Newborn Screening Hearing Centers shall be established nationwide.

Established Newborn Screening Centers pursuant to Section 12 of Republic Act No. 9288 shall adopt and implement a program to develop its capacity to become a Newborn Hearing Screening Center in accordance with the standards formulated by DOH through collaboration with health institutions capable of setting up a newborn hearing screening center.

Newborn Hearing Screening Centers duly certified by the DOH after having complied with the standards formulated in collaboration with the NHSRC shall be established in strategic areas.

The DOH shall provide technical support to the establishment of Newborn Hearing Screening Centers other than those under the Newborn Screening Centers.

1. No NHSC shall be allowed to operate unless it shall be duly-certified by DOH based on the standards and procedural guidelines approved by DOH.

2. All NHSC shall be subjected to a periodic announced and unannounced monitoring by DOH and shall make available their records to a monitoring team, including their financial books to determine compliance with fee structures and other certification rules and regulations.

SECTION 22. Functions of NHSC

All NHSC shall undertake the following functions:

a. Newborn hearing loss screening;
b. Initial evaluation of newborns at risk of congenital hearing loss;
c. Recall of babies with high risk of congenital hearing loss;
d. Follow up and referral programs, and
e. Maintain and submit database of all newborn screened in their center.

SECTION 23. Certification

The DOH has the sole responsibility of approving or disapproving the certification of NHS facilities. The NIH-NHSRC will assist the DOH in formulating guidelines including good laboratory practices. Renewal of certification shall be every three years.

SECTION 24. Applied Research on Newborn Hearing Screening

a. The Secretary of Health in collaboration with the NIH shall make awards of grants or cooperative agreements to provide technical assistance to agencies to complement an intramural program and to conduct applied research related to infant hearing detection, diagnosis and treatment/intervention.
b. Qualification requirements for this award will depend on the track record of the concerned agencies and evaluation of the proposal or plan of activities. The NIH will evaluate the proposal and will submit its recommendation to the DOH for final action.
c. Renewal for granting the award will depend on compliance to the terms of the award and outcome evaluation of previous activities.

The following activities shall be carried out;

a. Provide technical assistance on data collection and management;

b. Develop standardized procedures for data management to ensure quality monitoring of infant hearing loss detection, diagnosis and intervention program;

c. Study the cost and effectiveness of hearing detection conducted by programs in order to answer issues of importance to policymakers;

d. Identify the causes and risk factors for congenital hearing loss that might lead to the development of preventive interventions;

e. Study the effectiveness of early hearing detection, diagnosis and treatment/ intervention programs by assessing the health, developmental, cognitive, and language status of these children at school age;

f. Promote the sharing of data regarding early hearing loss with birth defects and developmental disabilities monitoring program for the purpose of identifying previously unknown causes of hearing loss; and

g. Other areas of research or programs that may enhance the implementation and outcome of the Universal Newborn Hearing Screening Program.

SECTION 25. Government Intervention on Newborn Hearing Loss

In the event that a newborn fails the initial screening, the following government interventions at the various levels should be done:

At the Local Government Unit:

a. The barangay health worker (BHW) with the assistance of the public health midwives (PHMs) shall accompany and refer the newborn detected with hearing loss to the nearest health facility offering Newborn Hearing Screening Services

b. The municipal or city health officers or their designated officers shall provide referral for validation of the hearing screening results and possible appropriate intervention to the identified UNHS referral centers. For indigent patients, the local government unit should provide appropriate assistance for the referral.

c. If the validation of the hearing screening tests and/or the treatment/ intervention of congenital hearing loss of the newborn are beyond the clinical capability of the provincial hospital, the latter shall provide referral for the treatment of the newborn to a DOH certified referral centers.

d. The local government unit hospitals concerned shall have the funds for the treatment/intervention of newborn hearing loss from the internal revenue allotment of the local government unit concerned

SECTION 26. Newborn Hearing Screening Fees

a. The Philippine Health Insurance Corporation (PHIC or PhilHealth) shall include the cost of hearing loss screening in its benefit package for newborn care. Such screening test may include among others testing costs, registry, follow--up and the reasonable overhead expenses.

b. For this purpose, the PhilHealth shall develop a program for the gradual coverage of hearing screening, audiologic diagnostic evaluation, and intervention services subject to Section 10 of Republic Act No. 7875, as amended by Republic Act No. 9241, otherwise known as the œNational Health Insurance of 1995 .

c. No screening fee shall be charged to a patient who availed of accredited behavioral-reflexive tests, such as the Tuning Fork test, Penlight Visual examination method and other indigenous methods.

d. Only methods approved by the DOH, upon recommendation by the NIH, shall be allowed as newborn hearing screening process.

SECTION 27. Funding - The amount necessary to effectively carry out the purposes of this Act shall be included in the annual General Appropriations Act.

SECTION 28. Separability Clause - If any provision of this Act shall be held unconstitutional or invalid, the other provisions hereof shall remain valid and continue to be in full force and effect.

SECTION 29. Effect vity Clause - This Implementing Rules and Regulation shall take effect immediately after its publication in a newspaper of general circulation.

(SGD.) ESPERANZA I. CABRAL, MD
  Secretary of Health