1 
Republic of the Philippines 
HOUSE OF REPRESENTATIVES 
Batasan Hills, Quezon City 
NINETEENTH CONGRESS 
First Regular Session 
HOUSE BILL No. _____ 
---------------------------------------------------------------------------------------------------- 
Introduced by  
ACT Teachers Party-List Rep. FRANCE L. CASTRO,  
GABRIELA Women’s Party Rep. ARLENE D. BROSAS,  
and KABATAAN Party-List Rep. RAOUL DANNIEL A. MANUEL 
---------------------------------------------------------------------------------------------------- 
AN ACT 
MANDATING THE PROVISION OF COMPREHENSIVE RENAL 
REPLACEMENT THERAPY (RRT) TO PATIENTS WITH END STAGE 
RENAL DISEASE IN NATIONAL, REGIONAL, AND PROVINCIAL 
GOVERNMENT HOSPITALS, INCREASING FOR THE PURPOSE THE 
PHILHEALTH PACKAGE RATE FOR MEMBERS, AND APPROPRIATING 
FUNDS THEREFOR 
EXPLANATORY NOTE 
Renal diseases are the fourth leading cause of death among Filipinos, according 
to the 2019 Global Burden of Disease, Injuries, and Risk Factors Study.1  Meanwhile, 
according to the National Kidney and Transplant Institute, one Filipino develops 
chronic kidney disease (CKD) every 40 minutes, equivalent to 36 Filipinos getting the 
renal disease in a single day.  In 2021, there are more than 7 million Filipinos with 
CKD.2  Moreover, one Filipino dies from kidney failure every hour.3 
The number of patients undergoing dialysis is increasing every year.  From 4,000 
dialysis patients in 2004 recorded by the Department of Health (DOH), the number rose 
1 Institute for Health Metrics and Evaluation: Philippines profile. University of Washington, 2021. 
http://www.healthdata.org/philippines.  
2 De Villa, Kathleen. “Chronic kidney disease: 1 Filipino develops it every 40 minutes,” Inquirer.net, 
25 July 2022, https://newsinfo.inquirer.net/1616181/chronic-kidney-disease-1-filipino-develops-it-
every-40-minutes 
3 “UP webinar takes on the challenges of kidney disease and dialysis in a time of COVID,” University 
of the Philippines, 1 December 2020, https://up.edu.ph/up-webinar-takes-on-the-challenges-of-
kidney-disease-and-dialysis-in-a-time-of-covid/.  
July 28, 2022
10:03 am
2630


2 
 
to 23,000 by 2013.  For two-to-three times dialysis sessions a week, a patient has to 
spend ₱25,000 to ₱46,000 a month or ₱300,000 to ₱552,000 a year.  On top of this, 
maintenance medication also costs about ₱20,000 a month.4  With an average monthly 
income of patients with CKD at only ₱4,838.16, most of them could not afford 
treatment, according to a 2013 research. 
 
In 2015, some 691,489 claims were filed by PhilHealth for hemodialysis, the 
most among procedures covered by the agency.  The total benefits paid were ₱4.67 
billion.  Yet, patients with PhilHealth coverage can only claim half of the cost of their 
treatment.  According to the National Kidney and Transplant Institute (NKTI), only 
15% of the partially-subsidized patients are PhilHealth members.5 
 
Because of the high cost of hemodialysis, poor patients had to beg around for 
funds to pay for their treatment.  Many of them regularly solicit funds at the offices of 
the Members of Congress, Philippine Charity Sweepstakes Office, and offices of 
political parties and charitable organizations.  Poor kidney patients survive, either at the 
cost of being in deep debt or after begging around. 
 
Dialysis services are inadequate especially in regions and far flung areas.  Even 
NKTI, the government’s specialty health facility for kidney transplant and kidney-
related diseases, was only able to serve, out of the total 2,694 outpatients served in 
January 2015, 27% or 723 service patients and 1,971 or 73% were pay patients.  The 
NKTI said that with limited income and resources, it can hardly afford to expand its 
services.  While there are regional or provincial hospitals with dialysis facilities, most 
are presumably just like in NKTI, where there is no free treatment for renal diseases. 
 
In 2015, during the 16th Congress, the House of Representatives approved House 
Bill 5956 mandating the Philippine Health Insurance Corporation to increase the 
coverage for dialysis treatment to ninety (90) sessions per year.  PhilHealth accordingly 
issued Circular 024-2015 (August 27, 2015) that increased the dialysis sessions covered 
by PhilHealth from 45 to 90 sessions per year and pegged hemodialysis cost to ₱2,600 
per session from the previous ₱4,000 per session. The new hemodialysis package 
includes facilities and dialysis machine use, drugs and medicine (0.9 sodium chloride, 
heparin, bicarbonate or acetate hemodialysis solution, e cart drugs), supplies and others 
(fistula kits, blood tubing, dialyzer [low flux], syringe, and gauze), and professional fee.  
However, the new package no longer includes the injection of epoetin alfa or beta 
previously included in the old PhilHealth’s case rate for hemodialysis. 
 
Patients complained of increased out-of-pocket expenses in the form of co-pay 
mechanisms and injections and laboratory procedures which they now have to shoulder.  
According to the Hemodialysis Patient Organization, the co-pay charge per session was 
increased by ₱350-P550 per hemodialysis session.  Injection of epoetin drug costs 
                                                             
4 “The worsening problem of renal diseases,” Council for Health and Development, 16 June 2015, 
https://web.archive.org/web/20190816111852/http://www. chdphilippines.org/2015/06/the-
worsening-problem-of-renal-diseases.  
5 Ibid. 


3 
₱1,200-2,400 per session, bringing the cash-out of patients to ₱1,500 to ₱3,000 per 
hemodialysis session.  In 2016, the monthly cash-out of patients can run as high as P 
13,752-P19,054.  The amount does not even include the laboratory procedure expenses. 
According to NKTI,6 the hospital has to charge co-pay, otherwise, it would incur losses 
as a result of the reduction of PhilHealth benefits. 
In response to the clamor of dialysis patients, Bayan Muna Party-List 
Representatives filed House Resolution 1761 to investigate the plight of peritoneal 
dialysis patients during the 16th Congress, and a similar House Resolution 244 during 
the 17th Congress.  HR 244 became one of the measures consolidated into House Bill 
9156 or the Comprehensive Renal Replacement Therapy Act which was passed on Third 
Reading. 
During the 18th Congress, Bayan Muna Representatives Carlos Isagani T. Zarate, 
Ferdinand R. Gaite and Eufemia C. Cullamat, ACT Teachers Party-List Representative 
France L. Castro, Gabriela Women’s Party Representative Arlene D. Brosas and 
Kabataan Party-List Representative Sarah Jane I. Elago filed HB 251 as one of their 
priority legislations.  This Bill was again passed on Third Reading as HB 6803. 
Accessibility and affordability of dialysis treatment and renal transplantation 
may spell the difference between life and death for many end stage renal disease 
patients, especially the indigents.  This Bill thus provides comprehensive, accessible 
and free dialysis and transplantation, and preventive measures and treatment for chronic 
kidney diseases with the hope of saving as many lives as possible. 
Immediate passage of this Bill, thus, is earnestly sought. 
________________________________ 
Rep. FRANCE L. CASTRO 
ACT Teachers Party-List 
________________________________ 
Rep. ARLENE D. BROSAS 
GABRIELA Women’s Party 
________________________________ 
Rep. RAOUL DANNIEL A. MANUEL 
KABATAAN Party-List 
6 Letter addressed to Bayan Muna Rep. Neri Colmenares signed by NKTI Executive Director Jose 
Dante P. Dator dated January 27, 2016 


4 
Republic of the Philippines 
HOUSE OF REPRESENTATIVES 
Batasan Hills, Quezon City 
NINETEENTH CONGRESS 
First Regular Session 
HOUSE BILL No. _____ 
---------------------------------------------------------------------------------------------------- 
Introduced by  
ACT Teachers Party-List Rep. FRANCE L. CASTRO,  
GABRIELA Women’s Party Rep. ARLENE D. BROSAS,  
and KABATAAN Party-List Rep. RAOUL DANNIEL A. MANUEL 
---------------------------------------------------------------------------------------------------- 
AN ACT 
MANDATING THE PROVISION OF COMPREHENSIVE RENAL 
REPLACEMENT THERAPY (RRT) TO PATIENTS WITH END STAGE 
RENAL DISEASE IN NATIONAL, REGIONAL, AND PROVINCIAL 
GOVERNMENT HOSPITALS, INCREASING FOR THE PURPOSE THE 
PHILHEALTH PACKAGE RATE FOR MEMBERS, AND APPROPRIATING 
FUNDS THEREFOR 
Be it enacted by the Senate and the House of Representatives of the Philippines in 
Congress assembled: 
SECTION 1. Short Title. -  This Act shall be known as the “Comprehensive Renal 
Replacement Therapy Act.”  
SEC. 2. Declaration of Policy. – It is a declared policy of the State to make available 
essential goods, health and other social services to all citizens at affordable cost and to 
deliver medical care to indigents free of charge. Pursuant to this, the State shall 
continually improve the delivery of health services and hospital facilities to make those 
accessible to all. 
In line with this policy, the State shall adopt an integrated and comprehensive 
approach to health service delivery that shall include comprehensive renal replacement 
therapy for patients who are diagnosed with End Stage Renal Disease (ESRD). 
SEC. 3. Definition of Terms. – As used in this Act: 
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5 
 
a. Dialysis facility refers to a health facility that provides treatment for ESRD 
to indigent patients and disseminates information on the various forms of 
renal replacement therapy such as kidney transplantation, peritoneal dialysis 
and hemodialysis;  
 
b. End Stage Renal Disease or ESRD refers to the final stage of chronic kidney 
disease in which the kidneys no longer function well enough to support the 
needs of a patient’s daily life; 
 
c. Hemodialysis or HD refers to a medical procedure to remove fluid and waste 
products from the blood and to correct electrolyte imbalances using a 
synthetic membrane or dialyzer which is also referred to as an “artificial 
kidney”; 
 
d. Indigent refers to a patient who has no source of income or whose income is 
not sufficient for family subsistence as identified and assessed by the social 
worker of the Department of Social Welfare and Development (DSWD) or 
the social worker of the concerned local government unit;  
 
e. Kidney transplant or KT refers to a surgical procedure to place a healthy 
kidney from a living or deceased donor into a person whose kidneys no 
longer function sufficiently to sustain the person’s life; 
 
f. National, regional and provincial hospitals refer to hospitals and stand-
alone dialysis facilities operated and maintained either partially or wholly by 
the national, regional and provincial government or other political 
subdivision, or any department, division, board or agency thereof; 
 
g. No balance billing refers to the government policy of not charging the 
medical expenses incurred over and beyond the PhilHealth package rates to 
a PhilHealth member who has undergone medical treatment; 
 
h. Peritoneal dialysis or PD refers to a treatment for kidney failure and a type 
of dialysis that uses the person’s peritoneum or the lining of abdominal 
cavity, as the membrane through which fluid and toxic substances are 
exchanged with blood;  
 
i. PD First Policy or PD refers to the policy where peritoneal disease dialysis, 
when feasible, is offered as the first dialysis modality to RRT patients; 
 
j. Renal replacement therapy or RRT refers to a therapy that partially replaces 
the functions of the normal kidney. This may be in the form of kidney 
transplantation, peritoneal dialysis and hemodialysis.  
 
SEC. 4. Establishment of Dialysis Services Wards or Units in National, Regional, 
Provincial Government Hospitals. -  Within five (5) years from the effectivity of this 


6 
 
Act, all national, regional, and provincial government hospitals, including all stand-
alone dialysis facilities shall establish, operate and maintain a dialysis service facility 
in their hospitals.  These dialysis facilities shall have all the necessary dialysis 
machines, equipment and supplies.  The same hospitals and dialysis facilities are 
mandated to train nephrologists, dialysis nurses, dialysis technicians, and operating 
room nurses in both peritoneal dialysis and hemodialysis. 
 
All national, regional, and provincial government hospitals, including all stand-
alone dialysis facilities shall have a dialysis service area that is compliant with the 
licensing and accreditation requirements imposed by the Department of Health (DOH) 
and Philippine Health Insurance Corporation (PhilHealth).  The dialysis service area 
shall have the necessary personnel, dialysis equipment and supplies for both 
hemodialysis and peritoneal dialysis, as required by the DOH and the PhilHealth of 
private dialysis clinics.  
 
The dialysis facilities shall further have a non-treatment place, which shall serve 
as a waiting area for chronic kidney disease (CKD) patients and a business area 
dedicated to the provision, display, and dissemination of information on the prevention 
of CKD. 
 
All patients diagnosed with ESRD shall be referred to a DOH-accredited 
transplant facility to receive orientation and counseling on the advantages of undergoing 
transplantation as the best treatment for kidney failure.  They shall likewise undergo 
medical evaluation for suitability for transplantation.  All potential organ donors of the 
patient shall be evaluated to determine compatibility.  If no living donors are available, 
the patient shall be enrolled in the deceased organ donor waiting list to ensure that all 
patients with ESRD have an option to avail of kidney transplantation. 
 
SEC. 5.  Chronic Kidney Disease (CKD) Prevention and Health Promotion. - All 
national, regional, and provincial government hospitals, and stand-alone dialysis 
facilities should establish CKD prevention strategies and health promotion activities 
which include advocacy activities targeting relatives of dialysis patients who are at high 
risk in developing CKD themselves, the provision of instructional materials on the 
common symptoms of kidney disease and regular educational activities such as healthy 
diet and lifestyle, availment of regular tests to diagnose kidney disease, information on 
the most common causes of kidney failure, and advisories on the appropriate protocols 
for the diagnostic evaluation of possible kidney disease. 
 
Patients and their relatives shall be informed on the availability of the proper 
medicines from government health centers such as those for diabetes and hypertension, 
and the importance of the regular intake of medicines and monitoring of kidney function 
through regular laboratory testing and check-up by a qualified physician.  All activities 
pertaining to the aforementioned programs shall be documented accordingly. 
 
SEC. 6. Quality Standards of Dialysis Services and Transplant Facilities. - Hospitals 
and dialysis centers for both hemodialysis and peritoneal dialysis, and transplant 


7 
 
facilities shall comply with the safety and quality standards of dialysis or transplant 
services, which shall be strictly monitored by the PhilHealth and the Health Facilities 
and Services Regulatory Bureau of the DOH. 
 
SEC. 7. Philippine Renal Disease Registry. - Private and public hospitals, dialysis 
centers for both hemodialysis and peritoneal dialysis, and transplant facilities shall be 
mandated to report to the Philippine Renal Disease Registry of the DOH the incidence 
and prevalence of patients receiving peritoneal dialysis or hemodialysis treatment, and 
who have received a kidney transplant as a requirement for the renewal of their 
respective DOH licenses to operate a dialysis center or transplant facility.  Registration 
of all dialysis patients in the PhilHealth dialysis database shall be required prior to the 
availment of both peritoneal dialysis and hemodialysis. 
 
SEC. 8. PhilHealth Benefit for Kidney Transplantation. - The PhilHealth Z-benefit 
for a kidney transplantation from living donors shall be expanded accordingly. This 
shall include the cost of laboratory work-up for both recipient and donor candidate, 
hospitalization for the transplant operation, including induction immunosuppression 
and maintenance oral immunosuppression, machine perfusion of procured organs, the 
cost for organ retrieval, all medications required during the hospitalization, and post 
discharge laboratory examinations up to one (1) month for the recipient, and up to one 
(1) year for the donor. 
 
The cost for organ retrieval and machine perfusion shall be established by the 
DOH-Philippine Organ Donation and Transplantation Program to be observed by all 
organ procurement organizations or organ and tissue retrieval units. 
 
The PhilHealth benefit package for kidney transplantation shall cover the 
evaluation and screening of the kidney donor and recipient up to the transplant and post-
transplantation procedures and remedies. This is inclusive of both pre- and post-kidney 
transplantation procedures and remedies and shall include cases involving ESRD 
patients. 
 
In order to support kidney transplantation as the best treatment option that 
provides the highest quality of life for ESRD patients and ensures the return of the 
patient to full rehabilitation, the PhilHealth shall provide life-time support for all 
maintenance immunosuppression of the transplant patient, as long as the transplanted 
organ is functioning and the patient remains dialysis-independent. 
 
All renal replacement therapy facilities shall be required to engage in regular 
organ donation advocacy activities. All donor-Filipinos citizens shall carry the organ 
donor card to be prescribed by the DOH. Health RRT facilities will likewise establish 
an organ and tissue donor referral system that will identify all potential organ and tissue 
donors to the Philippine Network for Organ Sharing (PhilNOS). 
 
SEC. 9. PhilHealth Benefit for Dialysis Treatment. - The PhilHealth shall increase the 
Z-benefit package rate for the principal member and the members’ qualified dependents 


8 
 
for maintenance peritoneal dialysis covering three (3) peritoneal dialysis exchanges per 
day for three hundred sixty five (365) days, while the package rate for hemodialysis 
treatment shall be increased annually to cover a minimum of three (3) hemodialysis 
sessions frequency a week, four (4) hours per session, or as may be necessary.  The 
professional fee of the attending physician and hospital charges shall be incorporated in 
the PhilHealth benefit package for dialysis treatment. 
 
For purposes of providing optimal financial risk protection to the most 
vulnerable groups including the poorest of the poor, the “no balance billing policy” of 
the government shall be strictly observed in the case of indigents patients. 
 
The breakdown of the PHIC hemodialysis benefit package shall include standard 
HD treatment, dialyzer and epoetin injection, and all other supplies needed as well as 
the minimum basic laboratory tests consisting of complete blood count, creatinine, 
calcium, phosphorus, potassium, albumin, hepatitis B surface antigen (HBsAg) and 
anti-hepatitis C Virus (Anti-HCV).  The laboratory tests shall be done at a frequency of 
at least four (4) tests per year for the first six (6) tests, and twice a year for the last two 
(2) tests. The schedule of these tests shall be determined by the attending physician 
during the course of the annual dialysis treatment sessions. 
 
SEC. 10. Periodic Assessment and Benefit Package Adjustments for End Stage Renal 
Disease Patients. - A periodic assessment and reasonable adjustments of the benefit 
package for dialysis and transplant patients shall be made by the PhilHealth after taking 
into consideration its financial sustainability and changes in the socio-economic 
conditions of the country. 
 
SEC. 11. Free Dialysis Treatment to Indigent Patients. - Dialysis treatment in all 
national, regional, and provincial government hospitals shall be provided free of charge 
to indigent patients.  A PD First Policy shall be observed for all indigent patients, unless 
there is a contraindication to its use in a particular patient. 
 
SEC. 12. Treatment Options. - The PhilHealth shall develop a care rate package that 
shall provide the highest benefit for kidney transplant procedure, peritoneal dialysis, 
and hemodialysis procedures. 
 
The benefit package shall include a screening test for both the kidney 
transplantation donor and recipient. The screening test for possible kidney 
transplantation of both the donor and recipient shall include: 
 
1) For the donor, the screening testing shall include blood typing, complete 
blood count, fasting blood sugar, creatinine, hepatitis B surface antigen, 
anti-hepatitis C antibody, urinalysis, chest x-ray and ultrasound of the 
kidneys, ureter, and urinary bladder 
  
2) For the recipient, cardiac evaluation and other tests as may be needed. 
  


9 
 
During the availment of the full benefits of dialysis within the first two (2) years 
of dialysis initiation, the cost of dialysis treatment shall be paid for by the PhilHealth as 
described in Section 8.  These options are provided to encourage more patients to 
undergo kidney transplantation and attain full rehabilitation. 
 
If the patient passes the criteria for the PhilHealth Z-benefit package for 
transplantation, the expenses for selected laboratory tests may be reimbursed to the 
patient by the healthcare institution after the PhilHealth pays the benefit to the 
healthcare institution for such laboratory expenses. 
 
SEC. 13. Rehabilitation Program. - The DOH, in coordination with the Department of 
Labor and Employment, the Technical Education and Skills Development Authority, 
the DSWD and other pertinent agencies, shall establish a comprehensive rehabilitation 
program for both kidney donors and dialysis patients who have undergone kidney 
transplant procedure in order to help them reach their fullest physical, psychological, 
social, vocational, and educational potential consistent with their physiologic or 
anatomic condition, environmental limitations, life plans and desires. 
 
SEC. 14. Dialysis Facility.  The dialysis facility shall comply with the licensing 
requirements imposed by the DOH for hemodialysis services before it operates as such.  
Hospitals desiring to provide peritoneal dialysis treatment services shall provide the 
necessary equipment and qualified staff to perform such a procedure as prescribed by 
the PhilHealth.  Hospitals with existing hemodialysis facilities shall immediately 
establish a peritoneal dialysis unit to provide a cost-effective dialysis option to patients. 
 
SEC. 15. Training for Peritoneal and Hemodialysis, and Transplant Treatment and 
Services. - The DOH, National Kidney and Transplant Institute (NKTI), Philippine 
Society for Transplant Surgeons (PSTS), and the Philippine Society of Nephrology 
(PSN) shall provide training for medical personnel such as physicians, surgeons, nurses, 
technicians and coordinators who shall work in hemodialysis and peritoneal dialysis 
facilities, operating rooms, transplant wards, and for non-medical barangay health 
workers who will assist home-based peritoneal dialysis treatment.  The NKTI shall 
accredit the facilities that may provide training for these personnel, which training shall 
include hands-on workshops for dialysis. 
 
SEC. 16. Establishing a Chronic Kidney Disease (CKD) Counseling Clinic. - All RRT 
facilities shall establish a CKD counseling clinic and shall separately personnel trained 
to engage patients and explain to them the normal functions of the kidney, the stages of 
CKD, the laboratory examinations routinely performed for CKD patients, the common 
medications required that can control the progression of kidney disease, the metabolic 
complications of ESRD, and the indications for renal replacement.  These clinics shall 
monitor the kidney function of patients so that a timely referral to a nephrologist or 
internist/pediatrician with specialized training in CKD can be made. 
 
 
The NKTI shall provide education and training modules for the medical staff of 
CKD counseling clinics.  


10 
 
 
SEC. 17. Availment of Persons with Disability (PWD) Benefits by CKD Patients. - CKD 
patients shall be classified as PWD. They shall be entitled to PWD benefits in 
accordance with Republic Act No. 7277, as amended, otherwise known as the Magna 
Carta for Disabled Persons.  The PhilHealth and DOH Health Technology Assessment 
Council shall conduct an in-depth study on both the direct and indirect cost of being 
afflicted with kidney disease and undergoing treatment for it. 
 
SEC. 18. Creation of a Renal Disease Control Program. - All RRT facilities shall create 
a Renal Disease Control Program that shall promote the early recognition of kidney 
disease, identify persons at high risk for the development of kidney disease and initiate 
preventive strategies to either prevent the development of kidney disease from diabetes 
and hypertension, or to delay its progression to end stage renal disease.  The DOH will 
establish a database of these patients to ensure that they are regularly monitored for 
disease progression and that they are receiving appropriate treatment for CKD. 
 
SEC. 19. Penalties. - Any head or chief of hospital, administrator or officer-in-charge 
of a hospital, dialysis center, and health facility who fails to comply with Sections 5 and 
6 of this Act shall be meted with a fine of Fifty thousand pesos (₱50,000.00) up to a 
maximum of One hundred thousand pesos (₱100,000.00).  
 
 
 
Likewise, persons receiving free treatment of medicines for ESRD, PD or HD 
services from government hospitals, such as the PHIC, who are found selling these 
medicines or services instead of using them for their own treatment, shall be penalized 
with the suspension of their PhilHealth membership and other government assistance 
for a period of six (6) months, upon due process and hearing.  If these persons are found 
to have committed the same violation for the second time, they shall be permanently 
ineligible to receive government assistance. 
 
SEC. 20. Appropriations. - The initial amount necessary to implement the provisions 
of this Act for national and regional hospitals shall be charged against the current year’s 
appropriations of the DOH.  Thereafter, such sum as may be necessary for its continued 
implementation shall be included in the annual General Appropriations Act. 
 
 
For provincial hospitals, the local government concerned shall provide the 
necessary funds for the establishment and operationalization of its dialysis service units. 
 
SEC. 21. Implementing Rules and Regulations. - Within ninety (90) days from the 
effectivity of this Act, the SOH, in coordination with the PhilHealth, the NKTI, and 
other relevant stakeholders, shall issue the implementing rules and regulations to 
implement the provisions of this Act. 
 
SEC. 22. Separability Clause. - If any provision or part hereof is held invalid or 
unconstitutional, the remainder of the law or the provision not otherwise affected shall 
remain valid and subsisting.   
 


11 
 
SEC. 23. Repealing Clause. - Any law, presidential decree or issuance, executive order, 
letter of instruction, administrative order, rule or regulation contrary to or inconsistent 
with the provisions of this Act are hereby repealed, modified or amended accordingly. 
 
SEC. 24. Effectivity. - This Act shall take effect fifteen (15) days after its publication 
in the Official Gazette or in a newspaper of general circulation.  
 
 
Approved,