1

Accessibility of Healthcare Among Poor Women and their Children in

Coastal Communities: The Case of Paombong

CHAPTER I

THE PROBLEM AND ITS BACKGROUND

Introduction

Health, aside from education, is one of the fundamental aims of

development. It is the primary idea of extensive meaning of human capabilities that

indicates the true meaning of development. It is necessary to increase productivity in

work and thriving education is dependent on sufficient health as well (Todaro & Smith,

2012). Respectively, a vast number of studies confirms that there is a very strong

relationship between health and economic growth (Mayer, 2014). Thus, healthcare is

undoubtedly essential for every folk in maintaining health status and promoting human

development. Despite of this, however, not everyone has given a chance for an access

(Gijsel, 2016).

Access to healthcare is important especially for women for they are vulnerable

and more prone to suffer from certain illnesses. Breast and cervical cancer are the two

usual cancers that affects women. Every year cervical cancer kills half a million of

women while another half a million die because of breast cancer. This cases mostly

happens in low and middle-income countries. In line with this, gallstones, Urinary Tract

Infection (UTI), kidney disease and hypertension are some of the health problems

common for women (Stoppler & Shiel, 2017). In addition to this problem, maternal

mortality rate remains surprisingly high. According to World Health Organization (WHO)

135 million women give birth per year, an estimated 20 million of them suffer from
 2

pregnancy related illness, and about 303,000 women die while giving birth every day.

Poverty, distance, and unavailability of services are factors that hinder them for seeking

healthcare.

Similarly, healthcare access is also significant for children because their physical

development has an immediate effect in overall development of their future (WHO,

2017). However, there are plenty of health problems they encounter. Enormous children

are dying every day because of diseases such as diarrhea, pneumonia, and measles

which can be cured or prevented (Reaves, 2017). Further, malnutrition still remains a

major issue for every child. Malnourished children are more likely to have weak immune

system resulting to a greater chance of getting sick or in severe cases, death. In

developing countries, 10.4 million malnourished children die. This figure tells that a vast

number of children are deprived of nutrition, water, sanitation facilities, shelter, and

access to healthcare (WHO, 2017).

According to WHO (2017), 400 million people are unable to access the needed

health services. Disadvantaged people like poor women and children, rural dwellers,

and indigenous groups are twice likely to be denied of proper healthcare.

In the case of the Philippines, inequity in health status and access to healthcare

services are the challenges encountered. Only few Filipino women experience the

attention of health professionals such as a midwives or doctors. The primary reason is

due to lack of financial means (Gijsel, 2016). The country also deals with inadequate

health facilities. Furthermore, pharmacies that were managed by Department of Health

(DOH) have difficulties restoring their stocks. Available health workers in LGUs are

decresing in the last few years because health workers choose to migrate and work in
 3

other country. Thus, healthcare resources are under scarcity in the country where

facilities, medicines and health workers are insufficient (Cetrangolo, Mesa-lago, &

Carisma, 2013).

As such, poor coastal communities often translate into poor access to health

services because of its remote location (World Wide Fund, 2012). These communities

are too small and isolated to support their needs of health services that’s why residents

are required to go to urban health centers to access healthcare (Wakerman et. Al,

2012). Numerous coastal regions in developing nations are poorly served by health

facilities (WWF,2012). Consequently, there are undeniably challenges in accessing

healthcare in coastal communities. Geographical access to healthcare units, financial

affordability of healthcare services, availability of professional health workers and health

equipment, cultural acceptability, and accommodation of patients are important

conditions in accessing healthcare.

The objective of this paper is to describe the accessibility of healthcare in coastal

communities. A household may be geographically accessible to healthcare units but

suffers from unavailability of doctors, expensive healthcare utilization, or continuous

rejection of healthcare workers. Thus, the aforementioned indicators are crucial on

telling whether a healthcare is accessible particularly for poor women and children on

coastal areas. The study will provide empirical evidence and comprehensive information

concerning the current status of healthcare of poor women and children access in

Paombong. In addition, the study will also explain the barriers that prevent the residents

in accessing health. The knowledge obtained from the study will be useful as a starting

point for projects that aim to improve accessibility of healthcare.

Statement of the Problem

The general problem of the study is: How may accessibility to health care among

poor women and their children in coastal communities in Paombong, Bulacan be

described?

The study will seek to answer the following questions:

1. What are the existing healthcare programs of the government in the coastal

communities?

2. How may accessibility to heath care among poor women and their children be

measured in terms of :

2.1 geographic accessibility;

2.2 availability;

2.3 affordability

2.4 accommodation; and

2.5 acceptability?

3. What are the barriers identified in healthcare accessibility based on the

experience of participants?

4. How do participants address those identified barriers relating to healthcare

accessibility?

5. What are actions taken by the government to improve accessibility of healthcare

among participants in the coastal communities?

6. What measures may be proposed to improve the accessibility of healthcare in

coastal communities based on the findings of the study?

Significance of the Study

The knowledge that will be obtained from the study will be beneficial to the following

stakeholders:

Residents of Paombong. The study can be used to reveal the current status of

healthcare accessibility in Paombong to the public eye in hope to have a better access

to healthcare. Furthermore, it can raise their awareness regarding the issue addressed.

Department of Health Officials. It would provide significant information to the

DOH Officials about the occurring interventions to healthcare access, use and cost. It

will serve as a tool to implement projects in relation to healthcare accessibility in

Paombong.

Management Economics Students. The findings of the study can be used in

the measurement of the barangay`s development since health is one of the key factor

and important indicator for development.

Future Researchers. The study will provide empirical evidence to future

researchers that have the same topic so that they can use the findings of the study to

further strengthen the foundation of their research. It will also serve as a reference

especially when conducting a widespread research.

Scope and Delimitation

The study focuses on the accessibility of healthcare in coastal communities in

Paombong, Bulacan. Specifically, it is limited to three (3) barangays namely Masukol,

Binakod and Sta. Cruz. The accessibility of healthcare will be measured in terms of: (a)
 6

geographic accessibility, (b) availability, (c) affordability, (d) acceptability; and (e)

accommodation.

There will be a total of one hundred twenty-eight (128) participants. The 90 poor

women and children will be picked through stratified sampling approach, while the 28-

key informant will be chosen through purposive sampling with the criteria based on the

researchers. The study will be limited to women and their children living within the three

(3) barangays. Their children should age 12 years and below. The women will be

chosen based on their monthly earnings below ₱9,626 per month. Additionally, women

and their children living outside the barangays are excluded in the study. Survey, focus

group discussions and key informant interviews are the instruments that will be use in

the study.

The study will be conducted from January to May 2018.

CHAPTER II

REVIEW OF RELATED LITERATURE

This chapter presents the relevant theories, related literature and conceptual

framework which researchers have pursued to shed light on the topic under study.

Relevant Theories

The Theory of Access was developed by Roy Penchansky and J. William Thomas in

1981. The theory defined access as the degree of fit between the patient and the healthcare

system. Access has independent yet interconnected dimensions that represent distinctive

measurements which are known as the 5 A’s; availability, accessibility, acceptability,

affordability, and accommodation. It also states that access is the center of these dimensions

which cannot be isolated from it.

The theory will help as a foundation in measuring the accessibility of healthcare in

coastal communities. The 5 A’s of access will be used to identify and to measure the existing

issues encountered by poor women and their children in terms of accessing healthcare.

Related Literature

This section provides the reviews of related literature which will give a clear

overview in the study

Universal Health Coverage (UHC)

Universal Health Coverage (UHC) is a health system from WHO constitution of

1948, stating that health is an essential human right, and from the Health for all agenda
 8

prepared by Alma Ata declaration in 1978. This means that the entire people and

community receive quality health services while also assuring the affordability of health

services. The given definition mirrors its three related objectives particularly equity in

excellent health services that is enough to improve the health of the users and the

security of people against financial risk of obtaining health services. It also includes all

component of health system like health delivery system, health facilities, health

personnel, information system, governance and legislation. It also encompasses

population based services such as health campaign.

Tracking progress toward UHC focus on two things: the portion of the population

that can access the indispensable quality health services and the portion of the

population that pay a huge amount of family income on health. WHO, together with the

World Bank has developed the framework to monitor the progress of UHC by tracing

both categories. Moving toward UHC demands strengthening health systems and

successful financing structures (WHO, 2017).

In the Philippines, Universal Healthcare (UHC) also known as Kalusugang

Pangkalahatan (KP) is described by Aquino administration, that healthcare services

should be available and accessible for every Filipino. It aims to guarantee that Filipinos

shall be able to afford and acquire quality health benefits. This includes supplying

sufficient resources such as health facilities, health professionals and health financing.

To achieve UHC in the Philippines, there are 3 goals to be pursued namely: Financial

risk problem, improved access to quality hospitals and healthcare facilities and

attainment of health-related Millennium Development Goals(MDGs) (DOH, 2017).

HEALTHCARE PROGRAMS AND SERVICES

Dental Medicine

The dental medicine in Philippines provides dental services and maintains dental

examination and initiate dental treatment. Dental main which is the one that takes cares of

present admitted patients for dental surgical interventions. They also have an out-patient dental

section that cater the unconfined patients that also need dental care and treatment.

Prosthodontia Section, here they specialize constructions and fabrication of dental prosthesis.

This is the department that specialize dentures. Healthcare programs in the Philippines is one

way to be implemented to improve the healthcare access in the country here are agendas for

Philippine healthcare.

Healthcare programs in the Philippines is one way to be implemented to improve the

healthcare access in the country here are agendas for Philippine healthcare.

Advance quality, health promotion and primary care

These will conduct annual health visits for all poor families and special populations

(NHTS, IP, PWD, Senior Citizens). Also, will develop an explicit list of primary care entitlements

that will become the basis for licensing and contracting arrangements. Transform to improve

select DOH hospitals into mega-hospitals with capabilities for multi-specialty training and

teaching and reference laboratory. Support LGUs in advancing pro-health resolutions or

ordinances. Establish expert bodies for health promotion and surveillance and response.

Cover all Filipinos against health-related financial risk

Raise more revenues for health, will impose health promoting taxes, increase NHIP

premium rates, improve premium collection efficiency. Give more chance to have GSIS, MAP,

PCSO, PAGCOR and minimize overlaps with PhilHealth. Expand PhilHealth benefits to cover

outpatient diagnostics, medicines, blood and blood products aided by health technology
 10

assessment. Update costing of current PhilHealth case rates to ensure that it covers full cost of

care and link payment to service quality. Enhance and enforce PhilHealth contracting policies

for better viability and sustainability

Harness the power of strategic HRH development

Revise health professions curriculum to be more primary care-oriented and responsive

to local and global needs. Streamline HRH compensation package to incentivize service in high-

risk or GIDA areas. Update frontline staffing complement standards from profession-based to

competency-based. Make available fully-funded scholarships for HRH hailing from GIDA areas

or IP groups. Formulate mechanisms for mandatory return of service schemes for all heath

graduates.

Invest in eHealth and data for decision-making

Mandate the use of electronic medical records in all health facilities. Make online

submission of clinical, drug dispensing, administrative and financial records a prerequisite for

registration, licensing and contracting. Commission nationwide surveys, streamline information

systems, and support efforts to improve local civil registration and vital statistics. Automate

major business processes and invest in warehousing and business intelligence tools. Facilitate

ease of access of researchers to available data

Enforce standards, accountability and transparency & Value all clients and patients,

especially the poor, marginalized, and vulnerable

Publish health information that can trigger better performance and accountability. Set up

dedicated performance monitoring unit to track performance or progress of reforms. Prioritize

the poorest 20 million Filipinos in all health programs and support them in non-direct health

expenditures. Make all health entitlements simple, explicit and widely published to facilitate
 11

understanding, & generate demand. Set up participation and redress mechanisms. Reduce

turnaround time and improve transparency of processes at all DOH health facilities. Eliminate

queuing, guarantee decent accommodation and clean restrooms in all government hospitals

Elicit multi-sectoral and multi-stakeholder support for health

Harness and align the private sector in planning supply side investments. Work with

other national government agencies to address social determinants of health. Make health

impact assessment and public health management plan a prerequisite for initiating large-scale,

high-risk infrastructure projects. Collaborate with CSOs and other stakeholders on budget

development, monitoring and evaluation

ACCESSIBILITY TO HEALTHCARE

Geographic Accessibility

Health and Place Initiative (2014), defined geographic access to healthcare as

the time when patients can physically access the services in the health centers from

their community. In the article of HAPI (2014), people tend to find healthcare facilities

difficult to access because of the distance and travel time and much more difficult for

people who live in rural and remote areas.

In the journal article of Kumar, Dansereau & Murray (2014), which focuses on the

access and distance to health facilities and stated that distance and travel time are one

of the barriers in access to health care. According to the article, places that are way too

far from health care provider have big impact in utilization of healthcare and outcome in

health. Some families in India choose to travel longer just to have proper medication.
 12

Households, on some cases doesn’t have the means to acquire healthy life because

they often lack resources for transportation. According to the research, geographic

access is more important than socio-economic factors especially in rural and remote

areas with scarce health services.

Availability

Access to health services depends on the availability of supplies, health facilities, human

resources, and health programs (Cetrangolo, Mesa-lago, & Carisma, 2013).

Chen, Yin, and Xie (2015) found out that one of the problems in healthcare is the

unequal distributions of healthcare resources in rural and urban areas due to the fact that rural

areas have a much poorer economic condition, lack of government investments, and low

resident’s payment capability. According to Titus, Adebisola, and Adeniji (2014), accessibility of

household to medical facilities are very low because of the inadequate and unequal distributions

of public health facilities. There are also disparities between patients and health personnel

because of the inadequate supply of health workers.

Affordability

Affordability is defined as a measure of someone’s ability to purchase a good or

service. According to Swartz (2012), in health care, affordability describes whether a

person’s income is sufficient enough to pay for primary healthcare cost. There are

plenty of people who cannot obtain medical care because it is expensive (Glynn,

MacKenzie & Fitzgerald, 2016). In the case of America, when their country has grown,

they conducted public programs and implemented the Affordable Care Act to help poor

people obtain healthcare by the use of public health insurance. However, the

enrichment of their country does not increase their generosity proportionately towards
 13

poor people. Also, it does directly increase the affordability of healthcare for those

people living in poverty (Swartz, 2012)

One of the goals of the government is to help poor people obtain medical care

and to make public health insurance available to the poor so that they can somehow

afford healthcare services. Their assumption is that if poor people have health

insurance, doctors and other healthcare providers will give the same and equal services

to poor people like what they do to middle class and rich people. Even though public

insurance have grown, it became clear that poor people still encounter barriers while

obtaining health care and it is beyond simply their inability to afford it. One of the

barriers is that not all healthcare providers are willing to treat people with public

insurance coverage only (Swartz, 2012).

Acceptability

The factors influence acceptability of healthcare services by consumers includes need,

desires, expectations, beliefs, values and levels of independence on the people around you.

The cultural and religious beliefs affect the delivery and acceptance of healthcare. Also,

openness to the technologies and newly-developed techniques. In some cases, gender is a

barrier in accepting healthcare. In certain cultures, women is not allowed to see and be

examined by the male health workers. Additionally, there is some inappropriate behavior the

health care providers some humiliate and abuse health consumers. Dr. Tello says that most

physicians are not explicitly racist yet they are under the racist system. Furthermore, poor

patients more likely to cure themselves naturally before seeing the doctors. Accepting treatment
 14

to official healthcare workers sometimes tend to be second on their choices. The satisfaction of

consumers in the services bases on how they trust their provider.

Accommodation

Saurman (2015) mentioned in his article that accommodation involves a sufficient

service is well organized to receive clients and clients are able to use the service. This

include hours of operation, appointment system, waiting hours and the like.

Healthcare Status of Coastal Communities

Department of Health, Australia (2014), stated that women should have access

to healthcare, according to what they need and acceptable to them, as near as possible

to their community, but the available choices are different base on their location from

the health centers.

In the case of Australia, women who live in coastal remote area experienced

difficulties in getting antenatal health care due to their distance from the health facilities,

cost of the healthcare and scare supply of services. In some cases, women who are

required to give birth or to consult doctors in health facilities are forced to travel away

from their community, lead to additional cost of care, and separated temporarily from

family especially to other children. Reported neonatal death, wherein a baby dies on

28th to 30th day after birth, are high among women who live in rural areas and fetal

death, the death of a fetus during pregnancy, are much higher in coastal community of

Australia. Women tend to suffer more because healthcare is not close to their homes

which makes difficult for them to access (DoHA, 2014).

United Nation Children’s Fund (2015), conducted a report in the case of

Philippines specifically in Barangay Matarinao, Eastern Samar, a poor coastal village.

Due to the difficulties in accessing the healthcare facilities, midwives and doctors are

the ones who travel for hours, three times per week from Rural Health Unit in Salcedo in

order to reach Brgy. Matarinao because women and their children in the barangay

cannot afford to do so. Barangay Matarinao has reported cases of high number of

malnutrition, diarrhea and other preventable cases in children.

Related Studies

A study made by Dill (2011) entitled Healthcare Seeking Behaviour, Barriers

in Accessing Medicines and Coping Strategies in Africa: Evidence from Koboko

District focus on identifying where do households seek healthcare, challenges in

accessing healthcare and coping strategies of acute illness costs. The study used

interview, focus group discussion and survey questionnaires as the method to gather

data and conduct the study. It concluded that most household in Koboko District seek

healthcare from public sector, even richer households. Regarding barriers in accessing

medicines the study found out that unavailability of drugs and high prices are the

challenges that households encounter, while geographical access and quality of

medicines were not a severe problem. A large number of households sell assets or

even their food for consumption, to cope with acute illness costs.

The author made a great examination of the data through quality and quantitative

techniques that resulted to a more comprehensive finding. The author also made sure

that all details in their study is well defined. On the contrary, the authors provide a

limited information about the accessibility of medicines because the instrument used
 16

particularly the questionnaires did not include about accommodation and/or

acceptability which is included in her parameter.

The above study is similar to the current study in terms of the method it used in

order to collect data which is interview, focus group discussion, and survey

questionnaires. Both study also focus on coping strategy and accessibility. It was then

different in terms of setting and respondents.

In the research entitled Barriers Preventing Access to Healthcare Services

for Women in Rural Samoa conducted by Paige Lynn Miller in 2012, the study states

that there are many barriers that prevent women from Rural Samoa in accessing

healthcare services, some of it are the traditional medicine, availability, affordability,

transportation, etc. It is shown that less accessibility to healthcare programs/services

may lead to major health issues. All of the health issues mentioned in the study is

caused or worsened by poverty and socio-cultural factors. The researcher used

exploratory, quantitative and qualitative (through Ethnography) design in this study, it is

said that the use of mixed design will strengthen the research foundation. The

researcher used cross-sectional approach to collect data, formulated a questionnaire

composed of 26 questions based on determinants and barriers of access to healthcare

services and conducted personal interviews to one hundred one women in the Village of

Iva in Rural Samoa with ages 20 years and older. The researcher verbally verified the

data gathered with the participants after the conclusion of each interview. The findings

of this study is that the barriers preventing women in Village of Iva from accessing

healthcare services are the availability of healthcare facility and transportation,

affordability of the medicines and services and the transportation cost. The study shows
 17

that if women does not have or have minimal access to healthcare services it may lead

to low life expectancy, high maternal mortality rate, sexually transmitted disease,

obesity and diabetes. Additionally, traditional medicine, high cost of prescription drugs

and being unaware or having less knowledge in healthcare services prevents the

women in Rural Samoa from accessing the healthcare services and programs provided

by the government for them.

The study has a good foundation based on the related literatures and studies.

The researcher has a great research techniques and methodology which shows how

reliable the study is. However, the study did not elaborate or further explain some

factors that contribute to the barriers that prevent access to healthcare. The study said

that the future researchers should focus on the infrastructure and adequacy of the

public healthcare system, further examine the pressure of the affordability constraints of

transportation, user fee and prescription drugs in a larger sample size, compare the

level of access to healthcare services between women living in urban and rural areas.

As we can see based on the recommendations of the study, there are many factors that

the research did not cover.

The study is somehow similar to researchers because the study assesses the

accessibility of healthcare for poor people in remote areas. Researchers will also apply

the same method that the study used which is mixed method and some of the

parameters in the study are quite similar to what are going to use.

The study of Sulemana and Dinye (2014) entitled Access to Healthcare in

Rural Communities in Ghana: A study of Some Selected Communities in PRU

District focused on evaluation of the healthcare access of the poor, the problems
 18

encountered, coping strategies and suggestions to assess such problems. The

researchers performed case study as the method and technique to gather the data from

PRU District. The data were collected from the sampling size of 200 in selected seven

rural community households. Qualitative and quantitative data were also collected from

focus group discussion and key informant interviews for chiefs, assemblymen, teachers

and youth for additional information. The study revealed that people in rural

communities experienced difficulty on physical healthcare accessibility in terms of

health facilities. This includes, unavailable health facilities and health equipment, poor

system in transportation, long travel distance and lack of financial means. The study

concludes factors hindering access to health facilities and services in Ghanaian context

are numerous especially in rural communities ranging to physical access problem,

financial problem and technological problem.

This study analyzed the factors affecting the healthcare accessibility based from

the result of data collection and provides a clear assessment on the relationship to each

other. However, the researcher didn’t explain further the travel distance or the criteria to

consider in addressing what makes it at great distance from the community.

The above study was similar to the study undertaken currently by the

researchers for it both focused on assessment of accessibility of healthcare especially

for the poor, challenges encountered and coping strategy of the respondents. It was

then different to the current study in terms of the setting because researchers will

emphasize on coastal area while the authors used rural setting and other factors such

as acceptability, accommodation are not present in the study conducted by researchers

of Ghana.
19