University of the Philippines Manila

College of Arts and Sciences

INDIGENT HEART HEALTH:

Critical Political Economy of Cardiovascular Healthcare for the Filipino Masses

An Undergraduate Thesis Presented to the Department of Social Sciences College of Arts and Sciences

University of the Philippines Manila

In Partial Fulfillment of the Course Requirements for the Degree Bachelor of Arts in Development Studies

Presented by Chris Daniel M. Francisco

2011-07128

Presented to Prof. John N. Ponsaran

Thesis Adviser

May 2015

ii    

College of Arts and Sciences

University of the Philippines Manila

Padre Faura, Ermita, Manila

APPROVAL SHEET  

This undergraduate thesis entitled INDIGENT HEART HEALTH: Critical

Political Economy of Cardiovascular Healthcare for the Filipino Masses presented

and submitted by Chris Daniel M. Francisco in partial fulfillment of the course

requirements for the Degree of Bachelor of Arts in Development Studies is hereby

recommended for approval.

_________________________

Prof. John N. Ponsaran, MPM Thesis Adviser………

Development Studies Program

This undergraduate thesis is hereby accepted and approved as partial fulfillment

of the course requirements for the Degree of Bachelor of Arts in Development Studies.

____________________________

Prof. Clarinda Lusterio-Berja, MA Chairperson…...……..

Department of Social Sciences.

iii    

ACKNOWLEDGEMENTS

To FATHER GOD, I just want to thank You for everything. Thank You for not

giving up on me, when I often do give up on myself. Thank You for giving me the

opportunity to even experience these things in my life. Though this is your work in me,

this is still for You. You never fail to amaze me, Dad. I love you.

To PAPA and MAMA, congrats! We’ve finally made it. All of your hard work

paid off. Though I’m not that much of an award-getter, everything that I do is for you,

guys. Your happiness has always been mine. Thank you for spoiling me once in a while

(5 out of 7 days). Hehe! But now that Kuya and I have already graduated, I salute you,

Ma and Pa. I am really proud to be your son. I love you.

To KUYA JAMA, thank you, bruh, for staying late at night just to accompany

me and check on me from time to time. Thank you for the little pieces of advice that you

give once in a while. I’m really blessed to have you as my Kuya. I’ve always looked up

to you. You’ve been my motivation since day one. I love you, man.

To CLARENCE, thank you for giving me encouraging words whenever I feel

depressed. Thank you also for your prayers during those times. I’m sorry if I didn’t get to

spend much time with you back then. I’ll make bawi. Promise. I love you!

To SIR JOHN-JOHN, thank you for being my mentor, life advisor, friend and

second daddy. I have never met someone like you – the passion, the effort, and the

influence. Though I’m mostly pasaway, you never gave up on me. I’m sorry if I

disappoint you most of the time. But at least I know for once I made you proud. Thank

you for everything. – Love, your most favorite student, Chris. P. S. Congrats! May bago

na kaming kapatid (Liam)!

To #TEAM PONSY (Jhaypee, Aj, Paula, Arianne, Bea, Camille, Sheena, Pau

H, and Dey), thank you so much for being my thesis buddies. We’ve endured two

loooooong sems. Though it was really tiring, I just want to say that I loved every moment

of it. To those sleepness nights (?) and kasabawan, thank you. You, guys, always had my

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back. I am so proud to be TEAM PONSY. Ang hirap ah. But still, everything was worth

it. I love you, guys!

To all my DS PROFESSORS (Sir Allan, Ma’am Ruth, Sir Pipoy, Sir Roland,

Sir Chester), ATE MARY, and ATE JULIE, thank you for being part of my DevStud

life. It wouldn’t be complete without you, guys. Thank you for teaching me a thing or

two during the years. I will miss all of you. See you again soon!

To BABIES NI PONSARAN (DevStud 2011), thank you for the four years

we’ve spent together. I will always treasure every moment spent with you, guys. I’m

really proud that I’m a part of this batch. Kakaiba kayo. Sobrang sarap maging kaibigan

ninyo. Sobra. But above all, thank you for the fun. I will never forget any of you. Mahal

na mahal ko kayo. Nga pala, sasablay na tayo!!!

To SHUFFLERS (Jullius, Paolo, Jude, Dalisay, Dey, Vince, Custodio, and

Jen), thank you for everything, guys. Salamat sa mga tawanan, kalokohan at pagsasama.

You…complete…me. I love you for life!

To ATE PORTIA (of GEAMH) and ATE LYNNE (of MCP), thank you for

helping me schedule interviews with the doctors. You’ve been a great help. If it weren’t

for you two, I wouldn’t be able to finish this. Haha!

To CHRIS, you’re the man! I always believed that you can do it. Now that

you’ve graduated, sasaya ka na ulit. Haha! But still, this was one hell of a ride, partner.

On to the next one. I love you.

To everyone else who I have not mentioned, thank you for being part of

my journey.

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ABSTRACT

This study validates the claim that both biological and social conditions influence

health outcomes. It relates the negative impacts of the current public health system to the

problems and difficulties experienced by indigent cardiovascular patients. Likewise, it

examines how the socio-environmental conditions impact individual health-related

behaviors. Critical interviews from doctors and patients were used to scrutinize the flaws

of the health system, to validate facts and disprove particular misconceptions regarding

the disease, to analyze the patient-doctor dynamics involved, and to relate the health risks

of a person based on his or her socioeconomic status. Furthermore, secondary data was

used from journals, articles and statistical reports to support the claims.

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TABLE OF CONTENTS Page

Approval Sheet ................................................................................................................... ii

Acknowledgement ............................................................................................................. iii

Abstract .............................................................................................................................. v

Table of Contents .............................................................................................................. vi

List of Figures ................................................................................................................. viii

List of Tables ..................................................................................................................... ix

Chapters

I. Thesis Proposal

Introduction ................................................................................................. 1

Significance of the Study ............................................................................. 5

Problem of the Statement ............................................................................ 6

Scopes and Limitations of the Study ........................................................... 8

II. Study Framework

Theoretical Framework ............................................................................... 9

Conceptual Framework ............................................................................. 11

Definition of Terms ................................................................................... 12

Review of Related Literature ..................................................................... 14

Research Methodology .............................................................................. 20

Ethical Considerations ............................................................................... 21

III. Background of the Study

Denationalization of Public Health ........................................................... 23

Distressing Cardiovascular Problems ...................................................... 24

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IV. Presentation and Discussion

Victims of Cardiovascular Diseases .......................................................... 28

Social Determinants of Health: The Inconspicuous Health ...................... 32

Hidden Expenses ....................................................................................... 35

Case 1 ............................................................................................ 39

Case 2 ............................................................................................ 44

Noncompliance: A Predetermined Choice ................................................ 49  

V. Summary and Conclusions, and Recommendations

Summary and Conclusions ........................................................................ 54

Recommendations ..................................................................................... 57

Bibliography ..................................................................................................................... 60

Appendices

Appendix A: Letter of Request to Dr. George R. Repique Jr. ............................... 66

Appendix B: Letter of Request to Dr. Rustico A. Jimenez ................................... 67

Appendix C: DOH Data Sheet Request Form ....................................................... 68

Appendix D: Interview Questions for Doctors (Cardiology) ................................ 69

Appendix E: Interview Questions for Cardiovascular Patients ............................. 70

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LIST OF FIGURES

Figures

1. Conceptual Framework ....................................................................................... 11

2. Death by cause, all ages, Philippines, 2002 ......................................................... 25

3. Projected prevalence of overweight, Philippines, males and females aged 30 years or more, 2005 and 2015 ............................................................................. 31

4. The Determinants of Health by Dahlgren and Whitehead .................................. 33

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LIST OF TABLES

Tables

1. Heart Disease Statistics: Top Cause of Mortality ................................................ 26

2. Mortality Rate Trend Deaths Due to the Disease of the Heart ............................ 27

3. Top Causes of Morbidity ..................................................................................... 29

4. A CABS Patient’s Quotation of Prescribed Medicines ....................................... 37

1    

CHAPTER ONE

Thesis Proposal

Introduction

Health is an influential resource. If treated properly, it offers to people a life path

filled with favorable opportunities. On the other hand, those who treat it poorly will

suffer the consequences it bears. While there is an argument on the fact that health

decisions are made voluntarily regardless of social class, the differences in health

outcomes in relation to health inequities are not merely caused by lifestyle choices or by

other health-seeking behaviors. Rather, it is deeply rooted in the structural features of the

society (Barnes et al., 2013).

Chronic Disease and Poverty

Poverty is indistinguishably associated to poor health, whereas one amplifies the

other and vis a vis (Health Poverty Action, n. d.). The poor social climate within

unfortunate communities makes the people more susceptible to health instabilities. As

stated by Susan Everson-Rose in the news article entitled Low Self-Rating of Social

Status Predicts Heart Disease Risk written by Stephanie Stephens (2014): “The social

environment in which we live [in] has a critical impact on our health and well-being.”

Furthermore, it is proven that through the “culture of poverty,” the prolonged exposure to

social drawbacks may lead to life-long diseases, commonly called as chronic diseases.

As indicated in the Non-Communicable Diseases Fact Sheet of the World Health

Organization (EuroHealthNet, 2013), chronic diseases tally more than 36 million deaths

each year. These long-term ailments are mainly caused by non-modifiable risk factors

such as age, sex, heritable characteristics, among others. However, for the socially

disadvantaged members of the society, it is well recognized that their population is more

prone to modifiable risk factors such as poor diet, physical inactivity, and tobacco and

alcohol use. Even though these elements are highly fixable, their social subservience in

2    

the community limits their capacity to prevent the development of the disease (as cited in

WHO, 2013).

Due to poverty, individuals suffer from financial hardships, lack of social support

and employment participation (Salway, 2007). For these reasons, poor people face

barriers to economic, political, and social opportunities for development. Not only do

individuals suffer health problems, they also experience detrimental effects on the

household well-being, as well as the whole community’s (Salway, 2007). Likewise, as

how Pryer et al. puts it in the chronic poverty report entitled Health and Poverty Linkages

written by Ursula Grant:

As with poverty, ill-health affects both the individual and household, and may have

repercussions for the wider community too. Sudden or prolonged ill-health can

precipitate families into an irretrievable downward spiral of welfare losses and even lead

to the breakdown of the household as an economic unit (2005).

With the existing condition of the poor, these individuals are relegated into

endless, intergenerational poverty and debt traps. Their low competencies and trivial

opportunities cause greater damages from repeated ill-shocks (as cited in Goudge and

Govender, 2000). With this, their health deteriorates along with their economic vigor.

Moreover, due to the “culture of learned helplessness” and “culture of defeatism,” they

accept their fate and resolve to resignation.

Neoliberal Society and Health

The socially isolated poor are severely deprived of health information. Not

only are they dispossessed of material resources, they are also excluded to participate in

socio-economic concerns. Poorly knowledgeable individuals in relation to health suffer

from impractical, uninformed yet unavoidable choices, thus, they are placed at the

disadvantage. Nonetheless, the health literacy of the marginalized sector only reflects the

quality and the efficiency of the health information management within the community.

3    

The lack of use of appropriate technologies and effective approaches, likewise, poses a

problem to the people as well as health professionals and researchers.

In the country, priorities have always been the most questioned aspect in every

administration when it comes to the provision of public service. Indisputably, the wave of

globalization paves the way for the privatization of public goods and basic social

services. This in the long run presents innumerable accounts of social exclusions and

inequalities within the society.

Health, as a public good, is being widely commercialized. The price rates for

medical services in public hospitals increase, closely matching charges from private

institutions. For those reasons, medically indigent patients are saddled with financial

constrictions.

The socio-economic boundaries which limit the capacities of the poor place them

out of the general priority concern. With the neoliberal policymaking scheme, the

institutions are restructured to yield profits, even at the expense of quality and genuine

service. A manifestation of which is found at pharmaceutical industries wherein there is a

connivance between the institutions and capitalist-oriented individuals. Furthermore, this

causes direct and indirect shocks to the community.

For years, the national budgeting in the country is unjustifiably misallocated.

Instead of distributing resources to health, the Philippines focuses on the military and

debt servicing. In due course, public hospitals are subsidized lesser, burdening them with

the pressure of adjusting their financial disposition to make ends meet. For example, the

Philippine General Hospital, the hospital said to care for the poorest of the poor, is not

exempted from the consequences brought about by the privatization of health. With the

series of budget cuts experienced, the hospital needs to constantly adjust its fees to carry

on its operations. Hence, it can be concurred that price rates for services related to

chronic diseases are doubled over, making it more inaccessible and unaffordable for the

general public.

4    

Cardiovascular Diseases in the Philippines

Among the chronic diseases, cardiovascular disease (CVD) is the number one

cause of deaths worldwide. As for the Philippines, recent data from the National Statistics

Office (NSO) showed that five out of 10 deaths in the country were caused by heart

diseases (Sindico, 2012). In addition, data also indicated that 21% of the 480,820

recorded deaths reported from January 2009 to March 2010 were caused by heart

conditions (ABS-CBN, 2011). However, despite these facts and figures, the case is still

often disregarded.

Though yearly the health mortality gap widens, the local efforts to address this

important issue are managed poorly. As a result, CVD-stricken people are “abandoned”

in the process, making them deal with the situation using their own means. Furthermore,

cardiovascular diseases can be deliberated as a development concern because of its macro

and micro-level impacts to the society.

5    

Significance of the Study

For the Philippine General Hospital, General Emilio Aguinaldo Memorial

Hospital, and health policymakers. This study provides a structural analysis of the

cardiovascular healthcare delivery in the Philippines. Likewise, it will provide a critical

analysis on the impacts of the commercial medical economy to the poor Filipinos with

cardiovascular conditions. With this, it could be used as a reference for a more pro-people

health policymaking and a more democratic budget appropriation that will respond to the

present health inequalities in the country.

For the medically indigent cardiovascular patients. This study contributes in

evaluating both the economic and social-environmental burdens of cardiovascular

diseases. It also seeks to clarify several misconceptions encountered in health-seeking

behaviors. In view of such, this study would be able to critically inform health

professionals, health workers, health institutions, and the local community so as to

develop an integrated and holistic approach to deal with the current state of

cardiovascular health in the country.

For the future researchers. This study seeks to provide a class analysis to

cardiovascular disease studies. Similarly, it opens up opportunities for other health-

related and indigent care studies. With this, it could be used to expand the limited and

understudied related research areas.

For the researcher. This study intends to fulfill the researcher’s personal desire

in analyzing the impacts of cardiovascular diseases towards the unfortunate. Through a

related experience by the researcher’s father, it has been clear to him that the case is

serious and should also be accorded serious attention. For those reasons, this study could

be used to benefit the patients and families experiencing a similar case.

All things considered, this study is for the benefit of the academe, the research

institutions and the respondents involved.

6    

Problem Statement

General: How do the dynamics within the public health system and community impact

the delivery of cardiovascular health services for the masses?

Specific Objectives:

1. To prove that cardiovascular disease is a poor man’s disease

Why are the poor the most vulnerable to cardiovascular

diseases? What are the risk factors that affect the poor’s health

predisposing them to contract such diseases? How wide is the gap

between the poor and the rich in accessing cardiovascular

healthcare?

2. To relate the social aspect of medicine in studying the healthcare system

Why is the social aspect of medicine important in studying

the prevailing healthcare system in the Philippines? What are the

social determinants of cardiovascular health and their effects?

How does the social aspect of medicine help in the prevention of

cardiovascular diseases?

3. To analyze and criticize the existing healthcare system and specifically

cardiovascular care services for the masses

What is the general orientation of the Philippine healthcare

system? What is the dominant paradigm in the cardiovascular care

in the Philippines? At present, is health seen as a public good or a

private good? What are the loopholes in the existing healthcare

system? Does the PhilHealth program sufficiently support

medically indigent patients?

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4. To calculate and evaluate the costs that involves the delivery of

cardiovascular healthcare in a public health institution

How much is the cost to treat cardiovascular diseases?

How is the price rates of health services related to cardiovascular

disease mortality? How do the economic and social burdens of

contracting a cardiovascular disease worsen the condition of

indigent patients?

5. To recommend alternative solutions to address the challenges and issues in

the provision of cardiovascular healthcare services to the masses

How can the health system be restructured in a way that

will foster an inclusive health development?

8    

Scope and Limitations

This research study will primarily focus on the socio-economic issues regarding

cardiovascular health cases in the Philippines. Likewise, this will be the basis of an even

wider analysis of the current Philippine public health system.

For the reason that this is an undergraduate thesis, the study will be restricted only

to the access, ability, and competency of the researcher. Moreover, this study will only be

limited to the financial resources available. Time constraints, however, will also bring

difficulties in the research process. Furthermore, the research may have problems with

the disclosure of information in the data gathering process with cardiovascular health

patients and their families, considering the sensitivity of the topic.

9    

CHAPTER TWO

Study Framework

Theoretical Framework

This study will mainly operate utilizing the critical political economy theory. This

theory will be used to critically assess the interaction of the economic, political, social,

and cultural processes in the Philippine medical economy. Furthermore, it will be

instrumental in scrutinizing the health status quo and the overriding paradigm in the

health system that brings about the current backward conditions of Philippine health care.

As a supporting theory, the Health Belief Model Theory (HBMT) will be used in

the study as a method of gathering the necessary information for the research. In

particular, the theory will be fundamental in establishing the step-by-step process from

the identification of the disease to its resolution. Moreover, it will help determine the

benefits, as well as the barriers, in taking recommended health actions and interventions.

This study will tackle the political economy of cardiovascular healthcare. The

institutions chosen for the study were intended to represent the condition of the current

public health system and to embody the poorest of the poor patients, or the indigent

patients.

The research will use primarily the four constructs mentioned in the concept of

HBMT, namely: perceived susceptibility, perceived severity, perceived benefits and

perceived barriers.

The first construct, perceived susceptibility, will be the starting point of the study.

In this phase, the respondents will be interviewed and surveyed to assess their

understanding of the risks and vulnerabilities with cardiovascular diseases. At this point,

the researcher can prove or disprove assertions from existing literature vis a vis first-hand

interviews. Likewise, he can further evaluate the respondents’ levels of health literacy, or

10    

the ability of a person to process, communicate and make use of health information, and

partly relate the quality of health informatics, or the management and promotion of health

information, within their respected communities.

After assessing the vulnerabilities and risks of contracting diseases, it is important

to evaluate the health problems’ severity (perceived severity). In this phase, the

population, independently, will weigh the seriousness of the contracted cardiovascular

disease. Internal and external signals (cues to action) will have a major role in their

decision-making process. With the way the respondents perceive the health conditions,

they may either have it treated or not.

Lastly, after weighing the severity of such disease, the population will decide

among the health choices which are available. It is most likely that the chances that they

will take are the ones which will benefit them the most (perceived benefit). Through an

effective deliberation and consultation, the population will likely engage in health

decisions which are recommended by professionals. Here, the study will also analyze the

medical and non-medical ways, or the patients’ health-seeking behaviors, to prevent, treat

or cure diseases.

However, it is clear that one of the burdens of the current healthcare system in the

Philippines is being cost-prohibitive (perceived barriers). In this phase, it can be

discerned whether or not the system is harmful or beneficial to its recipients. Thus, the

study will use this construct to criticize the dominant health system and expose how it

aggravates the health conditions of the people. Also, the study will analyze the role that

pharmaceutical industries and health insurances like PhilHealth play in the health

financing of the poor patients.

All in all, it can be assumed that the present health structure creates a “caste

system” which divides the people into those who can pay, those who can barely pay and

those who cannot. For those reasons, this study aims to analyze how the actors in the

medical economy impact the health and wellbeing of the marginalized.

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Conceptual Framework

This study will use several variables in the conduct of the research. The

demographics (i.e. age, gender, educational attainment, health literacy, lifestyle, etc.) of

the population, the socioeconomic status (SES) within the population, and the prevailing

health care policy will be the independent variables. On the other hand, the health-

seeking behaviors, the susceptibility of the people to cardiovascular diseases, the out-of-

pocket expenditures, and the patients’ level of health self-efficacy will be the dependent

variables. The independent variables will act as the cause in this research configuration,

while the dependent variables will act as the effect.

Figure 1. Conceptual Framework

 Independent  Variables  

 Demographics  (age,  

gender,  health  literacy,  etc.)  

 Socioeconomic  Status  (SES)  

 Public  health  

policies      

Process    

Cri=cal  Poli=cal  Economy  Theory  

 Health  Belief  Model  Theory  (HBMT)  

         

   

Dependent  Variables  

 Health-­‐seeking  

behavior    

Suscep=bility  of  the  individual  to  heart  

diseases    

Out-­‐of-­‐pocket  expenditure  

 Self-­‐efficacy  

 

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Definition of Terms

• Cardiovascular Disease (CVD) is caused by the process of atherosclerosis, or the

build-up of fatty or fiber-like substances that creates blockages in the arteries. It is

the leading cause of death globally, and could be considered as a “poor man's

disease” (World Heart Federation, 2014).

• Indigent Patients are patients who are considered to be in need of financial

support for medical expenses and other living expenses. They are patients without

medical insurance or support. Also, they are patients who are known for being the

poorest of the poor (University of the Philippines, n. d.).

• Health-seeking Behaviors refer to the actions done by individuals to address their

health problems, taking into account their perceptions on a certain disease. These

perceptions may be affected by socio-cultural and economic factors (Olenja,

2003; as cited in Ward, 1997).

• Healthcare Administration is the field that refers to the general management of

hospitals, as well as healthcare systems and networks. Its goal is to attain

specified health outcomes and to provide efficiency in the dynamics within the

hospital and the overall medical system. It is also known as health management,

health systems management, health administration, and medical and health

services management (Indiana University, 2014).

• Health Economics is a study of economics with regard to healthcare. It studies

the dynamics of healthcare systems and policies and how the available resources

are managed and allocated. It is by which health-related decisions are made to

address efficiency without neglecting equity concerns (Kernick, 2003).

• Health Informatics pertains to the strategies and techniques, as well as

machineries and technologies, to better educate the healthcare providers,

researchers and consumers for the optimal use of health information (University

of Virginia, 2012).

• Health Literacy refers to the capacity of an individual to absorb, obtain, interpret,

communicate and make use of basic health information and services to improve

13    

awareness and health decision-making (Centers for Disease Control and

Prevention, 2014).

• Healthcare Policies pertains to the laws and regulation that control the provision

of healthcare delivery. It is the plan of action which shapes the health priorities of

the society to achieve set goals. Also, it is the main guideline that a country

follows in determining health resource allocations (World Health Organization,

2014).

• Health Self-efficacy refers to the sense of control over an individual’s

environment and behaviors, affecting his or her health-seeking behavior

(Schwarzer and Luszczynska, n. d.).

• Out-of-pocket expenditure on health pertains to the cost-sharing of the patient,

even sometimes the health worker, to afford health service provision. It is a part

of private health expenditure to promote self-medication out of necessity (World

Bank, 2014; Organisation for Economic Co-Operation and Development, 2001).

• Political Economy is a social science that studies the interrelationship of the

political and economic processes in the society in relation with the laws, customs,

and administration of the distribution of a particular good (SAGE, n. d.).

• Social Medicine is a branch of medical science that seeks to understand the

interrelationship of the overall health with regard to the social, economic and

political systems of the environment. It is an approach that studies the prevention

and treatment of diseases in relation to the social structures in the community. It is

often characterized by government regulation, instead of privatization (Anderson

et al., 2005).

• Socioeconomic Status (SES) and Cardiovascular Disease are directly connected

wherein the social and economic position of an individual translates to his

chances to contract a heart disease. The lower the SES, the higher the risks are for

cardiovascular diseases (Clark, 2009).

14    

Review of Related Literature

Globalization and Cardiovascular Disease

According to the World Health Organization (2013), cardiovascular diseases

(CVDs) are the leading cause of deaths worldwide. In 2008, approximately 17.3 million

people died from CVDs, constituting 30% of the recorded global deaths. Statistically,

more individuals die from CVDs than from any other diseases and illnesses each year (as

cited in WHO, 2011). Furthermore, it is projected that in 2030, the number of deaths

caused by CVDs will rise to 23.3 million and counting (as cited in WHO, 2011; Mathers

& Loncar, 2006). Hence, the stable trend of mortality rates as estimated by the

aforementioned studies proposes that CVDs will still remain as the prominent cause of

overall deaths. Although it has been argued that CVDs are deliberated to be a serious

matter, the general response for its prevention strategies was global neglect.

As presented by Beaglehole et al. (2007), cardiovascular disease is not included in

the global development agenda. In the United Nations Millennium Declaration of

September 2000 (as cited in Fuster & Voute, 2005), three of the eight Millennium

Development Goals specifically tackle health issues. However, it does not include

addressing chronic diseases in its provisions. The exclusion, per se, is startling because

living with a chronic ailment obstructs individual potential for growth and prosperity

(Beaglehole et al., 2007). Also, being chronically ill already disempowers and heavily

burdens the individual including his/her family and community. Much more, while the

contracted disease immobilizes the individual’s capacities to do certain things physically

(Beaglehole et al., 2007), it also affects the socio-economic circumstances of the person.

As a supporting claim to the ‘global neglect’ premise, international aid and

development agencies reasoned out that contracting a cardiovascular disease is a personal

accountability (Beaglehole et al., 2007). They also stated that it is a result of unhealthy

personal choices (as cited in WHO, 2005). However, it is a weak claim because the

accessibility, healthiness and appropriateness of the available choices should be

15    

considered. It widely varies per place as presented and influenced by the social structure

of the community. Thus, it can be established that the impacts of the environment to poor

health, specifically contracting a cardiovascular disease, can also be measured through

the levels of socioeconomic statuses (SES) and other social factors aside from the

economic costs of the chronic diseases.

In comparison, in most high-income countries, social security systems protect

CVD patients up to a certain extent and offer them financial provisions to afford

necessary care (as cited in Moise & Jacobzone, 2007). While in the low and middle-

income countries taking over 80% of CVD deaths (WHO, 2013), the people are left

uninsured or underinsured because the medical insurance systems are hollow and limited.

Hence, cardiovascular disease is a development issue.

In low and middle-income countries, CVD risk factors and other defining social

determinants are more wide-open to the vulnerable people. Even as pointed out by Dr.

Jeff Critchfield, division chief of hospital medicine in San Francisco General Hospital,

the uninsured and underinsured patients are high-risk patients for prolonged ailments

(Beresford, 2011). Also, they are more inclined to resort to frequent hospitalizations and

even readmissions after discharge. Nonetheless, poor people living in such economies

have less access to reachable and quality health service provisions, health programs and

health insurances (WHO, 2013).

According to Beaglehole et al. (2007), cardiovascular diseases and poverty are

interrelated. Chronic diseases, such as CVDs, are tied to the poor as they are more

susceptible to health fluctuations. The more the person is unfortunate, the more he is

prone to contract a heart disease.

Moreover, according to the Health Poverty Action organization (n. d.), poverty

intensifies the risks of having poor health. Likewise, poor health contributes to the

prolonging of poverty towards the people as it negates positive pushes out of the

16    

condition. Furthermore, the primary cause of poverty and poor health can be best

explained in a structural analysis of the society.

First, the quality of the communities where the deprived live appears to be an

endless, spiraling poverty trap. The socioeconomic atmosphere within unfortunate

communities fosters a relatively degenerate situation. Aside from the meager conditions

of the housings, the site locations are mostly hazardous and detrimental to the people.

Likewise, people coming from within are being socially isolated, which translates into ill-

treatment and blind bias. Nonetheless, the limited environment presented by these areas

eliminates the people’s opportunities for self-development and self-help.

A recent study by Johnson (2013) proposed that even the primary institutions such

as schools in the less fortunate communities are passively-oriented. Even the livelihood

sources within the place are low-grade and are sometimes economically non-existent

which forces the people to work ‘outside.’ Moreover, the kind of work with which they

come across pays less than the set standard set by law.

Instead of empowering the people to engage in self-improvement opportunities,

the current social system tends to be a deplorable force against them. Due to the

continuous inefficiencies and misappropriations within these communities, the struggle

for a community-based structure is far from reach. Even so, the welfare of the individual

is harmed by both internal and external forces in the place brought by his or her low

social standing.

Second, the way of life within a poor community differs from its rich counterpart.

The ease of access to readily-consumable resources is not conceivable. For example, in a

study by Johnson (2013), most of the poor live within “food deserts” or areas with no

option of healthy and reasonably-priced food. Nutrition is undeveloped in the community

as it is assumed that in these areas, the food literacy is low. However, food literacy is not

a determining factor in food selection.

17    

For example, the people in poor communities are inclined to smoke more than the

people who live in more developed communities (Heart UK, 2013) as explained by

various social forces present influencing health-related choices the people make. In

addition, the level of participation of an individual in physical activities is another aspect

which determines the vulnerability of a person to chronic health problems.

In relation to this, a study in India identified that some cardiovascular diseases are

called “lifestyle diseases” which are said to be the kinds of problems met with affluence

(Reddy, 2013). The difference in socioeconomic statuses defines the individual’s chances

on healthcare and treatment. Likewise, there is a direct proportion when it comes to SES

and affluence. The higher the SES, the higher the material comfort an individual will

receive. On the other hand, lower SES results in low material comfort.

From a historical context, the impact of the first wave of lifestyle-related

cardiovascular disease risks struck the developed Western countries. However, the

solution was to adopt a practical way of living. Thus, the alteration of the routines

minimized the CVD death rates of the population. As time progressed, disadvantaged

populations and communities became the primary victims of CVD (Reddy, 2013;

Beaglehole et al., 2007).

Although there have been specific cases of people having low SES who live and

benefit within an affluent community, the cardiovascular risk factors were only partially

mitigated and undercompensated (Abeyta et al., 2012). Likewise, as mentioned by Dr.

Ralph R. Frerichs in an article in The New York Times publication (1985) entitled Heart

Disease Tied to Poverty, poverty is responsible for the CVD deaths regardless of the race,

the gender or the affluence. Charles George, the medical director of the British Heart

Foundation, also pointed out that the differences between social classes define the

number of thousands of coronary heart disease (CHD) deaths in the nation each year.

Nonetheless, it has been proven through several CVD statistics that throughout the ages,

poverty is a perilous social health-related risk.

18    

The impacts of poverty with cardiovascular diseases are present in both adults and

children (Stein, 2011). It is proven that prolonged social drawbacks inflicted during

childhood may result into serious damages to the heart in the long run. The accumulated

effects from such drawbacks will possibly deteriorate one’s health in a “wear-and-tear”

injury course on the cardiovascular health of the individual involved (Franks, 2011).

Aside from poverty, ignorance is another crucial aspect in promoting

cardiovascular risks (Adeoye, 2011). Knowledge is important when it comes to disease

prevention and health promotion. As mentioned in a study by the British Heart

Foundation (2012), poor health consciousness is linked with higher death rates. Health

consciousness is heavily dependent on the quality of health informatics people receive (as

cited in BMJ, 2012). Likewise, having progressive and comprehensive health literacy

may be the deciding factor of a person’s life. Moreover, health consciousness can be the

basis of early detection and early prevention of the disease.

For instance in Nigeria, people who live at high-risk areas have low health

literacy rates. This is attributed to any of the following factors: (1) they are too ignorant

to lay-off any risk signals, (2) they are unaccustomed to the symptoms of the heart

disease, (3) they are unaware of the consequences of certain health-related actions or (4)

they are simply noncompliant with the recommended health activities for the promotion

of their heart health (Adeoye, 2011).

Aside from the unawareness of health benefits available, some heart patients do

not apply for health insurances because of the complexity of the application (British

Heart Foundation, 2012; as cited in Ward, 2007). For example, most heart patients find

difficulties to fulfill the criteria of entitlement for defined welfare benefits. Likewise, the

problem is due to the incomprehensibility of the forms, or even the unattainability of the

application, per se.

Additionally, heart welfare systems are interlinked with one another, making it

overly extensive and confusing. While having medical insurances improve the chances of

19    

accessing health services and assistance, the acquisition of a health insurance would not

lead to the coverage of specific cardiovascular conditions. Clearly, medical insurances

may hinder the optimal use of health care services.

As identified by O’Connell et al. (2001) in a research in Albuquerque, New

Mexico, 37% of heart failure admissions were due to the nonconformity of recommended

health actions. Additionally, roughly 21% of it was because of the lack of social

assistance and initiative to resort to pre-medical check-ups for symptoms. The

nonparticipation of the medically indigent and socially excluded patients is caused by the

actual experience or perception of these people towards the overlying health care system

(Asch et al., 2006). Furthermore, when patients experience social, political, and economic

rejections, they will feel traumatized and discriminated, thus, making the health treatment

even more problematic.

In the political, social, and economic policy-making, the people are not placed at

the center of health policies. Through the privatization and urbanization efforts, health

policies are restructured in a way to adapt into a globally-competitive scheme. Public

goods such as health are denationalized, widening the difference in the health inequalities

present in the society.

The economic costs of cardiovascular diseases are already a cause of burden and

the social implications multiply this exponentially. With the contemporary health system

scheme, public hospitals are forced to adjust to price rate hikes, restructure budget

appropriation and forego public interests to make ends meet.

20    

Research Methodology

This study will cover the three primary actors within the cardiovascular healthcare

system, namely: the hospital administration (or the government), the health workers and

the cardiovascular disease patients.

This study will conduct sets of in-depth interviews with qualified doctors and

specialists from the University of the Philippines – Philippine General Hospital, General

Emilio Aguinaldo Memorial Hospital, and Medical Center Parañaque. These set of key

informant interviewees (KII) will be the source of a professional point of view about the

subject matter. Likewise, it will be used to affirm and disaffirm patients’ perception on

health-related behaviors. Through this, the present medical economy and the dominant

health structure it represents will be critically evaluated.

This study will make first-hand inquiries in relation to the experience of

cardiovascular outpatients. It will be followed by a debriefing by the researcher and an

explanation of the study after the participation of the respondents, in order to enlighten

contributors about the purpose and goals of the research. Through this, it may reduce any

possibility of psychological harm or post-traumatic stress to the respondents.

Secondary sources like academic and medical journals and articles and books

from libraries and online sites will also be used as supplementary materials for this study.

21    

Ethical Considerations

This study will analyze and criticize the prevailing health structure in the country.

The researcher will ensure that all the facts and assertions to be specified in the study will

be evidence-based. Likewise, no form of plagiarism or data alteration will be committed.

For the side of cardiovascular health patients, the researcher will be sensitive to

run the interviews. He will also be mindful in interacting with the respondents, taking

into account their level of vulnerability and availability. Likewise, the researcher will

enlighten the respondents on the purpose and benefits of the study.

This study will conduct the interview in a manner that would lend respect, dignity

and security towards the respondents. Lastly, it will guarantee that everything would be

done voluntarily, keeping the respondents’ identities and responses anonymous.

22    

CHAPTER THREE

Background of the Study

Every individual is like an unmolded clay pot, precarious yet shapeable. Apart

from each person’s innate character lies his potential to be fashioned to think, feel and act

in a particular way. By nature, people are designed to socialize, and be socialized. It is a

lifelong practice of acquiring and learning social customs and values in an effort to

participate and integrate in the society.

In relation to health, the individual perceives and accepts health-related decision-

making based on his or her life chances.

Life chances, as supposed by Anthony Giddens, refers to the possibilities of an

individual of gaining access to the limited yet valued outcomes (Breen, n. d.). In the

socialization process, the individual’s positionality in the society factors prominently in

the equation. Power disparities split populations into social groups, or classes, generally

the minority or the elite, and the majority or the masses. Customarily, the former controls

the pool of resources in the society. They promote their own good, strive for their own

advantage, and struggle for their own benefit. As Breen (n. d.) pointed out in reference to

Weber’s (1978: 53) work: “…power is the probability that one actor within a social

relationship will be in a position to carry out his own will despite resistance, regardless of

the basis on which this probability rests…” In relation to this case, the poor are deprived

of influence and control – a clear-cut representation of the concept of social inequality.

The pillars in which our social institutions are founded are structured in such a

way that it will serve the interest of the exclusive privileged groups. Needless to say, in

terms of social mobility, the underprivileged and underrepresented classes have

diminished chances, thus, receiving reduced outcomes. In view of that, an individual’s

positionality, per se, dictates his life chances. Hence, it could be concluded that the better

social location would lead to better life chances. Likewise, the better life chances, the

better the health autonomy.

23    

Denationalization of Public Health

According to Dr. Edelina P. Dela Paz (2015), during the 1970s, the public health

system was better, more cost-friendly and more efficient than it is today. Since the

government continuously funded the country’s health budget, the health institutions were

further developed. This made hospitals and health centers more competent and more

accessible. Likewise, health access was catered to the needs of the majority of the people.

However, in the 1980s, the public healthcare delivery started to gradually decline

while the number of patients consistently grew year after year. As the rate of returns was

minimal, the government pushed for the privatization of the public health system. They

subcontracted medical services and sold hospitals’ rights to private companies (Nisperos,

2015). A concrete example of which is the building of central blocks in hospitals (Dela

Paz, 2015).

The conception of creating a central block in the hospital included the

construction of private rooms, which was a way to compensate for their costs and losses.

This further separated the hospital tenants into two classes, namely: the paying class and

the charity class. Through this, health patients began to experience discrimination based

on their socioeconomic capabilities. Not only does the system economically categorize

the people, but it also socially excludes them in the provisions of healthcare delivery.

Such was the case of the Philippine General Hospital (PGH) wherein the central

blocks were primarily built to help subsidize and assist indigent patients. However, in the

transitional phase of the new policy, most patients experienced difficulties adjusting to

the price changes. In effect, indigent patients did not have the financial capacity to make

ends meet. During the 1990s, alongside the increasing number of indigents, the costs of

health services continued a stable, upward trend (Dela Paz, 2015). This trend persisted in

the country’s public health system to date.

24    

Roughly three years ago, health patients were categorized according to their

capacity to pay (Dela Paz, 2015). The categories ranged from Class A to D; with each set

having different measures for benefits and assistance. In Class A, the health patients are

required to fully pay for the healthcare services they need. Class A patients are also

considered to be part of the paying class. In Class B and Class C, the health patients are

required to pay part of the charges of the corresponding health services. Although the two

classes have similar benefits, the latter costs less. Lastly, in Class D, the health patients

are encouraged to avail of “charity” care. In this class, the health patients are treated as

indigents.

In theory, this kind of hospital management, supposedly, can support those

patients who experience financial difficulties. However, in reality, this setup brings

together impediments such as tedious application process, absurd criteria for

qualification, uneven distribution of services within the low class groups, and the

deteriorating performance of health services. Likewise, the proposed benefits of the

central blocking system did not materialize. On the contrary, it even made the public

health system more problematic than before.

Distressing Cardiovascular Problems

Indigent patients are conceivably more vulnerable individuals than most cases.

Being poor subjects the person to various forms of deprivation that are deleterious to their

well-being.

In Figure 2, the World Health Organization (n. d.) indicated that out of the

449,000 total deaths in the Philippines in 2002, 57% of it, roughly 253,000, were related

to chronic diseases. Cardiovascular diseases, the leading cause for most ill-health-related

deaths, accounted for 27%. Likewise, diabetes, also a contributing factor to

cardiovascular-related problems, accounted for 3% of the statistics.

25    

 

Figure 2. Deaths by cause, all ages, Philippines, 2002

(Source: World Health Organization)

In Table 1, the statistics determined that both the diseases of the heart and the

diseases of the vascular system are the leading causes of mortality in the country.

Mortality from heart disease cases averaged about 82,290 from 2004 to 2008, while

mortality from vascular-related disease cases averaged 55,999. In 2009, the incidence

from both statistics increased by 18,618 cases, or about 22.6%, and by 9,490 cases, or

about 16.9%, respectively.

26    

CAUSES

5-Year Average

(2004-2008) 2009

Number Rate Number Rate

1. Diseases of the Heart 82,290 94.5 100,908 109.4

2. Diseases of the Vascular System 55,999 64.3 65,489 71.0

3. Malignant Neoplasms 43,185 49.6 47,732 51.8

4. Pneumonia 35,756 41.1 42,642 46.2

5. Accidents 34,704 39.9 35,990 39.0

6. Tuberculosis, all forms 25,376 29.2 25,470 27.6

7. Chronic lower respiratory diseases 20,830 24.0 22,755 24.7

8. Diabetes Mellitus 19,805 22.7 22,345 24.2

9. Nephritis, nephrotic syndrome and

nephrosis 11,612 13.4 13,799 15.0

10. Certain conditions originating in the

perinatal period 12,590 14.5 11,514 12.5

Table 1. Heart Disease Statistics: Top Cause of Mortality

(Source: Philippine Health Statistics (PHS), 2009)

Table 2 presents a mortality rate trend due to the disease of the heart from the

years 2005 to 2009. It indicated that there had been an increase of cases with an

approximation of 1,000 cases in every region (excluding ARMM).

27    

REGIONS 2005 2006 2007 2008 2009

NCR 13,636 14,741 14,935 14,990 15,985

CAR 789 921 973 1,030 1,171

I 5,149 5,672 5,984 6,445 7,044

II 2,768 3,078 3,055 3,204 3,474

III 9,925 10,419 12,221 12,430 14,121

IV-A 11,912 12,412 13,739 13,599 14,783

IV-B 1,543 1,748 1,919 2,038 2,187

V 5,292 5,732 6,134 5,886 6,724

VI 6,830 7,215 7,608 8,455 8,843

VII 6,366 6,636 6,408 6,754 7,824

VIII 2,770 3,339 3,428 3,737 3,770

IX 1,748 1,912 1,975 2,365 2,605

X 2,558 2,726 2,972 3,190 3,785

XI 2,237 2,451 2,825 3,323 3,695

XII 1,550 1,835 2,019 2,290 2,631

CARAGA 1,378 1,603 1,450 1,644 1,855

ARMM 515 595 618 711 340

Table 2. Mortality Rate Trend Deaths Due to the Diseases of the Heart

(Source: Philippine Health Statistics (PHS), 2005-2009)

28    

CHAPTER FOUR

Presentation and Discussion

With the modern technological advances in the medical field, difficulty in the

diagnosis and treatment is minimized. Likewise, in a medical diagnosis, the patient

undergoes a 4-way stage test. First, the patient will consult a health worker or a doctor

about his health complaint. To further probe into the patient’s present condition, a brief

situationer of his own and his family’s past health conditions will be considered through

the evaluation of their medical records. After which, the physician will advise the patient

to undergo physical examination, general laboratory tests, and imagery. Once the results

come out, the physician will make scientific deductions through the connections made

from the data presented. The patient will then be advised to take other definitive or

specialized examinations. Though this kind of diagnostic process is scientific, accurate

and empirical, it is limited to the data presented without figuring the root causes of its

existence.

Likewise, CVDs are prompted by the combination of several modifiable and non-

modifiable health risk factors.

Victims of Cardiovascular Diseases

Modifiable risk factors1 are the controllable variables which are highly dependent

on the individual’s health-related behavior. These include hypertension, tobacco use,

diabetes, obesity, and physical inactivity (World Heart Federation, 2012).

Hypertension, or high blood pressure, is the paramount cause of CVDs worldwide

(World Heart Federation; as cited in Mendis, Puska and Norrving, 2011). Often, it has no

                                                                                                                         1  According  to  Better  Health  Channel  (2005),  depression,  social  isolation  and  the  lack  of  quality  social  support  belong  to  this  category.  

29    

symptomatic manifestations, thus, it comes unnoticed. It is influenced by one’s eating

habits, daily routines and even climate changes. Due to the rapid pumps in the blood, the

heart and arteries will be overworked which will result in blockages, leading to heart

failure (Better Health Channel, 2005). Table 3 indicated that in 2012, hypertension

accounted for 512,604 cases, which was third among the top causes of mortality in

the country.

Diseases Number of cases Rate per 100,000

population

1. Acute Respiratory Infection 2,793,066 2,876.0

2. ALTRI & Pneumonia 569,122 586.0

3. Hypertension 512,604 527.8

4. Bronchitis 338,789 348.8

5. Urinary Tract Infection 276,442 284.7

6. Acute Watery Diarrhea 235,110 242.1

7. Influenza 232,584 239.5

8. TB Respiratory 93,094 95.9

9. Acute Febrile Illness 85,471 44.7

10. Dengue Fever 44,172 45.5

Table 3. Top Cause of Morbidity

(Source: Field Health Science Information System 2012)

   

  Tobacco use, or smoking, is not just a cause for lung cancer, but for CVD as well.

It is estimated to be causing nearly 10 percent of all CVDs (World Heart Federation; as

cited in Mendis, Puska and Norrving, 2011). Not only does it reduce the oxygen in the

blood, it also contaminates the supply, weakening the artery walls, making them stickier,

and then slowing down the blood flow due to clumped blood cells (Better Health

Channel, 2005). This in turn may cause blockages, leading to heart attacks, angina (chest

pain) strokes and peripheral arterial damages.

30    

Diabetes, or raised blood glucose, also increases the cardiovascular risks of an

individual. There are two types of diabetes: type 1, which is formerly known as insulin-

dependent or juvenile-onset diabetes; and type 2, which is formerly known as non-

insulin-dependent or mature-onset diabetes (Better Health Channel, 2005). The lack of

recognition, understanding and mitigation of this condition would lead to severe

complications with the heart (World Heart Federation; as cited in Mendis, Puska and

Norrving, 2011).

Being overweight or being obese is an indicator that individual is prone to have

health problems such as hypertension and diabetes. In a report made by the Food and

Nutrition Research Institute (n. d.) entitled What is the current nutritional status of

Filipino adults?, it has been proposed that in every 10 adult Filipinos, three (31.1%) of

them are overweight and obese. Likewise, in Figure 3, the study also indicated an

expected increase in body mass index (overweight and obesity) in both men and women

from 2005 (base year) to 2015 (anticipated year).

31    

 

Figure 3. Projected prevalence of overweight, Philippines, males and females aged 30 years

or more, 2005 and 2015 (Source: World Health Organization)

In a span of 10 years, the increase in the number of overweight women rose up to

as much as 10 percent. On the other hand, the number of overweight men rose by only

one percent. The growth rate represents a rising trend of obesity in the country. Likewise,

the study showed that the raised body mass index is directly proportional to the factors

which induce chronic diseases.

According to the study co-edited by Mendis, Puska and Norrving (2011) entitled

the Global Atlas on Cardiovascular Disease Prevention and Control, physical inactivity,

or leading a sedentary lifestyle, is the fourth leading risk factor for cardiovascular

diseases. It can be defined as less than the standardized ratio of moderate-to-vigorous

activity per week, less than 5 times a week and less than 3 times a week, respectively. It

32    

was also verified that insufficient physical activity leads to a 20 to 30 percent increased

threat of all-cause mortality compared to people who live more actively.

Social Determinants of Health: The Inconspicuous Stimuli

The social determinants of health (SDH) are factors which pertain to the social

and environmental conditions in which an individual’s wellbeing is continually shaped.

Health risks may take place even as early as one’s formative years. The physical

manifestations may or may not be evidently seen during the course of one’s lifespan.

However, these impressions are accumulated through time, increasing the risks of

contracting such diseases later in life. As how Lang et al. puts it:

We have to bear in mind that every risk factor is a link in a chain that we can sometimes, but not always, piece together from end to end. The biological “downstream” effects of risk factors are accepted and integrated. But the notion that there is an “upstream” cause in this causal chain is examined much less often. For example, the various SDH are not limited to the personality of an adolescent who starts to smoke, but integrate that adolescent’s behaviour within a wider social, economic and societal context. These causal chains may link back to what we consider “fundamental” causes, which we find at the origin of many diseases or behaviours. These fundamental causes include factors such as social environment during infancy, level of education, income, economic and social policies, and education policies (2012, p. 604).

The influences of the social environment wherein the individual grew up, studied,

worked and lived in contribute to the improvement or deterioration of one’s well-being.

In Figure 4, it has been argued by Dahlgren and Whitehead that every individual

is fixated at the focal point of health influencers (HEART UK, 2013).

33    

Figure 4. The Determinants of Health by Dahlgren and Whitehead

(Source: HealthKnowledge)

Human beings are endowed with particular characteristics2, which as expected,

would naturally influence their cardiovascular health. These risk factors are then further

aggravated by the personal health-related choices that an individual makes. It involves

the individual’s way of life, daily routines, and habits.

Since every person is a product of the community, he or she, as well as his or her

health outcomes, is also affected by the impacts imposed by his social support groups.

For example, if an individual lives in a community of chain smokers, that person would

have a stronger urge to smoke as well. Supposing that the person resides in a community

that is filled with alcoholics, he or she would also have the tendency to drink more. In the

same manner, if an individual is surrounded by unhealthy eaters, the person would most

                                                                                                                         2  These  characteristics  pertain  to  the  non-­‐modifiable  health  risk  factors  that  affect  an  individual’s  risks  of  having   cardiovascular   diseases.   These   include   a   person’s   age,   ethnicity,   gender,   family   history,   and   the  like,  which  are  pre-­‐determined  biologically.      

34    

likely do the same. Likewise, if the people in the community would exercise healthy

living, the individual would also be inclined to do so.

The next layer refers to the structural conditions which affects health. These

factors are commonly measured in terms of the quantity and quality of opportunities

received by individuals. However, in most cases, the poor suffer dehumanizing

conditions than most people do. Likewise, as stated in the position statement of the

Australian Medical Association entitled Social Determinants of Health and the

Prevention of Health Inequities:

“Disadvantage has many forms and can be absolute (e.g. not having access to education or suffering from unemployment), or relative (e.g. poorer education, insecure employment). Each of life’s many transitions - such as leaving school, getting a first job - can affect health by moving people onto a more advantaged or less advantaged path. People who have been disadvantaged in the past are at greater risk in every subsequent transition. Disadvantages tend to congregate among the same people and their effects tend to accumulate through life and are passed on from generation to generation (2007; as cited in WHO Europe, 2003).

Moreover, everyone is exposed to various stimuli, thus, health paths are at

variance. For instance, a rich person, who is well-educated and well-employed, would be

able to access greater opportunities for self-development. On the other hand, a

marginalized person, with a limited access to education and employment due to

privatization and labor crises (e.g. contractualization, low wages, minimal work

incentives), respectively, would only be able to engage with substandard opportunities.

The presence of socioeconomic handicaps in the society further demarcates the health

inequality gap between social groups. Poor people, therefore, are subjected to continued

social ostracism, thus, leading to social phobia. Likewise, it is important to note that there

are disparities within each social cluster3.

The last layer refers to the conditions which influence the society as a whole. The

government creates health and social policies based on the public’s needs. Since people

are socialized within the dynamics of the community, they are exposed to different

                                                                                                                         3  See  epidemiological  polarization  

35    

socioeconomic (opportunities based on the differences in status), cultural (opportunities

based on cultural variations), and environmental (opportunities based on the exposure to

external hazards) variables. With this in mind, they develop risk vulnerabilities to such

diseases based on the conditions it presents. However, it is more often than not that the

poor experience adverse conditions.

However, whichever the case may be, both the rich and the poor have equal risks

and vulnerabilities in contracting a cardiovascular disease (Alix, 2015; Misa, 2015; Villa,

2015). In contrast to the popular belief, affluent persons have greater risks since they live

more lavish lifestyles than the underprivileged. However, since there are no or minimal

means to “intervene” with the poor, they suffer longer with the negative impacts of the

disease (Alix, 2015). Thus, the poor population struggles longer and suffers more.

Hidden Expenses

Physical Work

Contracting a cardiovascular-related disease is a life-changing experience. Upon

diagnosis, the individual has the responsibility to actively police his or her health choices.

Some conditions have the ability to limit the individual to participate in physically-taxing

activities. After a pronounced manifestation of the disease, the individual is restricted to

carry out tasks he or she was accustomed to. In some cases, the individual may

experience gradual physical deterioration, or physical incapacitation. In due course, this

would lead to the complete dependence of the individual towards his social group.

Thus, if the ability to perform physical labor is deferred, the individual’s

economic productivity would be compromised.

36    

Economic Work

In the medical economy of the Philippines, one of the most criticized features is

its user-fee scheme. Since it is assumed that every patient has the ability to pay for the

services, hospitals would address health needs provided that it be remunerated first. This

pay-first policy, better known as out-of-pocket expenditure system, requires the patient to

shoulder a bulk of the expenses necessary for the treatment. Nisperos (2015) argued that

the Philippine health system protects patients with insurance coverage. However,

approximately 60–70% comes from out-of-pocket expenses, far more than the projected

seven percent. As this method imposes a substantial financial demand, the poor, who lack

an established economic source, cannot easily access these health services.

Likewise, the costs of services may vary depending on the intensity and extent of

each case. A patient may possibly spend from a quarter of a hundred thousand pesos (₱

25,000) to almost more than a million (₱1,000,000) in total. Aside from the high cost of

hospitalization, cardiovascular-related treatments are delicate procedures. Thus, to

perform procedures, doctors use high-end equipment and prescribe high-priced drugs.

Since the health system is widely commercialized, patients are forced to contend with

higher health spending4. All the more, those indigents have greater health needs.

Table 4 presents a breakdown of a doctor’s prescription for a patient who had

undergone a Coronary Artery Bypass Surgery (CABS).

                                                                                                                         4  Health  spending  is  completely  case-­‐dependent.  For  example,  an  inpatient  has  a  higher  health  spending  than  an  outpatient  due  to  the  costs  of  the  hospital  accommodation  (e.g.  a  confined  hypertensive  patient  pays  more  than  a  hypertensive  patient  who   is  not.).  Unlike  outpatients,   they  are  required  to  undergo  a  fixed   set   of   tests,   surgeries   (if   necessary)   and   medication.   Although   there   is   an   option   to   refuse   the  treatment,  they  are  still  entitled  to  pay  charges  that  were  already  accumulated  during  the  period  of  their  stay.    Aside  from  this,  they  are  also  required  to  pay  additional  yet  “unnecessary”  fees.  In  some  hospitals,  they  take  into  account  almost  every  single  material  used  in  the  course  procedures.  Aside  from  the  actual  use  of  medicines   and   fluids,   they   even   tally   the   number   of   cotton  balls,   tissue   rolls,   packs   of   syringes,   pair   of  gloves,  face  masks  and  robes,  and  bottles  of  disinfectants,  and  add  it  into  the  aggregate  bill.    

37    

Name of Medicine Purpose Guidelines for Intake Price in Market

(per piece)

Metoprolol 50mg

(Cardiosel) Hypertension

Two tablets a day (one

tablet per time5) ₱ 4.15 (x 2)

Aspilet 80mg Blood Thinning One tablet per day ₱ 2.65

Imdur 30mg Prevention of

Myocardial Pain

One tablet per day

(1/2 tablet per time) ₱ 27.50

Crestor 5mg (Rosuvastatin) Cholesterol One tablet per day

(taken before bedtime) ₱ 30.25

Lipanthyl NT 145mg Good

Cholesterol

One tablet per day

from Friday to Sunday

(taken before bedtime)

₱ 49.00

Sangobion capsule Iron Supplement

One capsule per day

(Mondays,

Wednesdays and

Fridays only)

₱ 19.25

TOTAL (Aggregate Per Day) ₱ 136.95

Table 4. A CABS Patient’s Quotation of Prescribed Medicines

                                                                                                                         5  The  intake  of  medication  is  done  two  times  during  the  day:  one  in  the  morning,  another  in  the  evening.    

38    

As clearly seen in the table, in any given day, the patient has to spend at least ₱

64.55. At most during Fridays, the patient has to fully pay ₱ 136.95 to meet the terms

prescribed by the physician. Doctor Oliver C. Alix (2015) and Dr. Corazon A. Villa

(2015) commonly agreed that pharmaceutical drugs are not expensive6; rather, they

remain financially reasonable. However, since a cardiovascular condition is a lifelong

concern, patients are forced to cope with the continuous drug intake (e.g. maintenance

drugs, supplements, vitamins). Hence, more drugs equate to more expenses. Since buying

medicines are cost-burdening, most patients become vulnerable to irrational drug use7.

The urgency of this health action alone strains the household resources, especially

for someone who earns a net income less than the minimum wage; the allocation for

medication would take a considerable amount of the budget. Since indigents are

financially crippled, they are compelled to limit their expenses on other basic social

requirements such as food, shelter, education, and clothing. In due course, their economic

development would be deferred.

Emotional Work

Cardiovascular disease patients, as well as their families, suffer from an emotional

stress. The hardships of dealing with the situation test their mental and emotional

strength. In the long run, the emotional exhaustion will lead to negative physical and

economic manifestations, thus, aggravating the circumstances even further. With stress as

a major contributory factor, the household productivity – as an economic and social unit

– would likely collapse.

                                                                                                                         6  Nisperos  (2015)  argued  that  the  drug  industry  in  the  country  is  more  import-­‐oriented.  The  government  invests  in  foreign  companies  for  medication  (Misa,  2015)  rather  than  investing  on  national  drug  industries.  Likewise,  companies  place  patents  on  drugs,  giving  them  the  right  to  control  prices.  They  place  about  20  years’   worth   of   patent   on   medicines.   Dela   Paz   (2015)   emphasized   that   this   was   a   way   for   private  businesses   to   profit.   It   was   estimated   that   the   return   on   investment   (ROI)   would   only   take   five   years.  Thus,   the  extra  15   years   left   on   the   contract  would  be  used   for   self-­‐interest.  At  present,   the  prices   for  generic  medicines  here  in  the  Philippines  are  relatively  higher  than  most  countries.    7  In  some  cases,  patients  consume  drugs  irregularly  to  save  money  (e.g.  drinks  medicine  behind  schedule,  halves  the  pills  or  tablets,  buys  drugs  irregularly)  

39    

To further support the correlation of the facts stated above, the following cases are

predisposed to prove the adverse implications brought about by different CVD cases.

 

Case #1

Edgar, who is a 57 year-old hukom ng barangay, provides solely for his family

of three. His wife, Eden, is a housewife, while his youngest daughter, Cess, is a

graduating BS Office Administration major at Cavite State University (CSU). Edgar

earns merely ₱ 600 per month, considering the demand for his work. Though Edgar’s

family is supported by Cess’s older sisters working at Dubai, it is not sufficient to

cover the household’s aggregate expenses.

On September 2014, in an untimely instance, Edgar suffered a heart attack.

Shortly, it was followed by indications of several heart complications. At first, they

had difficulties in finding either a hospital or a health center near their home at Trece

Martires City, Cavite that would accommodate his case. Even though a hospital in

General Trias already applied first aid to Edgar, he was still endorsed to seek out help

in the Philippine General Hospital (in Manila). Both the hospital accommodation cost

and the lack of hospital facilities were seen as the family’s primary concerns. As a

result, the family had no choice but to follow the referral.

Bearing in mind the physical distance between Cavite and Manila (aside from

the urgency of his condition), Eden and Cess sought for barangay assistance to bring

Edgar to Manila via ambulance. After arriving at the PGH, Edgar was placed at the

Emergency Room. However, it was hours (from 12 midnight to 10 in the morning)

before he was attended to by the doctors. Fortunately, he was given treatment and was

sent to a ward. They have been encouraged to avail the charity care package provided

by the hospital. However, due to the deficiencies of the policy, they are still forced to

pay a substantial amount of the medical expenses using their disposable income.

Edgar was diagnosed with a stroke. The right half of his body was completely

immobilized. This required him to depend on the use of a wheelchair. It also impaired

his capability to talk. This made communication a burden. As a result, these

deficiencies made him physically reliant on his family.

 

40    

Socioeconomic Implications

During Edgar’s one month of confinement in a PGH ward, they have already used

an estimated total of ₱ 50,000 alone. As he struggled to improve his condition, he

underwent weekly therapy priced at ₱ 150 every session. For maintenance medication, he

also paid around ₱ 1,800 monthly (takes medicine four to five times a week). Even

supposing that Edgar is still working, his ₱ 600 salary would only be able to pay for

therapy or for minute portions of the medical bills. Furthermore, despite the fact that her

daughters abroad give an approximate ₱ 12,000 – ₱ 17,000 worth of allowance per

month, it is still not enough.

The case of Edgar could be considered as a form of patient dumping8. The

criticism in the particular issue presented is centered at the backwardness of public health

institutions, mostly those that are based in the rural areas. In rural health clinics, for

example, the equipment are limited and underprovided. Eden even mentioned that the

lack of rooms and the unavailability of particular services in the nearest hospital, General

Emilio Aguinaldo Memorial Hospital (GEAMH), have driven them to consider hospitals

elsewhere like the PGH.

Since the public health system is “specialist-oriented” rather than “general-

oriented,” the role of rural health clinics and community-based health centers is

overshadowed. Nisperos (2015) pointed out that a step-by-step progression should be

followed in seeking medical help. First, the patient should go through proper diagnosis

through a community hospital. If the condition would not yet be settled, then he would be

referred to a provincial/municipal hospital. However, if the condition is complex that

would need a specific, advanced treatment, he then would be encouraged to go to a

specialized hospital. In the case of the PGH, patients from all over the country, including

those patients who are deeply-stricken with chronic diseases, are accommodated. The

                                                                                                                         8   Patient   dumping   refers   to   the   premature   rejection   of   indigent   patients   by   hospitals   (who   are   fully  capable  of  treating  and  accepting  patients)  due  to  economic  concerns.  This  phenomenon  pertains  to  the  transfer  of  patients  from  a  hospital  to  another  (e.g.  Private  hospitals  commonly  transfer  patients  to  public  hospitals,  who  charge  much  cheaper.).  

41    

primary push factors for this occurrence are because of the insufficiencies of other state

hospitals and the unfitness of community health institutions in catering even to the most

basic health needs of the people.

In the course of emergency cases, patients are classified in a triage category,

which are based on the clinical urgency of their conditions. Clinical urgency pertains to

patient prioritization based on the criticality of the case of the patient, to determine which

patient would be treated first. This method helps doctors and nurses to prioritize their

workload efficiently and systematically. This, likewise, allows patients to know how long

they would have to wait to receive care. However, in the situation of Edgar, he had to

wait 10 hours in spite of his obvious clinical urgency.

According to Cess, there was no actual assurance whether or not her father would

be given care as soon as possible. She was very displeased with the way the hospital

handled the situation of his father, noting the possibility of her father dying at any given

time. Cess also mentioned witnessing other patients in the room die at their bedside

without receiving any medical attention at all. This led her to say that, “Hihintayin na

lang ba namin mamatay si Papa? (Are we just going to wait for dad to die?)”.

Aside from Cess, Eden had continuously nagged different doctors and nurses in

the hospital to check on her husband. However, her requests were often met with

frustrating or irritating responses. If not answered in a high-pitched voice, a reply of

“Titingnan namin mamaya (Let us look it up later.)” or “Mayroon pa akong mga

pasyenteng inaasikaso (My hands are full attending to other patients.)” would be ushered

back to people like Eden. According to her, “Sobrang nakaka-stress magbantay, baka

pati kami magkasakit na sa kakaisip at kakaproblema nito (Being a watcher is so

stressful that even us might get sick of our constant worrying about this matter.).” As a

result, both Eden and Cess experienced chronic stress and psychosocial trauma.

However, in the PGH health workers’ defense, they also experience having an

overtaxed brain. As health intermediaries, they carry double burden presented by the

42    

working conditions. Doctor Cherie A. Tecson–delos Santos, a doctor from the Philippine

General Hospital, pointed out in her feature article entitled On the UP-Philippine General

Hospital’s lack of an ‘ounce of compassion’ that:

The healthcare staff literally gives their own blood to patients whose lives depend on it. They sacrifice time away from their own families, miss important events in their loved ones’ lives, miss seeing their children grow, work to the wee hours of the morning with barely an hour’s worth of sleep, and suffer each and every single time they lose a life. Most of them do not even get any compensation from the hospital. Yet, every morning, they dust themselves up and go through the same cycle again in the hopes of helping a stranger in need. PGH workers are hostages to a system that cannot sustain the population that it serves. It does not have the best conditions, and it intermittently makes a monster out of the saintliest of saints, but working in it, for the most part, collectively brings out the rawest sense of humanity: the desire to save another human’s life, at the expense of one’s own well-being (2014).

Healthcare workers are “hidden victims” in the healthcare system. Since indigent

patients are socioeconomically disadvantaged, the health staff shoulders bills using out-

of-pocket spending to pay for laboratory procedures and medical prerequisites like

neuroimaging, OR services and antibiotics. They, likewise, are more susceptible to

transmittable viruses because of the physical contact and aerial exposure to such, and the

persistent weakening of their immune system due to prolonged stress and irregular rest

patterns.

Parallel to the case above, delos Santos also mentioned in her article specific

problems encountered in the hospital, stating that:

PGH units tend to 60 patients in a 40-patient capacity ward. The ER continuously admits the sick, even when some of them are left with no recourse but to sleep on cardboards on the hallway. Only 2-3 nurses and doctors go on duty in a ward with 45 beds, half of whom should be admitted in an ICU (2014).

The hospital wards are overpopulated. According to her first-hand experience, the actual

number of housed patients in a ward exceeds the room capacity by fifty percent. The

hospital bed-to-patient ratio is disproportionately allocated, whereas bed sharing, even at

high-risk diseases ward, is an inevitable option. In addition to the wards, even the ER is

also overcrowded and, thus, manifests similar problems.

43    

As a whole, the hospital environment is poorly ventilated, badly lit and awfully

sanitized – below the accepted relative standard. Aside from the physical deficiencies of

the hospital, the overall health human resources distribution is widely disproportionate.

With the absence of a stable source of income, the economic security of the

household has been compromised. The family, therefore, needs to exhaust their

lifesavings to pay off several expenses such as the emergency fee, diagnostics’ fee,

professional fees, fees on maintenance medication, fees on follow-up checkups, and

overdue bills and loans, and so on. Given their situation, they are forced to find

alternative sources to pay off their dues. With no one in the family with a health

insurance, they must shoulder every medical expense.

Because Edgar can no longer assume the headship of the family, Cess would take

responsibility for this position (as Eden has no stable source of income). This case

represents the dynamics of a female-headed household (FHH)/female-maintained family

(FMF) as an effect of cardiovascular diseases. Female-headed Households experience the

feminization of poverty. Both a woman and a head, Cess is highly susceptible to suffer

the perils of the multiple burdens of the disease. Moreover, a female head who is living in

poverty would likely suffer more than a woman who is fairly well-off. Aside from the

limited employment opportunities for women, they also earn rather less than men. In the

labor sector, this could be measured by assessing the gender pay gap9. Due to the

patriarchal makeup of the society, women, as well as the social minorities, are given

prejudiced treatment. Likewise, women do not only experience subjectivity in their place

of work, they are also subjected to reduced capacities in relation to health and

decision-making.

                                                                                                                         9  According  to  the  Organisation  for  Economic  Co-­‐operation  and  Development  (2013),  the  gender  pay  gap  refers  to  the  difference  between  the  incomes  of  men  and  women  for  the  same  task  or  work  effort.    It  is  recognized  that  the  wage  gap  is  measured  by  multiple  causes  ranging  from  the  actual  hiring,  through  the  wage   negotiations,   and   to   the   incentive   systems.   It   is   also   known   for   its   other   terminologies,   namely:  gender   wage   gap,  male-­‐female   income   difference,   gender   gap   in   earnings,   gender   earnings   gap,   and  gender  income  difference.    

See  also  glass  ceiling.  

44    

As she is graduating the following year, Cess would take the opportunity of

working at Dubai to be able to provide for her family’s needs.

Case #2

Maria, a 61 year-old retired factory employee, co-provides with her husband

by selling goods in a self-owned sari-sari store in Cavite. They primarily use their

earnings just for the two of them, but sometimes Maria lends a portion to their

relatives and friends who are in need. However, even though their profit is

indeterminate (varying from day-to-day), they handle their expenses relatively with

ease.

In the year 2013, there was a day when she just suddenly felt numbness across

several parts of her body. She could also feel tightness within her chest area. Soon

after, she began to feel weak, sensing fatigue and exhaustion. Without thinking twice,

she had it checked the following day. According to the doctor’s diagnosis, there were

several indications of cardiovascular blockages. As a result, she was confined for a

couple of weeks. She was given the necessary treatment, and then, was given the

clearance to be discharged.

However, after a year, she was required to complete a medical examination to

serve as a follow-up on her condition. She underwent several tests like 2D echo,

ultrasound, and CBC (complete blood count) test. To her surprise, the results

confirmed that she had already suffered a mild stroke before, and now, an

enlargement of the heart.

From then on, she is careful with what she eats. She also attends Zumba

classes during her free time. But amidst all that, it does not change the fact that Maria

shelled out more than a hundred thousand pesos (> ₱ 100,000 and counting) to pay off

her medical expenses.

 

45    

Socioeconomic Implications

Maria is a PhilHealth member. However, as she could recall, she paid ₱ 45,000

from her ₱ 70,000-hospital bill, approximately 64% coming from her disposable income.

For anyone who earns ₱ 190/day10, it would take that person eight months to pay with a

gross income of ₱ 45,600 (₱ 190 x 30 days = ₱ 5,700; ₱ 5,700 x 8 months = ₱ 45,600) to

settle the bill. Noting that Maria earns inconsistently, she is, by all accounts,

economically unstable, thus, paying the bills would be an automatic burden. Likewise,

she expressed her grief when she mentioned that she had a cousin who needed to pay

around ₱ 500,000 worth of medical expenses in the PGH. Even supposing that her cousin

is also a PhilHealth member, ₱ 320,000 would still come from out-of-pocket expenses

(assuming that the patient would also get a 36% PhilHealth coverage).

                                                                                                                         10  This  is  the  daily  wage  rate  of  a  retailer  in  Trece  Martires  City,  Cavite.    

46    

Comparative Subcases:

(1) Ram, a 46 year-old high school teacher, provides solely for his family of six. In his

26 years of service in teaching, his starting salary of ₱ 3,102/month have increased

up to ₱ 33,000/month. On March 4, 2015, his speech unexpectedly became slightly

abnormal. If it was not for his wife, he would not be able to recognize the

unexpected change. Soon after, a creeping numbness moved in the right half of his

body. Since they suspected that it may be a stroke, they had it checked the next

day. According to the doctor, he was advised to take maintenance drugs regularly,

as well as to undergo weekly therapy. However, his salary is not enough to

compensate for the expenses on other basic necessities. Their family is also

burdened with bills and loans, thus, placing health spending as the least priority.

Despite the fact that Ram is PhilHealth-insured, he still had to disburse ₱ 12,000

from the ₱ 35,000 billing.

(2) Janet is a newspaper peddler who earns a rough estimate of ₱ 100 a day. In an

unfortunate timing, she suffered a stroke which immediately required her to

undergo intensive care (in the ICU). However, the hospital did not readily

accommodate her because of the inability to pay a down payment worth ₱ 25,000.

Although Janet is a PhilHealth member, she was not subsidized since she did not

pay her premiums regularly. Aleta Manzano, Janet’s niece, said that if they are

going to wait for the remittances abroad, her aunt might die. Aleta offered her car

as collateral to the hospital, but it was rejected. She also called their relatives and

friends for help to get the money for the deposit. Eventually, after trying different

means possible, she earned the required cash. However, their efforts were useless

as Janet died four days after in the hospital. Even in Janet’s short hospital

confinement, the family had disbursed more than ₱ 30,000 a day, inclusive of

medicines, room rate, and doctors’ fees. However, according to Aleta, it was

exclusive of the ₱ 12,000 a day in cash the family had to pay on top of the bill.

With an estimate hospital billing of ₱ 200,000, even the family had difficulty

getting Janet out of the morgue. (Based on an article cited in the DOH website

entitled “PhilHealth policy cannot cover all medical expenses” written by Kirstin

C. Bernabe)  

47    

The common denominator among these four cases is that all of them have health

insurances. However, the benefits that they receive from their health insurances (if they

were even subsidized by it) are inadequate. The following inferences further show the

problems with this scheme.

Criticisms

1. PhilHealth members are required to pay premium contributions11

monthly.

Although premiums are only valued at ₱ 20012, not everyone has the

capacity, or even the willingness to pay for it. Such was the case of Janet.

Even so, Dela Paz argued that:

Sa akin, hindi mo kailangan magbayad ng premiums kasi kung wala ka na ngang pambili ng pagkain, tapos poproblemahin mo pa yung premiums, talagang pagpunta mo ng hospital hindi ka aasikasuhin. Ano yun, wala kang ganung karapatan? It negates the basic right of every individual for health, when it should be provided on the onset of service. (For me, you do not need to pay your premiums anymore because if you cannot even sufficiently pay for your sustenance, then you would worry about paying your premiums; it is for sure that when you go to the hospital, they would not help you. Does that mean you do not have kind that right? It negates the basic right of every individual for health, when it should be provided on the onset of service.) (2015).

The failure to pay for these premiums would lead to the removal of the

member’s health benefits. The successive inability to contribute premiums

would also lead to further penalty (e.g. additional charges). If this was the

case, PhilHealth, therefore, precludes financially deprived people from getting

quality care.

                                                                                                                         11  Premium  contribution  is  the  term  used  for  the  regular  payment  to  PhilHealth.    12  ₱  200  is  the  lowest  possible  total  monthly  premium  available  (for  salary  bracket  ₱  8,999.99  and  below).    

48    

2. PhilHealth uses a case-rate payment system in subsidizing its members.

Since PhilHealth does not cover all types of disease cases, members

receive indefinite assistance. The benefits of this insurance only apply to a

particular set of conditions. Thus, the procedures and tests needed for other

health complications would not be covered, leaving them underinsured. In

some cases, even the most eligible member would not be subsidized if his or

her health problem falls outside of the case-rates list. Even supposing that it is

within the coverage, the patient would merely receive a fixed amount,

regardless of the actual cost of the treatment. Such were the cases of Maria

and Ram, who were 36% and 34% subsidized, respectively.

PhilHealth coverage also excludes other cases such as outpatient

diagnostic tests and emergency room treatments for nonemergency cases.

3. Vision: “Bawa’t Pilipino, Miyembro. Bawa’t Miyembro, Protektado.

Kalusugan Natin Segurado.”

Amelita L. Buted mentioned in her article entitled “Ensuring Universal

Coverage for all Filipinos,” that:

After 20 years, membership coverage has grown to an estimated 81.63 million beneficiaries or about 82% of the projected population of almost 100 million. This translates to at least 4 out of every 5 Filipinos who are now enrolled in the program… The target this year is to cover the remaining 18% of the un-enrolled population through various initiatives that will make it easy for them to register in the program. This includes removal of documentary requirements upon membership, expanding access points and pushing for group enrollment schemes (2015).

Though it was claimed that a greater number of people are PhilHealth

members, roughly around 18,000,000 more Filipinos are still left uninsured.

Even supposing that the un-enrolled 18% would be covered in a couple of

years or so, they would, likewise, shoulder every health expense during the

extent that they are not.

49    

Although the government strives for the universal coverage of all

Filipinos, the premise would still not hold as the insurance concept merely

offers unsustainable assistance. Since some people experience problems

completing the criteria for membership, they are forced to become unenrolled.

Also, not all hospitals are PhilHealth accredited. In fact, private hospitals

outnumber public hospitals in PhilHealth accreditation (Ponsaran, 2015). If

for instance a poor PhilHealth member would seek help in a private hospital,

he would likely spend more. If he would opt to go to a public hospital, it is

uncertain whether he would receive thorough care or not13.

Nisperos (2015) argued that the government should disinvest in the

PhilHealth program. He emphasized that the government should direct the

funds allotted for PhilHealth towards the public health system, instead of

funding a third party. If this adjustment would be sanctioned, everyone, rich

or poor, would receive equal treatment, thus, would be given quality health

assistance (Dela Paz, 2015).

Noncompliance: A Predetermined Choice

More or less, people address health concerns due to negative cues to action. Since

most people are health illiterate (either poorly educated or uneducated), active

participation in health promotion activities is minimal. As how Alix puts it:

I know that this would sound really bad, but even though the literacy rate in the Philippines is high – can read, can write, proud to have the ability to speak English, people cannot critically think. For me, I’d rather have someone who can’t speak English, but can critically think… So in my opinion, the problem here is while individuals can read, write speak a little bit of good English, they can’t make a critical decision or critical analysis of the more important things… The level of understanding of people is not high enough that when they get sick, they will go to the hospital to have it checked and evaluated (2015).

                                                                                                                         13  It  is  a  misconception  that  private  hospitals  deliver  more  quality  care  than  public  hospitals.  Some  doctors  argued  that  the  only  difference  with  the  delivery  of  care  is  the  technological  endowment  gap  between  the  two.    

50    

In the context of the Philippine education system, schools implement a method where

students are spoon-fed with information, instead of engaging them to think critically and

creatively. This socializes them to passively accept things as they are. As individuals

imbibe a more submissive and apathetic character, the decision-making process would be

indefinite and unrewarding, and this would most likely extend to their health-related

choices14.

Doctor Darwin O. Misa (2015), Alix (2015), and Villa (2015), likewise, pointed

out that most of their patients were not that knowledgeable with regard to their

conditions. Not only do they lack a basic knowledge about the disease, they are also

disempowered to even simply ask about their situation. Likewise, even though the

physicians and nurses explain the dos–and–don’ts, the patient’s capacity to internalize the

information – as well as the inclination to apply it – still affects his health path. As

mentioned in the committee report of HEART UK entitled BRIDGING THE GAPS:

Tackling inequalities in cardiovascular disease:

Lower levels of health literacy result in poorer health outcomes: compared to those with high levels of health literacy, they have less knowledge of diseases and self-care; worse self-management skills; lower uptake of screening; lower medication compliance; and higher rates of hospitalisation. People with low health literacy also have lower levels of engagement in health promoting behaviours (2013; as cited in Taggart et al., 2012).

In the rural communities, people have a negligent attitude towards their health.

Unless there is an intermediation of positive cues to action, their health-related behaviors

are most often made impulsively. Even in most cases, individuals do not detect basic risk

indicators (such as the increase of blood and sugar levels) since some of which rarely

show symptoms15. Aside from this, most people do not have personal basic tools and

devices such as a BP apparatus, a Glucometer and so on. Hence, close monitoring would                                                                                                                          14  Health-­‐related   choices   are   complex,   involving   several   factors,   like  how  Olenja   (2003)   puts   it:   “Health  seeking  behaviour  is  preceded  by  a  decision  making  process  that  is  further  governed  by  individual  and/or  household  behaviour,  community  norms  and  expectations  as  well  as  provider  related  characteristics  and  behaviour.”    15   The   danger   with   cardiovascular-­‐related   diseases   is   its   instantaneous   character.   It   could   happen   to  anyone,  anytime  and  anywhere.  Since  it  hardly  shows  symptoms,  a  person  can  never  be  able  to  mitigate  its  effects,  unless  it  is  done  proactively.    

51    

be almost impossible. All the more, that people are mostly unacquainted with the

traditional methods of self-checking. As a result, they experience more severe cases,

multiple complications, or worse, die medically unmediated.

Aside from the incompetence of the country’s health information system, cultural

beliefs and personal suppositions mutually produce several misconceptions and myths

about cardiovascular diseases.

Most Common Myths about Cardiovascular Diseases (Source: AHA, 2014)

1. “Heart disease runs in my family, so there’s nothing I can do to prevent it.”

Explanation: Family history – via genetics – is a huge factor when it

comes to the development of heart diseases in individuals.

However, its risks can be reduced if the person actively

performs heart health promotion activities such as eating a

healthy diet, exercising regularly and managing blood

pressure.

2. “I’d know that if I had high blood pressure because there would be warning

signs.”

Explanation: Hypertension is called the “silent killer” because you would

not usually recognize it from happening. In some cases,

individuals never experience symptoms of it. Moreover, the

failure to mitigate high blood pressure would result into

serious health problems in time.

3. “I’ll know when I’m having a heart attack because I’ll have chest pain.”

Explanation: Heart attack symptoms may not always manifest evidently.

In some instances, it presents subtle symptoms such as

nausea, shortness of breath, and discomforts in several areas

of the body.

52    

4. “My heart is beating really fast. I must be having a heart attack.”

Explanation: It is normal that a person’s heart rate varies from time to

time. It speeds up or slows down depending on the activity

performed or emotion expressed. However, there is always a

possibility that it is a sign of arrhythmia, or irregular

heartbeat. Most of it is harmless, yet, it may impact the

heart’s function if it lasts long enough.

5. “I don’t need to have my cholesterol checked until I’m middle-aged.”

Explanation: Children, who have family histories of heart diseases, can

have high cholesterol levels. This makes them strong

candidates or developing heart diseases as adults.

Alix (2015) and Misa (2015) also mentioned that some patients resort to

alternative medication from faith healers (e.g. pagpapatawas, pagpaalbularyo,

pagpalaway). Edgar was one of those who sought the help of faith healers, as it was their

superstitious belief. However, in his opinion, it did not work.

Most people, due to false information received from mass media or by word of

mouth, become if not partially misled, totally misinformed. Alix (2015) even related a

personal experience of hearing actual accounts of people buying “health supplements” on

the AM radio. According to him, business entities explicitly sell placebo medicines to the

public. Since most people are ill-informed, they tend to consume medicines which have

“No Approved Therapeutic Claims16.” Likewise, they are also inclined to drink herbal

medicines and juices which have no actual, scientific-based effects. Maria even admitted

that she drinks the broth of boiled “Tawa-tawa” and Guyabano leaves, having no prior

idea of its effects.

                                                                                                                         16  Alix  (2015)  was  very  precise  to  note  that  these  types  of  drugs  have  not  yet  been  proven  under  scientific  investigation,  or  there  are  still  no  concrete  evidences  of  their  effects.      

53    

Furthermore, patient nonconformity is more of a necessity, rather than a choice.

Aside from the established difficulty of accessing health services (e.g. expensive medical

prerequisites, physically distant hospitals, backward community centers, patient dumping

cases), patients, who also have families, attend to other important obligations such as

their work, household duties and personal commitments. Since indigent patients are

socially deprived, they tend to focus on family needs more than their own health. Ram

and Edgar were too busy working for a living. Maria, amidst her serious condition, also

had to prioritize other needs, for instance, looking after her granddaughter from time to

time and manning their mini sari-sari store. She even said that their net income from

retailing is not usually used for health spending. Instead, it is either loaned to fund for the

schooling of her granddaughter or borrowed to pay off family debts.

Lita, a 69-year old housewife, said: “Ang naaalala ko ay nagsimula akong

magpacheck-up nung ikinasal ako. Pero siguro, ang huling pacheck-up ko ay almost 20

years ago pa. (I remember, I only started having check-ups since I got married. Likewise,

my last check-up was almost 20 years ago.)”. According to her, medical examinations

were not of primary concern since it was not immediately necessary. However, as she

was growing old, she decided to have her tests out of the fear that she may already have

suffered from a chronic condition. Since then, she was diagnosed with hypertension.

Maria, likewise, gave a similar response, saying that: “Minsan kasi kapag may sumasakit,

hindi ko na lang pinapansin. Pero nagpapacheck-up ako kapag may nararamdaman, o

kapag mayroon na. (Sometimes though, whenever I feel discomforts, I just ignore it. But

usually, I get myself checked whenever I already feel something, or it is already there.)”.

Similarly, Ram said that before he had even suffered a stroke, he was not particularly

apprehensive over his health-related behaviors.

54    

CHAPTER FIVE

Summary, Conclusions and Recommendations

Summary and Conclusions

Since the poor deal with chronic social drawbacks, they become the most

vulnerable population for CVD cases. Unlike affluent people, they suffer more from

negative social conditions such as material deprivation and a poor socio-environmental

climate. As their most basic social needs are not sufficiently met, they are incapable of

preventing such diseases from even happening. The lack of the means and resources to

take these predicaments head-on, likewise, weakens their coping mechanisms to capably

recover and reintegrate into the society.

With the creeping privatization of health services, indigent cardiovascular patients

struggle with higher out-of-pocket spending. However, it is also important to note that

they do not only experience economic disadvantages, but also physical and psychosocial

stresses as well. Not only is it exhaustive and wearisome for the chronically-ill person,

but such conditions demands a serious extent of work and attention from the household in

the same manner. As a result, the poor experience multiple burdens.

As public service providers, the government is accountable and responsible for

addressing the health needs of its people. Likewise, it is in their mandate to provide a

genuine, accessible and sustainable health care delivery to every Filipino. However, it is

very ironic that the repressive orientation of the Philippine public health system further

aggravates the disadvantaged position of the poor.

First, it supports a pay-for-service policy. Since indigents are either uninsured or

underinsured, they experience mass cases of discrimination such as unequal treatment,

reduced assistance, or worse, patient dumping. Furthermore, auctioning health services to

the highest bidder would only further demarcate the haves from the have-nots, the rich

from the poor.

55    

Second, it is more focused on addressing trends of diseases, thus, producing only

trends of preventions. The public health system is reactionary in character since it

provides symptomatic remedies, instead of eliminating the underlying causes of health

problems. Since a cardiovascular disease, for instance, is an accumulation of episodic

events rather than independent, separable causes, the prevalence of these cases would not

be reduced.

And third, it fails to recognize the need to promote the health of communities

where all things are sourced. An individual is a product of the community; therefore, his

health is contingent to the health of the community. Instead of focusing on specific,

individual cases, engaging the problems in a more holistic standpoint would most likely

satisfy public health needs. Investing on prevention strategies, likewise, produces a

resilient population which can further withstand negative health impacts.

Health illiteracy is also prevalent among people living in abject poverty. Since the

social structures such as the media, schools and the communities foster a character of

compliance, the individuals themselves do not have the capacities to critically think.

Because of this, they are incapable of managing and using health information properly.

They, thus, have a higher tendency to fall into the trap of misinformation, thus, resulting

to false beliefs. Likewise, they are also unaccustomed to perform positive health-seeking

behaviors. Even supposing that they are, they are not equipped with the material means to

work with such. As the poor are substantially deprived and ill-educated, they have greater

vulnerabilities of developing CVDs.

It is true that cardiovascular diseases could affect anyone regardless of status.

However, the lack of continuous intermediation to prevent the ailment separates those

with differing social positions. Though it is often argued that cardiovascular diseases are

mostly caused by voluntary lifestyle behaviors, not everyone has the access to positive

health influences. Since the poor have low socioeconomic capacities, they are merely

limited to substandard health facilities and low level of health information. As such, it

56    

could be established that cardiovascular disease is an ‘endemic’ disease of the poor if the

availability of the interventions are to be considered.

The government argues that the country does not have the budget to fund its

public health system. Thus, they sanction revenue-enhancing policies and privatization

skins to compensate for turnover losses. However, more often than not, health is merely

commercialized for the benefit of self-fulfilling interests. Because of this, the people’s

rights to health are exploited.

Even so, victim blaming is always a case of problem shading. The disease is not

in the people, but it is in the system. The government should place the people at the

center of their priorities, placing them at the center of development. They should give

them what they truly deserve. Rich or poor, everyone has the inalienable right to health,

and this should never be taken for granted.

57    

Recommendations

It is absurd that health issues on chronic diseases are not tackled in the

Millennium Development Goals of the UN. Statistics, likewise, indicate that a huge

number of people live and die yearly with such. Cardiovascular diseases, for instance, are

not given priority concern. Even in the Philippines, many Filipinos are suffering from

CVD-related diseases. Likewise, the prevalence/mortality trend is still growing.

In addressing cardiovascular diseases, the government should engage in an

effective population health assessment and risk-to-disease surveillance. One of the most

optimal solutions is to promote a social determinants-based approach/socio-

environmental approach. Besides, a disease can be caused by a multitude of reasons,

thus, can be treated by a multitude of alternative options. If the social determinants of

health are studied, the government could create a sustainable environment (e.g. good

housing, unpolluted environment, better schools, vast economic opportunities, sustainable

communities) for the people to work with. If the social inequalities between the poor and

the rich are eliminated, inequalities in health would also be reduced. Thus, the more the

better life chances that the people have, the healthier and better-off they would live.

In the same manner, the government should utilize an integrated impact

assessment in evaluating health policies and programs. Through this, the effectiveness of

every course of action would be evaluated by measuring its influences on the physical,

social, and economic environment. It should incorporate the following (cited in the World

Health Organization):

• Economic Impact Assessment

• Environmental Impact Assessment

• Health Impact Assessment

• Social Impact Assessment

• Well-being Impact Assessment

58    

The government should also fix its problematic health information system

management. It therefore should (1) generate timely, simple yet creative Public Service

Announcements (PSAs), (2) explore both mainstream and alternative media in health

promotion campaigns, (3) develop and integrate both modern and community-driven

health knowledge, and (4) prompt the active participation of the community in the health-

decision making process (through open dialogues, public debate and consultations).

Because the more the people are health educated, the more they would be resilient against

diseases.

The shortage in the country’s health human resources, likewise, limits its ability

to provide quality care for its people. As the incidence of the people getting sick

increases, the number of abled bodies to attend to those needs should also increase.

Sufficiently training the health workforce using different perspectives to health (e.g. life

course perspective theory, evidence-based approach principle) would make them better

understand how chronically-ill people would be treated. Likewise, incentivizing them,

would procure better health care delivery to the public.

Even so, the government should convert the payment scheme for health services

from an insurance-based towards a taxed-based. The insurance-based concept would

always require a patient to disburse out-of-pocket expenses, whereas in a taxed-based

model, it would not. Instead of investing on PhilHealth, the taxes of the people should be

directly used to subsidize health services.

The government should also stop engaging in Public-Private Partnerships

agreements. Though at some point it does have a lot of merits (e.g. better facilities and

equipment in public hospitals), it is more often than not that the negative impacts

outweigh the positive. The PPP is gradually converting the entire health care system into

a business. Public hospitals are converted into semi-private hospitals, when some are

already transformed into fully functioning private hospitals. These cause price rates for

treatments to become more expensive. Because of this, not all people would be able to

access health care.

59    

The government should as well veer away from devolution. It is important to

maximize service by giving the local institutions the right to manage their own

communities. However, since there is minimal accountability in devolution, the invested

authority is most often exploited (due to bad governance and corruption). It is, likewise,

ineffective since the LGUs do not have the capacity to provide for all of the needs of the

people. The government, therefore, should actively implement policies in regulating its

local institutes. Government institutions such as the DOH should have a role to play in

funding and developing the quality of public health delivery as a whole.

Likewise, it has been seen that the improvement in community health is (1) linked

to the development of individual health, (2) associated to individual health resiliency, and

(3) connected to the increase of individual health autonomy/self-determination. Thus, to

better reduce the prevalence of cardiovascular diseases, the government should

emphasize on the importance of investing in social medicine in the country.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

60    

BIBLIOGRAPHY

Articles, Journals, and Facts and Data Sheets

Abeyta, I., Tuitt, N., Byers, T., & Sauaia, A. (2012). “Effect of Community Affluence on

the Association Between Individual Socioeconomic Status and Cardiovascular

Disease Risk Factors, Colorado, 2007–2008”. Retrieved from

http://www.cdc.gov/pcd/issues/2012/11_0305.htm

Anderson, M., Smith, L., & Sidel, V. (2005). “What is Social Medicine?”. Retrieved

from http://monthlyreview.org/2005/01/01/what-is-social-medicine/

Asch, S. et al. (2006, March 16). “Who Is At Greatest Risk for Receiving Poor-Quality

Health Care?”. Retrieved from

http://www.nejm.org/doi/full/10.1056/NEJMsa044464#t=articleDiscussion

Australian Medical Association. (2007, March 5). “Social Determinants of Health and the

Prevention of Health Inequities”. Retrieved from

https://ama.com.au/system/tdf/documents/AMA_Position_Statement_on_the_Soc

ial_Determinants_of_Health_and_the_Prevention_of_Health_Inequities_2007_0.

pdf?file=1&type=node&id=40625

Barnes, M., Cullinane, C., Scott, S., & Silvester H. (2013, August). “People living in bad

housing – numbers and health impacts”. Retrieved from

http://england.shelter.org.uk/__data/assets/pdf_file/0010/726166/People_living_in

_bad_housing.pdf

Beaglehole, R., Reddy, S., & Leeder, S. (2007). “Poverty and Human Development: The

Global Implications of Cardiovascular Disease”. Retrieved from

http://www.circ.ahajournals.org/content/116/17/1871.full

Beresford, L. (2011, July). “It Takes a Village”. Retrieved from

http://www.the-hospitalist.org/details/article/1234641/It_Takes_a_Village.html

Better Health Channel. (n. d.). “Heart disease – risk factors”. Retrieved from

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Heart_disease_yo

ur_risk-factors_explained?open

Bindra, R. (2008). “The uses of epidemiology and other methods in defining health

service needs and in policy development”. Retrieved from

61    

http://www.healthknowledge.org.uk/public-health-textbook/research-methods/1c-

health-care-evaluation-health-care-assessment/uses-epidemiology-health-service-

needs

BMJ (2012); 344:e1602 Retrieved from

http://www.bmj.com/content/344/bmj.e1602#ref-1

Breen, R. (n. d.). “A Weberian Approach to Class Analysis”. Retrieved from

https://www.ssc.wisc.edu/~wright/Found-c2.PDF

British Heart Foundation. (2012, February). “Heart patients and the benefits system”.

Retrieved from

https://www.bhf.org.uk/pdf/Heart%20patients%20and%20the%20benefits%20sys

tem%20report.pdf

Centers for Disease Control and Prevention. (n. d.). “What is Health Literacy?”.

Retrieved from http://www.cdc.gov/healthliteracy/learn/

Clark, A. M. et al. (2009). “Socioeconomic status and cardiovascular disease: risks and

implications for care”. Retrieved from

http://www.nature.com/nrcardio/journal/v6/n11/abs/nrcardio.2009.163.html

EuroHealthNet. (2013). “Making the link: Chronic diseases and health equity”. Retrieved

from http://eurohealthnet.eu/sites/eurohealthnet.eu/files/publications/Fact-Sheet-

Chronic%20diseases%20and%20health%20equity-V2%5B2%5D.pdf

Field Health Service Information System. (2011). “TOP CAUSE OF MORBIDITY”.

Department of Health, DDO Office.

Food and Nutrition Research Institute. (n. d.) What is the current nutritional status of

Filipino adults?”. Department of Health, DDO Office.

Franks et al. (2011). BMC Cardiovascular Disorders, 11:28

http://www.biomedcentral.com/1471-2261/11/28

Fuster V, Voute J. MDGs: chronic diseases are not on the agenda. Lancet.

2005; 366: 1512–1514.

Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P,

Norrving B editors. World Health Organization (in collaboration with the World

Heart Federation and World Stroke Organization), Geneva 2011.

62    

Goudge, J and Govender, V (2000) ‘A Review of Experience Concerning Household

Ability to Cope with the Resource Demands of Ill Health and Health Care

Utilisation’, EquiNet Policy Series No3. EQUINET, Centre for Health Policy,

Wits University and Health Economics Unit, University of Cape Town

Grant, U. (2005). “Health and Poverty Linkages: Perspectives of the chronically poor”.

Retrieved from

http://www.chronicpoverty.org/uploads/publication_files/CPR2_Background_Pape

rs_Grant_05.pdf

Health Poverty Action. (n. d.). “Key Facts: Poverty and Poor Health”. Retrieved from

http://www.healthpovertyaction.org/policy-and-resources/the-cycle-of-poverty-

and-poor-health/the-cycle-of-poverty-and-poor-health/

Heart UK. (2013). “BRIDGING THE GAPS: Tackling inequalities in cardiovascular

disease”. Retrieved from

http://heartuk.org.uk/files/uploads/Bridging_the_Gaps_Tackling_inequalities_in_c

ardiovascular_disease.pdf

Indiana University. (n. d.). “What is Health Administration?”. Retrieved from

http://pbhealth.iupui.edu/index.php/explore-population-health/what-is-health-

administration/

Kernick, D. (2003). “Introduction to health economics for the medical practicioner”.

Retrieved from http://pmj.bmj.com/content/79/929/147.full

Lang, T., Lepage, B., Schieber, A.C., Lamy, S., & Kelly-Irving, M. (2012). “Social

determinants of cardiovascular diseases”. Public Health Reviews. 33: 601-22.

Retrieved from

http://www.publichealthreviews.eu/upload/pdf_files/10/00_Lang.pdf

Mathers, C. D., & Loncar, D. (2006). “Projections of global mortality and burden of

disease from 2002 to 2030”. PLoS Med, 3(11):e442

Moise P, Jacobzone S; ARD-IHD Experts Group. OECD study of cross-national

differences in the treatment, costs and outcomes of ischaemic heart disease.

Organisation for Economic Co-operation and Development. Available at:

http://www.oecd.org/dataoecd/30/56/2511003.pdf.

63    

O’Connell, A., Crawford, M., & Abrams, J. (2001, February). “Heart failure disease

management in an indigent population”. Retrieved from

http://lib.ajaums.ac.ir/booklist/AM.Heart%20%20%20%20Journal_February%20

%20(2)_107.pdf

Olenja, J. (2003, February). “Health Seeking Behavior in Context”. East African Medical

Journal. Retrieved from

http://www.ajol.info/index.php/eamj/article/view/8689/1927

Philippine Health Statistics. (2009). “HEART DISEASE STATISTICS: TOP CAUSE OF

MORTALITY”. Department of Health, DDO Office.

Philippine Health Statistics. (n. d.). “MORTALITY RATE TREND DEATHS DUE TO

DISEASES OF THE HEART, 2005 - 2009”. Department of Health, DDO Office.

Romualdez, A. Jr. et al. (2011). “The Philippines Health System Review”. Health

Systems in Transition (Vol.1 No.2). Retrieved from

http://www.wpro.who.int/philippines/areas/health_systems/financing/philippines_

health_system_review.pdf

Salway, S. et al. (2007). “Long-term ill health, poverty and ethnicity”. Retrieved from

http://www.jrf.org.uk/sites/files/jrf/1995-health-ethnicity-poverty.pdf

Schwarzer, R. & Luszczynska, A. (n. d.). “Perceived Self-Efficacy”. Retrieved from

http://cancercontrol.cancer.gov/brp/constructs/self-efficacy/self-efficacy.pdf

Taggart, J. et al. (2012). “A systematic review of interventions in primary care to improve

health literacy for chronic disease behavioral risk factors”. BMC Family Practice,

13 (49) Retrieved from http://www.biomedcentral.com/content/pdf/1471-2296-

13-49.pdf

University of Virginia School of Medicine. (2012). “Health Informatics”. Retrieved from

http://www.medicine.virginia.edu/clinical/departments/phs/administrative-

divisions/informatics/HealthInfDef-page

Ward C. (2007). “Improving access to financial support for heart failure patients:

understanding the claims process and the doctors’ role”. British Journal of

Cardiology; 14:275-9

Ward, H., Mertens, T., & Thomas, C. (1997). “Health seeking behaviour and the control

of sexually transmitted disease in Health Policy and planning”; 12:19-28

64    

World Health Organization. (2013). “Cardiovascular diseases (CVDs): Fact sheet”.

Retrieved from http://www.who.int/mediacentre/factsheets/fs317/en/

World Health Organization. (2013). “Non-communicable diseases: Fact Sheet”.

Retrieved from http://www.who.int/mediacentre/factsheets/fs355/en/

World Health Organization. (2005). “Preventing Chronic Diseases: A Vital Investment.

Geneva, Switzerland: World Health Organization”

WHO Europe. (2nd Ed). (2003) “The Solid Facts: Social determinants of health”.

Retrieved from

http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

WHO Geneva. (2011). “Global status report on noncommunicable diseases 2010”.

World Heart Federation. (n. d.). “Cardiovascular disease risk factors”. Retrieved from

http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-

disease-risk-factors/

Interviews

Alix, O. Adult Cardiologist, Medical Center Parañaque. Personal Interview. (2015,

March 13).

Dela Paz, E. Vice Chairperson, Health Action for Human Rights. Personal Interview.

(2015, February 18).

Misa, D. Adult Cardiologist, General Emilio Aguinaldo Memorial Hospital. Personal

Interview. (2015, March 5).

Nisperos, G. Vice Chairperson, Health Alliance for Democracy. Personal Interview.

(2015, March 4).

Villa, C. Adult Cardiologist, General Emilio Aguinaldo Memorial Hospital. Personal

Interview. (2015, March 11).

News Articles

ABS-CBN. (2011, October 20). “Heart disease is PH’s top killer: NSO” Retrieved from

http://www.abs-cbnnews.com/lifestyle/10/20/11/heart-disease-phs-top-killer-nso

Adeoye, S. (2011, September 30). “Poverty kills the heart”. Retrieved from

http://www.dailytimes.com.ng/article/poverty-kills-heart

65    

Bernabe, K. (2012, January 24). “PhilHealth policy cannot cover all medical expenses”

Retrieved from http://www.doh.gov.ph/sites/default/files/012412-5.pdf

Buted, A. (2015, February 23). “Ensuring Universal Coverage for all Filipinos”.

Retrieved from http://www.philhealth.gov.ph/news/2015/ensuring_universal.html

Johnson, T. (2013, February 28). “Echoes of Tuskegee: The Socioeconomic Cycle of

Heart Disease”. Retrieved from

http://www.theatlantic.com/health/archive/2013/02/echoes-of-tuskegee-the-

socioeconomic-cycle-of-heart-disease/273431/

New York Times. (1985, February 24). “Heart Disease Tied to Poverty”. Retrieved from

http://www.nytimes.com/1985/02/24/us/heart-disease-tied-to-poverty.html

Reddy, S. (2013, July 29). “Heart disease doesn’t spare the poor”. Retrieved from

http://www.livemint.com/Politics/p0Y9TZCQnY1m2WqxvLrs7H/Poverty-and-

heart-disease.html

Sindico, R. (2012, July 9). “5 out of 10 Filipinos die of heart disease – NSO”. Retrieved

from http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-

filipinos-die-heart-disease-nso

Stein, J. (2011, September 14). “As U.S. poverty rates climb, so may health woes for the

poor”. Retrieved from

http://articles.latimes.com/2011/sep/14/news/la-heb-poverty-health-20110914

Stephens, S. (2014, May 6). “Low Self-Rating of Social Status Predicts Heart Disease

Risk”. Retrieved from

http://www.cfah.org/hbns/2014/low-self-rating-of-social-status-predicts-heart-

disease-risk

Tecson-delos Santos, C. M. (2014, July 14). “On the UP-Philippine General Hospital’s

lack of an ‘ounce of compassion.’” Retrieved from

http://www.up.edu.ph/on-the-up-philippine-general-hospitals-lack-of-an-ounce-

of-compassion/

66    

APPENDIX A

13 February 2015 Dr. George R. Repique, Jr. Provincial Health Officer Province of Cavite Dear Dr. Repique: Greetings of peace and solidarity! I am Chris Daniel M. Francisco, a fourth year BA Development Studies major from the University of the Philippines Manila. I am currently writing a thesis about the country's current public health system, specifically on cardiovascular healthcare of indigent patients. In this regard, I would like to request for your approval to conduct several interviews with the cardiovascular outpatients and cardiologists of the General Emilio Aguinaldo Memorial Hospital (GEAMH) about the following:

• The relationship between the patient's socioeconomic standing and their corresponding health options/health opportunities

• The economic and social costs/impacts experienced by the heart patients

• The quality of the health awareness/health literacy of the patients

• The quality of the post-care transitions/rehabilitation program prepared by the corresponding health institution

• The overall pre- and post-medication experience of the heart patients

The data that would be gathered in this fieldwork would substantially enrich my research study. Your approval on the matter would be highly appreciated. Thank you very much for your kind consideration. Respectfully yours, Chris Daniel M. Francisco

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APPENDIX B

27 February 2015 Dr. Rustico A. Jimenez Hospital Director Medical Center Parañaque Dr. A. Santos Ave., Sucat, Parañaque City Dear Dr. Jimenez: Greetings of peace and solidarity! I am Chris Daniel M. Francisco, a fourth year BA Development Studies major from the University of the Philippines Manila. I am currently writing a thesis about the country's current public health system, specifically on cardiovascular healthcare of indigent patients. In this regard, I would like to request for your approval to conduct several interviews with the cardiovascular outpatients and cardiologists of the Medical Center Parañaque (MCP) about the following:

• The relationship between the patient's socioeconomic standing and their corresponding health options/health opportunities

• The economic and social costs/impacts experienced by the heart patients

• The quality of the health awareness/health literacy of the patients

• The quality of the post-care transitions/rehabilitation program prepared by the corresponding health institution

• The overall pre- and post-medication experience of the heart patients

The data that would be gathered in this fieldwork would substantially enrich my research study. Your approval on the matter would be highly appreciated. Thank you very much for your kind consideration. Respectfully yours, Chris Daniel M. Francisco

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APPENDIX C

COLLEGE OF ARTS AND SCIENCES

UNIVERSITY OF THE PHILIPPINES MANILA The Health Sciences Center

DEVELOPMENT STUDIES PROGRAM

___________________

_____________________________

_____________________________

_____________________________

Dear Sir/Madam:

I, Chris Daniel M. Francisco, am a fourth year BA Development Studies student from the University of the Philippines Manila. As part of our course requirement, I am currently writing a thesis entitled “INDIGENT HEART HEALTH: Critical Political Economy of Cardiovascular Healthcare for the Filipino Masses.” My research study aims to critically analyze the dynamics within the public health system and the community in relation to the indigent cardiovascular patients. And I believe that with your help, I would be able to develop my research even further.

I would like to request for your assistance in obtaining the necessary data needed for my research. These may encompass the following: Cardiovascular Disease Statistics (Trends/Movements, Mortality Rates, Incidence Rates, Geographic Variation, and etc.); Correlative Studies between Poverty and Cardiovascular Disease; Social Determinants of Cardiovascular Disease; and other data sets regarding cardiovascular healthcare studies.

If you have any questions, please do not hesitate to contact me through my details given below.

Thank you very much, and I hope this matter will merit your favorable consideration.

Chris Daniel M. Francisco BA Development Studies chrisdaniel.francisco@gmail.com 0917 824 3694

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APPENDIX D

Interview Questions for Doctors (Cardiology)

1. Statistically, cardiovascular diseases are the number one cause of deaths worldwide. Why

are these the most prevalent among diseases?

2. What are the factors/determinants that influence or impact the heart health of an

individual? What are the barriers/problems that CVD patients experience?

3. What are the most common cardiovascular diseases do patients suffer from?

4. What age group is the most affected population with regard to CVDs?

5. Are there misconceptions or misbeliefs when it comes to an individual’s cardiovascular

health? Enumerate some.

6. Are there traditional/alternative forms of cardiac medication?

7. During your consultation with the patients, up to what extent or areas do you investigate

about? What are your most frequently asked questions to know their medical history?

8. How knowledgeable/aware are the patients with regard to their condition? To the

prescribed medication?

9. Why is there a high incidence rate of re-hospitalization/re-admission because of

complications or aggravations to their condition? What are the causes?

10. Can you describe to me what a discharge plan/care transition plan looks like? What are

the roles of the cardiologist/health worker to the rehabilitation of the patient?

11. Why are health-related medications pricy? Are price rates directly proportional to heart

mortality rates?

12. “Heart disease is a poor man’s disease.” What are the reasons why the poor are the most

vulnerable? Relatively, how accessible are heart-related health services for the poor?

13. Health knowledge is important. Is it accessible for the heart patients? For the poor

patients?

14. How helpful/efficient are health insurances in catering to the needs of the indigent?

15. How do indigent patients cope with the financial and social problems they experience?

How do hospitals/health workers engage this situation?

16. Are there policies or programs for cardiovascular healthcare here in the Philippines? What

should the government do to address the increase in CVD-related problem?

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APPENDIX E

Questionnaire for the Patients/Families of Patients

1. What is your name?

2. How old are you?

3. Where do you live?

4. How many are you in the family?

5. How much do you earn weekly/monthly? (per household)

6. If the budget of the household is not enough for the weekly/monthly living

expenses, how do you usually cope up to it?

(Perceived Susceptibility, HBMT)

1. What is your perception of being healthy? As a follow-up, where did you

learn about that notion?

2. Are there any health advisories or health educating bodies in your

community? Are there any government health-related projects or

programs as well?

3. How conscious are you of your health? Are you fully aware of the

consequences of the health-related choices you make?

4. How did you know of your heart condition? (i.e. check-up, physical

manifestation)

5. What is the first thing that came up to your mind when you learned about

your heart condition? Does heart disease run in the family?

(Perceived Severity, HBMT)

1. What do you know about your heart condition?

2. In your opinion, is treatment for the certain heart condition a priority

concern? What instances or indications did you take into consideration to

do or not do something about it?

71    

(Perceived Benefits, HBMT)

1. What actions did you try to treat your heart condition? (i.e. professional

advice and medication, alternative medicine) What are the reasons behind

those said actions?

(Perceived Barriers, HBMT)

1. Do you have health centers in your community? Why did you choose this

hospital

2. Do you have a health insurance? If yes, can you name it and describe the

benefits you get from it? If no, why is it so?

3. What problems do you encounter in dealing with the treatment of your

heart condition?

4. Do you see your social status as an impediment to your health

opportunities?

(Wrap-up Questions)

1. How is the rehabilitation period going?

2. What can you say about the whole experience from start to finish? Can

you tell us your (brief) story? (e.g. changes, economic struggle)

3. What suggestions or comments can you think of that would make the

medical process accessible and affordable for all of those who need it?