Alyanna Angelina M.

Cabral PS 199

2012-65902 Prof. Abadingo

RESEARCH PROPOSAL

Topic: The relationship of healthcare decentralization in the Philippines to the quality of health
seeking behavior of patients in health centers.

Research question: What is the relationship between the healthcare decentralization in the
Philippines with the health seeking behavior of patients in health centers?

Hypothesis: Weaker implementation of healthcare services in the local healthcare centers causes
poorer health seeking behavior of patients in these health centers.

General Objective: To determine the effectiveness of the implementation of healthcare policies

in the local level.

Specific Objectives:

1. To show the wider inequity of healthcare accessibility caused by poor decentralization of

healthcare

2. To observe how patients in local health centers react to this inaccessibility through their
health-seeking behavior
 REVIEW OF RELATED LITERATURE

One major problem in the present healthcare system in the Philippines is the
inaccessibility of quality healthcare services. This is especially true for those people who live in
rural areas. Aside from socio-economic factors, one important factor contributing to this
inaccessibility is the decentralization of healthcare. Poor implementation of healthcare policies
from the national to local governments compromises the access to quality healthcare of most
people. In 2013, it can be remembered that there was an outbreak of measles in Metro Manila.
This clearly showed the failure of Department of Health to supervise and ensure that all locals
were able to undergo immunization in local health centers. This is a manifestation of how health
policies are not effectively implemented from the national to the local level. This review essay
will show the relationships established by the literature reviewed, and it will show the
commonalities that bind several literatures, such as the consideration of socio-economic factors
and the common themes that these literatures discuss.

The literatures reviewed exhibit limitations and most of the literatures reviewed have
limitations concerning the conduction of research. In Aboagye and Agyemang’s research, the
strength of their generalization was reduced due to small sample selection (Aboagye &
Agyemang, 2013). Like Aboagye and Agyemang, Duysburgh et al. (2014) also faced problems
with sample selection. Their study was said have faced the problem of selection bias.

Duysburgh et al. (2014) also encountered time and resource constraints amidst their
gathering of data. There were problems with audio-recording and full transcription of interviews
was not possible. Also, only a few districts and health facilities were covered in their field visits
in each country that they studied. Aside from that, researchers encountered inadequacy of data
gathered. This is what happened with Jimenez Soto et al. (2013), when the usefulness of their
decision-support model was compromised by the unavailability of some measures of critical
parameters. These time and resource constraints compromised the depth and comprehensiveness
of the researchers’ analysis of the complexities of newborn care.

Aside from the technical constraints such as time and resources in gathering data, some
literature reviewed also encountered limitations regarding the area of knowledge of their study.
One example is the study by Zhong (2010) which made use of an inequality measure called
“Theil index”. In measuring the inequity in healthcare utilization, the Theil index failed to take
into account the socio-economic factors of inequity. Meanwhile, X. Zhang, Miège, and Y. Zhang
(2011) also had limitations with regards to the area of knowledge of their study. In conducting a
study about the people with HIV/AIDS in rural China, the researchers focused on the
organization of healthcare services and the factors that perpetuate the inaccessibility of treatment
for this disease, thus failing to assess other aspects of treatment such as drug regimen, etc.

Some of the literature reviewed showed how the government’s decentralization of health
polices affect people’s access to healthcare. The literatures also showed how people’s health-
seeking behavior is affected by the government’s decentralization of healthcare policies. In order
to fill the gap of prior literature, this study will connect the findings of these literatures by
showing that as the government determines healthcare accessibility through its decentralization
of healthcare policies; people react to this accessibility through their health-seeking behavior.
The purpose of this study is to show the interplay between the accessibility of healthcare and the
health-seeking behavior of patients in the context of decentralized healthcare.

The scope of this study will cover the local governments of barangays and its residents.
One limitation of this study is that, it fails to consider the dissemination of information as a
measurement of healthcare service quality. Instead, this study only focuses on health facilities
and healthcare providers as measurement of healthcare service quality. Also, this study fails to
take into account the residents who seek healthcare services in public hospitals, since the scope
of this study is limited to health centers.

The literature reviewed can be organized according to the relationships that they
establish: (1) relationship between the decentralization of healthcare policies and the quality of
healthcare (2) relationship between the quality of healthcare and the health-seeking behavior, and
lastly (3) direct relationship between decentralization of healthcare policies and the health-
seeking behavior.

Firstly, Duysburgh et al. (2014) showed in his study the relationship between the
decentralization of healthcare policies and the quality of healthcare. He showed how the poor
implementation of comprehensive newborn policies to hospitals at referral level translates to
substandard quality of newborn care. Also, X. Zhang, Miège, and Y. Zhang (2011) stated that
problems in healthcare accessibility in rural areas remain due lack of sufficient training of
medical staff, indicating poor quality of healthcare service in the local level.

Secondly, Auer, Sarol, Tanner and Weiss’s study established the link between the quality
of healthcare and the health-seeking behavior. In their study, it is shown that poor quality of
health service, which is in the form of inefficiency and the lack of empathy among healthcare
providers in listening and interacting with patients, accounts for the health-seeking delay among
patients (Auer, Sarol, Tanner, & Weiss, 2000).

Lastly, Aboagye and Agyemang showed a direct link between relationship between
decentralization of healthcare policies and the health-seeking behavior, connecting the two
earlier relationships established. Their study showed the relationship between financing and
organization of health services with the maternal health-seeking behavior of patients in Ghana.

Aside from these relationships that these literatures were able to establish, some of the
literatures reviewed have commonalities with each other. One commonality is the consideration
of socio-economic factors in the study. Aboagye and Agyemang’s study about maternal health-
seeking behavior showed that socio-economic factors contribute in women’s attitude towards
their decisions and choices of health facilities. Similarly, Duysburgh et al. (2014) claimed that
socio-economic inequalities play a role in the quality of newborn care. X. Zhang, Miège, and Y.
Zhang (2011) included in their study the impact of HIV/AIDS on social and economic conditions
of rural households. Meanwhile, Jimenez Soto et al. (2013) emphasized the vulnerability of
disadvantaged population in rural areas to the negligence of the national government in terms of
implementing healthcare policies, thus showing the role of social structure in the decentralization
of healthcare policies.

Zhong’s study also has common themes with X. Zhang, Miège, and Y. Zhang’s study.
Both studies showed the impact of decentralization on people’s access to healthcare. Zhong
(2010) claimed that the effective implementation of healthcare policies to the local level
accounts for the lower degree of inequity in healthcare access. Meanwhile, X. Zhang, Miège, and
Y. Zhang (2011) found that the new service in the decentralization of healthcare narrowed of the
inequality in healthcare access among patients living with HIV/AIDS in rural China.
 In studying the issue or problem of their studies, some of the literature reviewed made
use of an institutional approach. The institutional approach in political analysis involves the
description of formal political structures or the comparison of these structures. Duysburgh et al.
(2014) discussed the issue of increasing mortality rate among the newborn by assessing and
comparing newborn health policies and status in three countries.

Some studies made use of Rational Choice Theory. The Rational Choice involves the
construction of complex models of political behavior replete with equations and mathematical
appendices. This theory assumes that individuals are self-interested (Marsh & Stoker, 2010).
Jimenez Soto et al. (2013) approached the issue of healthcare policy implementation by
designing a model which aimed to estimate the costs and impact of scaling-up strategies. In the
end, as a result of their calculations, they were able to come up with community-based strategies
which aim for the extension of service delivery at the local level.

Some of the literature reviewed made use of the behavioral approach. The behavioral
approach in political analysis explains the behavior of political actors involved through empirical
observation (Marsh & Stoker, 2010). Indeed, these studies made use of interview and
questionnaires in gathering empirical data. Aboagye and Agyemang explained the maternal
health-seeking behavior of patients in Ghana through a health system perspective, stating that
financing and organization of health services affect health-seeking behavior. Auer, Sarol, Tanner
and Weiss (2000) stated that the delayed health-seeking of Tuberculosis patients is caused by
inefficiency and the unemphatic style of health care providers in listening and interacting with
patients.

Lastly, Marxist approach was used in some literatures. The Marxist theory in political
analysis focuses on class relations and has a commitment to equality (Marsh & Stoker, 2010).
Aboagye and Agyemang took into account the socio-economic factors in explaining the health-
seeking behavior of their subjects. Aside from that, Duysburgh et al. (2014) also considered
socio-economic and geographic inequalities in discussing the quality of newborn care.
Meanwhile, Zhong (2010), and X. Zhang, Miège, and Y. Zhang (2011) explained the impact of
decentralization to healthcare accessibility by stating the narrowing of inequity in healthcare
access among people.
 This study answers the question “What is the relationship between the healthcare
decentralization in the Philippines with the health seeking behavior of patients in health
centers?” Basically, this study will explain the health-seeking behavior of people in rural areas,
considering their access to quality healthcare, which is determined by the present condition of
healthcare decentralization in the Philippines. This study addresses the problems in the
accessibility of quality healthcare. Regarding its contribution to the study of political science,
this study also fills the data gaps of prior research by showing the interplay between the
accessibility of healthcare and the health-seeking behavior of patients in the context of
decentralized healthcare. This study also veers away from the traditional study of political
science which focuses solely on political institutions. Instead, this study also focuses on the
behavior of political actors and sees these political actors as not just passive receivers of policies.

For this study, a Marxist theory will be used. In using this theory, poor health-seeking
behavior of people in local areas is seen as a reaction to the inaccessibility of healthcare due to
government’s poor implementation of healthcare policies from national to local level. And in this
poor implementation of healthcare policies, those in the lower class are most affected since local
healthcare institutions are the supposed to be the most accessible to them. Therefore, this study
will explain the health-seeking behavior of people in local areas by showing how these people
react to the inequity in healthcare accessibility.

For the conceptual framework, this paper will present the relationship between healthcare
decentralization (independent variable) and health-seeking behavior (dependent variable).
Healthcare decentralization is operationally defined in terms of implementing healthcare policies
to local governments and supervising the proper implementation of these policies on local areas.
On the other hand, health-seeking behavior is operationally defined in terms of visiting health
centers and availing health services from these health centers.

For intervening variables, socio-economic status and the quality of healthcare service also
affect the health-seeking behavior of people. Socio-economic status is operationally defined in
terms of upper class, lower class, and middle class. Quality of healthcare service is operationally
defined in terms of adequate healthcare facilities, and competent and emphatic healthcare
providers.
 Regarding research design, this study will make use of a descriptive research design. The
researcher decided to take this kind of research design because one of this study’s objectives is to
determine whether equity of healthcare decentralization is associated with healthcare
accessibility. Also, this study will observe health-seeking behavior by estimating the proportion
of those residents who avail of healthcare services provided in health centers in a barangay.
Since it is said that an objective of this study is to observe health-seeking behavior of barangay
residents, this study will specifically make use of a case study type of descriptive research
design.

Regarding the gathering of necessary data, first, the researcher will conduct health center
visits in order to observe the quality of healthcare service provided. This is to examine the effects
of decentralization to the accessibility of residents to quality healthcare. Since the researcher’s
standards will be the sole basis in the assessment of healthcare service provided, it is expected
that this procedure will produce data with subjectivity.

Second, the researcher will examine the records of the health center’s patients in order to
find out the number of residents availing healthcare service for a certain disease. This procedure
is expected to produce accurate data since they are based on written records. Next, the researcher
will conduct interviews among residents in order to find out the number of residents who have
diseases but do not avail healthcare services from health centers. Unlike the earlier step, this
procedure is expected to produce inadequate and unreliable data since the researcher may not be
able to cover the whole population and the truth of the answers of the sample is not certain.
Anyhow, these steps will be done in order to estimate the proportion of those residents who avail
of healthcare services provided in health centers, and in turn, observe the residents’ health-
seeking behavior.
 REFERENCES

Aboagye, E., & Agyemang, O. S. (2013). Maternal health-seeking behavior: The role of
financing and organization of health services in ghana. Global Journal of Health Science,
5(5), 67-79. Retrieved from
http://search.proquest.com/docview/1436927412?accountid=33511

Auer, C., Sarol, J., Tanner, M., & Weiss, M. (2000). Health seeking and perceived causes of
tuberculosis among patients in Manila, Philippines. Tropical Medicine & International
Health, 5: 648–656. doi: 10.1046/j.1365-3156.2000.00615.x

Duysburgh, E., Kerstens, B., Diaz, M., Fardhdiani, V., Reyes, K. A. V., Phommachanh, K., . . .
Zaka, N. (2014). Newborn care in indonesia, lao people's democratic republic and the
philippines: A comprehensive needs assessment. BMC Pediatrics, 14, 46.
doi:http://dx.doi.org/10.1186/1471-2431-14-46

Jimenez Soto, E., La Vincente, S., Clark, A., Firth, S., Morgan, A., Dettrick, Z., . . . Widiati, Y.
(2013). Investment case for improving maternal and child health: Results from four
countries. BMC Public Health, 13, 601. doi:http://dx.doi.org/10.1186/1471-2458-13-601

Marsh, D., & Stoker, G. (2010). Theory and methods in political science. New York, NY:
Palgrave Macmillan.

Zhang, X., Miège, P., & Zhang, Y. (2011). Decentralization of the provision of health services to
people living with HIV/AIDS in rural china: The case of three counties. Health Research
Policy and Systems, 9, 9. doi:http://dx.doi.org/10.1186/1478-4505-9-9

Zhong, H. (2010). The impact of decentralization of health care administration on equity in

health and health care in canada. International Journal of Health Care Finance and
Economics, 10(3), 219-37. doi:http://dx.doi.org/10.1007/s10754-010-9078-y