CHAPTER I

INTRODUCTION

Background and Rationale of the Study

The 1987 Constitution provides that all Filipinos should have access to health

services. This policy finds full expression in Article II, Section 15: “The State shall

protect and promote the right to health of the people and instill health consciousness

among them.” Article XIII, Section 11 provides that “The State should adopt an

integrated and comprehensive approach to health development which shall endeavor to

make essential goods, health and other social services available to all the people at

affordable costs. There shall be priority for the needs of the underprivileged, sick, elderly,

disabled, women and children. The State shall endeavor to provide free medical care to

paupers.” Philippine Constitution (1987).

Many developing countries promote social health insurance as a powerful

instrument to eliminate unmet health needs. However, even as countries find the

resources needed for universal coverage, this alone may not be enough to ensure access

and appropriate care. One of the least understood problem is the lack of utilization of

social health insurance among the insured. Studies have shown that patient perceptions of

quality of care, cultural, economic, and geographical factors can affect the utilization of

health services in social health insurance programs in developing countries. Quimbo

(2008).

In developing countries it is particularly important to understand insurance

underutilization because the greatest burden of health care spending falls on the less
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privileged and marginalized groups. In the Philippines, 46 percent of total health care

expenditures are accounted for by out-of-pocket payments with a support value of only

54 percent. PhilHealth Stats and Charts (2013). Insurance underutilization therefore

suggests that there is an ineffective use and distribution of public resources, missing the

intended poor households who lose out on financial resources to which they are entitled.

Evaluation studies of social insurance program effectiveness around the world

typically focus on system problems such as lack of resources or limited coverage rather

than the lack of patient information. Underutilization of insurance may be due to the lack

of awareness of benefits, potentially high transaction costs relative to potential benefits,

or a cumbersome claims process. The political nature of the indigent program in the

Philippines can mean household coverage changes year to year; thus households may not

be aware of their coverage itself let alone the claims process. This problem may be

especially acute for target beneficiaries whose premium payments are fully paid out of

public subsidies. Presumably, if insurance premiums are paid by the beneficiaries

themselves, there is a natural tendency for the beneficiaries to be educated on the

mechanics of the insurance program.

To address the remaining gaps and challenges on inequity in health, the Aquino

Health Agenda (AHA), through Administrative Order No. 2010-0036 was launched last

2010. It contains the operational strategy called Kalusugan Pangkalahatan (KP) which

aims to achieve Universal Health Care for all Filipinos. KP seeks to ensure equitable

access to quality health care by all Filipinos beginning with those in the lowest income

quintiles. KP further fulfills President Aquino’s “social contract” with the Filipino

people, as stated in Section 7 of Executive Order 43 series 2011: The implementation of

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KP/Universal Health Care shall be directed towards the achievement of the health system

goals of financial risk protection, better health outcomes and responsive health system.

In support of the Aquino Health Agenda to provide Universal Health Care for All

Filipinos, the Philippine Health Insurance Corporation introduced a program called

Primary Care Benefit 1 (PCB1) Package and was launched on April 01, 2012 which aims

to expand the number of services included in the Primary Health Care Benefits for

PhilHealth Members; increase the utilization rate for services included in the Primary

Health Care Benefits; enhance the incentives for PCB providers to promote healthy

behavior, prevent diseases and/or associated complications, and facilitate appropriate

referral and lastly to ensure complete and timely reporting of health data for monitoring

and performance assessment and evaluation purposes. The target clients of this program

initially include the indigents, the sponsored program members, organized groups and

overseas workers programs members, and all their qualified dependents.

The PCB1 Package includes three (3) main provisions. The first provision include

the delivery of primary preventive services such as free consultation, visual inspection

with acetic acid, regular blood pressure measurement, breastfeeding program education,

periodic clinical breast examination for females, counseling for lifestyle modification and

smoking cessation, body measurements (Body Mass Index), and digital rectal

examination for males.

The second provision is about certain diagnostic examinations that should be

provided to the clientele as per case to case basis. Diagnostic examinations such as

Complete Blood Count (CBC), urinalysis, fecalysis, sputum microscopy, fasting blood

sugar, lipid profile and chest x-ray. The PCB1 provider shall ensure that these diagnostic
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examinations are available to the clientele when needed. They may forge a Memorandum

of Agreement to higher facility to provide those diagnostic examinations that are not

available on their facility.

The third provision is about the drugs and medicines that should be given to their

clientele whenever needed. These drugs and medicines includes medicines for Asthma

including the nebulization services, medicines for acute gastroenteritis with no or mild

dehydration, for Upper Respiratory Tract Infection and Pneumonia (minimal or low risk),

and drugs for urinary tract infection. PCB 1 providers shall ensure that their clients with

health care needs beyond their service capability must be referred to appropriate health

care facilities.

Use of health care services is a complex phenomenon. There are times that

knowledge and awareness of the target clients on the programs implemented are left

behind while more focus are given to the program formulation and implementation.

Government health programs and the utilization of its health services are dependent on

the awareness and knowledge of the individual on the services it offers. Macato (2013).

Moreover, it is vital that the target clients are knowledgeable of the programs being

implemented. Italia (2012). Furthermore, it is the responsibility of the health care

providers to inform the population and motivate them how to avail these benefits and

privileges. Lack of knowledge of the existing policy is one of the reasons for the

underutilization of the health services. Kruk (2010).

The indigents and Local Government Unit (LGU) sponsored members should be

well informed about their privileges and benefits provided for them under the PCB
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1Package. Moreover, they should be enjoying the full use of these benefits and privileges

that they are entitled.

PhilHealth together with the Department of Health and the Local Government

Unit conducted several information dissemination campaign to empower the target

consumers of this program. Series of symposia and fora were conducted in every

Municipality and District Health Center about the benefits and privileges offered under

the PCB1 Package and the process of availing it. One best example of this is the Alamin

at Gamitin (ALAGA KA) Program, a joint campaign of the DOH and PhilHealth to

inform the population of the services and benefits they could avail from PhilHealth and

other Health services offered by the Department of Health.

Despite all the information dissemination from activities, still many indigents and

LGU sponsored members are still unaware of the existence of the PCB 1 Package. Many

still do not know the procedure on how to avail of the benefits. But even if they are aware

and knowledgeable, some still do not readily comply with the required documents

because of limitations such as mobility or preoccupation of responsibilities at home. Italia

(2012).

It has been two years since the implementation of PhilHealth Primary Care

Benefit 1 (PCB1) Package, and the assessment of its utilization among the target clientele

and to the health care industry is necessary. After searching for available literature on the

subject, the researcher has not found any, thus the researcher decided to conduct this

study to find out the knowledge, and understanding on the utilization of PhilHealth’s

PCB1 program and services. The findings of this study will help in the continuing effort

of PhilHealth together with the Local Government Unit and the Department of Health to
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monitor the efficiency and effectiveness of the delivery of its health care program to the

Filipino people.

Objectives of the Study

The main objective of this study is to determine the knowledge, attitude and

extent of utilization of PhilHealth Primary Care Benefit 1 (PCB 1) Package among

indigents and LGU sponsored members in Iloilo City.

Specifically, this study aimed:

1. to determine the socio-demographic profile of the respondents in terms of age,

sex, civil status, educational attainment, average monthly family income, and

distance of residence from the health center;

2. to determine the respondents’ level of knowledge about the PhilHealth PCB 1

Package;

3. to determine the respondents’ attitude towards the PhilHealth PCB 1 Package;

4. to determine the respondents’ extent of utilization of PhilHealth PCB 1 Package;

5. to determine if there is a significant relationship between the socio-demographic

profile of the respondents and their knowledge of the PhilHealth PCB 1 Package;

6. to determine if there is a significant relationship between the socio-demographic

profile of the respondents and their attitude towards the PhilHealth PCB

1Package;

7. to determine if there is a significant relationship between the socio-demographic

profile of the respondents and the extent of Utilization of the PhilHealth PCB 1

Package;
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8. to determine if there is a significant relationship between the respondents

knowledge and their attitude towards the PhilHealth PCB 1 Package;

9. to determine if there is a significant relationship between the attitude of the

respondents towards and the extent of utilization of PhilHealth PCB 1 Package;

10. to determine if there is a significant relationship between the respondents

knowledge about and the utilization of the PhilHealth PCB 1 Package;

11. to determine whether there is a significant relationship between the knowledge

about and utilization of PhilHealth PCB 1 Package when attitude is controlled.

Theoretical Framework

This study is anchored on the theory of Reasoned Action by Martin Fishbein and

Icek Ajzen (1975) which posits that a person’s behavior is determined by its behavioral

intention to perform it. This intention is itself determined by the person’s attitudes and his

subjective norms towards the behavior.

The theory of reasoned action proposes that a person’s attitude towards the

behavior and the subjective norms will determine the person’s behavioral intention to do

a certain behavior. The attitude toward the behavior refers to the sum of beliefs about a

particular behavior when weighed by the evaluation of these beliefs and the subjective

norms. This refers to the influence of people in one’s social environment on his/her

behavior. When an individual believes that the advantage of doing the behavior is greater

than its disadvantage then he/she decides to act on the behavior especially when he/she

expects to benefit from it.

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Conceptual Framework

Applying the theory to this study, it is assumed that the respondents’ utilization of

the benefits and privileges of the PhilHealth PCB 1 Package may be influenced by their

attitude towards the package, which in turn may be influenced by the amount of

knowledge on which it is based and how it was acquired. Knowledge and attitude are

expected to vary according to the characteristics of the respondents.

In the context of age, it is assumed that the older individuals who are

knowledgeable about the benefits and privileges of the PCB1 Package may have a

favorable attitude and are more likely to avail of its services. However, some age-related

diseases or cognitive deficits may make them physically handicapped, and this conditions

may prevent them from utilizing the services. Furthermore, middle-age group individuals

may have more knowledge on the benefits and privileges of the PCB1 Package, however

they may be too busy or preoccupied with responsibilities at home or at work that they

cannot have the time to avail of the services.

Both men and women have equal opportunities of learning about and utilizing the

PCB 1 Package, however men may not utilize these benefits as much as women would

because of the need to maintain their masculine image making them more reluctant to be

identified as weak and easily to get sick.

It is assumed that being married has the assurance of family support. However,

the widowed and separated individual may also have the support of their children and

friends. Married individuals may share and motivate their partners to avail of the benefits

and privileges of the PCB1 Package, while the widowed or separated individuals living
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alone may not avail of the services in PCB1 Package since nobody motivates them to

avail the benefits and privileges of the package.

With regards to the educational attainment, the higher the educational level the

respondents have completed, the more likely that they have better knowledge and attitude

towards the utilization of the benefits and privileges. On the other hand, those with low

education may also obtain some information about the benefits and privileges of the PCB

1 Package through media, radio, television or even the word of tongue from their

associates thus making them utilize their benefits and privileged.

It is also assumed that the income earned by the individuals may affect their

decision to avail of the PCB1 Package. It may be expected that those with low income are

more likely to utilize the benefits and privileges much more often than those with higher

income as the need of the former for socio-economic assistance may be greater. On the

other hand, the opposite may be true to those with low income who may not have enough

money to sustain their daily living such as food and other basic necessities, and thus may

not give priority to purchasing medicines after being diagnosed with a disease.

Distance from the health care facilities may play a role in the utilization of

benefits and privileges of the PCB1 Package. It is assumed that those who live far from

the health care facility may find it bothersome and may not utilize the benefits and

privileges stipulated under the PCB1 program, while those who live near the health

facilities may utilize its services more often. On the other hand, those who reside far from

the health care facility may still be be eager to avail of the benefits and privileges they are

entitled since the necessity of it is far more important than the distance.
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It is also presumed that knowledge about the benefits and privileges under the

PCB 1 Package which is considered in this study as independent variable is believed to

have an important influence in the utilization of health services. Indigents and LGU

sponsored members who are well informed about the PCB1 Package would likely be

more wager to avail the said Package. Furthermore, it is believed that attitude of the

respondents towards the benefits and privileges of PCB 1 Package may also influence the

utilization of the Package. Those respondents who had a favorable attitude towards that

package may more likely to utilized it to those who had an unfavorable attitude towards

the benefits and privileges of the PCB1 Package.

Hypothesis

1. There is no significant relationship between the socio-demographic profile of the

respondents ‘and their knowledge of the PhilHealth PCB 1 Package.

2. There is no significant relationship between the socio-demographic profile of the

respondents and their attitude towards the PhilHealth PCB 1 Package.

3. There is no significant relationship between the socio-demographic profile of the

respondents and the extent of utilization of PhilHealth PCB 1 Package.

4. There is no significant relationship between the respondents’ knowledge about

and their attitude towards the PhilHealth PCB 1 Package.

5. There is no significant relationship between the attitude of the respondents

towards and their extent of utilization of PhilHealth PCB 1 Package.

6. There is no significant relationship between the respondents’ knowledge about

and their extent of utilization of the PhilHealth PCB 1 Package.

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7. There is no significant relationship between the respondents’ knowledge about

and their extent of utilization of the PhilHealth PCB 1 Package when attitude is

controlled.

Figure 1 shows the assumed relationship among the variables of the study

Antecedent Variable Independent Variable Intervening Variable Dependent Variable

Age
Sex
Civil Status Attitude towards Extent of Utilization
Educational Knowledge about PhilHealth Primary of PhilHealth
Attainment PhilHealth Primary Care Benefit 1 Primary Care
Average Monthly Care Benefit 1 (PCB 1) Package Benefit 1 (PCB1)
Family Income (PCB1) Package Package
Distance from the
Health Center

Operational definition of the variables and other terms.

For the purpose of clarity and understanding, the following terms were defined

conceptually and operationally.

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Antecedent variable

Age- refers to how old the respondent as of their last birthday.

Sex- refers to the biological classification of the respondent, either male or

female.

Civil Status-refers to the marital status of the respondent whether single, married,

and widowed /separated.

Educational Attainment refers to the highest grade/year/degree of education

attended by the respondent.

Average Monthly Family Income-refers to the average total income of the

family earned per month from all sources

Distance from Health Cente- refers to the proximity of the place of residence

and the facility (District Health Canters) where the respondents was enlisted and profiled

expressed in Km.

Independent Variable

Knowledge on Primary Care Benefit 1 (PCB1) Package. In this study it refers

to the level of understanding of the respondents regarding the available benefit and

privileges provided for them covered in the PhilHealth Primary Care Benefit 1 (PCB1)

Package. Knowledge of the respondents depends upon the number of correctly answered

items in the ten item questionnaire about the benefits and privileges, which are

answerable by true or false. The total score obtained was categorized into high level of

knowledge (8-10), average level of knowledge (5-7), and low level of knowledge (0-4).
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Intervening Variable

Attitude towards the PhilHealth Primary Care Benefit 1 (PCB1) Package. In

this study it refers to the opinion or feeling of the respondents towards the Primary Care

Benefit 1 (PCB1) benefits and privileges. The attitude was measured by a set of ten

questions. The questions were answerable by strongly agree, agree, disagree, and strongly

disagree, and the total score that a respondent can obtain is 30. The total scores was

categorized into; highly favorable attitude (21-30), favorable attitude (11-20), and

unfavorable attitude (0-10).

Dependent Variable

Extent of Utilization of Primary Care Benefit 1 (PCB1). In this study it refers

to the extent of use of the benefit and privileges provided in the PhilHealth Primary Care

Benefit 1 (PCB1) Package. This was measured by a set of 13 questions answerable with

yes or no followed by their extent of utilization answerable with multiple responses.

Items were scored based on the percentage of the services under the PCB 1 Package the

respondents had utilized. A total score of 100% for those who completely utilized the

services offered. Scores were categorized into; high utilization (51 percent to 100

percent), and low utilization with scores of (50 percent and below).

Other Terms

PCB1 Package stands for Primary Care Benefit 1 Package which includes 3 main

provisions; the delivery of primary preventive services, diagnostic examinations and

provisions of drugs and medicines.

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District Health Centers refers to the health unit owned, administered, managed

and financed by the local government unit which is either attached to or directly

supervised by the City/Municipal Health Office.

The District Health Centers on this study consist of the following;

1. Arevalo District Health Center

2. Bo. Obrero District Health Center

3. Jaro I District Health Center

4. Jaro II District Health Center

5. Lapaz District Health Center

6. Mandurriao District Health Center

7. Molo District Health Center

8. Sto. Rosario District Health Center

9. Tanza District Health Center

Member refers to any person whose premiums have been regularly paid to the

National Health Insurance Program. In this study the members refers to the profiled

members from different District Health Centers in Iloilo City.

Dependent refers to the legal dependent of the member. It may be the Legal

Spouse, Child or Children– legitimate, legitimated, acknowledged and illegitimate as

appearing in birth certificate ,adopted or stepchild below 21 years of age, unmarried an

unemployed, children or children 21 years old or above but suffering from congenital

disability, either physical or mental, or any disability acquired that renders them totally

dependent on the member for support, parents (non-member or the membership status is
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inactive) who are 60 years old and above, including stepparents (biological parents

already dead), and adoptive parents (with adoption papers).

Indigent refers to any person who has no visible means of income, or whose

income is insufficient for family subsistence, as identified by the DSWD based on

specific criteria.

Sponsored Members- refers to the marginalized and less privileged person or

families whose coverage is jointly shouldered by the National Government and the Local

Government Units or by private individuals and companies, members of the Congress

and other philanthropist

Significance of the Study

The result of the study will be most beneficial towards the government goal of

achieving Universal Health Coverage (Kalusugan Pangkalahatan), to deliver quality

health care services to every Filipino especially the marginalized groups in our society.

This study can serve as baseline information about the socio-demographic profile of the

indigents and LGU sponsored members, their knowledge, their attitude on the package

and utilization of their benefits and privileges under the PCB1 Package. The findings of

this study will be valuable to the following:

The recipients of care (the clients). The result of the study will provide the

indigents and the LGU sponsored members’ collective idea of their strengths and

weakness so that they can, and work cooperatively with the local government unit to

further enhance their utilization of their benefits and privileges. Furthermore, the data can
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motivate other indigents and LGU sponsored members to avail of the benefits they are

entitled to under the PhilHealth PCB1 Package.

Department of Health (DOH). The result of this study will provide the

Department of Health the profile of the indigents and LGU sponsored members in the

community and the extent of their utilization of the Primary Care Benefit 1 (PCB1)

Package. The data can be used as bases in redesigning the health care delivery system to

make it more suitable to the specific needs of the clientele.

PhilHealth. The result of this study will provide the corporation the necessary

information on the socio-demographic data of the indigents and LGU sponsored program

members as well as their level of knowledge, attitude and utilization of the benefits and

privileges under the PCB 1 Package. The data can serve as reference for future

amendments in order to improve services of the program to the needs of its target

clientele.

Local Government Unit (LGU). This study will provide the LGU’s relevant

information about the indigents and LGU sponsored program members and reveal the

extent of their knowledge, attitude and utilization of the PCB 1 Package. The result of

this study can be used as a basis for preparing or designing programs and innovations to

better address the needs of the PhilHealth indigents and LGU sponsored members and

assist them on how they can avail of their benefits and privileges.

Health Care Providers – the result of this study can raise the awareness of the

health care providers on how they can improve the beneficiaries’ access to the benefits

and services of the PCB 1 Package. The data can also help the health care providers

understand why some beneficiaries could not utilize their services. They can use the data
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in formulating plans and strategies on how to improve dissemination of the information

in the community about the available health care package and the benefits and privileges

the target clientele are supposed to avail.

Future researchers. This study can be used by future researchers as a source of

information in identifying the indigents and LGU sponsored members, their utilization of

the benefits and privileges and to determine other variables that can be associated with

extent of utilization of the PCB 1 Package.

Scope and limitation of the Study

Even though several behavioral theories state that there are many factors that can

influence a person’s behavior, this study only focused on the knowledge, attitude and

utilization of the indigents and LGU sponsored program members of their benefits and

privileges under the PCB 1 Package.

The respondents of this study were selected from different districts in Iloilo City,

thus the result of this study cannot be generalized to all PCB 1 beneficiaries outside Iloilo

City. Considering that the collection of data was conducted only from August 11, 2014 to

August 29, 2014, a period of three (3) weeks. This study could yield more comprehensive

findings if it was conducted longer. Generalization was made only to the indigents and

LGU sponsored members’ population from different districts in Iloilo City. Other

PhilHealth membership categories such as individually paying members, employed

members, organized group, and lifetime members were excluded from this study.

Furthermore, those with cognitive deficits individuals and with mental disorders were

also excluded.
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While there may be other variables such as source of daily living and occupation

which should have been included that could affect the knowledge, attitude and utilization

of the benefit and privilege of indigents and LGU sponsored members, this study covered

only the socio-demographic profile of the respondents such as age, sex, civil status,

educational attainment, average monthly family income, and distance from the health

center as variables.