CASE ANALYSIS: Ang Kwento ni Rosario

PART I
Health does not exist in a vacuum and will always be affected by an endless
number of factors ranging from ones regular diet and own genetic make up on a
micro scale, to where one is taking residence and what policies the local
authorities implement in ones community on a macro scale. Health is multifactorial and this is evident with the case of 1 year, 4-month-old Rosario.
Rosarios family is destitute they cannot afford three full meals a day
instead, they have a regular diet of coffee, rice, and a meager P50 viand, that they
portion for 6 family members to last three meals. They live off on the P165 salary
of Jaime, Rosarios father, who is a laborer in Quezon City. With no other mentioned
sources of income, their family severely lacks financial security not only to afford
food but also a decent shelter, clean and potable water, proper sanitation, and
other services and goods such as medicine and milk formulas. Rosarios mother,
Lucy, was ill advised to hold off from breastfeeding all of her four children, and
instead she resorted to feeding them with diluted condensada and powdered milk.
In addition, the parents, with relatively low educational attainment, hold beliefs,
misconceptions and practices that do not promote health like how bottle feeding
paraphernalia are washed only by soap and water, that vaccines cause sickness,
calamansi is bad for the health, or that parasitic worms are normal and that these
aid in digestion. These considerations in Rosarios immediate context have led to
her and her siblings being 2nd degree malnourished children, regularly contracting
cough, fever, diarrhea and having unmanaged infestation by parasitic worms.
Unfortunately, Rosario, given her age, her lack of vaccines, poor diet and other
factors leading to her increased vulnerability, is also the sickliest. Among her
siblings, she is the thinnest, pale and regularly diarrheic. It was actually just a
matter of time for her to contract an illness, as she eventually did go down with
measles, and due to a variety of factors was unable to recover and ultimately died.
Considering another level in Rosarios context, the condition of their familys
community and place of residence, Barrio Tanyong, further elucidates the case of
Rosario. It is described to be located beside a highly polluted and contaminated
body of water, with poorly built infrastructure leading to accidents that increase
the risk of exposure to canal waters. Even more disturbing, the communitys main
water source (90%) consists of two public pumps or deep wells that have a high
possibility of being contaminated, given the communitys close proximity to the
canal.
Another direct and major contributor to the unfortunate outcome in the case
is the healthcare system, in the forms of the physician with whom Lucy consulted
before, the barangay health center and a private hospital. It was unclear whether
the doctor that Lucy consulted with before practiced in either of the latter health
care facilities, but what was evident was he/she did not think what was best for the
patient, instead exploiting Lucys poor grasp of health-related concerns. Despite
Lucy feeling quite well and nourished enough to breastfeed, she was still
diagnosed to have a heart condition and was told this was a contraindication, even

when there are actually very few instances when this is the case. The physicians
motive of personal profit is further evidenced when he/she urged Lucy to buy
infant formula from a small dispensary he/she owns. For the barangay health
center, it was understaffed of midwives and health workers, and under stocked
with vaccines and other medicine. In terms of health financing, their budget
allotment for medicine from the LGU for the year was already consumed, and they
were having trouble convincing the Sangguniang Bayan that the additional budget
will be used for its intended purpose, instead of being pocketed by the mayor and
municipal health officer. They were able to provide free consult, however the
instruction regarding the prescription given goes directly against the law,
supposedly ensuring Lucys right and choice to cheaper, but still bioequivalent
drugs. Another questionable practice by the health center was how they rejected
Lucy and Rosario for a second consult, instead referring them to a private hospital
without clear reasons as to why they could not be accommodated. Lastly, for the
private hospital, while it is understandable that as a for-profit endeavor they have
a fee for service system, their deposit system is contentious, as they have yet to
provide health care for the patient. It is also unfortunate that they do not seem to
have a charity ward or a program for indigents to at least support some of their
expenses, asking them to pay also for consumables like cotton, alcohol, gauze and
tape.
a. Identify which of the health problems presented in the case is core
and priority for health program development? Explain your choice.
Defining a core for all of the health problems in the case is problematic as
these problems have different roots and contexts, and they compound on each
other as certain socio-economic factors, such as financial security and educational
background, determine the likelihood of these problems arising as well as the
capability/vulnerability of the individual when forced to address these problems.
More useful to the case would be to strengthen an institution capable of addressing
basic and common health problems, instilling health promotion and education and
delivering health services especially catering to the felt and expressed needs of
the community as a whole the barangay health center. The case of Rosario is
neither isolated nor rare, she is representative of the highly vulnerable under 5
population, and what happened to her could have happened to any other child in
their community.
I would like to focus on strengthening the barangay health center as, if
managed well, it is capable of addressing a lot of the problems presented in the
case. The health center is supposed to be equipped enough to capably handle
common and basic illnesses (respiratory infections and measles being some of
them), and annually holds programs supported by the local and national
government to address year-round concerns like malnutrition and parasitic
infections. Supposing these problems were common in the community, they could
hold feeding and deworming programs in partnership with NGOs or through
funding from the local government. The BHC is also a venue for health education
and promotion, a place where people can get information, clarify misconceptions

and hopefully eradicate beliefs and practices that are not helpful and may even
increase the risk for acquiring sickness. They were in a position to correct the
information given to Lucy about breastfeeding her children, thus saving the family
some money instead of buying poor milk substitutes. Furthermore, as it is the
health facility closest to the ground, the community and its constituents, the BHC
is expected to be the most knowledgeable of the communitys felt and expressed
needs the need for proper sewage systems, toilets and sanitation, clean and
potable water sources, as well as the need to improve infrastructure so as to
minimize accidents. These community problems could be relayed to the proper
authorities and hopefully the barangay or municipal authorities could do something
about it.
The barangay health center is, of course, still limited in its scope and will
always be hindered by financial constraints. While the MHO is burdened with the
task of rallying for a bigger budget and support from the mayor and council, the
BHC must prove its worth to the community by providing as much as it can for the
good of a greater number of people, given its limited resources. Its programs
should benefit as many of its constituents as possible, and should work on
preventive rather than curative approaches if they are to better the wellbeing of
the community as a whole. The problem of under stocking could be addressed by a
thorough evaluation of what medications are easily or hardly consumed, by
identifying the most common diseases burdening the population, and using these
data, projecting what and how many medications or vaccines they should procure
for the next year. The BHC should also comply with the law and promote the
prescription of generic rather than brand names so as to lower the financial burden
of the patient. For uncommon diseases that the BHC may not be able to handle,
they should have a good referral system in place. They must properly inform the
patient as to the need for a referral and offer public, firstly, as well as private
health care options.
b. Problem Tree Analysis

c. Objective Tree Analysis

PART II
The Philippines is currently experiencing the double burden of disease,
wherein the top causes of morbidity are communicable, infectious diseases while
the top causes of mortality, from being previously occupied by communicable
diseases, have changed to more of the degenerative, lifestyle and noncommunicable diseases. In addition, there is also a threat from emergent and
resurgent diseases, thus placing a bigger toll on the health care system and the
economy. The double burden of disease poses a greater challenge for health care
providers, as such trends indicate that while people are getting sick from infectious
diseases, people are dying due to other causes- leading the health system to ask
which direction should they take? Where should the limited budget allotted for
health go? Ultimately, the decision whether to specialize in internal medicine and
manage degenerative, lifestyle diseases or into infectious diseases and treat
longstanding health problems in the country also lie on these trends and decide
the fate of new physicians who aim to uplift the lives of patients, but also to make
a living.
As a second year medical student, this status and these numbers are still
quite distant to me, owing to the fact that I have yet to be truly immersed in the

clinics to see physical representations of these data in the form of patients who
come in the hopes of treatment. At the very least, these numbers challenge me to
try and get a good grasp of all the diseases included in the lists, as these, by far,
are the most common and would definitely be cases I meet on a regular basis. It
also requires of me to be novel in that I should be able to address both morbidity
and mortality and contribute to improve those numbers by aiming to lessen the
burden of disease.
Such a feat could only be achieved by changing the paradigm of medicine
from being curative to preventive. By shifting the focus from illnesses to total well
being and healthy practices. As a friend of mine said, Medicine is ironic because as
a job, it works to eradicate itself. To truly have the patients best interests in mind
would mean working to keep them from incurring diseases and away from the
clinics. In the ideal healthy world, there would be a decreased demand for doctors
and other health care providers because there would be no illness to treat (except
perhaps for the usual rare chromosomal aberration). But as it is, the burden of
disease remains great and a means of affecting and improving it would be through
strengthening preventive medicine. Keeping healthy individuals healthy, and
working on those who are sick to recover and resume a healthy if not normal life.
Emphasizing on moderation and proper nutrition, keeping a healthy and active
lifestyle clear of vices, risk-taking and health-depreciating behavior lowers the risk
for contracting both communicable and non-communicable diseases, thus
addressing the double burden of disease. It is only recently that health care
systems in other countries are shifting their paradigm of curative to preventive
medicine, and the Philippines has yet to catch up. But for that to happen, not only
should authorities like DOH and LGUs step in, but also, on a grassroots level,
medical practitioners and the communities themselves should change their idea of
what the role of medicine should be.
On a personal level, I already am an advocate of preventive medicine
though I may have inconsistencies practicing it on myself as I have yet to
internalize that health is not just the absence of infirmity or disease but a total
physical, social, mental and emotional well being.