The burden of choice

Written by Ginger Ramirez

‘Why did they have to choose?’ – I often think about how many difficult decisions are made inside hospitals. Decisions that define life and death, decisions that people can bring with them throughout their lifetime.

I remember listening to one of our medical interns who shared why, in a place such as the Province of Northern Samar, a father he met at the emergency room needed to choose between which of his children would get admitted to the hospital. Two of this man’s three children, 1 and 3 years of age, were experiencing severe vomiting, diarrhea and poor oral intake from acute gastroenteritis. They had to be admitted for inpatient care. However, because the family could not afford it, they had to choose one child. One child will be provided the medical care urgently needed while the other child will be sent home to an island two hours away from the hospital. A child sent away, with the risk of complications and worsening of symptoms.


Children in Northern Samar,
through the lens of Filipino photographer Martin San Diego

There is another story recounted to me, this time about a mother who gave birth prematurely in one of the province’s district hospitals. Being born preterm, the baby’s lungs were still underdeveloped and although the baby was improving each day, he required constant oxygen supplementation. One day, the mother told the doctor that although there were signs of improvement, she decided to bring her child home. She was willing to be ‘discharged against medical advice’ which meant she was willing to bring her premature infant home without any oxygen supplementation and with the risk of death. One oxygen tank cost PHP 1,600 (31 USD/23 UKP) and the mother had already paid for 7 oxygen tanks. In this province, the poverty incidence is 52%, which means more than half the population lives below the poverty line, and the average monthly household income is about PHP 5,000 (98 USD/71 UKP). There was no way the mother could sustain the increasing health care costs. She had to make the difficult, almost impossible, choice: spending the remaining household income for the survival of one child or spending it to care for her family, her other three children who were waiting for her back home.


Girl in Northern Samar, 
through the lens of Filipino photographer Martin San Diego

These are two stories I encountered as a doctor in the Philippines. Such challenges are faced by parents and families every day, in our country where poverty cripples access to proper health care. In the Philippines 56.3 % of health expenditures are out-of-pocket (OOP), finances are among the most significant barriers to health care. Despite the expansion of the country’s social health insurance and other mechanisms to provide cash incentives and subsidies for indigent families, system inefficiencies, non-health expenses (for instance, transportation, food for companions, opportunity cost due to lost daily income) and other associated costs are persistent burdens carried by patients and their families.

Health care is a human right and no family should have to choose between providing health care and their basic needs. If we are serious about achieving #HealthforAll, we ought to begin looking after families who are most vulnerable because of their socio-economic conditions, families who are most likely to be placed in these situations of unjust choices.


Original GIF image can be accessed here

I believe it is a moral obligation to strengthen the health care system and provide safety nets for those who are at greatest risk of suffering from these inequitable conditions. Health professionals, academic institutions, government leaders and other key stakeholders have the power and responsibility to change this situation. We have to choose to fight for universal health care for the achievement of social justice and health equity and share this burden so that others will not have to carry them on their own.