Cash for care: unfair

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Growing practice of informal payment in public hospitals is increasing discrimination against poor patients, study warns

A child being examined at a hospital in Hanoi. Experts have warned against an ineffective medical system that impoverishing poor patients and enriching the pharmaceutical and medical equipment companies.

Tran Le Phuong gave her doctor VND2 million (US$96) at her last examination at his clinic before being admitted to an obstetrics hospital where she would request him to conduct a cesarean section.

"I also asked him to arrange a bed for me because the hospital is always overcrowded. Many mothers have to stay in temporary beds along the corridors," said the 35-year-old teacher in Ho Chi Minh City's Binh Chanh District.

Phuong said the doctor did not demand the extra payment apart from the high monthly examination fees during her pregnancy.

"Everybody knows most doctors at a major obstetrics hospital have a private clinic where they offer periodical examinations for pregnant mothers and help them give birth at the hospital. We pay them examination fees and another sum prior to delivery to ensure the best service," she said.

Phuong said most mothers, especially in Ho Chi Minh City, do this and the practice of giving money to medical workers is common in Vietnam.

In fact, a new report on informal payments in the healthcare industry says that the practice, which is the norm now, developed along with the advent of the market economy (1986) and has become even more pervasive since 2000. The main factors driving this, it says, are overloading at hospitals and the low salaries of medical workers.

It also says that under-the-table payments are widely accepted by both service providers and users.

While the study finds that the practice stems from a historical, deep-rooted tradition of making in-kind informal payments, usually, as gifts, it says in its current, growing form, it threatens the goals of equity, efficiency and sustainability in the healthcare system.

The report was released by Towards Transparency (TT), the official national contact of Transparency International (TI) in Vietnam and the Hanoi-based think tank Research and Training Center for Community Development (RTCCD). It was titled, "Informal Payment in Health Services in Vietnam: Causes, Perceptions and Impacts."

The study was conducted from August 2010 to February 2011 in Hanoi, Son La, Dak Lak and Can Tho.

The study focused on the "envelope" given to medical staff. In found the envelope value ranged from VND50,000 ($2.50) to VND5 million ($250), with some exceptions going much higher.

Voluntary act, but"¦


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Dr. Tran Tuan, founder and director of RTCCD, said he was not surprised that many people admitted to giving and receiving the envelope.

"However, I am impressed by the different attitude between the doctors and patients toward envelopes.

"About half of the interviewed patients said they gave money or in-kind gifts because it was common behavior among others. Only one third of the patients reported that health service providers sometimes extorted payments in subtle ways. Meanwhile, most interviewed service providers said informal payments were given voluntarily by patients," he said.

A taxi driver from Son La Province said he once took a patient with pleural effusion to the emergency ward of a central hospital. "When the patient was there, the doctors did nothing. I reminded the patient's relative to give them an envelope and the emergency aid was performed immediately," he said.

The study found patients made informal payments for various reasons including access to care, improved quality of care, ensuring availability of supplies, transfer to a higher-level hospital and "just to avoid shame."

For their part, healthcare providers said they accepted cash or envelopes to increase their income to meet rising living costs, because it had become a social norm, or to avoid embarrassment for patients who was offering payment.

Higher costs, same service

While most patients expect better services after making the informal payments, many health workers including doctors said envelopes did not improve the quality of treatment.

Interviewed doctors and nurses in the study admitted that patients who pay extra might get more "gentle counseling," more time with hospital staff and more attention after surgery.

"Giving or not giving envelopes does not change the quality of care. We do not reduce the amount of medicine prescribed to patients, use low-quality thread for stitching wounds, use unsterilized gloves or gowns in the surgery room because the patient does not give envelope or money," a surgeon in Son La said.

"The only difference is that patients giving envelopes are paid more attention after surgery," he said.

However, with many health services carrying a wide range of risks and dangers, a large number of respondents confirmed that payment was driven by the belief that it was risky not to pay.

"I know that the payment does not make a better quality of care. But if I am in the hospital next time, I am going to pay. Who on earth knows what they [medical personnel] will do, if they are treated badly? I will die for sure," a patient in Hanoi said.

The hierarchy

The study found that the amount of cash/envelope payments is considerably higher in central and provincial hospitals and in urban facilities compared to centers in rural areas. "Informal payments, envelopes in particular, were not reported to be a problem in most district and commune level health facilities," the study found.

It found the payments made differed between hospitals and between different departments within a hospital. They were more likely to be made in services with high chance of fatality like surgery, emergency care, obstetrics and pediatrics. Administrative staff and those providing routine care like cleaning services or injections also received cash, at smaller amounts and lesser frequency than doctors, surgeons, nurses, assistants and orderlies.

The study also found that "pre-existing relationships between the client and health professionals do not seem to affect either the amount of informal payment made, or the rate at which it is given. Even health workers report feeling embarrassed for not giving any in-kind gifts or envelopes to thank colleagues who provide treatment for their relatives."

It found most newly-graduated health workers did not accept any kind of informal payments. It took one to three years for the acceptance to begin.

According to the study, many health service providers and policymakers now believe that informal payments may lead to other negative impacts on health services in Vietnam by eroding the patients' belief, respect and trust in the healthcare system and creating internal conflicts within health facilities.

The PAPI (public administration performance index) survey released last month by the United Nations Development Program (UNDP) found many Vietnamese believe in giving "backdoor" money to receive better public services.

More than half of the survey respondents said "envelopes" are necessary for examination and treatment at public hospitals, while 31 percent admitted to actually paying the money, which ranged from VND5,000 per visit to VND30 million (US$1,500) a year.

The study concluded that the "model of private management mechanisms in public hospitals increases opportunities for informal payments." It said the lack of transparency in public health service management, economic pressures and the lack of investigations and follow up were other contributing factors.

The report recommended that priority be given to anti-corruption efforts in the health sector that, private management models in public hospitals be eliminated and strengthening the capacity of primary healthcare facilities to prevent overloading at major hospitals.

It said both financial and non-financial remuneration for health workers should be increased and an independent quality supervision system established.

Dr. Tuan said "the structure and mechanism of the medical system has created an environment of corruption.

"We aim to provide policymakers evidence that the situation has impoverished the residents and enriched the pharmaceutical and medical equipment companies," he said, referring to the practice of informal payments in cash and kind made by the corporate sector.

"The quality of care is altered treatment priority is not based on the severity of the illness but is slightly modified by the influence of money," he said.

"In other words, the quality of life of a patient is affected and there is no healthcare equity."

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