Feeling poorly

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Proposed increase in prices of medical services can be too much or too little, depending on who's paying, but affordable healthcare remains out of reach for Vietnam's impoverished

Two patients at Nguyen Trai Hospital in Ho Chi Minh City's District 5. Many poor patients are concerned by a government plan to increase hospital fees.

Nguyen Thi Ha is slightly apprehensive as she enters the cashier's booth, bill in hand, at the Hospital of Lung Diseases and Pneumonia in Hanoi.

The bill, for more than VND5 million (US$260), has been incurred for the treatment of her husband Nguyen Van Thong, who is suffering from tuberculosis. This does not include other daily expenses incurred staying away from home in Hanoi's Thuong Tin District.

For a poor farming family from Thuong Tin District, this is an astronomical sum, and this is true for millions of other families in a country with a per capita income of about $1,000 and where the minimum government salary is VND730,000 ($38) per month.

A simple question about the bill has tears flowing down from Ha's swollen eyelids. "It is really difficult for us to pay for the treatment," she says.

Ha and her 40-year-old husband earn less than VND5 million per each rice season [three-four months] as farmers.

It is not uncommon in Vietnam's rural areas for a family member's illness [and subsequent death, in many instances] to plunge the household so deep in debt that they have to sell the only source of livelihood they have their land.

Later, they subsist on hiring out their labor in surrounding areas or neighboring cities, forcing children to give up their education or parents to leave their children behind with relatives to work in cities to pay off their debt.

In fact, several NGO reports have noted that illness, accompanied by the lack of affordable healthcare, is one of the most common reasons for people to fall into poverty.

This dismal state of affairs could get worse for Thong and other patients nationwide who would have to spend a lot more on hospital fees if and when a draft document on the issue jointly prepared by the Ministry of Health and Ministry of Finance takes effect.

The document proposes increases in hospital fees that are up to ten times more than current rates, but policymakers argue that these increases are nominal, adjusted for inflation.

Nguyen Thi Xuyen, deputy minister of Health, said the 1995 document on hospital fees that is in use now was unsuitable because it stipulates examining fees of between VND3,000 and VND5,000 and hospital beds at just VND10,000 a day.

She said the proposed fees were between VND10,000 and VND30,000 for examinations and between VND50,000 and VND100,000 per day for a hospital bed.

Such an increase would not affect many patients because up to 62 percent of Vietnamese citizens have health insurance, Xuyen said. The poor are supported with health insurance fees while others will be able to pay all their fees, she added.

The family of Ha and Thong do not qualify for any health insurance assistance.

About 49.5 million people, or 56.6 percent of the total population had health insurance by the end of last year, according to the Vietnam Social Insurance the central agency in charge of managing social and health insurance.

Groundless factors

Pham Luong Son, head of Vietnam Health Insurance's policy division, was not convinced about the rationale for the increase.

"There should be a clear and reasonable foundation for the increase in hospital fees. I think the draft was not based on enough technical data for such an increase," Son was cited by the Tuoi Tre newspaper as saying on July 18.

According to Son, drafters had proposed medical examination fees of VND30,000 per person because they estimated that there are about 20 patients being examined a day and the daily cost for an examining room is VND600,000.

This is not the situation in Vietnam's hospitals, where around 50 patients are being examined in each examining room every day, he said.

Son also said the proposed hospital bed price of between VND100,000 and VND180,000 per day was also not feasible. Most hospitals would not be able to supply such services that require actual hospital beds and facilities like televisions, while hospitals at present have simple beds that are sometimes shared by two or three patients because of overcrowding.

Better service?

A recent editorial in the Tuoi Tre newspaper said the draft document on hospital fees should have included a plan to improve medical facilities and services that are overloaded and fail to meet demand.

"The number of patients sharing beds remains high, even three or four patients sharing a bed in some cases and the current solution is shortening the treatment period for inpatients," the paper said.

"Following an increase in hospital fees, patients should be supplied with minimum services like giving each patient a bed of her/his own and each doctor examining a maximum of 30 patients a day. But with the current demand, such simple requirements cannot be satisfied," it added.

Local media have many times reported constant overloading at many hospitals where each doctor has to examine some 100 patients a day and doesn't have enough time to conduct thorough examinations and offer detailed consulting services to the patients.

According to a report by the Ministry of Health about state-run hospitals, only 38 percent have nutritional departments and 51 percent have their own kitchens while 16 percent lack conditions to provide round-the-clock care for seriously ill patients.

Insurance fees follow suit

Facing a hike in reimbursement of hospital fees for patients with health insurance, the central insurance agency is looking to significantly increase insurance premiums.

Nguyen Minh Thao, deputy director of Vietnam Social Insurance, said they would increase health insurance fees by 40 percent once the draft regulations on hospital fees are approved. The current health insurance fee is VND450,000 per year.

However, Thao also said that Vietnam Social Insurance would suggest that the government supports policyholders with the surplus amount that can be taken from current subsidies granted to public hospitals.

Life and death

According to Vietnam Social Insurance, the 62 percent of patients having health insurance are mostly civil servants, workers and retired workers. People who don't have health insurance are those who don't have stable incomes, like households living near the poverty line, daily-wage laborers and farmers.

In April, the Ministry of Labor, War Invalids and Social Affairs had said the number of poor families in Vietnam will increase to between 17 to 22 percent if the new poverty lines are approved and take effect from next year. The ministry has submitted a proposal to the government to define poverty at a monthly average income of VND300,000 ($13.2) per person in rural areas and VND600,000 ($31.6) in urban areas. Another option is to set the threshold at VND480,000 ($25.3) and VND700,000 ($36.9), respectively.

While it is clear that an increase in hospital fees would affect those without health insurance, policyholders would also suffer.

Under the Health Insurance Law taking effect in July 2009, poor patients have to pay five percent of hospital fees, and the rest is reimbursed by the health insurance agency. Having to pay five percent will also hit many families hard, and can mean the difference between life and death.

Truong Thi Ngoc of An Giang Province in the Mekong Delta says the health insurance agency used to pay in full the hospital fees for the treatment of her six-year-old son at the HCMC Tumor Hospital. Her son suffers from leukemia, or blood cancer. With the new policy, they have to pay a portion of the costs. Ngoc and her husband have had to leave their rice fields in the Mekong Delta to work for daily wages as construction workers in HCMC to take care of their child.

"We have to borrow more money to pay for each of his treatment periods. But we can't afford it if the hospital fees increase. Maybe we will have to take him back home to An Giang then."

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