Incentives another symptom of a diseased health care system

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Poor patients are being squeezed out of the health care system as doctors accept significant commissions from the pharmaceutical industry and more affluent patients


A boy waits to receive acupuncture treatment at a hospital in Hanoi July 1, 2011.

Dang Thi Kim Oanh has been reluctant to go to the hospital to be examined and treated for a goiter she has been suffering from for more than 10 years.

"The Tumor Hospital is among a few that could offer adequate treatment for this. But I have heard that patients must wait for hours before being examined and that if you need surgery, you will have to wait several months," she said.

The small-trader in Ho Chi Minh City's District 8, who earns a mere VND70,000 per day, said she was afraid of having to pay additional unofficial fees to doctors, surgeons and nurses a common practice among many Vietnamese patients.

Experts have blamed the lucrative commissions offered by pharmaceutical companies and the acquiescence of patients willing to give "gifts" to doctors and medical workers who in turn supply profit-driven medical services, increasing the financial burden of poorer patients.

Trinh, a tubal infertility patient in Hanoi, said she had to pay more than VND13 million for a surgery of her fallopian tubes, of which only VND2.8 million came in the way of hospital and medicine fees. The rest was given as under-the-table payments to the hospital staff members in the hopes of receiving better health care.

"The surgery was unsuccessful. I am thinking about doing an In Vitro Fertilization but I am afraid that I will have to pay much more in support," she said.

According to a report released on March 12 by the Hanoi Medical University, more than 76 percent of obstetric and surgical doctors admitted to receiving "support" from pharmaceutical and medical equipment firms.

Jairo Acuña-Alfaro, policy advisor on anti-corruption for the United Nations Development Program (UNDP) in Vietnam, said the report was consistent with the organization's findings over the past five years.

"It seems that the core of the problem is about pervasive or damaging incentives in the sector," he said.

Acuña-Alfaro said the practice has decreased the quality of the service and forced the low income patients, who have few resources to pay, to buy medicines they do not need.

"It's basically an extra burden on poor patients already facing increased fees for medical services in addition to these out-of-pocket expenses," he said.

The Ministry of Health has announced that fees for 70 percent of 220 health services will increase by up to five times as of April 15.

Health Minister Nguyen Thi Kim Tien said the increases are due to inflation and the fact that the basic salary in Vietnam has increased nearly sevenfold since 1995.

Giant kickbacks

In 2010, local media found that some doctors in HCMC were receiving substantial commissions from pharmaceutical companies for prescribing their products.

A doctor at the HCMC University Medical Center received monthly kickbacks of VND528 million ($25,396) for selling US Schering Plough (SP) Pharmaceuticals drugs to treat hepatitis. He also received another VND459 million for pushing just one SP sale each month.

Another doctor at the center received VND226 million also for prescribing SP hepatitis medication at his private practice. A doctor at the Medic Medical Center and another at Cho Ray Hospital received similar commissions from SP.

Vietnam's annual per capita income is around $1,300.

Acuña-Alfaro said salaries for doctors and medical workers are not enough to sustain a decent standard of living, forcing them to become dependent upon earning pharmaceutical commissions.

"This suggests that the [privatization] of health services has moved toward commercialization. Patients seem to be viewed as opportunities for profit. This has created serious problems and placed pressure on authorities because incentives to profit exist irrespective of patient needs," he said.

But he noted that the problem is not unique to Vietnam and called for thorough solution to the issue by ending these types of pervasive incentives.

"When doctors prescribe a medicine tied to a commission, he is not going to think about the health of the patients, but the profit he is going to make when that patient goes to buy the medicine," he said.

Nguyen Tuan Anh, a researcher at Hanoi University of Pharmacy, believes informal payments to doctors are "a dominant factor" in the high price of medicine.

Anh published a study last year in which he interviewed doctors, pharmaceutical representatives, government officials and pharmacists in both the private and state hospital sectors. The study concluded that 40 to 60 percent of the final price could be spent to induce doctors to prescribe particular medicines, and to persuade hospital procurement officers to buy them.

Doctors surveyed said they took cash and non-cash offers to make up for low salaries, and that it was common for commissions from the pharmaceutical industry to become the main source of income for some physicians.

A 2009 survey by the Hanoi Medical University found more than 54 percent of doctors received official monthly incomes of less than VND2 million ($96).

Low salaries, overcrowded hospitals and a lack of appropriate training have deteriorated the ethics of many doctors and medical workers, the study found.

According to Acuña-Alfaro, the problem is exacerbated by the gift-giving culture of Vietnam, where people tend to want to show their appreciation for quality service, adding, "It will be very easy to differentiate a gift of VND20,000 from obvious bribes of VND2 million or even more which are given to procure faster or better treatment."

In a recent online forum held by the central government's website, Health Minister Tien admitted that even her own family members sometimes resort to offering unofficial donations to hospital staff members in order to receive preferential treatment at overcrowded hospitals.

No excuse

Less than a third of Vietnamese doctors consider it necessary to inform the patients of mistakes which take place during the course of their examinations and treatment, according to a survey of 1,000 doctors in Hanoi, HCMC and Hue released on March 12 by the Hanoi Medical University.

Just 30 percent of doctors think their patients should be informed of such information.

"I think it is necessary to inform patients of relevant mistakes," said Jairo Acuña-Alfaro, policy advisor on anti-corruption for the United Nations Development Program (UNDP) in Vietnam, adding that it's a question of medical ethics.

When 37-year-old patient, Hua Cam Tu, was admitted to Can Tho General Hospital in the Mekong Delta last December, her husband signed a waiver giving the hospital permission to remove the left kidney in a worst-case scenario, but the right kidney was supposed to remain intact.

Tu's husband, Nguyen Thien Tri, said he had been informed that the surgery was successful and the right kidney remained intact.

"I only saw her the following day in critical condition. The doctor instructed an ultrasound scan and I heard the medical workers asking each other why they did not see any kidney," he told Tuoi Tre (Youth) newspaper, adding that the doctors explained their priority had been saving his wife's life, not informing him of her situation.

The doctor who removed both Tu's kidneys has been suspended and she is now being treated at the Hue National Hospital and several people have agreed to donate one of their kidneys to help her.

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