Shunning Hippocrates

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Privatization of healthcare breeds unethical medical practices at public hospitals

Patients at a hospital in Hanoi. Experts say urgent government action is needed to ensure that disadvantaged sections of the society get good quality healthcare and are not ripped off by doctors prescribing costly medicines or unnecessary diagnostic tests.

The "socialization" of healthcare in Vietnam is turning even public hospitals into "profit-making machines" denying patients, especially poorer ones, experts say.

Socialization in Vietnam refers to the opening up of various sectors to multiple sources of investment.

Many public hospitals are focusing on ways to increase their revenue and in the process foisting unnecessary medical tests on patients, they add.

"Health centers have become profit making opportunities for the doctors and the nurses. That might be creating some pressure for poor people because they cannot afford the increasing fees," said Jairo Acuña-Alfaro, policy advisor on public administrative reform and anti-corruption with the United Nations Development Program (UNDP) Vietnam.

Acuña-Alfaro said that healthcare privatization, besides its benefits, could make some hospitals pay more attention to maintaining targeted revenue rather than to providing good service.

On April 5, the Vietnam Social Insurance, which overviews health insurance in the country, announced an inspection of reimbursements made at hospitals in Phu Tho, Ben Tre and Ha Giang provinces.

The inspection, to be launched next month, follows a scandal involving a hospital in the northern province of Phu Tho found illegally setting quotas for its departments and divisions.

In 2011, the Phu Tho Area General Hospital aims to get 16,050 inpatients and 80,000 outpatients. It plans to have 3,700 patients undergo CT scans and 16,000 take ultrasound scans.

For the pediatric division, this means receiving a minimum 140 child patients a month, each paying at least VND1 million (US$48) for treatment and running a minimum prescription bill of VND230,000 ($11).

For the emergency department, the target is to get 108 to 114 patients per month, with an average 5-day treatment time and an average VND2.3 million in fees per person.

If these targets are reached, the hospital staff would be rewarded with bonus payments, the Tuoi Tre newspaper reported March 24.

A week after the exposé, the Health Ministry's Examination and Treatment Management Department confirmed that the hospital had set up quotas for its divisions, breaching an instruction given by the ministry in June 2010.

Pham Luong Son, head of Central Health Insurance Policy committee, said that the Phu Tho Area General Hospital was just one among many hospitals in Vietnam to have imposed such a quota system to bring in more money by inflating patient bill.

"A patient who had dorsal vertebrae pain is required to take an MRI (magnetic resonance imaging) scan, which costs over VND2 million ($95.5), or one with a sore throat has to go through all kinds of tests, including the HIV test," Son said.

"Test fees alone can go up to VND500,000-700,000, which is a lot of money for many patients," he said.

Commenting on the quota, Acuña-Alfaro said, "It is hard to believe that this is happening.

"It is creating a wrong incentive. Hospitals are just becoming profit making machines. It should not be about the number of patients. It should not be about how much [money] the prescriptions given to those patients (cost)," he told Thanh Nien Weekly on the phone April 12.

"The incentive has to be in terms of quality of services. And not about how many people come to the hospitals and how many people go back to their houses with medicines they don't need," he added.

Privatization's side effects

The push for healthcare privatization that Vietnam embarked on in the nineties under the "socialization" model has had undeniable benefits but also adverse impacts on poor people, experts say.

Statistics from the Health Ministry's Examination and Treatment Management Department shows that there are 34 public hospitals directly under the ministry's management and 83 private hospitals nationwide. The list, posted on the department's website in October, 2010, mentions that public hospitals at provincial and district levels are waiting to be updated.

A study released last week by ActionAid, an anti-poverty NGO, on the possible impacts privatization could have on access to public services in Vietnam said that the "socialization" would mobilize investment to extend service supply resources, diversify types of healthcare services, and create pressure to increase service quality.

The poor have benefited indirectly because of decreased burden on public hospitals, while support policies like health insurance cards have reduced barriers limiting access to health care services, the report found.

"This is considered a success of state support policies designed to limit the negative impacts of privatization on the poor," the report said.

However, it also found that financial abuse in service costs at public hospitals in the context of privatization has not been resolved.

A doctor at a public hospital in Ho Chi Minh City admitted that health privatization has created pressure on public hospitals in terms of revenue because rich people have shifted to private hospitals.

"Thus, public hospitals have to use hundreds of ways to earn money, especially from outpatients, through unnecessary services," he told Thanh Nien Weekly, on condition of anonymity.

"I am well aware that many doctors at public hospitals  prescribe unnecessary ultrasound scans and other medical tests."

He said healthcare privatization had also triggered a brain drain from public health care services, the quality of services provided to people who can not afford treatment at private clinics and hospitals has also suffered.

The doctor said that under the health autonomy policy, public hospitals contribute 70 percent of their revenue to the state budget. They had only the remaining 30 percent with which to pay salaries and other overheads. Considering the official salary for a new doctor at a public hospital is a mere VND1.5 million ($75), this 30 percent had to be augmented to provide the staff with "bonuses" for a reasonable remuneration, he said.

Revise autonomy decree

With the negative impacts of privatization on poor people becoming apparent, the government should take immediate action to redress them, said Acuña-Alfaro of UNDP Vietnam.

He said a decree on hospital autonomy needs to be revised to make sure it does not create incentives for public hospitals to become profit-making concerns, he said.

"They need to ensure a wider coverage of protection policies so that poor people have access to basic services. They need to strengthen the health insurance program," he said, adding that services at communal levels should be improved.

The team that conducted the ActionAid study suggested the government increase supervision to limit abuse of healthcare costs and unnecessary procedures in public hospitals.

"Survey data shows that both people and local authorities are worried about unnecessary tests," the report said.

One person who has drawn no benefit from the socialization aka privatization of healthcare is Pham Thi Dai, a small trader at a roadside market in HCMC's Go Vap District.

She has never thought about going to a private hospital. "It's too expensive and I couldn't afford the fees," said Dai, who migrated to the city from the northern province of Bac Giang almost ten years ago after a divorce, and has two school-going children to take care of.

"We also avoid getting examined at public hospitals. Usually, I just buy medicines from pharmacies whenever my children or I get a cold or sore-throat."

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