Hospitals in bad health

Many of the nation’s poorest can ill afford to pay for quality healthcare, with proposed fee rises a bitter pill to swallow

A Ministry of Health (MoH) draft document on medical  fee hike is expected to help public hospitals  improve their treatment and facilities. However, how the services and facilities will be ameliorated is up in the air.

Despite four big electric fans running at full speed,  the room, where hospital fees are collected, at the Hanoi’s Central Hospital for Tuberculosis was stuffy due to overcrowding.

 Nguyen Thi Vinh was finding it hard to worm her way through the crowd to approach the cashier’s booth to pay her husband’s VND6.2 million ($326.3) bill, equal to five months’ hard work on farm in her hometown of the northern mountainous Yen Bai province. However, the sum was equivalent to just one week’s treatment to her husband’s illness.

“In total, we have spent nearly VND20 million (more than $1,000)  treating the disease, except for daily expenses on food and accommodation. We will have to pay more for treatment. But, we have run out of money and we do not qualify for state health insurance,” said Vinh, who is a mother of three.

For a poor farming family like Vinh’s, such big medical fees are really burdensome. The same is true for many other families in Vietnam whose per capita annual income sits around  $1,000.

In Vietnam’s rural areas, it is not uncommon to see a family in big debt resulting from medical treatment. As a result, farmers have to sell their most valuable assets like houses and land, and even transfer the ownership of cultivable land so as to have enough money to pay medical treatment.

Vinh was really shocked when she was told that her family, like millions of other patients nationwide, might have to pay far more than existing medical fees, if and when a draft document on partial hospital fee augmentation jointly devised by the MoH and the Ministry of Finance takes effect at the end of this year.

The draft, which is now waiting for feedback from the public and relevant ministries, focuses on increasing the fees of 350 out of 3,000 medical services offered by public hospitals nationwide.

Of which, 220 and 60 services will be increased by 2.5 and 2.5-5 times, respectively, and the others will go up by seven-10 times, against the existing levels. For example, the draft proposes VND30,000 ($1.57) for a check-up, which is up to 10 times more than the current fee, and the daily inpatient fee will be VND100,000 ($5.24), instead of VND18,000 ($0.94) currently.

Reasons behind the increase

The proposed medical fee hike was ascribed to inflation, which has increased almost 2.5 times between 1995 and now.

“All costs for hospitals’ operations such as power, petrol, water and chemicals have multiplied. Many public hospitals are suffering from losses and cannot offer high quality services, because the existing fees are charged based on the government’s hospital service pricing schemes issued in 1994,” said Nguyen Duy Quang, vice head of the MoH’s Legislation Department.

The government issued Decree No95/CP-ND on August 27, 1994 on partial hospital fees, which has helped hospitals generate 50-90 per cent of their total revenues from collecting fees and health insurance.

However, a MoH statement said state budget funds for public hospitals remained low. According to a MoH survey, hospitals were provided by the state with an average VND30 million ($1,578) per bed per year, which was enough for hospitals to pay minimum salary for their staff.

Meanwhile, according to the survey, hospitals had to use collected fees and health insurance, the pricing schemes of which were issued 15 years ago and became outdated, to cover medical treatment services.

For example, the Decree No95 stipulated check-up fees ranging from VND3,000 and VND5,000 ($0.15-$0.26) and a hospital bed fee at just VND10,000 ($0.52) per day, while the real fees at present have jumped 10-fold due to inflation.

In another case, the decree prescribed fees for some tests at VND3,000-VND9,000 ($0.15-$0.47), but the real fees for these tests have increased by five to 10 times.

The MoH said that public hospitals had to improve their technologies for better treatment services, and if they continued charging the fees under the former document, they would continue suffering further losses and not be able to perform quality services.

“If the state continues subsidising hospitals, it means that the state is also subsidising those who can pay all hospital fees. Meanwhile, those benefiting social policies such as the poor are enjoying their medical treatment via health insurance.

“Thus, the proposed medical fee changes still abide by the decree, in which partial fees will be increased up for items such as drugs, blood, chemicals, water, power, fuel, maintenance and direct fees for check-ups and treatment,” Quang said.

Who will benefit?

Quang said this revision would not affect those with health insurance such as factory workers, retired people, the poor, ethnic minority people and children under six years old.

But, Vinh said she had never dreamt of health insurance assistance. “So do many households in my village. They only hear about the assistance and don’t think they can benefit from it,” Vinh said.

Do Thanh Trung, a Hanoi-based Bach Mai Hospital kidney patient, said that many like him also had no medical insurance and had been treated at the hospital for years.

“During the last eight years, I have come to the hospital three times a week for treatment. My monthly treatment costs are nearly VND10 million ($526.3) including dialysis, assorted medicines and traveling costs,” said Trung, who is a northern Thai Binh province farmer.

“I cannot imagine how we can manage if the hospital fees increase,” he said.

According to the MoH, 55 million, or 63 per cent of 86.5 million Vietnamese people, have had health insurance. This means that the remaining population, who do not have health insurance and stable incomes such as farmers, households living a little above the poverty line and self-employed labourers, will be greatly affected by the proposed hospital fee hike.

Moreover, under the Health Insurance Law which took effect in July 2009, poor patients have to pay 5 per cent of total hospital fees and the rest is reimbursed by the health insurance agency. However, for many poor families, the even 5 per cent has hit them hard.

“I think that the draft is very good for public hospitals, because the new fee levels will help them offset big expenses, better infrastructure and medical treatment quality,” said Nguyen Ngoc Hien, vice director of Hanoi’s Bach Mai Hospital.

But, many patients showed their concern over whether public hospital services would be improved.

“I support the increase, but in the case that public hospital services must be improved. I have had medical treatment in many hospitals, but all of them lack beds. One bed is often shared by three to five patients,” says Pham Thanh Bang, an arthritis patient from Hanoi’s E Hospital.

But Pham Thi Bich, an osteomyelitis patient from Hanoi’s Saint Paul Hospital, said that the proposed hike almost made no sense, because many public hospitals had already increased their fees.

“It is quite wrong for the MoH to say that hospitals are charging VND3,000-VND5,000 ($0.15-$0.26) for a check-up and VND18,000-VND20,000 ($1) for a bed per day. In fact, the fees have already been pushed 10-fold over the past years,” Bich said.

In fact, the MoH’s draft on partial medical fee hike does not feature a specific plan to improve medical facilities and services nationwide that are overloaded and fail to meet demand.

Local media have many times reported constant overloading at almost public hospitals where each doctor had to examine 100-120 patients per day.

Moreover, the draft also does not mention a transparent financial mechanism and the specific foundations for calculating the proposed fee hikes. It also does not detail the fees of services needed to be increased, as well as clearly affirm that medical treatment quality and facilities will be ameliorated after there are fee hikes.

Tran Quy Tuong, vice head of MoH’s Health Examination and Treatment Management Department, said that the treatment quality depended on many factors such as the knowledge and professional skills of health workers, medical facilities and equipment.

Therefore, even the  MoH could not affirm whether the treatment quality would be improved or not, and whether a hospital bed would surely be for one patient.

Nguyen Cao Luan, head of Bach Mai Hospital’s Hemodialysis Department, agreed that higher costs for medical services were necessary, but a roadmap on gradual increases of medical fees was needed to minimise the negative effects on the poor.

“I think that public hospitals should establish funds to assist poor patients. The funds will partly  come from the hospitals’ collected fees,” he said.