| Vietnam’s Medical Assistance Situation : Challenges and Views - Dr. Rafi Kot
As Vietnam has taken the decision to open its gates, in 1989, to the West and took a step of relaxing its approach to the economy and to foreign influx, it has started to face new challenges in multiple sectors. One of them relates to the health industry which quiet directly has taken an adverse effect on the health assistance industry making it a real challenge in terms of access and proper medical service. Here’s Why: Geography and transport: Vietnam’s geographic shape is described by locals as of a dragon. Quick view on the map will show that its an “S” shaped form, 331,114 sq/km, 3670 km of seashore, Bordering China to the North, and Laos and Cambodia to the west. With its Capital in the North - Hanoi, and its economic Hub- Ho Chi Minh city (HCMC) in the south , –some 1780 km away by road number 1 –Which is the only main connecting route between north and south. (Lately a new mountain route along the Ho Chi Minh war trail has been opened to alleviate congestion and supply Vietnam with an alternate connection between North and South. Unfortunately this rout is seldom used due to its remoteness ) At the middle of this road are situated two of Vietnam’s other major cities –Hue and Danang, some 80 kms apart. It is crucial for the reader to understand this, since in between this long stretched road except of these two mid cities, there are many small towns, non however developed enough to be considered as a key player in terms of medical service provider. Its worth noticing also that these 4 cities which I have mentioned, are the only cities which operate a 24 hrs all weather airport. All other airports in Vietnam are NDB based and close down at last light. This has a major impact in terms of accessibility to many parts of the country, which might not be considered remote by land access but very restricted in terms of Air access. Vietnam’s road conditions have improved considerably in the last 15 years, mainly thanks to Overseas Aid. However, as the Roads improved, so did increase the number of cars and motorbikes on them. Vietnam’s population of 86 million (1.3% Growth rate), has only last year purchased more than 500,000 motorbikes alone... Obviously traffic congestion is at its peak, (as are road accidents) rolling slowly at an average pace of 40-60 km an hour on the highways and slower even in the cities. Just imagine dispatching an ambulance 120 km away, seeing it return after 6-8 hours. The Air traffic in and out of Vietnam has increased considerably. From once a day Flight to neighboring Thailand and twice weekly to Singapore during the mid-late 90’s, to a Presently traffic on these same routes leaves 3-5 times on a daily base, not mentioning daily direct flights to Europe –Frankfurt, Paris and Moscow, the Western US Coast, West Asia and Australia . Local low budget carriers stop as well on a daily base in the two major cities, Hanoi and HCMC making travel affordable to a large number of Vietnamese. Taking also in account that flight time from HCMC to BKK is 1hr and 5 minutes and to Singapore 1hr and 45 minutes, (both Destinations with excellent medical facilities) has significant importance and impact on the health and assistance industry, a subject I will touch later. MAP OF VIETNAM
Red circles : Available Tertiary level Facilities and 24 hr access Airports Green Circles : Most Frequently visted sites by Tourists Economy: Based on EIU estimates, the economy is valued at US$68.6 billion for 2007 and is expected to stand at around US$109.1 billion in 2012. Real growth is estimated at over 7% in the medium term, one of the highest rates in the world, slowing to 6.5% in 2012. GDP in 2007 stood at 834$ per capita. Vietnam hopes to cross the 1000$ per capita at 2010. However current rise of food, oil prices, weak USD, has contributed to a creeping inflation rate of 15%. In view of the fact that more than 90% of the population does not use banking services, rather deals with cash, makes it even harder to control inflation. A large part of the economy remains under government control, despite more than two decades of economic reforms. As a consequence, Vietnam has a large number of unprofitable, outdated State-owned enterprises, which are desperately in need of reform. Pace of reform, however, remains slow. While a basic market economy appears to be flourishing, the State remains bureaucratic and oriented around command, not market philosophy. This makes Vietnam a difficult country for foreigners to deal with, although arguably conditions are slowly improving. Population and Demographic indicators: Based on data of the Ministry of Health, Vietnam’s population in 2007 was estimated at 86 million The population growth rate has however slowed gradually over the years, from around 1.9% in 1990 to around 1.37% in 2007 ( = + 1.6 million added pop.). This rate is relatively low when compared with other countries in the region. 58% of Vietnam’s population is under 30 years of age. Despite the rural nature of the country, population density is high, at 252 people per square km in 2005. Outside the major cities, population density is at its highest in the two main areas of economic activity, the Red River Delta in the north, and the Mekong Delta in the south. Hanoi, the capital, had a population of over 4.6 million in 2007. Vietnam's largest city is Ho Chi Minh City, with a population of just under 8.4 million in 2007. These number are “official” , although estimates are much higher due to influx of Rural population into the cities in aim of finding work. Health System
Leading Causes of Death, 2004 (WHO) Cases Rate/100,000 Intracranial injury 2,521 Road Accidents 3.07 HIV disease 1,754 2.14 Transport accident 1,609 Road Accidents 1.96 Pneumonia 1,224 1.49 Intracerebral hemorrhage 1,070 Road Accidents 1.30 Acute myocardial infarction 775 0.94 Stroke 771 0.94 Respiratory tuberculosis 770 0.94 Heart failure 627 0.76 Septicemia 507 0.62 Data for 2006-7 is not available however it would be accurate to guess that Road accidents have surpassed any other Mortality reason. Organization: Vietnam’s health system is based on its socialist model were it is arranged around several layers. Being a communist country, Vietnam has a strong system of local government organization, based on villages, communes, districts and provinces. However, Village and Commune level have very little to offer in terms of equipment and talent, therefore referral to district hospitals is almost immediate. A district hospital would typically serve a population of up to 200,000. Since this hospital is budgeted by the district, obviously treatment capacity of these facilities is low-limited, again, making it almost mandatory to refer patients to the Provincial hospitals, which provide the most specialist care available outside the major cities. The problem is that the rural population, knowing that the first two layers –Commune and district are useless, often refers itself directly into Provincial hospitals, or even the large city hospital, resulting in overcrowding, sometimes leaving 3 patients sharing a bed. Each of the 53 provinces has its own Health Service Office reporting to the local People’s Council, which is responsible for drawing up and administering health policies at provincial level. The Ministry of Public Health is responsible for drawing up and administering health policy at national level. The vast majority of public hospitals are administered by the district and provincial health service offices. Government funding for hospitals is provided by the Ministry of Finance. Until recently, government funding was calculated on the basis of the number and type of hospital beds in each province, but there is now a move to allocate funding according to population size. But,- The Ministry of Health also has its OWN hospitals- directly funded by itself, and usually these hospital consider themselves “above the rest” in terms of equipment , talent, better budgets. The main and best facilities in this group are located in Hanoi, Danang, Hue, and HCMC. The Military forces of Vietnam have also their network of hospitals, which are very well equipped and are open for public (income source), excelling mainly in Trauma and burns. The MOH has circulated a price list for services among the Public hospitals. Prices range from 110 USD for an appendectomy, 85 -115 USD for a variety of Limb Fractures, 8 USD for gastroscopy, 2 USD for an X-ray, 0.20 USD for a CBC, 45USD for a CT scan and 3 USD for an ultrasound. The list remains a list, since The doctors obviously demand some extra for their services. General Obstacles and Weakness that you should know: Vietnam’s fast growth has created a high demand for QUALITY medical services. The fast growth pace of the country has outstripped its local talent. Although funds and budgets in the large cities are quiet in reach, there is a notion, almost a cultural believe. that buying high tech equipment in Hospitals will close Vietnam’s gap in terms of knowledge . This includes many times diagnostic equipment which diagnose pathologies the hospital has no ability or skills to treat. However, the fast growth has outstripped talent availability, in terms of numbers and much desired quality. When it comes to training physicians and nurses,- its a time consuming effort and process. With a weak foreign language knowledge, lack of funds and scholarships, no Post graduate training schemes, No CME system, low salaries and therefore motivation, there is a very small chance Vietnam will be able to close the gap in terms of medical skills and information. In the end of the day, its doctors who do good medicine, not machines. With the proximity, plus low travel costs plus no need of visa, and availability of proper medical facilities in neighboring countries, which move ahead as well, the chances for Vietnam to create a critical mass in order to match knowledge and know-how seems even more remote. It is estimated by the MOH that between 2006 and 2007 some 30,000 Vietnamese seek medical treatment in neighboring countries spending some 1.3 billion USD. Leading demand was in disciplines of Oncology and Cardiac Surgery. A lack of a TRULY screened blood bank and blood by products. Add also the genetic lack of Rh - among Asians, compared to Caucasians. The fact that many Provincial hospitals although under same control have different policies and different attitudes. There are only few hospitals designated for seeing and treating foreign patients. Once a foreign patient is admitted, many times he is kept as long as possible, since the notion is that foreigners pay more. It is also an administrative labyrinth involving letters and permits to see a patient for an external evaluator which wishes to assess the situation and report back. A system of phoning and trying placing an overseas GOP does not exist . Many times the foreign clinic asked to evaluate the patient medically, will also place a GOP in behalf of the assistance company. Except of foreign owned facilities, cashless service is nonexistent. Many times, a hospital is approached by an evacuation company promising a bonus if patient would be evacuated by them, resulting in treatment kept to the minimum until patient is evacuated. Vietnam’s Pharmaceutical market is lacking medications due to excessive beurocracy, creating a situation were drug companies prefer to import simple medications that sell, rather than items which are needed. Because all medications in Vietnam need a “visa” given by the MOH only for a year, non transparent re-registration issues, there are continuous problems with availability and continuity. This reflects mainly in terms of sudden lack of int’l standard vaccines for children, among many other items. The Private Sector: The private sector is on the rise. An answer to a dilapidating public system. However, since the private sector is highly disregulated it actually siphones patients by Physicians from the Public sector into a non regulated private market. Once a physician has an “ownership” on his patient, some of these physicians are re-routing their private patients back into the hospital, this time under their guidance, using and taking advantage of the hospital facility, equipment, operation theatres, ending pocketing the fees to their own pocket. This has created a system, although no one will admit, well functioning, motivating the doctors to work, were by now the driving force is coming from the patients rather than the doctors. The idea of regulating this inevitable existing market and taxing it, therfore channeling monies and funds for the poor has not matured yet in the MOH. Vietnam has currently(2007) 18 private owned hospitals, 2 private foreign owned, 3,669 Private registered clinics (Single discipline) and 4 private foreign owned medical multi disciplinary centers. Among the hospitals it’s important to mention the fact that 4 deal with General Medicine, one deals with OBGYN, and one, recently opened will deal with CV disease. These hospitals and the multi disciplinary clinics operate on int’l standards and are able to give most answers in Primary Health care, as well as good response expected of tertiary level facilities. Interesting to mention that hospital groups in neighboring countries are not considering Vietnam as an investment opportunity, rather prefer efflux of patients out of Vietnam. The Ministry Of health is actually more busy regulating and controlling the private sector than addressing the real problem at the public level. Rules prohibiting import of refurbished (and cheaper) medical equipment, prohibiting the facilities to own their in-house pharmacies, Inability to use public health insurance in private facilities, daily changing and re-changing regulations- all contribute to a relative lack of interest among private investors in a country were Health care would seem a lucrative business from outside. Although the MOH and MPI’s (Ministry of Planning and Investment) call fro foreign investors to bring hi tech in and see patients is loud and echoing- de facto what happens is that outdated regulations “suck” and pull down every effort to renovate and implement high tech. Since the social health insurance refuses to pay for patients seen in Private sector, the number of patients in these facilities is relatively very minor. The main core of the providers is in Ho Chi Minh city and in Hanoi. Another multi disciplinary center is available in Danang and is the only one actually between Hanoi and HCMC. The foreign medical facilities have in and outpatient capacities. They are providing services mainly to :
As a General director of such a facility one faces many challenges:
Alliances forged with hospitals done previously during the “4 year ago trip to S E Asia”… while newer and better facilities are emerging. Inability to understand Asian mentality, strategies, structure and rivality among receiving hospitals. The 24 hour emergency number resulting in a recording directing the patient/dr to call 911. Mainly in cases of North American insurance companies. The inability of Assistance companies to take a decision, because big decisions can only be taken during day shift, forgetting sometimes world time tables. Air Ambulance and Exit abilities Company Frequency type Origin What’s on board Prices availability remarks VASCO On Demand B200 Vietnam Stretcher, Oxygen, Power, All monitoring equipment Lower than competitor on same route – state owned Yes Easy to get flight permits within Vietnam Medical Wings On Demand B350 Thai Stretcher, Oxygen, Power, All monitoring equipment Neonatal incubator Capacity High, Private Venture Non immediate Needs to divert via int’l airport for exit Visa stamps. BKK airways On Demand ATR 42/72 Thai Modified stretcher Power ,monitoring equipment High due to type of AC Mostly at night , because carrying passengers during day time Will carry Patient ONLY to BKK hospital group. Thai X 3Daily A-300 Thai Stretcher, Oxygen Cheap 3-4 days Short flight -65 minutes Lufthansa 3days /week A-340 B-747 400 German Stretcher, Oxygen Cheap 1-3 days Stretcher in BKK Airport Flt stops in BKK, Short flight -65 minutes then cont to Frankfurt Singapore Airlines X2 Daily B-777 Singapore Stretcher Oxygen Cheap 1 day Flt time 1:45 hrs Air France X 5 Daily B-747 400 France Stretcher Oxygen EXPENSIVE 2-3 To Europe Vietnam Airlines X1 Daily A-320/1 A-330 Vietnam Stretcher Oxygen Cheap Same day If A330, no stretcher ability, yet. So, Vietnam, although pacing slowly forwards remains a challenge in terms of medical care, quality and solutions which are not always available, and most probably won’t be for quiet a lengthy period of time and The role and burden on The private sector will probably continue to increase. More of our useful articles: |
