First published in ITIJ 93, October 2008
Despite, in 1989, relaxing its economic policy and rules governing the inflow of foreign goods and services, Vietnam has faced new challenges in various sectors. One of these has been the health industry, where problems regarding access to care and an insufficient number of international-standard facilities has had an adverse knock-on effect on the assistance industry in the country. Dr Rafi Kot explains
The geography and infrastructure of a country plays a large part in the logistics of its assistance and healthcare industries. It is important, therefore, to consider the physical structure and man-made transportation links of Vietnam, a country that attracts a growing number of tourists each year to its stunning scenery and World Heritage sites.
Vietnam’s geographic shape is described by locals as like a dragon. A look at the map will show that it’s an ‘S’ shape covering over 300,000 sq km, with 3,600 km of coastline, and bordering China to the north, and Laos and Cambodia to the west. The country’s capital city – Hanoi – is in the north and its economic hub – Ho Chi Minh City (HCMC) – is in the south, some 1,780 km away by road number 1, which is the only main connecting route between each end of the country. Recently, 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, but due to its remoteness, this route is seldom used.
Along the middle of road number 1 are situated two of Vietnam’s other major cities – Hue and Danang, which are some 80 kms apart. It is crucial for the reader to understand this geography, since in between these four major cities, along this long road, there are many smaller towns that have poor medical infrastructures and so often rely on such services in these larger cities. It’s also worth noting that these four major cities are the only cities in the country that operate 24-hour, all-weather airports. All other airports in Vietnam are Non Directional Beacon-based and close down at last light. This is a major factor in terms of accessibility to many parts of the country, which might not be considered remote by land access but are very restricted in terms of air access.
The condition of Vietnam’s roads has improved considerably in the last 15 years, mainly thanks to overseas aid, but it has meant a massive increase in the amount of traffic on the roads. Vietnam’s population of 86 million (growing at just 1.3 per cent) purchased more than 500,000 motorbikes alone last year! As a result, traffic congestion is a major problem, especially in the cities, and road accidents are at an all-time high. Resultantly, the reality is that a road ambulance can be dispatched to a hospital 120km away and not return for up to eight hours.
"these four major cities are the only cities in the country that operate 24-hour, all-weather airports"
Air traffic in and out of Vietnam has also increased considerably. Up to the late 1990s, flights to Thailand ran just once a day, and to Singapore twice-weekly, whereas they now run three to five times each day. Additionally, the airports run daily direct flights to Europe – Frankfurt, Paris and Moscow – as well as the US, western Asia and Australia. Local low-budget carriers also fly from Hanoi and HCMC on a daily basis, making travel affordable to a large number of Vietnamese. This has, of course had a huge impact on the healthcare and assistance industries, as flight times to medical centres of excellence, such as Bangkok and Singapore, are only an hour to two hours away.
A tax on the public
Vietnam’s public healthcare system is based on a socialist model and is organized into several layers.
Being a communist country, Vietnam has a strong system of local government organization, based on villages, communes, districts and provinces, and its healthcare organization follows a similar structure. However, village and commune level care have very little to offer the local population in terms of medical equipment and talent, so most people in such areas are immediately referred to a district hospital. Such establishments typically serve a population of up to 200,000. Since these hospitals are only funded by district budgets, however, they too have a limited capacity for treatment, so patients are often further referred to a provincial hospital, where the best specialist care can be found outside of the major cities.
The problem is that the rural population, knowing that the first two levels of care – commune and district – are useless, often go straight to a provincial hospital, or even a larger city hospital, resulting in overcrowding and sometimes leaving three patients sharing a bed!! In fact, Vietnam currently has a total (public and private) of just 147,200 hospital beds – although this is an eight per cent increase on 2005.
Until recently, government funding was allocated on the basis of the number and type of hospital bed in each province, but there is now a move to calculate funding according to population size. At the same time, the Ministry of Health (MOH) has its own hospitals, which it funds directly, meaning they have better equipment and more talent. The main – and best – facilities in this group are located in Hanoi, Danang, Hue, and HCMC. The Military of Vietnam also has its own network of hospitals, which are very well equipped and, as an extension to thier services to forces personnel, additionally treat the families of servicemen in order to help provide an extra income for the military. Such medical centres excel mainly in trauma and burns.
The MOH circulates a price list for services provided in public hospitals, with fees such as US$110 for an appendectomy, $85-115 for a variety of limb fractures, $8 for a gastroscopy, $2 for an X-ray, $2 for a CBC, $45 for a CT scan and $3 for an ultrasound. On top of these prices, doctors charge extra for their services – a city doctor able to charge more than his peers in the countryside.
Thus, although a socialist state, Vietnam no longer has a free health system. The State does, however, still collect a social health insurance from the population, which many refer to as more of a tax, claiming the public health insurance scheme is useless as most of the money collected isn’t reinvested in healthcare. This situation leads to under-the-table payments in order to obtain proper medical treatment.
"the reality is that a road ambulance can be dispatched to a hospital 120km away and not return for up to eight hours"
The public healthcare system is overloaded due to over demand, and has serious funding issues due to the cheap price lists dictated by government that do not reflect the real cost of treatment. In a further effort to avoid creating a ‘haves and have nots’ polarity in society, Vietnam prohibits the sale of private health insurance.
Demand outstrips supply
While a basic market economy appears to be flourishing in Vietnam, the State remains in control of a large part of the economic infrastructure, shrouding it in bureaucracy and orienting it around ‘command’, rather than ‘market’ philosophies. This makes the country a difficult place for foreigners to work in, although arguably conditions are slowly improving. Based on Economist Intelligence Unit 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 seven per cent in the medium term, one of the highest rates in the world, slowing to 6.5 per cent in 2012, while GDP in 2007 stood at $834 per capita, which is hoped will rise to $1,000 per capita by 2010.
However, the current rise in the price of food and oil prices, together with a weak American dollar, has contributed to a creeping inflation rate of 15 per cent. In view of the fact that more than 90 per cent of the population does not use banking services, instead dealing in hard cash, it is hard to control inflation.
Nevertheless, Vietnam’s swift economic growth has created a high demand for quality medical services, although it has not been able to keep up with this demand in terms of qualified doctors. This has been compounded by spending on high-tech equipment as opposed to investing in staff. Thus, some of the larger, city hospitals have state-of-the art diagnostic devices but not the ability or skill to treat the diagnosed pathology. This problem is unlikely to be solved in the short-term, as medical training in Vietnam is hampered by generally poor foreign language skills, a lack of funds and scholarships, an absence of post-graduate training schemes and continuing medical education system, low salaries and therefore motivation. As soon as the MOH puts greater emphasis on training and knowledge rather than on the accumulation of machinery, things may start to change.
But with hospitals in neighbouring countries boasting technology together with skilled personnel, the chances of Vietnam developing its own medical knowledge and knowhow seems even more remote. Low-cost travel options and no need for entry visas mean these nearby countries are increasingly visited by Vietnam nationals seeking medical treatment – especially in the fields of oncology and cardiology. It is estimated by the MOH that between 2006 and 2007 some 30,000 Vietnamese sought medical treatment in neighboring countries, spending some US$1.3 billion in the process.
There are only few public hospitals designated by the government for the treatment of foreign patients and these are to be found in the main cities. They include: Bach Mai Hospital in Hanoi, Viet-Tiep hospital in Haiphong, Hue University Hospital, Danag Hospital ‘C’, and Cho Ray Hospital in Ho Chi Minh City. When a foreign patient is admitted, however, they are often kept in for longer than is necessary in order to make as much money out of them as possible. On the other hand, we have heard of one international assistance company that promises bonuses to hospitals that direct patients into their care. Treatment is, thus, kept to a minimum by the hospital until the patient is evacuated by the assistance company.
Over-treatment, where is does occur, is made easier by hospitals charging patients what they wish, instead of MOH rates – an illegal practice but something the MOH has little power to stop given that certain hospitals have the backing of provincial officials. Any external medical practitioner or assistance company representative must also navigate through an administrative labyrinth involving letters and permits in order to gain access to the patient.
"The main - and best - facilities in this group are located in Hanoi, Danang, Hue, and HCMC"
The practice of phoning for or trying to obtain an overseas guarantee of payment (GOP) does not exist in Vietnam. Often, a foreign clinic asked to evaluate the patient medically, will also assign a GOP to the patient on behalf of the assistance company. Except for in foreign-owned private facilities, cashless service is nonexistent.
Also of note is the fact that Vietnam’s pharmaceutical market is lacking medications due to excessive bureaucracy. A situation has been created where drug companies prefer to import simple medications that sell, rather than items that are really needed. Also, all medications in Vietnam need a ‘visa’ given by the MOH, but these only last for a year, and the industry is marred by non-transparent re-registration issues, leading to resultant and ongoing problems with availability and continuity.
Private sector challenge
The private sector in Vietnam is growing: the answer to a dilapidating public system. Thus, Vietnam currently (2007) has 18 privately owned hospitals; two private, foreign-owned hospitals; 3,669 privately registered Vietnamese-owned clinics (single discipline); and four private, foreign-owned multi-disciplinary medical centres.
Among these hospitals, it’s important to mention the fact that four deal with General Medicine, one deals with OBGYN, and one (recently opened) will deal with CV disease. These six hospitals, together with the multi-disciplinary clinics, operate to international standards and are able to deal with all aspects of primary healthcare, as well as providing good tertiary-level facilities.
However, the plethora of private ‘clinics’ , which are situated all over the country, leave little to be desired in terms of what they offer with regards to standards of care or facilities, and should therefore be avoided at all cost by foreign patients unless in an emergency and where there is no alternative medical facility specifically geared to treating foreign patients. The few foreign patients who do end up in such facilities are usually backpackers who have little funds or no insurance.
In terms of foreign investment in healthcare, Vietnam gets overlooked in favour of neighbouring countries with more comprehensive regulations. Rules prohibiting the import of refurbished (and cheaper) medical equipment, prohibiting facilities from owning their own in-house pharmacies, an inability to use public health insurance in private facilities, and regulations that seem to change on a daily basis all contribute to a relative lack of interest among private investors. Meanwhile, the MOH is busier regulating and controlling the private sector than addressing the real problems at public level.
The main core of providers servicing foreign patients – both hospitals and clinics – are in HCMC and Hanoi. One multi disciplinary centre is in Danang and is the only private treatment facility between Hanoi and HCMC. Foreign patients may be treated at any private medical institution, but as doctors even in these private institutions often do not speak English, patients are invariably steered politely to alternative, suitable establishments.
All the private facilities in Vietnam that are foreign-owned provide both in- and out-patient services, predominantly to expatriates, able-to-pay locals, and tourists. However, as a general director of such a facility, one faces many challenges:
* Costly and hard-to find staff. Most physicians in such facilities are foreign, and there has been a move away from employing GPs in favour of specialists.
* The sourcing of medicines – even generic medicines. Bringing drugs into the country also remains a constant difficulty. The knock-on effect of this is the problem in treating pre-medicated patients entering Vietnam.
* The availability of single-use equipment. Such materials often have to be bought from overseas, adding to their expense and causing problems in terms of continuity of supply.
* The lack of a properly screened blood bank and blood by-products.
Despite these issues, private clinics such as ours strive to offer the best possible service to our clients. Family Medical Practice, for example, operates six medical centers throughout the country, and following demand has had to invest in a variety of high-tech equipment and working modes such as e-filling and digital radiology in order to communicate effectively between our different centres. This is especially important in times of emergency when dual evaluations can be done in real time.
There are several risks to travellers who visit Vietnam, and given the remoteness of some of the areas visited by these visitors, there is a real challenge in the country in terms of access to appropriate medical care. The increasing mortality rate attributed to road traffic accidents is the number one risk for foreigners in Vietnam. This is especially poignant when you consider that Neurosurgery is only in its infancy in this country and available at only two or three hospitals.
But it’s the openness of Vietnam, and its increasingly intrepid explorers that pose a similarly important problem in terms of access to emergency medical care facilities. Two areas in particular are increasingly frequented by tourists looking to get off the beaten track – and both are many miles away from hospital services.
The first is Vietnam’s central highlands, which are littered with UXOs and unexploded mines. Tourists frequently visit here, however, interested in the history of the Vietnam War, and the ethnic communities that live in the region. Most of the 1,000-km route through this region has no hospital or other medical facilities, but those working in the region know the terrain and available resources, so we know how to reach those who may find themselves with a medical emergency or in distress. If the patient/tourist can’t be directed down the shoreline to the nearest hospital, they will usually be reached by car, as only two of an original 88 airstrips in the region are still operational.
In the north of Vietnam, which is similarly remote, the main route in is by road or train. There are no airstrips. Evacuation from here is either by car or helicopter. Fortunately enough, cases arising from these areas do not occur more than two or three times a month.
The country’s emergency aircraft and helicopter fleet is very limited, and includes a few old Mil Mi-8 helicopters, three (new) Eurocopters and a Beechcraft 200. None is a dedicated medevac aircraft and none of the helicopters operates a winch. There is also the added problem of obtaining timely permits for certain flight paths, especially over Lao and Cambodia. Severe weather conditions during the rainy season must additionally be factored into any evacuation.
"Vietnam's swift economic growth has created a high demand for quality medical services"
Last but not least, a real challenge in Vietnam, with regards to the treatment of foreign visitors, lies in effective dealings with the international assistance industry. Too often, there is an automatic steer of patients out of Vietnam for treatment, due to a lack of knowledge concerning medical infrastructure available in the country. And the majority of international assistance companies with bases in the region prefer to have headquarters in Singapore or Thailand even though most of their difficult emergency cases actually are coming out of Indochina meaning Vietnam would geographically be a better base for them.
It is also important for those companies with dealings in Asia to understand the mentality, strategies, structure and rivalry among receiving hospitals. Many hospitals in the region, despite belonging to the same umbrella group, compete for business, and unless the assistance company uses its own initiative to determine the best and most appropriate facility for the care required by its client, it may end up using a less suitable facility. It is, therefore, essential that assistance companies with traveller clients in Vietnam create and maintain a proper database regarding the medical facilities available throughout the country.
At the same time, with the low-cost airline boom, travel out of Vietnam is at an all-time high, and there has never been a greater need for outbound assistance services in the country. Besides International SOS, there are no foreign-owned or local assistance companies based in Vietnam, but due to Vietnam’s convenient geographic position in Indochina, there should be: it’s quicker to evac from North Laos to Hanoi than fly all the way to Bangkok.
The new breed of travellers in the country has a growing access to travel insurance, but it is very cheap and provides minimal cover. However, Family Medical Practice, together with AIG, is planning a dedicated, 24-hour alarm centre for Vietnamese travelling abroad, which will be staffed with bilingual Vietnamese operators.
All in all, Vietnam is making progress in the right direction in terms of standards of care and the treatment of foreign visitors, but it still faces big challenges with regards to access to care and the prioritizing of education and staffing in the public sector. In a bureaucratic system, where regulations often hinder rather than help access to medications and other supplies, change will likely continue to be slow. The role of the private sector will continue to grow, but the pressure on it will also. Further investment by foreign medical providers would help alleviate this situation, but better use needs to be made of the private facilities already in existence in the country – especially international assistance companies, who need to update their databases regarding the availability of medical care in the country, and where it can be found.