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5/1/1993 - Gaining markets but loosing health? (Part 1) No free lunch in Vietnamese hospitals. by Carole Beaulieu

NOT FOR PUBLICATION WITHOUTWRITER SCONSENT CB INSTITUTEOFCURRENTWORLDAFFAIRS GAINING MARKETS BUT LOOSING HEALTH Part No lunch Vietnamese hospitals Peter Bird Martin ICWA West Wheelock St Hanover NH 03755 Dear Peter The Socialist Republic Vietnam believes state health system Canada Right Health Vietnam Right Wrong Health probably socialized Vietnam United States Decree modifying health services financing better secrets about The Socialist Republico Vietnam sadly jokes Raphael Kot Israeli doctor Vietnam since German humanitarian organization That decree hospitals budgets Two thirds people excluded health Only veterans other target groups remained covered And always respected Walk government hospital clinic today Vietnam better piles pockets You medication treatment tests In hospitals deposit monthly salary before enter linen equipment salvage might If patient clinic before payment establishment revenues After doctor using equipment payment straight pocket The stiffer service faster I better Mlnh mother teachng Hanoi I choose doctor I longer But sometimes I wonder happens farmers Carole Beaulieu ICWA fellow writing about countries former French Indochina focus Vietnam Since Institute ofCurrentWorldAffairs theCrane Rogers Foundation hasprovidedlong fellowships enable outstanding young adults outside United States write about international areas issues Endowed bythelateCharlesR Crane theInstituteisalsosupportedbycontributionsfromlike mindedindividualsand foundations Minh wondering Some international organizations For years Vietnam success story Southeast Asia recalls Stephen Jarrett UNICEF New York In primary health tremendous gains Now indicators major drops attendance health stations surges peventible illnesses The system crtbling under pressure economic reforms If reorganize gains early morning rainy Hanoi winder Stephen Jarrett sitting meeting rooms Ho Tay Villas West Lake Villas biking center Hanoi The resort small bungalows surrounded fields vegetables patches meeting place Politburo Now functions hotel The souvenir booth entrance sells lacquer postcards Last departing Reuters correspondent Kathleen Callo rented villas going party At Bruce Springsteen voice shouted Born USA darkness West Lake On patio bungalow Vietnamese foreigners danced night On morning party Delegates Asia developing countries assembled workshop strengthening primary health services times economic transition During first years economic reforms China health system chaos admits Yu Dezhi deputy chief Planning Division Finance Department Chinese Health Ministry participant UNICEF workshop Barefoot doctors massively private market People villages where treatment While I listen Yu Dezhi embargo fever Hanoi during George Bush presidency American residents drawing petition President Clinton In hotel lobbies local journalists ambushing American businessmen hoping comment Bars restaurants bristling talks April meetings place New York between American businessmen Vietnamese authorities subject Prospects Economic Cooperation Between Vietnam USA explains New York woman teaching English Hanoi If Clinton embargo least should block loans World Bank review I vaguely think I leave Yu Dezhi Should I following embargo story instead But I I corridors crowded hospitals where people three I Hgors amount doctor I despair I doctors money I watch medicinal herbs small brown paper I track answers better found Washington Where Vietnam health system going Selling medici herbs Ln Ong street Hanoi According Yu Dezhi Vietnam stage China Just China Vietnam strong collective economy rural especially North The health services But development private economy warns Dezhi collective spirit ADd chaos Some already chaos Main health indicators point worseningo thestuationalthoughexperts admitevidence isstill sketchy Malnutrition rates goinE There resurgence malaria mountainous regions The number stunted underdeveloped children increasing In Vietnam rdeveloped children other income country South Southeast Asia except Bangladesh The cause malnutrition cannot found inadequate production The culprit likely poorly developed system procurement storaEe transportation According World Bank sectoral report health government policy suficiency retarded development distrlbutlon system It presently rewardln financially export outside Vietnam transport deficit regions within country As World Bank report there clearly public policy intervention sustainable means improving deficit regions letting exploit their comparative advantage crops other possibly Myanmar Disparities between cities countryside increasing In Hanoi Ho Chi Minh City children suffer chronic deficit In Red River delta close Bu working draft convincing confidential foreign governmental organization NGO paper Health Financing Vietnam contradicts generally accepted wisdom There evldence writes author report support assertion recent years witnessed deterioration health service supply either quantity financing quality So I The I seems report confusion But first history Vietnam record fertility deCline health improvement during three decades impressive matched income countries In infant mortality I000 births In Two years later figure halved again While Vietnamese expect until expectancy under French regime barely reached In after independence there strong commitment government improve health Nguyen Huu Hong Director Personnel Department Vietnamese Ministry Health Problems surfaced reunification Skilled health workers South country The primary health infrastructure south parallel developed Communist North The North poorer network reached isolated areas To cover whole country Hanoi spread itself The fiscal crisis matters worse Political imperatives given health began Supplies equipment maintenance declined Quality slipped utilization rates To supplement their income health workers began demand gifts People health years before economic reforms doctor Duong lecturer Hanoi Medical School Then reforms In doctors allowed private practice The pharmaceutical industry liberalized drugs began market In May public services began charge Almost immediately e_t_D P H N _t_DD_ Sectoral Review Document World Bank September Iin South private doctors never totally disappeared They practicing though illegal When lifted signs advertising Bac doctor reappeared streets Special tariffs Certain categories people exempt children veterans But those tariffs respected According NGO confidential attendance numbers began In public sector facilities consultations declined level The number patients dropped approximately former levels In drugs commune health clinics admits Mr Nguyen Huu Hong Health Ministry The staff badly The quality service According Raphael Kot health pyramid crumbled People bypassed system They stopped going health station because there nothing there They district hospital because feared would there flesh hospital statistics treated They straight pyramid provincial hospital Kot there By seriously Some attribute registered public clinics opening private health services outlets Dissatisfied public sector patients voted their Others disagree They artificial people clinics consultation drugs Once drugs markets there fewer occasions There ideology involved people health Gill Tipping British psychologist studylng health seeking behavior communes Quanh Ninh province north Hanoi They where convenient available In district Army hospital In another private doctor It varies According survey conducted Haiplong Vietnam third largest north Hanoi private sector choice people Close choose public sector establishment instead Over treat But those igures somehow misleading Concepts private public tricky country In Vietnam transition period wilder But before I words about medication report Permitting official charges opened floodgates The supervision means official tariffs either ignore supplemented various extra charges discretion health personnel General Statistical Office G Q iSt___R u_b_l _o__f__ V_ K The fgures should taken grain though Various factors For example State employees required medical check Sanatoriums deserving workers Those inflated utilization services Stratgie protection Sant Population Ministry Health Annex Huong Hanoi secretary rarely doctor She medicates When I I pharmacy explains Huong consumes antibiotics And those cheap roughly She advises family friends about which medication Self medication serious problem Pham Nog Que Medical Officer World Health Organization WHO Hanoi People consLe everything there counterfeit drugs market In according reports Ministries Health Inter samples ocounterfeit medicine discovered twice number previous Antibiotics accounted close fakes Despite repeated police raids pharmacies business proliferates The medication problem wolsened vagueness armaceutlcal legislation Pham Ngoc Que We tougher Many pharmacists unable borrow their pharmacy thLDc Vietnamese their diploma entrepreneur The entrepreneur opens thuDc under pharmacist staffs skilled person pockets profits gives monthly allowance pharmacist Pharmacists entrepreneurs The customer In years JTh thuDc sprouted Hanoi pavement On Van Mieu Street Temple Literature there consecutive pharmacies Two nnerous pharmacies lining Van Miu street V_ N November Building pharmaceutical industry priorities Vietnamese Government regulations pharmacies immediate plans Some Huong Hanoi interpreter never those pharmacies They consult traditional healers medicinal herbs In family herbs illnesses We doctors disease serious herbs Then governent hopitl How Vietnamese choose private physician government No knows There answers there studies The situation varies between Ho Chi Minh City Hanoi between countryslde between province province Ph Ngoc Que Survey Southerners favor private sector physicians Northerners Observers often attribute longer collective experience North Outside cities public sector still first choice people doctor Tran Tuan young doctor working various foreign organizatlons years In North people trust public clinic They believe services drugs better quality Other Hanoians disagree We would private doctors could Hung Hanoi civil servant I classroom where studying economics intenslve program funded Ford Foundation There private doctors The doctors still public service there As Hung speaks classmates agreement I begin wonder I social democrat class They experien public health cannot another choice But asked system Vietnam should favor We should mixed health system Hung Some public Some private A private doctor advertising office street Hanoi Although figures scarce private sector clearly developed South In Ho Chi Minh City private physicians registered The private maternities In Hanoi early there single maternity But distinction between private public difficult Vietnam especially North system confusing mixture private public activities carried within goverient premises government personnel sometimes patient sometimes State So private public Vletnam system socialized capitalist medicine explains Kayode Oyegblte Nigerian doctor Unicef health program Hanoi The capitalist developing faster public sector reorganizing Big private hospitals emerge Mr Hong ministry Health confirms Vietnamese authorities hospital possible Do anyone could invest hospital people I Mr Hong tells important priority With hospital foreigners would leave country anymore They could treated Vietnam So could country importantpeople But there important priorities strengthening primary health centers increasing salaries health personnel Compared African doctors Vietnamese doctors trained Yvan Hiidebrand M decins Sans Fi ontires Belgique iDoctors without Borders They sometimes They frustrated having little badly Nurses working In northern hospitals month about Doctors between In South doctors salaries closer I00 The difference complex allocation system based needs More later Staff district commune health stations around month Brigade nurses mainly farmers skills people commune In United States doctors often hospital Tran Do Trinh Vietnam National Heart Institute Director Cardiology Bach Mai hospital largest equipped hospital Hanoi Here leave because living Non State health services HCMC N Dan dally Until downfall European Communist Bloc Vietnauese leaders often taken Moscow other Eastern Europe capital treatments threatenin illnesses Since trips currency The country cannot Mr Hong Aocording World Bank minimum basket family adults ohildren Noi South A dootor salary North oover minimum So health workers private oonsultations Even nurses No study Been supplementary income nobody really knows Everyone I asked would Private physiolans estimated times salary government Fees greatly doctor aJother Doctors charge Some others Often charge consultation Patients drugs treatmerts injections The negotiated explains HurJg teachel Hanoi The doctor tells charges Public health centers tariffs compliance seems erratic Officially inserting intra uterine device IUD In women I service What I Raphael Kot shrugging shoulders When doctor You family What think people They Anyway caught fired He criticized Here people never sacked Despite every Hanoian I speak happy changes Everyone things better In subsidies hospital waited three hours names three recalls Huong mother Now I minutes I Huong doctor since calls subsidies favorite expression describe beginning economic reforms The doctor comes It little I better How about those cannot Again situations When I hospital farmer recalls Nog Thi Men teacher He operation money The slept dongs The operation itself would His family andiriends already everything could borrowed neighbors The eused heavily Men troubled incident She collective East Germany ThQse years When scholarships really students chilch therich subsidized economy Men The collective after mother tuberculosis It school I lucky friends helped operation How about farmers In districts where Mdecins Sans Frontires MSF works central province Vinh marxist slogan To according their according their abllity still applied The author their people Yvan Hildebrand Coordinator MSF They harvest Some people allowed delay payment Some charged So everybody scraxbles living cardiologist Tran Do Trinh private consultation At night writes books In first wrote enough himself first bicycle In another Czechoslovakian Babetta moped Twenty books later Doctor Trinh drives Honda scooter It early morning looks slept night We sitting those guest rooms finds almost every office Vietnam sparingly ftunished table Chinese On there larze photograph downtown Denver nizht University Colorado A diploma ident Doctor Trlnh Fellow American Collee Physicians proudly displayed dutifully dusted When I Trinh pointing finger floor In December American Bach Mai sitting X Ray Under hospital staff shelter That night Trinh teachin shelter The floor collapsed people present killed recalls Lightly wounded Doctor Trinh escaped through narrow basement window X Ray hopin X machine whole North Vietnam Trinh entered convinced machine destroyed The Zround where heavy piece equipment covered rubble Trinh looked around precious machine opposite corner The machine wheels smilin broadly It saved itself Bach Mai Hospital Monument recalling rebuilt Hanoi bombing Bach Mai Hospital modern hospital bares resemblance modern hospital In Cardiology Unit people three In Intensive Care Unit broken windows arepatched newspaper Cardiac monitors broken radios garbage They would better museum Dr Minh woman cardiologist studied Denver months At Bach Mai there hospital kitchen F ilies balconies their relatlves Those family street vendors huddled hospital courtyard Those others On wards people other recalls Men spent weeks there after heart operation At Bach Mai equipment refurbishment maintenance common complaints The holds country health stations There health station Viethan communes But station often Entrance Bach Mai Hospital words paper Many housed homes health workers quarters People Committee inadequate structures A survey three provinces found rural communes functioning sterilize usable weighing scale children Worse places filthy needo paint I telling doctors should operate clean Yvan Hildebrand there maintenance crews budget maintenance nobody In facilities revenues cover salaies There nothing maintenance Foreign NGO sending monitors EEG machines complains Raphael Kot never spare They never train people machine In_all hospitals I there single technician Thee thing Harloi Me dlcal School medical eFgineering With economic reforms health personnel dards living improve around while their fixed wages losing buying power More money diverted maintenance salaries This country badly needs health managers The commune Vietnam smallest administrative Each commune encompasses hamlets Doctor Tran Tuan Nowhere medical schools doctors learn about management The itself health management brand We Tuan office third floor Save Children UK office With laptop computer neatly arranged piles documents Tuan looks coming young manager But rings under urgent voice speaks country needs different story The medical schools doctors produce ymore They train specialists enough general practitioners single manager To matters worse reforms clearly understood V ethan confirms Tuan Many learned Last Vinh ative province Ho Chi Minh Doctors without Borders resistance director district hospital Tile refused close communal health stations resources better staffed inter communal health center required national policy We national policy recalls Yvan Hildebrand We telling He would budge Finally suggested superior He policy maintain communal health stations What could Some public servants support Others The disagreeme mirrored startling differences atttudes between provinces On matters health provinces power another NGO worker Two thffrds funds collecte locally Very comes national overnment Why would lsten Hanoi The provinces independent national goverrent districts independent provinces communes independent districts Dr Raphael Kot It system wthin system within system There almost health ministrles there provinces Reducing staff improve salaries efficiency element policy Five employees three patients waste money resources Banladeshi Unicef worker sitin commune health center Hanoi They would better fewer better employees Even Nguyen Huu Hong Health Ministry seemed agree comment So I asked We other The system complicated Hanoi level province district Anything collected Hanoi Many venting system Because receive their funds provincial people committee health bureaus often beholden central Ministry Health The center seems trying assert control implement policy without stifling local initiative quite challenge those people They hamlets prevention Lay option In Ninh Binll south Hanoi Raphael Kot frustrated firing attitude devised strategy His organization offered refurbish health stations revolving funds drugs traln people But there condition after training The staff members succeed month training raise Their salaries month Those training their raise I gambling those Kot Kot admits health workers district panic But I strung Israeli doctor previously worked Sri Lanka I think people perform better panic Amidst confusion Vietnamese struggle thorny question government should providing health services Our system Nguyen Huu Hong unable level after I believe system change Central Committee Party strong socialized system They subsidies In present clrcumstances tasks better private sector admits K S Oyegbite Unicef others better public sector The rnment focus those interventions Preventible communicable diseases leading causes mortality among adults children Malaria diarrhea respiratory infections majority reported illnesses In northern hamlet Save Children US succeeded ncreasin weight health small infants simply teaching mothers basic rules hygiene nutrition In communes brigade nurses doing anymore American working group In communes where Save Cg ildren UK established pilot project health station Sanitary conditions deserted The building itself still Hanoi collapsed There drugs equipment A kilometers another commune district people donated goods health worker maintain building In organized communes system holding Doc Tran Tuan wants general practitioners incentives countryside Maybe could offered aining after countryside suggests colleague Now overseas training specialists In Vietnam fewer health staff abandoned their China Doctor Tuan because Vietnese people trust government believe things impove future Dang Van Duong lecturer Hai Medical School offers pagmatic reason Health workers public equipment conduct private business Why would leave They would equipment office taxes K S Oyegbite believes there still primary health public system I telling Ministry Health there compete otherwise Vietnam system totally commercialized bearded Niger whose visit remote hamlet usually steers quite interest Doctor Kot tougher They introduce three compulsory service countryside young doctors insists Otherwise countryside catastrophe In September Hanoi launched national insurance scheme Very people carry membership Even fewer trust Hanoi struggling increase revenues public funds could increase This happening amidst announcement lllth HIV inected Vietnamese skyrocketing numbers prostitutes birth sends hundred thousands workers labor market Meanwhile family planning program stalled contraceptiveS Health doctors hospitals Hong Ministry Health We better water systems education against Aids young doctors willing countryside De collectivization agriculture major cause desertion With family farming again dominant agriculture commune ability extract evenue agricultural produce finance activities health Brizade nurses commune ceased activity Allen Dr S P S Dr April Vietnam system abolished increasing number graduates refused fulfill their obligations often gotten remote areas never given posting promised A blocks Institute Marxism Leninism Ho Chi Minh Thought researchers learning English studying Ho Chi Minh admiration Ame president Roosevelt New Deal Soon Institute American Reading Room Institute Last Institute changed Marxism Leninlsm Institute Ma Leninism Ho Chi Minh Thought Researchers FIOW studying political world hoping their programs ideas adaptable Vietnam But another story Next Looking New Deal Carole Beaulieu Hanoi really think New Deal possible Received Hanover April