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Web-only Exclusives
November 30, 2000

From Our Correspondent: Hirohito and the War
A conversation with biographer Herbert Bix

From Our Correspondent: A Rough Road Ahead
Bad news for the Philippines - and some others

From Our Correspondent: Making Enemies
Indonesia needs friends. So why is it picking fights?

Asiaweek Time Asia Now Asiaweek story

HOSPITALS IN FLUX

By Choong Tet Sieu


Check-Up Reading Asia's Vital Signs

Crisis Medical facilities are barely coping in Indonesia

Checklist How hospitals stack up

Rights Patients push for a bigger say

Rural Warriors A humanitarian organization trains an army of doctors in China

The East The future of traditional Asian medicine

The West Americans are turning to alternative therapies

Therapy Sang Lan: The injured gymnast hopes to walk again

Celebrities The "inside" stories of people in the news

Longevity The latest on staying healthy in Asia

Advances Breakthroughs in medical technology

IT'S NINE IN THE evening, and five-year-old Nicholas Tan is sleeping soundly. He had been rushed to the emergency department of the Kandang Kerbau (KK) Women's and Children's Hospital in Singapore two days earlier, wheezing painfully from a severe asthma attack. Doctors decided he should be admitted - quickly. "Nicholas never needed to be warded before, so we were a bit shocked," recalls his mother, Monica. The Tans were warned that their little boy might face a wait for a bed, but, as it turned out, he was quickly looked after. Nicholas's parents could afford a private room, but opted to put him in a ward with other children. "He might have felt lonely by himself," Tan explains. The ward was clean, bright and cheerful. There was even a pullout bed so she could keep her son company at night. It was all very different from the shabby image associated with state hospitals.

KK is a Singapore hybrid - and possibly an indicator for governments around Asia of what can be done to deliver quality health-care services without wrecking national budgets or handing everything over to the private sector. KK is a government facility run like a private institution. Most of its funds still come from public coffers, but the balance is raised through fees. The idea, says Aline Wong, Singapore's senior minister of state for health and education, is to allow government hospitals greater flexibility and creativity in how they serve patients. And this enables them to compete with private hospitals.

This kind of rethink is going on across much of Asia as hospitals adapt to changing times. Not long ago, falling sick usually meant a visit to a government facility - often with an interminable wait to see a doctor, a brief examination and a swift exit through the door with a bag of unspecified tablets. Now private hospitals account for 20% of beds in Singapore and 30% in Bangkok. In red-tape-bound Delhi, the private share of hospital care has shot up to 40% since investment restrictions were lifted in 1986.

Demand from the growing middle class has fueled this trend. Better-educated people want and expect superior care. And, until the economic crisis struck, more and more could afford it. Jose Ledesma, chief executive of St. Luke's Medical Center in Manila, says the private institution is "better equipped than 90% of hospitals in the U.S." Bangkok's high-tech Bumrungrad Hospital has also geared up to meet this demand, as has the newly opened Beijing United Family Hospital, which caters to wealthy Chinese as well as expatriates.

At Delhi's swanky Apollo Indraprastha Hospital, liveried guards stand ready to open the doors of arriving cars. Inside lies a world of polished granite, speed-lifts, sophisticated machines and attentive nurses. Whatever the procedure needed, from the fixing of an ingrown toenail to an organ transplant, Apollo can deliver. The philosophy seems to be to offer the latest medical technology combined with the opulence of an international hotel. But to some physicians, that's a prescription for waste and unnecessary costs. Says Dr. R.S. McCoy, who heads a Malaysian medical panel on health policy: "What we need is five-star medical treatment and three-star accommodation."

Of course, public hospitals haven't been locked in a time-warp during these changing times. A decade ago, cardiac patients in Malaysia were sent abroad for treatment; now they can be treated at Kuala Lumpur Hospital, which boasts a microsurgery unit. The Philippine government's Heart Center in Manila attracts as many affluent patients as poor ones because of its high standards of medical expertise. The enormous army-run Pramongkutklao Hospital in Bangkok is a leader in orthopedics, cardiology and pediatrics. "We have some of the best specialists here," says Dr. Supija Mokkavesa, surgeon general of the Thai army's medical department, which oversees the facility. "Many of our specialists work part-time at private hospitals, but [in those places] you pay a lot more for a consultation." Supija should know. The orthopedic surgeon holds weekly consultations at Samitivej Hospital, a highly respected private facility.

Treatment in Thai public hospitals, Supija insists, is on par with that in private ones. That is also true of Singapore and perhaps of some facilities in Malaysia and the Philippines. Dr. Milton Lum, a former president of the Malaysian Medical Association, says: "If you go in for an operation [at a government hospital], it will be done well, with a low rate of complications." Where these institutions do not measure up is in convenience (extended waiting times) and atmosphere (clinical in the worst sense of the word).

Hong Kong's public health service is cheap, reflecting the government's policy that no one should be denied adequate care because of a lack of means. The 44 public hospitals account for nearly 90% of all beds. But while treatment is available for all, there are worries about the quality of help. Apart from overcrowded wards, hospitals have been in the news for a seemingly endless series of blunders. Most were minor and were corrected in time, but some were serious, such as pumping air into a patient's veins. The government stays out of the private sector, allowing the 23 private medical institutions to charge whatever fees they think the market will accept.

But whether in private or government systems, the cost of health care in Asia is ballooning. Singapore's Economic Development Board estimates annual health spending for the region, excluding Japan, is likely to increase from the current $150 billion a year to about $255 billion by 2000. Rapid advances in medicine are a contributing factor. Each week seems to bring an announcement of a new drug, device or high-end treatment - with developed-world price tags to match. And as individuals live longer, they are increasingly prone to such "old age" problems as diabetes and heart disease - chronic ailments that are usually more expensive to treat. According to some estimates, half the amount spent on a person's health during his or her life is accounted for in the last six months.

For years Asia's governments have been searching for a way to spread health-care costs - a task made even more pressing by the economic downturn. Malaysia has opted for corporatization. Under the current national development plan, state hospitals will gradually be run like companies, though as government-owned entities. Physicians such as Lum see merit in the move. "There will be more business practices, such as being able to fire and hire as a corporate body," he says. "It will allow more flexibility and improve efficiency." It is also hoped the switch will help staunch the flow of experienced staff to the private sector.

But the Citizens' Health Initiative, a coalition of 45 Malaysian civic groups, worries that corporatization will only mean greater hardship for the less well-off. Chan Chee Khoon, associate professor of development studies at the Science University of Malaysia, questions how health services can be widely accessible under such a system. At the retooled University Hospital in Petaling Jaya, ward charges and fees for such basic diagnostics as blood tests and x-rays have shot up by between 150% and 200%. That's not much below private hospitals, says Chan. It's a bitter pill, especially as the economic recession bites deeper.

The Thai government has decided against any moves that will drive up costs to the public. "We don't want prices to increase when there is so much hardship for the poor," says Savit Bhotiwihok, the minister overseeing the country's economic privatization programs. Still, public hospitals are being given greater independence to help them become more competitive - including organizing fund-raising activities. Costs are being controlled as much as possible by sourcing drugs and other supplies locally. A similar debate is going on in the Philippines, where the populist Estrada administration seems to have put the idea of corporatization or privatization on hold. It plans to keep major facilities under government control, with the emphasis on primary health care - community clinics, immunization programs and the like.

In China, subsidies were reduced and a fee-for-service system introduced when control over health services was loosened under economic reforms in the 1980s. But without adequate financing, cash-strapped hospitals and doctors have turned to kickbacks to supplement their income. Now patients' families routinely present physicians with gifts to ensure relatives are properly looked after. Says a retired nurse: "This is particularly common where patients need surgery." She says it is "acceptable" because doctors are poorly paid and have to work long hours. Many people don't agree. In a survey conducted by a Beijing newspaper two years ago, doctors were rated among the most hated professions. The reason: their insistence on hongbao, red packets filled with cash.

Not that private care is any guarantee of quality. The sick in South Korea and Japan, where the great majority of health services are independently operated, will testify to that. Tokyo housewife Yamashita Misako finds a visit to a hospital "a full day's work." To secure an early consultation with a skin specialist for her son, she typically rises at 5:30 in the morning to drop off a tag in the hospital appointments box. "I'm lucky if I get out by noon," she says.

And then there is what the Japanese call "medicine soaking" - being supplied with, and charged for, unnecessary medication. Yamashita was given antibiotics, along with creams, for her son's allergic reaction "just in case he scratches it and gets infected." The companion practice is "test-soaking" - as in the case of a judo enthusiast who was taken to a Tokyo facility with a dislocated shoulder. A simple problem - except that hospital staff insisted on taking multiple x-rays before fixing his shoulder. He was forced to endure an extra 40 minutes of acute pain, followed by the discomfort of an invoice that had a couple more zeroes than necessary.

Koreans complain their physicians spend barely five minutes with each patient. "They have to see as many patients as they can to turn a profit," explains Dr. Choi Bong-joon, who works at Seoul's spanking-new Samsung Medical Center. The problem, he says, is that insurance premiums - which are most doctors' main source of income - are too low. (Premiums take up about 3.5% of salaries.) But paying more (8.4%) hasn't secured Japanese patients greater attention - they are usually sent away with what is known as the "three-minute treatment."

With eyes fixed firmly on the bottom line, Seoul hospitals are saving costs wherever they can. And that includes doing little to resolve the chronic shortage of nurses. The result: patients invariably have to recruit a relative to care for them throughout their hospital stay. When Kim Shin-ja went in for a kidney operation, her children, mother-in-law and cousins took turns looking after her. There's even a word for these volunteers: bohoja, meaning caretaker. "The nurses were so busy, I couldn't get them to help with simple things like turning down my bed," says 50-year-old Kim. Chung Yeon-ok, an official with the Korean Nurses Association, concedes the lack of staff is a serious problem. "Family members end up performing tasks they can't do properly. It has become so customary no one even thinks about it any more. Patients don't realize they aren't getting the service they deserve."

Across the region, there is a growing suspicion that in the rush to cash in on Southeast Asia's health-care boom, some operators are less than scrupulous about maintaining medical standards. Spurred by complaints from the public, Malaysia passed a bill in June requiring private medical centers to report all avoidable deaths to the health ministry. A government panel will assess these cases and advise on practices that would prevent such incidents.

MEDIO, a Japanese watchdog group that investigates medical mishaps, goes further. "We want a system similar to that for airplane accidents," says Ito Shunya. With an air crash, he explains, a team is assigned to investigate the incident and identify the cause. Yet doctors are not questioned when patients die or are left handicapped. Nor are they reassessed on their skills or knowledge once they qualify. Among the complaints MEDIO received: a man whose entire stomach was removed during what was to have been a relatively routine gall-bladder operation. What the doctor took to be a cancerous growth turned out to be a simple ulcer. For all Japan's technological superiority, Ito says, it lags behind many other countries in protecting the patient from bungling medics.

Throughout Asia, people want fair, cost-effective, accessible, high-quality health care. But how to achieve it? There is no magic prescription that will suit every country. And now economic woes are putting even obvious remedies beyond the reach of some governments. Health care is at a crossroads. Some see that as a dilemma. Others welcome it as an opportunity to re-examine choices.

- With reports by Michele Zack/Bangkok, Paul Mooney/Beijing, Arvind Kala/Delhi, Agnes Cheung/Hong Kong, Mangai Balasegaran/Kuala Lumpur, Wilhelmina Paras/Manila, Suh Kyung Yoon/Seoul, Jacintha Stephens/Singapore, Murakami Mutsuko/Tokyo


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