According to Resolution 33/NQ-CP dated September 15, 2019, regarding the pilot of full autonomy, four hospitals under the Ministry of Health were to implement this policy. So far, only two hospitals, K Hospital and Bach Mai Hospital, have been included in the pilot.
"We Got the Philosophy Wrong"
Concerns about the inability of public hospitals to acquire expensive medical equipment without private contributions are valid and reasonable. However, it is also important to recognize that the blurred lines between the public and private sectors have caused significant harm to the healthcare industry, with a number of skilled doctors and industry leaders getting entangled in legal issues.
In the private sector, profit must be a primary consideration, which inevitably leads to the creation of unnecessary services, the over-prescription of tests, and the unnecessary issuing of prescriptions in order to generate more revenue from patients and health insurance. There is no procedure strict enough to prevent these distortions because overly strict processes might paralyze procurement, bidding for medicines, and medical equipment. On the other hand, lax procedures allow patients to continue suffering, and medical ethics to further degrade.
In reality, most countries have two systems: public and private, with the private sector divided into for-profit and non-profit entities. In practice, no other country allows private participation in public hospitals like Vietnam does, and no other country requires public hospitals to be self-sustaining or to operate as businesses.
From an organizational perspective, if the public-private divide in healthcare is not transparent, it will undermine the public healthcare system. In five or even ten years, low-income individuals will bear the brunt of the consequences. At that time, public hospitals will continue to wither, and medical ethics will deteriorate. Under current conditions, we should not even talk about ethics, as there is no incentive in public hospitals to encourage staff to uphold ethical values.
When business is introduced, hospital leaders become pressured by the need for profits, which leads to the creation of services and often to the "kickbacks" and percentage-sharing schemes to bring in equipment. The abuse of prescriptions is inevitable.
The fundamental issue is: where did we go wrong? Why has this situation arisen? I believe the problem stems from the very philosophy of hospital autonomy, because public services cannot be expected to operate on an autonomous basis. If autonomy is required to generate revenue, then the hospital must be run as a business with a profit motive. When hospitals must generate services for profit, this leads to the current common practice where in the same public hospital, some patients are provided with private rooms with all amenities, including parking for their cars, while others are crammed into shared rooms with two to four people per bed.
In public hospitals, where the state has invested in land, infrastructure, equipment, and supplies, the situation where wealthy patients receive services at lower prices (compared to private hospitals) and are given priority care is highly inequitable. Therefore, the real issue is not whether to implement hospital autonomy, but how to improve the operational efficiency of public hospitals.
Policy Solutions at a Fundamental Level
To address this issue, we need not blend the public and private sectors but rather adopt fundamental policy solutions with two parallel approaches.
On one hand, we need to encourage socialization in its true essence by creating an environment where private hospitals can develop. On the other hand, we must return public hospitals to their true nature—providing basic healthcare services to specific groups of people. We cannot expect public hospitals to serve the general population while simultaneously providing the highest quality healthcare.
For public hospitals, we need to gradually limit their service to middle-income or low-income groups and provide only basic healthcare. Public hospitals cannot afford to give each patient a private room; they must accept shared rooms, as long as there is one bed per patient. The state must invest adequately so that public hospitals can meet these basic standards.
Of course, this goal must be pursued gradually: only when the private healthcare sector has developed significantly and meets the needs of the people will public hospitals be able to narrow their focus to priority groups.
Decades ago, when the private healthcare sector was weak and budgets were limited, public-private partnerships helped balance interests. However, today, the private healthcare sector has grown rapidly, with various market segments, from premium to basic, catering to the healthcare needs of the population. In fact, many private hospitals have invested heavily in the latest medical equipment to perform high-tech procedures.
Private healthcare will continue to expand, reaching rural and mountainous areas, if we have appropriate policies in place that promote fair competition, transparency, and equal access to funding from Vietnam's social insurance system.
In particular, the private healthcare services market must be competitive, with various customer segments and price levels. Therefore, it is impossible to regulate the prices of private healthcare services through administrative controls. The only tools for control are standards, regulations, and service quality assessments—not price control.
There is no need to worry that private healthcare pricing will affect patient rights because patients have the right to choose their healthcare provider. If the pricing at one hospital is unreasonable, patients will simply choose another.
Radical Surgery for the Healthcare Sector
Instead of requiring autonomy, the criteria for evaluating public hospitals should be their operational effectiveness. We must calculate the actual cost of healthcare services, which is the basis for health insurance to reimburse at the basic level, with patients covering any additional costs. The policy should be designed to make public hospitals compete with each other and with private hospitals for access to funding from the Health Insurance Fund, which would improve efficiency.
This process will take time, but it is certainly feasible. At that point, people who want high-tech procedures will go to private hospitals. This will truly be the proper socialization of healthcare, with private hospitals providing services to those who can afford them and have higher healthcare needs.
The Health Insurance Fund will cover basic service costs whether patients go to public or private hospitals, and patients will pay for the additional service fees. People will have the right to use their basic health insurance benefits at either public or private hospitals. For poor and near-poor patients who cannot afford additional fees, charitable donations will help cover part of the cost. In fact, even poor patients in public hospitals are not exempt from paying.
It is time to rethink our approach. A "radical surgery" of the healthcare sector needs to be discussed, starting with revisiting the core policies and fundamental philosophies.
Nguyen Quang Dong - Institute for Policy Studies and Media Development.
According to Vietnam Finance
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