Health Care Problems in Cambodia

CAMPRO Discussions on October 14-15, 2010

Compiled by Chan Sophal

So Sokbunthoeun: I am very upset at the poor condition of medical practice here in Cambodia and just want to raise your attention to it.

I have been sick since Saturday and only begin to feel a little better today. Part of the problem could have resulted from medical mis/maltreatment. My initial symptom was simply fever, nausea, and tiredness, which I believed was a common issue that can be recovered within a day or two with simple medication.

On Monday, the condition did not improve so I decided to visit a local clinic in case I can get a speedy recovery, but the situation actually got worse. The consultation with a doctor last about two or three minutes and I was given injection without being told what it was (i didn’t even know it was an injection as i thought they draw my blood for examination) and prescribed with a bunch of medicines after which new symptoms including difficulty breathing, constipation, and muscle pain emerged.

I thought something was wrong so I did google search on the medicines that were prescribed. One of medicines called Gabapentin was used for the treatment of epilepsy, which has nothing to do with my sickness at all. I was shocked having found that. I threw away all the medicines yesterday and began to feel better.

This is a professional ethic problem and a big one in Cambodia. Doctors usually appear arrogant and wouldn’t tell patients why they would prescribe certain medicines to them. Having experienced this, I doubt their overall qualification as doctors. Having access to the internet allows me to find out various information, but those local Cambodians who cannot read English and don’t have alternative are likely to become the victims of medical mis/maltreatment. There is a need for a comprehensive framework to deal with this issue. Any thought?

Hay Sovuthea: I share your concern and agree with you that professional ethics in medical field is extremely serious issues. I do firmly contend that very patient does have basic right to know what kinds/name of medicine is given. Last time when my kid was hospitalized, before paying, I asked for medical record, they felt a bit surprised though. Luckily, I was allowed to make a copy for myself. Generally, they produce only one record for themselves.

Sao Chhorn: I am not surprised. It is common in Cambodia. I agree with you that some doctors in Cambodia often practise very harmfully to their clients. We need to work to get rid of such terrible problem. How? We need to discuss. I have been criticized for igniting poor people to hate medical staff, because I use collective forces of poor people to demand for responsiveness of providers. Should I be proud and continue to do it? Can our group provide some more options?

Neak Samsen: For those who can afford, going to see Cambodian doctors at Royal Rattanak may be an option although the profits would go to the pockets of one of Cambodia’s top military generals and his Thai business partner. At the clinic, doctors allow you to ask questions and challenge their medical prescriptions.

Sao Chhorn: Dear Samsen, Thanks for your advice. It is helpful. However the clinic can accommodate only a small proportion of population. I strongly recommend our group to seek options to improve the situation for Cambodian especially for the poor.

Khim Keo Vathanak: The problem is not new, you just added another drop to the ocean and we all know that regulatory framework for medical practices in Cambodia is merely decorative. There are plenty of thoughts on how to fix these on papers.

Chan Sophal: I’m sorry that it happened to you, dear Bunthoeun. Having heard enough problems like our friends said and as we discussed before, shall we discuss how to change such a bad practice? If there are already solutions on papers as Vathanak has just said, how to invoke the ruler to cast tough words or threats on this matter? Any possible civic movement, like by bang Sao Chhorn has done? Please keep it up, bang Chhorn, and perhaps there are ways to scale it up. There is always a need for the 2 percent, front liners, to lead the drive for change.

Hak Sochany: Dear Vuthea, I have the same problem but you are lucky that at the end you receive a copy of the medical record. I was hospitalized last year at Calmette Hospital. Unluckily, I did not receive the medical record even I asked for it and I had quarreled with the chief of gynecological ward for about one hour regarding my request for my own medical record. He said I could have it only unless I bring a lawyer with me to talk to him. I have never had trust in public services, particularly on health services in Cambodia.

Khieng Sothy: I share the frustration with several similar personal experiences. Can patients sue the practitioner? Using bang Chhorn’s effort, for instance, we can use collective action to file legal complaints (in Class Action or Civil Lawsuit?). It might or might not be cost-effective (due to legal cost) but it’ll likely set a good example for the other practitioners?

Khim Keo Vathanak: Just to tease Buntheun that he had been in the US or outside Cambodia for too long. Buntheun’s case and many others are warnings that one must be careful when accessing health services in Cambodia, either public or private, they’re one of a kind. From time to time, we hear news about death/injury resulting from medical malpractices, but it seems the problem is only growing.

Demand side intervention raised by Bong Chhorn is good to build collective consumer voices, but it is only partial solution. Supply side interventions by working with and regulating the providers and fixing the underlying causes in the system are needed e.g. why practitioners have incentive to swindle, why regulators are not performing their jobs or performing poorly, why malpractices are not properly disciplined, etc.

Providers often use economic/livelihood as excuse for running private practices, but everyone knows doctors and medical practitioners do quite well on average regardless of regime/system compared to other professions. Do you agree?

While there seems some headway in this regard in the public sector (with lots of partner’s assistance), I’m afraid to say little has been done in the private sector. It’s exactly like in survival mode “chaek knear ros tov”. Then we go back to the issue of “regulation and enforcement” which demands the will and commitment of “leaders”.

Maybe there should be a day of “medical ethics” to promote and remind medical practitioners of adherence to professionalism.

What about using media to report and publicize malpractices in a more systematic way as disciplinary action?

PSI has franchising private clinics but are limited to a certain area of health services e.g. reproductive health and STI, but this idea should be widely promoted to build a good network of “qualified” providers.

I don’t think we’re poor of ideas, but of support as some ideas may impact some cronies.

So Sokbunthoeun: Thank you for your response and sympathetic comments as well as suggestion. I should not have been too surprised by the substandard medical practice here, but what really gets on my nerves is why people with “MD” uses some kind of medicines that completely has nothing to do with the sickness. Was it done on purpose to keep the patient sick so as to be able to get more money or it was simply a lack of medical knowledge? Why this kind of people is allowed to practice medicine at all? I find this very disturbing. It does seem that there are limited options on how to deal with this issue given the weak governance situation our countries, but a number of options that you have raised seem to be effective:

Bong Vathanak’s comment on publicizing and placing certain MDs under spotlight is perhaps one effective way to give warning to/pressure other MDs to adhere to professional ethic.

Bong Chhorn’s proposal for filing collective complaints seems to have been effective too. This is a more feasible way than filing individual complaint.

Bong Sophal’s comment on having some people with authority to push for accountability from medical practitioners is another feasible way given Cambodian political economic situation.

There is also a need for an independent watchdog to assist with providing medical information to people who suspected of becoming victims of medical malpractice. This watchdog should also collection information and publish annual reports in newspapers. If there is such an entity, the severity of the problem can be exposed and “people with authority” can be convinced to take action.

Let’s keep our demand for better accountability from medical practitioners and stay healthy. I have learned a lesson.

Ly Tayseng:

1. I have read somewhere and if I remember correctly the medical ethics was adopted by the association of medical doctors (Kanak Krou Peth) about one or two years ago.

However, ethics is often good on the paper and it does not work in practice. We have ethics for lawyers, ethics for judges and prosecutors, ethics for artists and movie stars, etc. The association of medical doctors, similar to the association of the lawyers rarely disciplines any doctors or lawyers for the abuse of ethics because the association is running by their friend doctors, lawyers, judges.

2. In addition to medical ethics, we do have a number of laws and regulations which could be used as basis to sue doctors for malpractice. We have law on management of pharmaceuticals , law on management of private practice of medical profession, paramedical and medical aid services, law on abortion, criminal code, Decree No.38 on Contract and other Liabilities (for tort/negligence). Of course, we would need a comprehensive medical law to regulate the medical practice, however, in the absence of such law, we still can take some legal actions based on the laws and regulations I mentioned earlier, depending on the nature and the consequence of the malpractice.

3. My firm has acted in two cases recently which involved negligence of doctor and nurses in delivering baby and resulted in death of the mother and the unborn child, and another case was the irregular abortion which resulted in death of the mother. In these two cases, the doctors and nurses have faced criminal charges. The victims family were managed to get substantial monetary compensation. I note that the senior officers in the ministry of health as well as the management of the national hospital whose doctors and nurses were sued have taken the case very seriously and they realize that they would no longer be less prudent on the practice of their colleagues. In the cases we have handled we have quite good evidence proving the malpractice of doctor and nurses. However, in many other cases, it has been quite hard to prove the malpractice of doctors and the damage or losses caused to the victims. Often we could feel the quality and standard of services of the doctors are not acceptable but it does not necessarily mean that they have mal-practiced or violate their ethics.

4. The medical profession is very technical and scientific, we do need highly skilled doctors and they must be equipped with adequate equipments and facilities in order to properly provide treatment. Medical equipments are very expensive, clinic and hospitals cannot afford to import them, even the universities where doctors and nurses study do not have enough modern equipments to experiment the diseases. Except those who have chance to study in developed countries and I also note that there are some very good doctors in town, most of them would only have chance to read the books and observe the poor treatment provided by their senior doctors or nurses. How can we expect they become skillful after their graduation? Then, how can we enforce the rules strictly on them?

5. As a consequence of low trust on medical services in Cambodia, a lot of Cambodian riches go to Singapore, Thailand, and Vietnam for medical treatment. I have heard that thousand of Cambodian middle classes go to have medical treatment in Vietnam every months. This is a big loss for Cambodia.

6. Although I would agree that civil movement to pressure the doctors may help improving medical services to some extent, I believe that the government must invest more on education of medical doctors and medical facilities. We would need to send as many good students as possible to study medicine in developed countries, and import as many modern equipments as possible. The Government should take this seriously because it is related to human life every day.

Heng Dyna: I particularly agree with your last point. We cannot expect reliable doctors/medical practitioners when our medical schools are corrupt. Many of my friends in the medical schools manage to pass the tests/exams by bribing or having to bribe. To me, it is something like “garbage machine is producing cakes.”

Bang Bunthouen’s case can be a mixture of intended and unintended consequences: (1) poor ethics, (2) doctor’s intention to earn more by providing more services/medicines, (3) his poor education and medical skills lead him to choose hazardous medicine. If the doctor is well educated/trained, despite (1) and (2), he can still choose a non or less side effect medicine. (i.e vitamin supplement).

So Sokbunthoeun: I totally agree. Improving the supply side of medical quality such as facility need to go hand in hand with the demand side from citizen for better accountability from mds. The supply side alone, however, is not enough. Intensification of resources provide some spillover effect but does not guarrantee success. Experiences from various countries show that while intensification of resources generated some success, it also failed badly when there is no mechanism of accountability is at work. This applies to all sectors of governance not just medical. Thanks for sharing your thought and legal expertise.

Ann Sovatha: I find it interesting that you chose this venue to vent your upset and concern about what happened to you personally. This mere fact alone means something. I see this as a beginning of a change, the one very much needed in our motherland. The change i’m talking about is the very act of voicing concern or distress when one’s personal well-being is threatened.

Although you did not do anything with the doctor that made you sicker, you let other people know that you had bad experience. You did not resort to keeping it to yourself or just found your own ways to cope with it. Now that’s the change I saw. Imagine if you were Bunthoeun from Prey Veng: tend the buffaloes, work the field everyday, no higher education, no Fulbright, no PhD from NIU, no CamPro to write e-mail to, what would you do? You’re fortunate you have Campro to write e-mail to, but are there similar venues out there for people like Bunthoeun from Prey Veng to voice their concern in a way that could translate into a force that could change things in their community? We all know we can’t make Bunthoeun from Prey Veng act and think the same way as our Bunthoeun here overnight, but both you and I know for sure that something needs to be done about it, and it needs to be done soon. I believe similar experience as the one you just had is happening every passing second in Cambodia. The question is what can you and I do about it?

Again, I see what you did as a very righteous thing to do, and I am sure you will continue to do that one way or another when you encounter experience that threatens your well-being again. By sharing what happened to you with us, you are being the change you want to see in Cambodia, Bunthoeun. Don’t let Cambodia change you (just like what you jokingly preached to me back in Illinois).

Chan Sophal: I have two points, having reflected on the good inputs by everyone so far.

1) I wish to hear more (from Tayseng, especially) on what constitutes grounds or evidences for legal actions against medical doctors or nurses. If we know this, we can advise the public to be prepared to collect such evidences when they risk using the health services. It applies to us as well. At least most of us, if not all, have babies delivered in Cambodia. So we should know what evidences to collect and how to collect them just in case. Do they include paperwork collection, voice recording, video recording or having witnesses around?

2) The whole issue in Cambodia is “the governance failures to correct market failures”, in my view. In the case of the healthcare problems, it’s a market failure in the sense that doctors/nurses are selfish, seeking to maximise their private incomes. Their regulators or those to uphold their ethics are also doctors themselves, making money in the same or similar ways. In a society where most people, ranging from poor to top ranks, seek short-term gains and quick fixes, very few doctors, if competent, would embark on a long term approach to building their competitiveness by providing effective treatment with high ethics. Indeed, this approach is even out of reach for poorly trained doctors/nurses, resulting from a governance failure to control the standard of medical schools.

Market failures are expected in any country. Government exists largely by taxing incomes/assets of and consumption by citizens in order to correct market failures expected to harm citizens. In developed countries, their good governance can correct market failures to a very large extent. That’s why they are developed. As governance is not yet strong in Cambodia, market failures tend to be unchecked or uncorrected, so the citizens, mostly the poor, suffer. In mature democracies, citizens can choose government that can correct market failures. In an electoral democracy in-the-making like Cambodia, this is an extremely slim probability. Hence, the chances are by all means lobby the existing government to deal with the market failures (to address the supply side), and educating/guiding the public to demand accountability from medical personnel and their regulators or rulers.

Khim Keo Vathanak: Just to expand a bit further on medical malpractices. The point I am making is already raised by Bunthoeun – some kind of watchdog to protect consumers. This is non-existent in Cambodia. This watchdog can have similar roles as labor unions that act in the interest of medical consumers. This must start from somewhere. An information hub to document all cases/stories of malpractices can be a beginning. But what’s constituted as malpractices from technical/medical point of views? we also need support from conscientious doctors with good hearts to provide technical advice.

Maybe the medicine Bunthoeun had also fixes other problem than epilepsy. who knows? we can’t say yet if we’re not pharmacist/doctor.

Chea Kimsong: One of my father closest friend and also used to save my father’s life is a Medical Doctor specialized in operation graduated in the 1970s in Cambodia and another MD specializing in Old Age Persons Diseases (Diabetes, high blood pressure…) in 1990s in France. He has a family with secured income (his wife is running a restaurant in France) and one or two apartments in Phnom Penh. Sometimes spending his time visiting young MDs conducting operation in a national hospital and giving little advises that might help people lives, one time saved a life of an old lady at the age of 70s or 80s by offering an operation at a very low cost.

Since 2008, he has set up a home based medical clinic and provide medical treatment to patients at a cheap or some time free treatment to some of the patients of his home town. Since late 2009, he helped facilitate a donation of medical equipment to the operational district hospital at his home town as well as my home town and offered operation services at very cheap services (200,000 to 300,000 riels per operation of one patient which much of this go to Operational District to cover their minimum cost) while the rest of fees cover his gasoline cost for traveling from and to Phnom Penh. Over a hundred people were saved or cured with this generous act. When asked a question why he didn’t charge a reasonable price for his effort? He replied: ‘Need money for what as I am now at the 60s and may not have much time to spend those money’.

Pol Van Choam Mony: Thanks for raising and discussing this issue. A few years ago, a clinic personnel member who worked as a physician or medic prescribing injection medicine for my daughter, when asked for the name of the medicine, firmly replied that it is a secret formula that he could not disclose, so as to avoid unfair competition from other clinics. Even though I argued that lack of medical record make it difficult for the next medical doctor to investigate the patient history, my argument was in vain, as though we need a lawyer to talk with them.

I understand that medical science is a complex theory that making the case against a medic without hard evidence is mostly sure to lose. According to a crime investigation report in Discovery Channel, it took many years and a strong competitor hospital to investigate before finding a criminal who killed a baby. I believe patients or their relatives must have the right to know what is supposed to be prescribed to their loved ones, and it also need their consent as well, let alone hard evidence and medical record. Sometimes the insurance company, if we have one, also need this to keep track of their expenditure.

We as patients or patient relatives should be informed and educated as well, at least in basic knowledge about our health issues and the way medicines work. Spending time researching about health issues and medicines as Bunthoeun did is the best way to have a clue to discuss with our physician, even though only the professional doctor should give consultation and prescribe medicines. While medical regulation is needed in every country, for the general public, health and hygiene education through electronic media and public discussion is also the best to prevent too much adverse effect from an un-regulated market.

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