Vietnam’s chronic disease: doctor shortage in remote areas

By Tran Van Phuc   August 21, 2019 | 10:39 pm PT
Rural Vietnam has seen doctors assigned duties completely outside their specialization, and even doing menial jobs like cleaning and guarding.
Doctor Tran Van Phuc

Tran Van Phuc

More than three years ago, a pregnant woman came to me, recommended by an acquaintance. She had traveled hundreds of kilometers from the northern highlands to Hanoi, the capital city, so that I could perform a fetal ultrasound for her. What she wanted to know is the exact date she would go into labor. For me or any other doctor, meeting her requirement was impossible. Either using the mother’s menses or relying on the calculation from her ultrasound result, the time for giving birth could only be predicted within a two week period.

That was her first child. It had taken her and her husband a lot of effort and time to conceive. Her path to becoming a mother had not been easy from the beginning, but what worried her most was that the entire mountainous district where she lived had just one obstetrician working at a small hospital in a small town.

Other nearby districts were in the same situation. Around six to eight hours away from her home, she could find a bigger hospital, a province-level one with better conditions and more obstetricians, but she knew she could not afford traveling all the way to the provincial center, stay there and wait in line for her turn to give birth at that hospital.

To meet me, she made her first ever trip out of her hometown and reached Hanoi with the hope of learning the exact date she would give birth so that she could return to the small hospital in her district and simply wait until that day.

And when the day comes, if the obstetrician in her district happens to be away from home or gets sick, her husband would immediately take her to nearby hospitals in neighboring districts. That was the plan.

Hers was not the only case I’d come across. I had known many other women who had to go to other districts to give birth. Many of them made the first trip of their life out of their hometown only to deliver children. On average, they had to negotiate a long tough road for several hours to get to the hospital. Just imagine the scene of motorbikes carrying pregnant women through the forests without any support apart from husbands who normally have no idea what to do if their wives break water. In fact, such a situation could even make a doctor like me anxious.

So, we can say that "the lack of doctors in rural areas" is a chronic disease that Vietnam suffers from. All medical staff understand this.

The disease claims lives, unfortunately.

On the morning of June 30, 2019, a pregnant woman, 37, showed signs of giving birth and was taken to the general hospital in Duc Tho District, Ha Tinh Province.

That afternoon, the doctors decided the time was ripe for her to deliver the baby. One hour later, it was announced that the baby had died and on his neck was an eight centimeter long cut that had been stitched.

The medical team taking care of delivering the baby reported that it had died before he was born, so they had to take his body out, but during the process they broke his neck.

The case is still under investigation, and what should be noticed here is that the one in charge of the hospital’s obstetrics department that day was a dentomaxillofacial specialist.

It is obvious that the hospital arranging for a dentomaxillofacial doctor to function as an obstetrician is unacceptable. But if we look at the problem carefully, we would see that this is the situation at most district-level hospitals.

If the hospital has only one obstetrician, it is impossible to make that doctor work 24/7, and even if there were two doctors in this field, they still cannot replace each other to make sure each of them would work around the clock each day. Doctors in other fields face the same situation and that is why local hospitals have always let surgeons, obstetricians, ear-nose-throat and eye doctors replace each other to be on duty during out of office hours. And it is "normal" that dentomaxillofacial doctors are sometimes in charge of the obstetrics department.

There is another problem. District level hospitals find it very difficult to recruit doctors. I’ve been to many rural areas in the country. They are vast lands where people live in a complete different world from the urban areas, especially mountainous areas that are home to ethnic minority communities.

While equality is required in healthcare, which means patients cannot be deprived of proper treatment just because they do not live in Hanoi or Saigon, the two biggest cities in Vietnam, the low population density in rural areas I have visited makes it extremely difficult to apply equitable healthcare policies.

Yet even a hill with just a few families needs healthcare services, and in general, people in rural areas are in greater need of medical care.

A doctor performs a healthcheck for patients in the mountainous district of Lang Chanh in Thanh Hoa Province in central Vietnam. Photo by VnExpress/Nam Phuong

A doctor performs health check on people in the mountainous district of Lang Chanh in Thanh Hoa Province in central Vietnam. Photo by VnExpress/Nam Phuong.

The lack of doctors in rural areas is not a new problem.

More than six decades ago, the entire northern region had just 404 doctors. They were trained for seven years under a French program and their professional skills were even better than some French doctors, but that was not enough. The north needed at least 3,000 doctors in the 1960s and therefore, the medical training course in general was then cut short to four years, and many minor or in-service healthcare courses had been organized to provide enough doctors for rural and mountainous areas.

And after all these years, district hospitals now have doctors, but most of them are nurses who’ve attended in-service training courses. It is a challenge for these hospitals to have doctors who have graduated from a conventional medical course. The reason cited often is the lack of a decent remuneration, or specifically, preferential treatment when working in rural areas. But I personally think that remuneration is just one side of the story, and that what matters more is the working and living environment for doctors in a rural hospital.

It is not easy at all for someone from a poor and remote area to perform very well at school and get into the Hanoi Medical University to go back to that poor hometown and work after graduation.

In many of my trips to district hospitals, what has shocked me is the scene of doctors trying to earn more by doing menial jobs like cleaning, cutting grass and growing medicinal herbs. To this day, this is not a rare situation. I have even heard a story that when a patient arrived for a surgery at a district hospital, it was the guard who jumped in to do the work, because he was a doctor too. All such stories, put together, do not indicate a working environment attractive enough to lure doctors.

A good working environment should be a professional one, a product of the digital age and broadband internet, which allows doctors to connect with the outside world and guarantees them (and their families) a life of some material comfort. It should be a place where doctors are treated with respect, instead of being punched in the face.

I think the chronic disease of doctor shortage in rural areas is just the tip of a big iceberg facing the medical fraternity and policy makers. It is an issue of national importance and urgency that cannot be dealt with piecemeal solutions. It needs comprehensive and integrated solutions.

Over the past 60 years, the healthcare sector has improved a lot, but in order to treat this doctor shortage disease, we desperately need a real breakthrough. 

*Tran Van Phuc is a doctor at the St. Paul Hospital in Hanoi. The opinions expressed are his own.

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