Fees Put Hospital Care Out of Reach for Poor

Pailin – For Vorn Yoeub, $25 could have saved her life. Instead, the meager sum financed her funeral. During the early morning hours of March 16, the mother of seven died while in labor with her eighth child after, her husband says, midwives at the hospital refused to treat her until they were given 100,000 riel, about $25. Too poor to pay the fee that night, Mrs Yoeub and her unborn child died before the sun came up.

Rather than transporting her body the few kilometers back to her one-room house, the hospital’s deputy director suggested her husband cremate the remains at a local pagoda. The cost of the cremation was $25-paid for by the medical administrator.

But when the husband told him about the midwives’ apathy, the deputy director only offered a straightforward explanation. Medical personnel are like soldiers, the man said. Some of them are hardworking; some are lazy. “I told him. I told him everything,” the husband, Mith Ran, said Wednesday seated outside his home. “I had no words to respond to him.”

Officials at the Pailin Provincial Referral Hospital, however, provided a very different account of the night Mrs Yoeub died, saying efforts were made to treat the 37-year-old but that her condition deteriorated too quickly for anyone to save her. “When I arrived, she was already serious,” said Prak Sokhorn, chief of ultrasounds services at the hospital. “We could not help her because she was bleeding internally.”

Moreover, staff at the hospital claimed her medical care was free, given her low economic status, and that if Mr Ran was expected to pay, services would not have been withheld until he did.

“For the poor, it’s all free,” Deputy Director Dr Ang Neang said Thursday on the hospital grounds.

But the case of Mrs Yoeub and the hospital employees shows how service fees, intended to be collected from those who can afford the payment, function as a barrier for poorer Cambodians who say they are denied healthcare until they pay the appropriate amount. Interviews at the Pailin hospital reveal several patients who said medical staff asked for money before agreeing to assist them or their loved ones.

Watching over his son-in-law who fell sick from an unknown stomach illness, Nop Sarom said he paid 500 Thai baht, or roughly $14.50, for nurses to provide medicine to his relative. Only after the money exchanged hands did his 40-year-old son-in-law receive an IV and pills, even though he had been sick for the past four days.

“For us poor people. It is a lot of money,” he said.

Sam Saroeun, a 75-year-old patient suffering from malaria and a bladder infection, said nurses told him to pay 300 Thai baht, or about $8.75, for treatment. He after a full day of negotiating he eventually convinced staff that he could not afford the charge and began receiving medication and IVs. Still, he complained he is only fed a bowl of white rice for meals.

His wife’s pregnancy was also not the first time Mr Ran’s family has been confronted with a service fee. In 2005, his now 16-year-old son, Mith Ren, contracted dengue fever and the family was asked to pay 50,000 riel, about $12.50, for any treatment at the hospital, he said.

The family could not afford the fee but a local Buddhist NGO, whose name Mr Ran could not remember, eventually paid it. In addition, Mr Ran said he was asked to pay when he visited the hospital on other occasions but, unable to do so, he would always return home and recuperate on his own. Arriving about 10 pm on the night of March 15 at the hospital, Mrs Yoeub was experiencing painful contractions. Staff directed her to the maternity ward located at the southern end of the hospital’s sprawling campus. There, three midwives offered her a bed and performed a quick medical checkup. They said her cervix was not yet dilated and told her and her husband the baby would likely be born in the morning.

A short time later, Mrs Yoeub began suffering more contractions and severe pain. Her husband eventually sought out the midwives who had gone to bed in a nearby room. He knocked on the door and received no answer. He returned again later and still received no reply.

On the third time, one employee answered the door and his wife was taken to a birthing room. There the three midwives, donning rubber gloves, brought up the issue of paying the fee. Mr Ran said he did not have the money and proposed to pay later. The midwives rejected his offer, removed their gloves and left the room.

His wife later died about 5 am, her sarong bloodied. Mr Ran blamed the hospital personnel for the death.

“It is the carelessness of the medical staff,” he said. “I just feel upset about the medics.” Yin Buntha, one of the three midwives tending to Mrs Yoeub, said the ailing mother was given blood and vitamins intravenously at the first sign of problems. And when her condition turned critical, Ms Buntha called the deputy director and Mr Sokhorn for assistance. Both she and Dr Neang said Mrs Yoeub also fell on her rear end while in the ward, which contributed to her bleeding. “I saw people coming and helping her. For me, I was the first one to help,” she said seated outside the maternity ward, a low-slung concrete building lined with wooden beds. “If I was careless, I wouldn’t have called the other people to come.”

She said no one asked Mr Ran for the $25 but that he was only told how much the procedure would cost. She said it was understood that he would not have to pay until after the birth and only if he could afford it.

A board standing outside a hospital office lists the various fees for the various procedures and medicines. Childbirth carried a listed price of 50,000 riel, or about $12.50. Ms Buntha said Mr Ran was quoted double the usual fee since his wife’s situation was considered to be more complicated and risky than a normal delivery.

Now, she said, some hospital employees no longer come to work since they are afraid of being blamed for a patient’s death. The other two midwives-Luy Chantha and Seng Sarath-that were present during Mrs Yoeub’s death could not be contacted for comment. In the end, Ms Buntha said Mrs Yoeub died because her case was too serious for the hospital to handle. “We are medical people, we are not gods,” she said.

For Mr Ran, the death of his wife was quickly followed by a string of other problems. An amputee with no steady employment, he is now facing eviction because his neighbor, who owns the land where he lives, wants it back to plant fruit trees. Four of his children are now living in an orphanage.

He claimed that Dr Neang, the hospital deputy director, promised to help find him some property to build on and was told the staff at the hospital would look after him. Neither have done so. He has received some donations from local officials and people who pity him. “But right now, it is quiet, so quiet,” he said. For his part, Dr Neang denied making any promises of land or money. He claimed Mrs Yoeub started hemorrhaging and died from losing too much blood. He then cut an interview with reporters short, saying he needed to meet with police regarding an unrelated case. There are signs, however, that Mrs Yoeub’s death and the subsequent investigation have made an impact, at least on the hospital’s maternity ward.

Although his pregnant wife was admitted Wednesday, Ly Pheap said he was not asked to pay for his son’s delivery until Thursday after his wife had already given birth. Midwives told him the price was 500 Thai baht-or nearly 60,000 riel, about 10,000 riel more than the listed price. However, because he is unemployed he was able to talk them down to 300 baht, or about $8.75.

But just two weeks before, the 25-year-old said he was asked to pay first when he arrived with injuries from a motorbike crash. He said medics declined to set his collarbone, which was broken after striking the bike’s handlebars, unless he first paid 25,000 riel (about $6.25).

“Once I gave the money, they did the surgery. They would not do the surgery first if I did not have the money,” he said while his wife slept in the maternity ward. “Here you have to pay money first. If you can not, they are not responsible for what happens to you.”

He attributed the apparent change in policy to the story of Mrs Yoeub, which circulated throughout the town and was aired on the radio. Now, he said, officials do not want a repeat of the same situation.

“This is a good thing for the poor,” he said.

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