The pri­vate paramedics tak­ing on the re­gion’s un­der­funded emer­gency ser­vices

In South­east Asia’s poor­est coun­tries, the pri­vate sec­tor, from swish hos­pi­tals to bare bones para­medic out­fits, is step­ping in to fill the void left by the pub­lic sec­tor’s woe­ful emer­gency ser­vices

Southeast Asia Globe - - Healthcare Special - By Holly Robert­son

IN the dusty out­skirts of Vi­en­tiane, young mo­tor­bike rid­ers roar down a ruler-straight road that stretches for 6km out of the city to­ward the Thai bor­der. There are no traf­fic lights or round­abouts to slow them down, and the bikes reach rapid speeds that con­trast with the oth­er­wise sleepy na­ture of Laos’ cap­i­tal.

Se­bastien Per­ret, a co-founder of the vol­un­teer emer­gency ser­vice Vi­en­tiane Res­cue, tuts dis­ap­prov­ingly at the sight. As wealth in the city has be­gun pil­ing up, so has the num­ber of ac­ci­dents – in­creas­ing num­bers of peo­ple own cars and mo­tor­bikes, and the tri­fecta of prob­lem­atic drink driv­ing, spo­radic en­force­ment of road rules and few peo­ple wear­ing hel­mets com­bine with speed to pro­duce of­ten fa­tal re­sults.

On a re­cent evening shift, Per­ret and his team mill around an old cargo con­tainer on the road­side, which has been con­verted into a makeshift am­bu­lance sta­tion. It’s a bare-bones op­er­a­tion. There are cracks in the wall, the bunk beds that vol­un­teers sleep in dur­ing shifts are spar­tan and, nat­u­rally, it’s cramped.

Per­ret refers to the reck­less petrol­heads as “fu­ture cus­tomers”, but in re­al­ity, none of the traf­fic ac­ci­dent vic­tims picked up has to pay for the ser­vice from Vi­en­tiane Res­cue, whose mem­bers at­tend about 700 in­ci­dents each month from four sta­tions dot­ted across the city. Roughly

270 mem­bers vol­un­teer their time, many work­ing through the night af­ter their jobs or school­ing are com­plete for the day. The en­tire op­er­a­tion runs on a shoe­string bud­get of about $5,000 per month.

“What amazes me the most is not the peo­ple we pick up on the street, but the way we do it,” Per­ret tells me. “It is spe­cial. And our vol­un­teers, wow. They are the best peo­ple I ever met in my life.”

Vi­en­tiane Res­cue ex­ists for one sim­ple rea­son: there is no gov­ern­ment-run emer­gency ser­vice in the Laos cap­i­tal. And, al­though it may seem un­usual at first glance, it’s not the only such ser­vice op­er­at­ing in the re­gion’s de­vel­op­ing coun­tries.

In Bangkok, where the pop­u­la­tion is dense and re­sources are stretched, vol­un­teers are sent out as first re­spon­ders to ac­ci­dents, pro­vid­ing ba­sic first aid ahead of the ar­rival of fully equipped am­bu­lances. Even wealthy Singapore, which has one of the best healthcare sys­tems in the world, runs its free am­bu­lance ser­vice off the back of the Singapore Civil De­fence Ser­vice, staffed by cit­i­zens ful­fill­ing the coun­try’s manda­tory na­tional ser­vice.

Am­bu­lances and emer­gency ser­vices are just one of the ma­jor gaps re­main­ing in the re­gion’s pub­lic health sys­tems. Al­though there are vast dif­fer­ences be­tween the qual­ity of healthcare pro­vi­sion in, say, Malaysia and Myan­mar, pub­lic healthcare is gen­er­ally deeply un­der­funded. Ac­cord­ing to the World Health Or­gan­i­sa­tion, South­east Asian gov­ern­ments con­trib­ute an av­er­age of 4% of GDP to healthcare fund­ing, com­pared to roughly 12% for af­flu­ent mem­bers of the Or­gan­i­sa­tion for Eco­nomic Co­op­er­a­tion and De­vel­op­ment, from New Zealand to Nor­way and Chile to the Czech Repub­lic.

But it’s not just NGOs fill­ing those gaps: pri­vate firms are also in on the act. “While much of South­east Asia’s pub­lic healthcare sec­tor strug­gles with growth and fund­ing is­sues, the re­gion’s pri­vate healthcare mar­ket con­tin­ues to en­joy solid growth, es­pe­cially in the more de­vel­oped ar­eas such as Singapore, Malaysia and Thai­land,” in­ter­na­tional pro­fes­sional ser­vices firm Deloitte says in its 2015

Healthcare Out­look re­port for the re­gion.

Ac­cord­ing to global re­search and con­sul­tancy firm Frost & Sul­li­van, the value of the re­gion’s healthcare mar­ket is set to reach $150 bil­lion this year. Busi­ness strat­egy con­sul­tancy LEK says in its re­port Pri­vate Healthcare Providers in South­east

Asia: Poised for Con­tin­ued Growth that a range of fac­tors, not least among them grow­ing wealth, are con­tribut­ing to ris­ing de­mand for qual­ity healthcare. “Sus­tained eco­nomic de­vel­op­ment in South­east Asia has led to a rise in in­comes, in­creas­ing the con­sumer base of those who are will­ing to pay for healthcare,” it says.

This is not only tak­ing place in more es­tab­lished markets, but also in de­vel­op­ing coun­tries such as Laos, Cam­bo­dia and Myan­mar, where emer­gency healthcare ser­vices are an in­creas­ingly in­te­gral part of pri­vate providers’ busi­ness mod­els.

One pri­vate healthcare provider hop­ing to cap­i­talise on this de­mand is the shiny new $35m Sun­rise Ja­pan Hospi­tal, which opened on Ph­nom Penh’s Chroy Chang­var penin­sula last Septem­ber. Cam­bo­dia’s shaky healthcare sys­tem has long in­spired mid­dle- and up­per-in­come pa­tients to travel over­seas for treat­ment – to Viet­nam, Thai­land or Singapore, de­pend­ing on an up­wards-slid­ing scale of means.

Dr Take­hiro Kozuma, the deputy clinic direc­tor at Sun­rise Ja­pan, says the hospi­tal, which spe­cialises in neu­ro­surgery and stroke care, wants to en­cour­age more Cam­bo­di­ans to stay closer to home when they fall ill. The emer­gency depart­ment is a key to its op­er­a­tions: the hospi­tal has 120 staff, 20 of whom work in emer­gency, and it has in­vested $75,000 in an am­bu­lance, with plans to pur­chase a sec­ond ve­hi­cle.

“[For] some pa­tients, for ex­am­ple stroke pa­tients, time is very im­por­tant. If pa­tients go abroad, their con­di­tion can get worse,” Kozuma says of emer­gen­cies. “Also, pa­tients pay money to other [over­seas]

While much of South­east

Asia’s pub­lic healthcare sec­tor strug­gles with growth and fund­ing is­sues, the re­gion’s pri­vate health care mar­ket con­tin­ues to en­joy solid growth, es­pe­cially in the more de­vel­oped ar­eas such as Singapore, Malaysia, and Thai­land”

Also, pa­tients pay money to other [over­seas] coun­tries, so we want to save money and

save lives in Cam­bo­dia”

What are the rea­sons that Cam­bo­dia’s doc­tors do not share the same rep­u­ta­tion as their in­ter­na­tional coun­ter­parts? In Thai­land we fol­low the stan­dards and prac­tices of the US and UK, so many Thai doc­tors go there to re­ceive train­ing or join in­ter­na­tional con­fer­ences. But the med­i­cal ed­u­ca­tion sys­tem here fol­lows the French style. So I think train­ing des­ti­na­tions or top­ics are quite lim­ited com­pared with the op­por­tu­ni­ties that we have in English-speak­ing coun­tries. Have you seen much ap­petite for change from within the Cam­bo­dian med­i­cal com­mu­nity? There has been grad­ual change – I think by now [Cam­bo­dian doc­tors] un­der­stand that fol­low­ing France’s sys­tem alone or only speak­ing French can cre­ate dif­fi­cul­ties in com­mu­ni­cat­ing with the in­ter­na­tional so­ci­ety of medicine. Why do peo­ple still seek treat­ment out­side of Cam­bo­dia? [Many peo­ple] have been us­ing hos­pi­tals in Bangkok or Singapore for years and years, so they have [reg­u­lar] at­tend­ing physi­cians. If they are re­ceiv­ing emer­gency treat­ment for se­vere asthma, al­though we have very qual­i­fied chest spe­cial­ists work­ing here, af­ter we sta­bilise their con­di­tion they still pre­fer to go abroad to see their physi­cian. There are cer­tain cases where we still have to re­fer the pa­tient be­cause our treat­ment fa­cil­i­ties here are lim­ited. But I think those cases are less and less – 80% of the cases could be treated at Royal Ph­nom Penh. coun­tries, so we want to save money and save lives in Cam­bo­dia.”

The hospi­tal, which was es­tab­lished in a part­ner­ship be­tween three Ja­panese com­pa­nies, is trad­ing on its af­fil­i­a­tion with Ja­pan, a coun­try re­spected lo­cally and in­ter­na­tion­ally for the qual­ity of its healthcare. There are five Ja­panese doc­tors work­ing at the 50-bed hospi­tal, while all the Cam­bo­dian med­i­cal staff have un­der­gone train­ing in Ja­pan.

This is an im­por­tant selling point for emer­gency med­i­cal ser­vice providers as, ac­cord­ing to Akiko Sasaki, the coun­try direc­tor of Ja­panese non-profit Side by Side In­ter­na­tional, “many peo­ple don’t trust med­i­cal skills [and] treat­ment in Cam­bo­dia”. Pri­vate emer­gency am­bu­lance ser­vices have gained a par­tic­u­larly bad rep­u­ta­tion, with dis­rep­utable pri­vate clin­ics fight­ing to ar­rive on the scene of traf­fic ac­ci­dents be­fore the pub­lic ser­vice (a phe­nom­e­non the gov­ern­ment has out­lawed but am­bu­lance driv­ers say per­sists). Mean­while, the pub­lic ser­vice, which is heav­ily sup­ported by Side By Side – it has do­nated more than 35 am­bu­lances as well as a slew of ve­hi­cles that have been con­verted – is of­ten crit­i­cised for be­ing slow to reach vic­tims.

Af­fil­i­a­tions with in­ter­na­tional healthcare providers are a com­mon theme among the more up­scale hos­pi­tals that have opened in Ph­nom Penh in re­cent years. Oth­ers in­clude Royal Ph­nom Penh Hospi­tal on Rus­sian Boule­vard, which is man­aged by Bangkok Hos­pi­tals Group, and Cho Ray Ph­nom Penh Hospi­tal in Ch­bar Am­pov district, a branch of its name­sake in Ho Chi Minh City.

Each takes a dif­fer­ent ap­proach again to am­bu­lance ser­vices: Cho Ray is among a num­ber of Cam­bo­dia-based hos­pi­tals that trans­port se­ri­ously ill pa­tients by road to Viet­nam for treat­ment – a jour­ney that can take five to six hours – while Royal Ph­nom Penh of­fers air evac­u­a­tions to Bangkok for those who re­quire spe­cialised treat­ment – and can af­ford the price. In gen­eral, the for­mer ser­vice costs hun­dreds of dol­lars, while the lat­ter can run into the thou­sands.

These glossy, well-equipped out­fits – the wait­ing room at Sun­rise Ja­pan

Pri­vate am­bu­lance ser­vices pro­vide early in­ter­ven­tion, which is pos­si­ble when you have highly trained emer­gency doc­tors who can im­me­di­ately assess a pa­tient’s health con­di­tion in or­der to em­ploy the right equip­ment, sup­ply and medicine, bed-to-bed un­til the pa­tient is trans­ported to a pri­mary care cen­tre”

feels more like the in­te­rior of a ho­tel than a med­i­cal in­sti­tu­tion – stand in stark con­trast to Cam­bo­dia’s pub­lic healthcare providers. At the Kh­mer-Soviet Friend­ship Hospi­tal, emer­gency depart­ment chief Dr Sourn Samith takes a break from di­rect­ing a team of doc­tors and nurses to give a tour of the fa­cil­i­ties.

In one sec­tion, a 35-year-old woman suf­fer­ing a hematoma af­ter she had a stroke lies in a coma, await­ing trans­fer to the ICU for surgery. “She was trans­ported by am­bu­lance,” he says, all the way from Prey Veng prov­ince, which lies some three hours away. “She had no treat­ment there. We just started her with oxy­gen.” A ju­nior doc­tor is ven­ti­lat­ing the pa­tient by hand, her chest ris­ing with each squeeze of his hands. The depart­ment does not have a me­chan­i­cal ven­ti­la­tor.

Most pa­tients can­not af­ford to pay for their own treat­ment, al­though a few are cov­ered by gov­ern­ment pro­grammes for the poor­est cit­i­zens. Dr Samith says they never turn away those who lack funds, but with­out oth­ers mak­ing up the short­fall it makes it dif­fi­cult to pay staff ad­e­quately or pur­chase life-sav­ing equip­ment. “If we could get more money from pa­tients, we could [pro­vide] sup­port for the staff and es­pe­cially im­prove our ma­te­ri­als and equip­ment,” he says.

Sasaki, whose NGO also pro­vides med­i­cal equip­ment to pub­lic hos­pi­tals in Cam­bo­dia, is much more stark in her as­sess­ment of the sys­tem. “It’s in a very sad state,” she says. It’s a re­al­ity that ex­ists through­out the re­gion, ac­cord­ing to the 2017 Global Health

care Out­look re­port from Deloitte, which de­scribed “an in­creas­ing gap [in South­east Asia] be­tween the state-of-the-art hospi­tal and treat­ment in­fra­struc­ture in pri­vate in­sti­tu­tions serv­ing med­i­cal tourism and the well-to-do, and the very ba­sic pub­lic in­fra­struc­ture for the lo­cal pop­u­la­tion”.

Nev­er­the­less, Robert Tyler, the coun­try man­ager of global med­i­cal provider In­ter­na­tional SOS Myan­mar, ar­gues that pri­vate am­bu­lance ser­vices are meet­ing a ma­jor need. In­ter­na­tional SOS treats 9,000 pa­tients a year in Myan­mar, with six to eight emer­gency am­bu­lance call­outs a month, in a coun­try that only be­gan in­tro­duc­ing pub­lic am­bu­lance ser­vices in 2015 and has a woe­fully in­ad­e­quate hos­pi­tals sys­tem. Tyler says pri­vate op­er­a­tors play an “es­sen­tial” role across the re­gion in terms of “rapid mo­bil­i­sa­tion of med­i­cal staff, ca­pa­ble to sta­bilise pa­tients dur­ing a life-threat­en­ing or limb-threat­en­ing in­jury or ill­ness”.

“Pri­vate am­bu­lance ser­vices pro­vide early in­ter­ven­tion, which is pos­si­ble when you have highly trained emer­gency doc­tors who can im­me­di­ately assess a pa­tient’s health con­di­tion in or­der to em­ploy the right equip­ment, sup­ply and medicine, bedto-bed un­til the pa­tient is trans­ported to a pri­mary care cen­tre,” he says.

As long as pub­lic healthcare in the re­gion’s de­vel­op­ing coun­tries lan­guishes be­low in­ter­na­tional norms, those with the means to do so will con­tinue turn­ing to pri­vate op­er­a­tors who can pro­vide higher stan­dards, caus­ing is­sues in the pub­lic sphere but pro­vid­ing a boon for healthcare busi­nesses.

Dr Samith, who says pri­vate op­er­a­tors usu­ally re­fer pa­tients who can­not pay to the pub­lic sys­tem, has a straight­for­ward so­lu­tion of his own in re­gards to ad­dress­ing the im­mense in­equities in Cam­bo­dia’s healthcare sec­tor: “For the pri­vate hos­pi­tals, I think they must keep the small place [for pro­vid­ing treat­ment] to the poor peo­ple.”

Top row, left to right: Pa­tients lie on beds at the Kh­mer Soviet Friend­ship Hospi­tal in Ph­nom Penh; a doc­tor checks an X-ray of a pelvis; IV drips above a hospi­tal bed; a doc­tor re­views brain scans.

Bottom: Fam­ily mem­bers sleep on the floor around a pa­tient’s bed at the Kh­mer Soviet Friend­ship Hospi­tal

This page: a Vi­en­tiane Res­cue am­bu­lance is fully equipped. Op­po­site page, clock­wise from left: vol­un­teers tend to a pa­tient in Vi­en­tiane; blood vials at the Sun­rise Ja­pan Hospi­tal in Ph­nom Penh; an au­to­mated ex­ter­nal de­fib­ril­la­tor on a wall at Sun­rise; nurses re­view a head scan at Sun­rise; a pa­tient is kept breath­ing by hand at the Kh­mer Soviet Friend­ship Hospi­tal in Ph­nom Penh

(cen­tre)

Royal Ph­nom Penh Hospi­tal direc­tor

Dr So­march Wongkhomthong on the chal­lenges fac­ing Cam­bo­dia’s med­i­cal ed­u­ca­tion sys­tem

Left to right: a nurse tends to a pa­tient at the Kh­mer Soviet Friend­ship Hospi­tal; pa­tients on hospi­tal beds in a lobby at the hospi­tal; a pa­tient is monitored as he sleeps

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