By Sun Narin and Koam Tivea
November 10th, 2010
Becoming a doctor brings with it a tremendous amount of responsibility and stress. Not only do you become the mother of your patients, as the idiom goes, you must be ready to take people’s lives in your hands, serving as the last hope for those suffering from a lifethreatening accident or illness. The doctor’s role in society is crucial and it is reassuring to think that doctors will be there if you need them. Often in Cambodia, however, the only way to get a doctor’s help is to pay them for it, and people without money are unable to receive proper medical care.
Despite the fact that Cambodia has two medical universities and a number of hospitals with improving human resources and advancements in technology, the majority of the country’s population hasn’t seen the benefits of improvements in these institutions. Although access to modern medicine is expanding, most people can’t afford it, and although poor people often try to take advantage of an improved health-care system, the country’s doctor’s are unlikely to care for patients who can’t promise payment prior to their procedure. People in most developed countries benefit from universal healthcare, which is funded by taxes, or health insurance, which is paid for by individuals or employers and usually supported by welfare or social security for people who don’t work for money. These systems do not guarantee quality medical care, but they make it much more likely by providing a guarantee to doctors that they will be compensated for their work, no matter how poor their patient might be.
Upon entering the medical profession, Cambodian doctors must take a physicians oath similar to the one outlined in the World Medical Association’s declaration of Geneva. One of the central tenants is that doctors practice medicine with “conscience and dignity” with the health of their client as their “first consideration”. Similarly,the International Code of Medical Ethics states that “a doctor must practice his profession uninfluenced by motives of profit”. They may swear to follow these high ethical standards, but unfortunately, the situation doctors face in reality makes it rather difficult in practice. Without any infrastructure to guarantee compensation for their services, too many doctors in the Kingdom demand payment before beginning treatment.
Mat El, an ethnic Cham living in Phnom Penh, says he believes that the discrimination and verbal abuse he says he endured while attempting to get treatment at the Cambodian-Russian Friendship Hospital was due to his poor background. Officials at the hospital could not be reached for comment this week. “They just wanted money,” he said. “They asked me how much money I had before treating me. If I did not give them money, they would not treat me or visit me often.”
In her fourth year studying medicine at the University of Health and Sciences, Yom Somna says she has seen firsthand the failure of medical professionals to follow their ethical obligations while training at Preah Kosomak hospital and the Cambodian-
Russian Friendship Hospital. “Doctors tended to care much more about their rich patients than their poor ones. They spoke gently to the rich patients,” she said, adding that poor patients weren’t so lucky.
In a field where professional ethics can be the difference between life and death, stories such as Mat El’s and Yom Somna’s not only damage the reputation of the doctors involved, but also the hospital and the medical community as a whole. It is perhaps unsurprising that doctors, given no other option, resort to corrupt practices to ensure their own livelihood. Still, prejudice and unethical practices counteract efforts to expand healthcare in Cambodia. With this in mind, the Ministry of Health organises ethics courses for medical students and practicing doctors and nurses to remind them of their ethical obligations, according to Dr. Paou Linar, the head of Child and Maternal Health Care in Phnom Penh’s Municipal Health Department. But what is really preventing proper treatment, according to a doctor at Calumet who requested anonymity, is not the doctors themselves, but a system that is unable to cover patients who can’t pay.
“Our country is different from the other countries like France where people are provided with free treatment because they have already paid with tax,” says the doctor at one of Cambodia’s largest hospitals. “The rich give us money,” and ultimately, hospitals need money to run. Having identified prohibitive costs as the root of most people’s inability to get suitable medical care, the Ministry of Health, along with local and international partners, launched the Equity Fund project in 2002 to provide financial support for medical care among the country’s low-income population. The results of the initiative, however, suggest that it’s actually not all about the money.
In an article published on healthdev.net in October of this year, it was reported that many users of the equity card, given to the project’s poor participants, still found doctors to be careless. The refusal by doctors in Kampong Saum to care for 35-yearold Sin Thea, who held an equity card, during childbirth reinforces the notion that money is not the only factor guiding doctors decisions. Improvements in funding for public healthcare must be matched by improved education and accountability among the next generation of doctors in the Kingdom, according to Yam Somna. “I will treat my patients without discrimination and apply what I have learned at school,” she says. Perhaps by then Cambodia will find a way to pay her for it.