Franco - Vietnamese Hospital : FVH
The FVH is a modern 200 bed private hospital located in South Saigon, Ho Chi Minh City, developed by a group of French doctors with the support of the World Bank and inaugurated in 2003. The mission of the FVH is to provide international standard health care at a price adapted to the economic reality of Vietnam. There is as well a clear commitment of FVH to provide teaching for nurses, medical students and doctors through specialised courses and rounds in the premises of the hospital which have been granted with the necessary meeting rooms and a large auditorium. Moreover the association FVH Medicine Vietnam funded by private donors has been established in order to take care free of charge children who require surgery.
Economy and health care in Vietnam
Vietnam has population of over 80 million inhabitants a majority of which
live in rural areas. A large majority of Vietnamese are under 30 years of
age born after the terrible losses of life during the 25 years of war. Ho
Chi Minh City still known as Saigon is the largest city in the south of
Vietnam with more than 7 million people, one of the highest densities per
km2. It is a booming economic hub growing at a very fast pace representing
one third of the gross domestic product (GDP) of the country. While the
mean national per capita income was $ 540 in 2004, Saigon boasted nearly
$ 2000 with a GDP growth of 11.6 % per year.
Life expectancy in Vietnam is 68 years up from 45 years in 1960 but mortality
under 5 years is still at a high of 39/1000 a better indicator of the health
care system, in remarkable improvement from the dismal figure of 1960 with
219/1000 mortality. Despite the impressive economic growth health care still
faces major challenges as the public infrastructures are not able to meet
many of the standards of modern medicine despite an excellent background
in basic training of doctors and medical professionals. For instance there
are 39 hospitals with 17’000 beds and over 4600 doctors in HCMC however
the available budget of the Ministry of Health is so restricted that many
of these hospitals are totally out dated and salaries of health professionals
are minimal.
In Vietnam the majority of the population does not have any type of medical
insurance. Only public employees benefit from a kind of social security
program which reimburses the official fees, which amount to about 30% of
the real cost in public hospitals. As such almost all the medical expenses
are charged to the patient whose family is more often than not in a very
tight situation in order to pay if expensive treatment is to be considered.
Therefore in public institutions these major financial constraints do not
allow for the development of specialised educational programs nor do they
permit recording reliable data on the epidemiology of many diseases let
alone enforce guidelines for evidence-based medical practice.
Hepatology at FVH
The FVH is staffed with permanent French and Vietnamese doctors and has
a specific structure of rotating specialists coming for short periods of
time from France, Switzerland and Belgium. The Division of Gastroenterology
and Hepatology benefits from the expertise of some 30 certified specialists
in liver diseases, digestive diseases and endoscopy. These rotating gastroenterologists
work in an outpatient clinic, a fully equipped endoscopy suite and take
care of hospitalised cases in the inpatient wards. The FVH has a high standard
quality Radiology Department and an up to date Medical Laboratory where
many of the biological assays including a full liver panel can be done within
the same day of consultation. Most of the patients come for consultation
without appointment and over the first two years of practice the number
of consultations specifically for liver disease and viral hepatitis has
gradually increased to amount to about 30% of total. Patients come not only
from HCM City but also from the heavily populated Mekong delta region, Cambodia
and several regions north of Saigon. In this setting the large number of
newly diagnosed cases of hepatitis B and hepatitis C has been awesome to
consider by usual standards in Western Europe. The epidemic pattern of viral
hepatitis in the country has been confirmed by our Vietnamese colleagues
who are confronted with the difficult task to correctly identify those cases
that would require expensive therapy that only a minute minority can afford.
Only the cost of medicines for a six month treatment of hepatitis C can
amount to 20 times the per capita income / year!
In this two year period of observation at FVH we have seen the shortcomings
of poor work-up of many cases at other institutions, the lack of rationale
behind decisions to treat, the loose follow-up of those who develop adverse
events, and the erratic compliance of patients who are unable to understand
the basics of a very complex therapy for which they engage in excessive
expenses in view of their income, expecting unrealistic results of incomplete
protocols. It must be stated that some information on hepatitis is given
through the media and patients are actively seeking medical advice. While
all the Interferons and antivirals used for treatment of hepatitis B and
hepatitis C can presently be found in pharmacies in Ho Chi Mihn City there
appears to be little or no control on quality of prescription.
Burden of liver disease in Vietnam
There is no single explanation for the large amount of cases of hepatitis
B and hepatitis C in Vietnam the incidence of which is estimated to be at
least 10 times higher than in the US or EU. Like in the rest of South East
Asia and China hepatitis B is more frequent than in the Western World, a
fact known for many years. There are a substantial number of cases due to
mother-foetal transmission of VHB. A program of detection during pregnancy
and vaccination at childbirth is theoretically in common practice. As well
the Government of Vietnam has started a vaccination program of sero-negative
young people.
There is no vaccination for hepatitis C and laboratory tests have only been
available for about ten years for screening. With the slow recovery from
war and the impact of economic embargo major delays in performing appropriate
screening tests have been seen in Vietnam. Moreover lack of single-use medical
material, needles and syringes for a prolonged period of time have all contributed
to the spread of VHB and VHC during dental, medical and surgical procedures.
It is unlikely that this critical issue has been solved except in major
hospitals. Other forms of transmission cannot be excluded with the use of
needles and other devices in traditional medicine practices. There appears
to be a high prevalence of VHC genotypes 1 and 6 in Vietnam which are unfortunately
more resistant to current therapies, with response rates under 50%.
The large number of cases of VHB and VHC leads to an increasing number of
cases of liver cirrhosis as the population ages, this complication of liver
disease developing after 20-30 years of evolution. In Asia the incidence
of liver cirrhosis is 150/100’000, more than 15 times that of Europe. Cirrhosis
is seen in young or middle aged men who may have a large intake of alcoholic
beverages as a co-factor as well as in middle aged women who by rule have
no alcohol consumption. Cirrhosis can lead to gastrointestinal hemorrhage
through oesophageal varices due to portal hypertension, a complication requiring
very costly hospital admissions and carrying a high mortality rate. Worldwide
up to one million people die from liver disease secondary to viral hepatitis
each year. As a further complication of cirrhosis the incidence of primary
liver cancer (HCC) is among the highest in the world. For these patients
surgical operations such as partial hepatectomy can be considered sometimes
but for the most part this is an irreversible complication. Liver transplantation
is not yet available in Vietnam.
Edited by Aldo Campana,