Saturday, November 04, 2006

Discussion: Vietnam and Health Care

(originally written for the Green Left Discussion List in late 2005)

This piece is mainly aimed at replying to some remarks about Vietnam and the issue of health care, and to clarify what the actual status is. But before I get to that, I’ll just make a few comments on some of the interesting pieces that have been sent to the list trying to assess 30 years since the triumph of the Vietnamese revolution over the vilegenocidal robber baron regime of Thieu-Ky and its US controllers, paymastersand terror machine. We could add another piece by Allen Myers in the latestGreen Left, based on his recent trip to Saigon, at

Some of these articles have been better than others. While having a numberof disagreements, the article by 'Tuan', a Vietnamese Trotskyist living inFrance who regularly returns, is overall pretty good, and we can get idea ofsome of the positives and negatives. makes it clear that, despite the rapid capitalist development in Vietnam,it is some light-years behind China, where, he claims, mega-capitalists withbureaucratic connections virtually "own entire provinces". In any case, thefact that VN is considerably behind China is hardly controversial.For anyone wanting a thorough account of this contrast, I'd urge you to geta copy of the latest 'Links' where I have a longish article on aVietnam-China contrast, which also gives some assessment of where Vietnam istoday 30 years later, in my opinion, and as you'll see, I'm not exactlywildly optimistic.Hopefully, Bob Gould would have also found Tuan's article quite interestingin terms of the degree of partial rehabilitation of Ta Tu Thau, as he askedabout. Being VNese, ‘Tuan’ is much better placed to look into these 'sensitive'matters than I am. My reply would have been I agree it would be very good,but I feel it is unlikely at this stage if only because most leadersprobably don't know who Ta Tu Thau is and have a vast number of pressingeveryday problems to deal with. So I was very pleasantly surprised to see atleast some kind of movement on that front.On Bob's other remarks about the future of the VN "super-NEP" and the needfor socialist democracy, as I said I generally agree, but I will take it upin more detail in another post. BTW, I certainly agree it is a "super-NEP",though "unchecked super-NEP" is quite incorrect.

Just briefly on the other article sent on the 30 years, that by Phil Hearse am afraid I'm going to sound a little uncomradely, and call it by itsname: pulp. Unlike ‘Tuan’, who clearly knows something, Hearse has simply gota copy of Gabriel Kolko's 'Anatomy of a Peace', written in 1997 about thesituation mostly in the early 1990s, quoted great chunks of it, added acouple of bits from some World Bank material probably from some BBC web article, and called it an assessment of Vietnam by himself 30 years later. I think Kolkohas done a good job, and his book is worth reading, but it is a very bitter piece:Kolko had been associated with the VCP throughout the war, wrote the bestleft book on the war - Anatomy of a War - which is a very thorough studyusing massive first hand sources, and was so embittered when Doi Moi (marketreform) began in 1986 that he never went back. Thus his second book was notonly written from a very bitter point of view, but also relied entirely onsnippets from the US Foreign Language Broadcasting Service and other bits and pieces of secondary and third-hand sources. The book isvery useful but very incomplete. But that's OK, that's his work. Hearse, bycontrast, doesn't even credit Kolko in "his" article, as he would have tocredit the majority of sentences in it. On many points, Hearse even revealsthat he has no conception of what he is talking about. I'll give a thoroughcritique later. For the moment, I'll just say that, as socialists, we can criticise the hell out of Vietnam and the VCP, but given the actual contribution to revolutionary history of that Party, some more loyalty tofacts would be welcome, as opposed to Hearse's desire to cling to any bit of useless gossip he doesn't even understand himself just because he is so overwilling to shit on the VCP.

But anyway, the main issue I want to discuss here is that of the health situation in Vietnam, given some remarks by Michael Berrell, and some claimsby Pham Minh.The fact that the VCP introduced fee-paying for health and education in1989, when the state had virtually collapsed, is well-known. It thus becamemore like other third world capitalist countries. It was also responding to thepressure from the IMF and World Bank, who were pressuring countriesthroughout the third world to introduce fees. But given its utter state of collapse, I believe it had no choice, at that point, whereas now I believe there is no reason to maintain this policy.It should be clear from what I've written on this list and in variousarticles, including my big Links article a couple of years ago(, that I'm against this policy (and I'm highly critical of many things in VN, so I don't "have to face" facts such as corruption and lack of tolerance of serious dissent,as Bob says), and I support the old socialist policy of pre-1989, oftotally free health and education, as in Cuba, ie, the way it was when VNwas ruled by those who Pham Minh thinks were "communist fanatics", beforethey introduced other things Minh likes, such as capitalism and'globalisation', Minh not realising these things go together. An assessmentof both the positive and negative sides of the health situation in VN can befound in my current Links article.

Michael B says "I notice that Vietnam is issuing free healthcards to allchildren under the ageof six, well why not free healthcare for all?"and Pham Minh says:"It (Myer’s earlier article) falsely claims that the Hanoi regime has decent programs to help poor working families. Nothing could be further from the truth. The one and only significant thing the regime does to tackle poverty is to allow the poor to sell ticketsin the state lottery! ... The poor in major centres like Saigon and Hanoican sometimes access very basic health services. However, in rural and other urban areas, health care is strictly user-pays ... Accordingly, the Hanoi regime's"health care policy" has caused many unnecessary deaths."

First on Minh: I'm sorry, I thought you supported capitalism. What you aredescribing is third world capitalism, like under the previous Thieu-Kytyranny which you support. Everywhere in the world it causes "unnecessarydeaths", including in some first world countries like the US. You need tosort your views out. This is also not simply a matter of theirgovernment's policies, but also of imperialism, an international system inwhich several large corporations have world monopolies on things likeexpensive medicines, which thus poor countries can't afford to subsidise,and so even third world capitalist countries are not as much as fault asimperialism itself, let alone a country recently bombed back into the stoneage and then embargoed for decades.But let's just clarify who does and does not pay in VN, since Michael B mentions children under 6 and Minh suggests the "Hanoi regime" provides"nothing" (a general rule of thumb is to distrust the judgement of peoplewho write worlds like "nothing", "everything", "everyone" etc).

In Vietnam, with 80 million people, health care is free for:

1.Ethnic minorities, some 10 million people, or 13% of the population, andabsolutely the poorest, and living in the remotest regions

2. People defined as "the poor", to whom free health care cards are providedunder the province-level Health Care Funds for the Poor (HCFP) program.According to the UNDP, this now covers some 11 million people (some 13% ofthe population, and 84% of the target group, which is thus some 13 millionpeople, or 17% of the population) by 2003 (Joint Donor Report, 2004). It is unclear to what extent this crosses over with the ethnic minorities. In the major ethnic minority regions, the central Highlands and Northern Mountains, minorities don't need cards, free health care is automatic as minorities,but in other regions where minority disadvantage is less severe, they receive thesecards as part of the 'poor', as do poor Vietnamese ethnic majority people. But between the 2 groups, allowing for some crossover, we are perhaps talking about 20-25% of the population.

3. As Michael notes, children under six (some 9 million people, and thelargest hospital-visiting group in many hospitals it seems)

4. All school children (ie, 6 years and over) are supposed to be covered by compulsory health insurance, with a parent payment of 15,000 VND ($1) forthe whole year. Thus this is not free, but $1 for the whole year would beunlikely to be seen as a burden by any other than the really absolute poor,who are supposed to be covered under 1 or 2 above and so do not pay the $1.

5. Compulsory health insurance covers all formal sector workers, whether in state, foreign-invested or registered private firms, perhaps some 12-15% of the population. No doubt workers are not "rich", but in VN's context, these people cannot be considered "poor" either - they are much better off and more secure than poor farmers or those working in the individual or small-scale informal sector (unregisteredmicro-private firms).

6. Retired people who previously worked in state, foreign or registeredprivate firms, who have to pay not only health insurance but also 'socialinsurance' for their workers. This is a reasonably large group at present,given the formerly very large state enterprise workforce, but of course thegroup is declining given the large proliferation of small informal privatemicro-firms since 1990.

7. 'Heroic mothers' who lost husbands or sons in the war, and other war-affected categories (ie war disabled) (By the way, I think it is gross discrimination, and one of my major critiques of regime policy, that they don't extend this to the rank and file soldiers who, due to circumstances beyond their control, fought on the losing side of the war).

Meanwhile, voluntary health insurance is available for 10,000 VND (66c) permonth, which is not considered expensive, but would certainly be a burden ona poor family with many members.

WHO field visits observed that initiatives such as fee exemptions, freeessential drugs, health insurance and hospital funds for the poor have beenlaunched "on a large scale since 2001" and that this policy has been"greeted enthusiastically by both patients and health workers".

Meanwhile, not all health services are user-pays in the first place, foranyone, not just the above groups. Free health services include:- a range of reproductive health services, including antenatal examinations,tetanus-toxoid shot, and contraception (IUDs, condoms, pills)- child vaccinations against TB, pertussis, tetanus, diptheria, measles,polio, hepatitus B, and in select areas, Japanese Encephalitis, cholera andtyphoid (the latter two essentially wiped out, as with polio)- treatment, including medicines, for target diseases, such as TB andmalaria, including dipping mosquito nets in chemical for more effectiveanti-malaria protection.

Vietnam's TB and malaria programs have both beenpraised as models by WHO, and I am happy to provide references to whoeverwants them. Given that TB is the biggest killer in Asia, this is highly significant.

Meanwhile, the cost of baby delivery, according to reports from foreign researchteams, WHO etc, is throughout rural areas some 30,000 VND ($2)The cost of a simple visit to the hospital for examination or for smallhealth problems, based on my own discussions with a large number of people fromrural areas, plus some reports, ranges from 500 to 3000 VND (3c to 20c), averaging around 2000 (13c). Although most of this sounds OK, I'll hasten to add that I do not support this system, because the problem is always where to draw the line, and so tends to exclude a great number who are just marginally above beingclassified as "poor", and serious health problems can thus drive them backinto poverty. Many tend to ‘fall through the cracks’ of this kind of incomplete system. Corruption and nepotism can result in the wrong people getting health cards in some cases. Moreover, given the low level of health funding in general, health workers salaries are low, so they have an incentive to charge unofficial fees, or to give preferential treatment to paying rather than insured or free patients. These are typical problems experienced by countries all over the third world.There is thus no substitute for universal free high quality health care.

Nevertheless, it seems to me that the above policies enacted by the VNgovernment deserve some acknowledgement, given the country's poverty and the lack of reparations after decades of destruction, and do not deserve thekind of bland "denunciations" by know-nothings on the issue claiming the “Hanoi regime” provides “nothing.”

The real issue in terms of fee payment for those not covered by programs,and even for some who are if the problem is serious and expensive enough, isfor major operations and expensive medicines. This is what can ruin thepoor, not basic health. In general, people go into debt to pay for suchoperations, borrowing from VN's very wide range of subsidised creditagencies (Bank for the Poor, Women's Union etc), or if they can't, they haveto rely on private loan sharks (ie, the kind of "private enterpreneurs" thatMinh no doubt thinks are so good), who charge super-high interest. This ofcourse is very normal in 3rd world capitalist countries, the only differenceis the far greater access to subsidised credit in VN. Of course I condemn this, and wish VN could be Cuba.

Nevertheless, a bit ofperspective is useful, and when Michael B asks "well why not free healthcarefor all?", I'm a bit surprised he in particular doesn't already know the answer, as hecontinually tells us that socialism cannot be achieved without a high levelof productive forces to create the wealth which can be spread around. I completely agree with Michael on this, except that I think he is often too economic determinist. So since you know this, Michael, why don't you ask yourself how much itcosts a poor country like VN, or for that matter Bangladesh, to buy just oneoperation unit to perform heart operations or cancer operations or radiationmachines etc, just to name a few? Or how much it costs to buy medicinesavailable only on the international pharmaceutical monopolies' market?Let's look at it this way. Leave aside the US for a moment. And leave aside the huge gaps that have opened in Medicare in Oz, and the absence of dental care form Medicare as you often point out, or the fact that we pay an extra tax for Medicare etc etc. In general, let's for argument sake say health in Oz is "free", if you can wait for an available public hospital bed. Does this "free" coverinclude all the anti-AIDS drugs that one needs to stay alive the rest ofone’s life? You know the answer. And if first world countries "can't afford"this for their citizens, then small wonder that third world countries can't afford it for other advanced operations and medicines which they find similarlyexpensive.

Still, I think the VN government could do much better, and the size of itshealth budget is pathetic. It is interesting that the education budget hascontinually risen in real terms, while the health budget has only risen inmoney terms, ie, the same as the overall rate of growth. This strange dichotomy finds its explanation in World Bank, ADB and other "donor" (theOrwellian word for "lender") policy - countries need more education funding to have a "skilled workforce" for "globalisation", but health is irrelevantto this, so VN is told is subtle but clear terms that "the health budget isunlikely to rise for the forseeable future". Of course, I think thegovernment should do things like allow the budget deficit to widen a littlemore, increase taxes, use more ‘mobilisation’ techniques etc etc.

In any case, a Politburo resolution earlier this year called for a rapid increase in state health funding and in health insurance to achieve universal health insurance by 2010 and “gradually reducing direct payment of hospital fees from patients”. If this is carried out it will be the most important thing the Party could do between now and 2010. But it might have a struggle with some of the technocratic layers in the govt more directly influenced by IMF and WB ‘low budget deficit’ fanatics. Still, “higher taxes” means on those who can afford it, ie the new rich, the new, largely small-scale, capitalist class. Michael continually tells us that VN needs capitalism to develop its productive forces, and Minh says VN’s post-1990 success has been due to “private enterprise.” I have always partly agreed, that VN needs “an element” of capitalism. But you need to be consistent. Capitalist profits do not come out of nowhere, they come form a portion of the social surplus being transferred to private hands. That is ABC in Marxism. It is no accident that so-called “inefficient” state firms contribute the bulk of the taxes to the state budget in VN. Not that they don’t tax capitalists, they do, but if a poor country places that tax too high, they will not invest and help “build the productive forces”. Once you accept an element of capitalism, you accept an element of accumulation, of “consumerism” etc etc.

Michael and Minh both think they can have it both ways by talking about “social Democracy” and Sweden. The Sweden discussion was interesting in its own right, but totally irrelevant tom discussing VN or anywhere in the 3rd world. Putting aside the criticisms of Sweden, let’s agree it is the best model available for capitalism. Surely the fact that it is based on an extremely rich country loaded with multinational companies that dominate the world market (something called “imperialism”) is part and parcel of it being able to give out better crumbs. If VN attempted too impose a Sweden-level tax on the capitalist class they would flee, go underground, turn to Mafiosi business activities (thus pay no tax), invest OS etc. That’s why the illusions, expressed openly by a centrist wing of the VCP, that more capitalism and privatisation will actually allow an expansion of social benefits, via more profits to tax, is more fantasy (BTW, in VN, the company tax rate, both domestic and foreign, is 28%, and the top individual tax rate is 45%, both reasonably high for poor countries).

It should also be pointed out that several years ago, the VN govt deferred taxes on peasants who had only the basic landholding, for the foreseeable future. Only peasants with greater than average holdings (ie rich peasants) pay taxes. Also, workers on up to $200 per month pay no taxes. That is a reasonably high wage in VN. Thus, since some 70 percent of Vnese still live in rural areas, and most of these work in agriculture, the taxes to create the state budget for the while country, including the mass of rural areas, where most of the poor live, has to come from tax on industrial and service enterprises (state, domestic private, foreign). It is simply difficult for any poor country with such a large agricultural workforce to be able to do this and to provide social security for all the rural dwellers.

Some might say, but VN did it before 1989. Yes it did, but on an extremely low level. Let’s not imagine they were able to perform the kind of expensive operations they can today, and all for free. Furthermore, VN’s system then to some extent relied on Soviet fair trade, which since 1989 has not been available. Moreover, while the state funded health and education, it was actually the state enterprises and the rural cooperatives that directly administered it, including passing on subsidies from fair trade to their members in the form of employing teachers, doctors, child-care workers etc. It was not all direct central state funding. Now, there is no law that says peasants are not allowed to form cooperatives to pay for collective social needs, in fact the govt encourages it, but few take it up. Since 1989, the govt merely gives choice.

So, if Minh is concerned about health for the poor, and since he has informed us that his relatives have done well out of the market economy, I would recommend that they propose the poorer farmers in their area that they set up a partial cooperative, so that the greater profits the better off members have are distributed to the poor in terms of things like free health services.

In any case, VN’s magnificent progress in health and education are well-known. Based on national income per capita, VN is a ‘low-income country’ ($430 GDP per capita), but based on health and education outcomes, it is equivalent to ‘middle-income countries’ (eg Thailand, $2000 GDP per capita). You can read that in any report by the UN, UNESCO, WHO, World Bank etc.

For example, it has got child mortality down to 23 per 1000, and infant mortality down to 19 per 1000, both lower than Thailand (and much lower than Philippines, China or Indonesia, much richer countries), and light-years lower than other low-income countries like Bangladesh, Pakistan, Kenya, Tanzania etc. The literacy rate stands around 93-94 %, the same as richer Thailand and Philippines, and much better than richer China, Indonesia and even Malaysia. Life expectancy, around 70, is equivalent to richer China, Thailand and Philippines, and about 10 years higher than the average for low income countries. It consistently has the highest rates in all of Asia for TB detection, some 85 percent. Primary school enrolment is around 95 percent. The percentage of women giving birth in health facilities is also around 85 percent and close to the highest in the region, and the proportion of children receiving the free child vaccinations is also the highest in the region.

It doesn’t achieve all this by simply being capitalist, which is something it has in common with other regional countries, nor by charging fees, which it also has in common, but by what is different, having had a revolution and trying to maintains some socialistic elements.

Minh asserts the govt gives nothing for poverty reduction except lottery tickets. Yet any report by any major or minor development agency will tell you VN has achieved the most impressive poverty reduction on record, from over 70% in the late 1980s down to 28% in 2002, and regarding ‘extreme poverty’, a report just released by the World Bank claims that “China's growth between 1981 and 2001 has reduced the proportion of extremely poor from 40 percent to 21 percent of the population - 400 million people. Vietnam reduced extreme poverty from 51 percent in 1990 to 14 percent in 2002”
Far from this being due to lottery tickets, the govt’s very active Poverty Alleviation and Hunger Elimination Campaign has received acolades from int’l development agencies, after the fact (most warned VN would be unsuccessful unless it took their advice and privatised everything). This campaign, funded mostly by the state budget but also “funding mobilsation” from large state enterprises and mass organizations builds and repairs schools and health care centres in poor and remote regions, builds roads in remote regions, builds clean water supply systems (VN still has a big need here but has made magnificent progress), other infrastructure, supplies advanced agricultural techniques, and provides a large amount of highly subsidised credit, wit no collateral, for poor people to develop their farming businesses, handicrafts, agricultural techniques, buy livestock, other micro-business start-up etc.

Compare this to what the ADB has been forced to say about its model neo-liberal pupil the Philippines: that there has been no drop in the poverty rate of about 33% in the last 20 years, and in rural areas, “the incidence of poverty has stubbornly remained the same at about 47 per cent since 1985”, while in the new stats for the period since 2003 “we will see an increase in poverty over the levels of 2000.”
Minh also mentions prostitution in VN, as if that is something unusual that exists only in former ‘communist’ countries, and not everywhere in the capitalist third world and first world. The govt claims there about 60,000 prostitutes, but most observers reckon more like about 200,000, a fairly average figure by world standards. However, what the former Thieu-Ky regime resembles is not so much the island city-state entrepot of Singapore, as Minh hilariously suggests, but an older version of Thailand, especially with the absolutely explosive prostitution of US-era Saigon. Today, NGOs tend to reckon there are about 2 million prostitutes in Thailand, and according to WHO, “an estimated 800,000 commercial sex workers are under 20 years of age. Of these, a quarter are below 14 years and approximately 3 in 10 are HIV infected.” (WHO, Regional Health Report 1998). I believe all this cash going back to the poverty-stricken villages played an important role in the Thai “model” of “poverty reduction”, in which the villages kind of benefit from needed cash, but at the expense of the young women’s lives. Thailand has the second largest AIDS epidemic in Asia, after Cambodia, with nearly a million people living with HIV-AIDS, and a cumulative total of some 300,000 deaths.Finally, people need to get a grip on what the VN discussion is about, at least from my point of view. We can make many recommendations about what the VCP should and shouldn’t do, and that is all very valid. But the discussion in VN itself and among all the bodies concerned with VN, which unfortunately means all kinds of international development agencies, lending agencies, trade bodies, foreign investor clubs, NGOs etc, is at the opposite end of the spectrum, ie, whether to plunge VN into full scale capitalism, and most of these forces, including some NGO’s advocate. My point is certainly not to dress up VN as some kind of “model”, as it is nothing of the sort, but to be clear about what we support and defend and what we don’t. My aim is basically to oppose the ‘hegemonic’ view that VN’s post 1990 success in reducing poverty and boosting social indicators is due to market capitalism, and thus, the argument goes, they need even more of it. My argument is that VN is much better health and education wise (and in other respects) than * capitalist * countries at similar economic levels, and in some cases better than those at higher economic levels, due to the non-capitalist revolutionary history and background, as well as the continuing elements of non-capitalism within the current super-NEP.

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