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Battling costly over-doctoring

Battling costly over-doctoring

Dissuading poor people from bankrupting themselves on costly medical procedures of dubious value is one way the Health Sector Support Project (HSSP) is endeavoring to improve health care.

Since 1999 the HSSP has been helping international donors, the Cambodian government and NGOs to identify and implement ways of improving public health care facilities in Cambodia.

It says unnecessary expenditure on medical treatment can deepen and perpetuate rural poverty:

"Medical treatments have become something of a fetish - people sell their land, their cows, and accrue huge debts to obtain even unnecessary treatments such as ultrasounds," said Reginald Xavier, HSSP director for Save the Children Australia (SCA).

Such behavior is rooted in traditional concepts of healthcare in Cambodia. Dr William Collins, in a 2000 study of health-seeking behavior in Kampong Chhnang, says rural Cambodians tend to look at health and illness holistically and consider the possibility that an illness has not only a physical dimension but also psychological, sociological and spiritual dimensions too.

Consequently, he says, different treatments from a variety of healthcare providers are nearly always sought. There is a strong preference for self-help experimentation until an effective remedy is found, and modern treatments are frequently viewed within a traditional framework:

"Injection[s] conjure up a world of traditional spiritualist associations related to psycho-social dimensions of health and this helps to explain why many [Cambodians] seemed so eager to seek medicine by injection rather than by tablet," his report says.

However, the uninformed amalgamation of traditional Khmer and modern Western medical practices can be detrimental to the health of the consumer - and materially crippling.

Dr Fred Griffiths, of HealthNet International, concurs. "Intravenous fluids, unnecessary injections, cough syrups and beautiful tablets are something that patients feel will help," he says.

According to Griffiths "it is the information barrier" that leads rural Cambodians to believe that "IV drips and coloured fluids constitute good quality of care... people just don't know [about appropriate treatment]".

The HSSP aims, working with NGOs, to improve health-care and raise awareness of available, appropriate and inexpensive treatments.

"We have encountered TB patients who have gone undiagnosed and received [inappropriate] treatment in the private sector for a number of years," Griffiths said. "The cost of three or four years of treatment in the private sector is far greater than the cost of going to a government hospital and being treated correctly for a couple of months."

SCA's Xavier says the lack of information about appropriate healthcare fuels a tendency to equate quality of care with the visible trappings of modern treatments, such as intravenous drips and injections. Moreover, such treatments do provide a "quick fix."

"Of course you feel better after an IV drip - you are rehydrated and that is an immediate effect," Xavier said.

Collins in his study says, "Western medicines, especially injections, are attractive partly because, like kos khyal [cupping, or coining], they work very quickly and produce a sense of instant change."

Despite the traditional beliefs and lack of information on health care that incline Cambodians to seek unnecessary and inappropriate treatments, Griffths said NGOs working under the HSSP have enjoyed considerable success in limiting the physical and financial damage of the thirst for "overtreatment."

"Health-seeking behaviour has changed dramatically: most people [in HSSP provinces] now seek treatment in the public sector where they know that the quality of care is monitored," he said.

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